* 
NATIONAL LIBRARY OF MEDICINE




         Bethesda, Maryland 
 
 
n^-csre^-f
FIRST LINES
OF THE
PRACTICE OF PHYSIC
   WILLIAM CULLEN, M. D.

LATE PROFESSOR OF THE PRACTICE OF PHYSIC IN THE
     UNIVERSITY OF EDINBURGH, &C.
WITH PRACTICAL AND EXPLANATORY
           NOTES,
     BY JOHN ROTHERAM, M. D.
IN TWO VOLUMES.
VOL. I.
          NEW-YORK:

      PRINTED BY L. NICHOLS,
FOR E. DUYCKINCK, BOOKSELLER, & STATIONER,
        NO. 110 PEARL-STREET.

             1806. 
a.;. 
CONTENTS
OF  THE
FIRST  VOLUME.
Preface
Introduction
CHAP. I.
CHAP. II.
CHAP. III.
CHAP. IV.
CHAP. V.
CHAP. VI.
   Sect. I.
   Sect. II.
CHAP. I.
  Sect. I.
  Sect. II.
  Sect. III.
  Sect. IV.
  Sect. V.
CHAP. II.
CHAP. III.
CHAP. IV.
CHAP. V.
  Sect. I.
  Sect. II.
  Sect. III.
  Sect. IV.
  Sect. V.
CHAP. VI.
        PART  I.

 Of Pyrexia, or Febrile Diseases

        B  O OK  I.

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

        BOOK  II.

 Of Inflammations, or Phlegmasia
 Of Inflammation in general
 Of the Phenomena of Inflammation
 Of the Proximate Cause of Inflammation
 Of the Terminations of Inflammation
 Of the Remote Causes of Inflammation
 Of the Cure  of Inflammation
 Of Inflammation, more strictly Cutaneous
Of Ophthalmia, or Injlammation of the Eye
Of Phrenzy, or Phrenitis
 Of the Quinsy, or Cynanche
Of the Cynanche Tonsillaris
 Of the Cynanche Maligna
 Of the Cynanche Trachealis
 Of the Cynanche Pharyngaa
 Of the Cynanche Parotidaa
Of Pneumonic Inflammation
PAGE
    v
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ibid
 SI
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 61
ibid
 88
 91
ibid
ibid
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 97
101
102
106
108
113
115
ibid
117
121
124
ibid
125 
CONTENTS.
CHAP. VII. Of the Peripneumonia Notha, or Bastard Peri-
                 pneumony
CHAP. VIII. Of the Gastritis, or Inflammation of the Stomach
CHAP. IX.  Of the Enteritis, or Inflammation of the Intestines
CHAP. X.   Of the Hepatitis, or Inflammation of the Liver
CHAP. XL  Of the Nephritis, or Injlammation of the Kidneys
CHAP. XII. Of the Rheumatism
CHAP. XIII. Of the Tooihach, or Odontalgia
CHAP. XIV. Of the Gout

                     BOOK   III.

              Of Exanthemata, or Eruptive Fevers
CHAP. I.    Of the Small-pox
CHAP. II.  Of the Chlhen-pox
CHAP. III. Of the Measles
CHAP. IV.   Of the Scarlet Fever
CHAP.V.    Of the Plague
   Sect.  I.     Of the Phenomena of the Plague
   Sect. II.   Of the Prevention of the Plague
   Sect.  III.   Of the Cure of the Plague
CHAP. VI.  Of Erysipelas, or St. Anthonys Fire
CHAP. VII. Of the Miliary Fever
CHAP. VIII. Of the remaining Exanthemata : Urticaria,  Pem-
                 phigus, and Aphtha

                     BOOK   IV.

               Of Hemorrhagies
CHAP. I.     Of Hemorrhagy in general
   Sect. I.     Of the Phenomena of Hemorrhagy
   Sect. II.    Of the Proximate Cause of Hemorrhagy
   Sect. III.   Of the Remote Causes of Hemorrhagy
   Sect.  IV.   Of the Cure of Hemorrhagy
CHAP. II.    Of the Epistaxis, or Hemorrhagy of the Nose
CHAP. III.  Of the Hemoptysis, or Hemorrhagy from the Lungs 263
   Sect. I.     Of the Phenomena and Causes of Hemoptysis      ibid
   Sect.  II.    Of the Cure of Hemoptysis                      267
CHAP. IV.   Of the Phthisis Pulmonalis, or Consumption of the
                  Lungs                                    269
   Sect.  I.     Of the Phenomena and Causes  of the Phthisis
                  Pulmonalis                                ibid
   Sect. II.    Of the Cure of Phthisis                        284
CHAP. V.    Of the Hemorrhois, or of tht Hemorrhoidal Swell-
                  ing and Flux                              290
   Sect.  I.     Of the Phenomena and Causes of the Hemorrhois  ibid
   Sect.  II.    Of the Cure of Hemorrhoidal Affections          295,
139
143
148
149
153
155
16 t
168
194
195
211
ibid
216
220
ibid
222
225
227
230

236
238
ibid
239
240
250
251
258 
PREFACE.
     TO deliver a System of the Doctrines and Rules proper for
      directing the Practice of Physic, is an undertaking that
appears to me to be attended with great difficulty; and after an
experience of more than  forty years in that practice, as well as
after much  reading and  reflection, it was with great diffidence
that I ever entered upon such a work.  It was, however,  what
seemed to be my duty as a Professor that  induced  me to make
the attempt ; and I was engaged in it by the same sentiments
that the illustrious Dr. Boerhaave has expressed in the following
passage of  the preface to his Institutions:  " Simul enim do-
cendo admotus eram sensu, propriorum cogitatorum explicatione
docentem plus proficere, quam si opus ab alio conscriptum  in-
terpretari suscipit.  Sua quippe optime intelligit,  sua cuique prac
caeteris placent,  unde  clarior  fere doctrina, atque animata ple-
rumque  sequitur oratio.  Qui vero sensa alterius exponit, infe-
licius saepenumero eadem assequitur;  quumque suo quisque sen-
su  abundat, multa refutanda  frequenter invenit, unde gravem
frustra laborem aggravat, minusque incitata dictione utitur."
It is well known, that a Text-book is not only extremely useful,
but necessary to Students who are to hear Lectures; and from
the same considerations that moved Dr. Boerhaave, I also wish-
ed  to have one for myself; while  at die same time, from some,
peculiar  circumstances in my  situation,  I had some additional
inducements to undertake such a work.
   Before I was established as Professor of the Practice of Physic
in this University, I  had been employed in giving Clinical Lec-
tures in the Royal Infirmary ; and upon diat occasion had deli-
vered, what, in my  own opinion,  seemed most just with regard
to  both the nature  and  the cure of the diseases of which  I had
occasion  to treat.  But  I soon found, that  my  doctrines were
taken notice of,  as  new, and  peculiar to  myself ;  and were ac-
cordingly severely criticised by those who,  having long  before
been trained up  in the system  of Boerhaave,  had continued  to
think that that system neither required any change, nor admitted
of  any amendment.   I found, at the same time, that my doc-
trines were frequently  criticised by persons who  either had not
been  informed of them correcdy, or who seemed not to under-
stand them  fully ; and therefore, as soon  as  I was employed t«
                             B 
VI
PREFACE.
 teach a more complete system of the Practice of Physic, I judg-
 ed it necessary to publish a Text-book, not only for the benefit of
 my hearers, but that I might also have an opportunity of obtain-
 ing  the opinion of the public more at large, and thereby be en-
 abled either to vindicate my doctrines,  or be taught to correct
 them.   These were the motives for my  attempting the volumes
 I formerly published ; and now from  many years experience  of
 their utility to my hearers,  as well as from the favorable recep-
 tion they have met witii from  the public,  I am induced to give a
 new  edition of diis Work, not only, as  I hope, more correct in
 many parts, but  also more  complete and comprehensive in its
 general extent.
   At the first publication of this work,  it  was intended chiefly
 for die use of those gentlemen who attended my lectures ; altho'
 even  then for die reasons  I  have  mentioned, it was rendered
 more  full than text-books commonly are ; and, in the repeated
 editions I have since had occasion to give, I have been constantly
 endeavoring  to render  it more  full and comprehensive.   In these
 respects,  I hope  the present edition will  appear to be rendered
 more fit  for general use, and better calculated to  afford satisfac-
 tion to all those who think they may still  receive any instruction
 from  reading on this subject.
   While I thus deliver my work in its now more improved state,
 with the hopes that it may be  of use to others as well as to those
 who hear my Lectures, I must at the same time observe, that it
 presents a system  which is in many respects new, and therefore I
 apprehend it to be not only proper, but necessary, that I should
 explain here upon what grounds, and from what considerations,
 this has been attempted.
   In  the first place, I apprehend that, in  every  branch of  sci-
 ence with respect to which new facts are daily acquired, and these
 consequently giving occasion  to new  reflections, which correct
 the principles  formerly  adopted,  it is necessary from  time to
 time,  to  reform and renew the whole system,^,with all the addi-
 tions and amendments which it has received and is  then capable
 of.  Thai at present, this is requisite with regard to the Science
 of Medicine, will, I believe, readily occur to every person who
at all thinks for  himself, and is acquainted with the Systems
which have  hitherto prevailed.   While, therefore,  I  attempt
this, I think it  may be allowable,  and upon this occasion even
proper, that I should offer some remarks  on the principal Sys-
tems of Medicine which have  of late prevailed in Europe, and
that I should take notice of the present state of Physic as it  is
influenced by these.   Such remarks,  I hope, may be  of some
use to those  who attempt to improve  dieir knowledge  by die
reading of books. 
PREFACE.
VII
   Whether the  practice of Physic should admit of reasoning, or
be entirely  rested upon experience, lias long been,  and may  still
be,  a matter of dispute.   I shall not, however, at present, enter
upon the  discussion of this  ; because I  can  venture to assert,
that,  at almost all  times, the practice  has  been, and  still is,
with  every  person,  founded  more  or less,  upon  certain princi-
ples established by  reasoning ; and therefore, in attempting to
coffer some  view of the present state of  Physic,  I must  give an
account of those systems of the principles of science which  have
lately prevailed, or may be supposed still to prevail in  Europe.
   When, after  many  ages   of darkness, which  had  destroyed
almost  the  whole of ancient  literature, learning was again re-
stored in the fifteenth century ;* so from causes which are   well
known, it was  the system of Galen alone that the Physicians of
those days became acquainted with ; and during  the  course of
die  sixteenth century,  the study of Physicians  was almost solely
employed in explaining  and confirming tha# system.    Early, in-
deed, in  the sixteenth  century,  the noted Paracelsusf had  laid
the  foundation of a Chemical system which was  in direct oppo-
sition to that of Galen ; and,  by the efficacy of  the  medicines
employed by Paracelsus andhis followers, their system came to
be received  by  many :  but the  systematic Physicians   continued
to be  chiefly Galenists,  and  kept  possession of the Schools till
the  middle   of the  seventeenth  century.   It  is  not,  however,
necessary here to enter into any further detail respecting the fate
of those two opposite sects ;  for the only circumstance concern-
ing  them, which I would at present point out, is^ that in the writ-

  J At this period the medical knowledge of Europe was chiefly, and indeed solely, such as h ad
been  derived ffom the  Arabians.  At the conquest or Constantinop  e by the Turks, about the
middle of the fifteenth century, several of the Greeks fled into Italy, and the people of Europe
communicating with them, found them t<i be intelligent, and some of them even learned men;
the Europeans wiiie thence  led \o study  the Greek language, in order to read the valuable
books which these fugitives had so much extolled ; and among other works, those of Galen
particularly attracted the notice of the physicians, which to their great astonishment, contained
all the medical knowledge that had been attributed  to the Arabians. To the  Greek wrileri,
therefore, the physicians of those times closely applied their attention, thinking  these books the
only true fountains of medical knowledge; and thus it was that the Galenical doctrines be-
came  prevalent all over Europe.

  + Tlie remarkable circumstances in the life of Aurtolus Philippus Theophrastus Bombastui
Taraci'Lus de Hokeuheim, as he called himself,  are too numerous for insertion in the  narrow li-
mits allotted to these Notes.  He was bom  at the village of Einfidlen, about two German miles
fr.ni Zurick, in the year 1493.  At three years old he was made an eunuch by an accident. He.
tiavelled all over the continent of Europe,  obtaining knowledge in chemistry and physic, and
then  travelled about the country practising what he had learned.  His chief remedies were
opium and mercury, and his great success increased his celebrity.  He cured the famous printer
trabeniui of Basil  of an inveterate disease ; this cure brought him acquainted,  with Erasmus,
and made him known to the magistracy of Basil, who elected him professor in 15'27. He lec-
tured two hours every day. While seated in his chair, he burnt with great solemnity, the writ-
ings of Galea and Avicen<..c ,• and declaied to his audience, that if God would not impart the
secrets of physic,  it was not only allowable, but even justifiable to consult the devil. He soon
leit Basil, and continued to ramble about- the country, generally intoxicated,  and never chang-
ing his c othes, or even going to bed.  He died  after an illness of. a few d.iys, in an inn at Salts-
burgh. in 1541, in his48th year, tho'he had promised himself that, by the ase of his elixir, he
should live to {lie u^e ut MetlAualcm. 
vm
PREFACE.
ings of both, the explanations they  severally attempted to give
of the phenomena of health or  sickness, turned entirely upon
the state of the fluids of the body.
  Such was the state of the  science of physic till about the mid-
dle of the seventeenth century, when the circulation of the blood
came to be generally known  and admitted ;  and when this,  to-
gether with the  discovery of the receptacle of the chyle, and of
the thoracic duct, finally exploded the Galenic system.  About
the same period a considerable revolution had taken place  in  the
system of Natural Philosophy.  In the course of the seventeenth
century,  Galileo had introduced mathematical  reasoning ;  and
Lord Bacon having proposed  the method of induction,  had
thereby excited a disposition to observe facts, and to make  ex-
pe iments.   These  new  modes  of philosophizing, it might be
supposed, would soon  have had some  influence  on the state of
m .'dicine ; but the progress of this  was slow.  The knowledge
of the Circulation didindeed necessarily lead to the consideration
as well as to a clearer view of the Organic System in animal bo-
dies ; which again led to the application of the mechanical  phi-
losophy towards explaining the phenomena of the animal cecono-
my; and it was applied  accordingly,  and continued,  till very
lately, to be the  fashionable mode of reasoning on the subject.
Such reasoning, indeed, must still in several respects  continue
to be  applied :  but it  would be  easy to show, that it neither
could, nor ever  can be, applied  to any great extent  in explain-
ing the animal ceconomy ; and we must therefore look for other
circumstances which had a greater share in modelling the system
of Physic.
  With this view, it  may be remarked,  that till the period just
now mentioned, every Physician, whether Galenist or Chemist,
had been so much accustomed to consider die  state and condi-
tion of the  fluids, both  as the cause of disease, and as the foun-
dation for explaining the operation of medicines, that what we
may term an humoral fathologv still continued to make a
great part of every system.   In these circumstances, it was soon
perceived, that  chemistry promised  a  much better explanation
than the Galenic or  Aristotellian philosophy had  done ; and,
therefore, while the latter was  entirely  laid  aside, a  chemical
reasoning was every where received.  Lord Bacon with his usual
sagacity, had early observed, that  chemistry promised a great
number of facts, and  he thereby  gave it  credit ; whilst  the
Corpuscularian philosophy, restored by Gassendi, readily united
with the reasonings of the Chemists ; and the philosophy  of Des
Cartes readily united with both.  From all these circumstances,
an Humoral,  and chiefly a  Chemical  Pathology,  came to pre-
vail very much till the end of the last century ; and has indeed, 
PREFACE.
IX
continued to have a great share in our systems down to the pre-
sent time.
  It is proper now, however,  to  observe, that about the begin-
ning of the present century, when every part of science came to
be on a more improved  and correct footing, there appeared in
the writings of Stahl, of Hoffman, and of Boerhaave, three
new,  and considerably different, Systems of Physic ; which have
ever since had  a great share in directing the practice of it.   In
order, therefore, to give a nearer view  of the present state of
Physic, I shall offer some remarks upon these different systems ;
endeavoring  to point out the  advantages,  as well as the disad-
vantages of each, and how far they still prevail ;  or, according
to my judgment, deserve to do so.
  I  shall begin with considering that of Dr. Stahl, which I
think appeared first, and for a long time after was the prevail-
ing system in Germany.
  The chief and leading principle of this system is, that the ra-
tional soul of man governs the whole oeconomy of his body.  At
all times, Physicians  have observed, that the animal oeconomy
has in itself a power or condition, by which, in many instances,
it resists  the injuries which threaten it  ; and by which it also, on
many occasions, corrects or removes the disorders induced, or
arising in it.   This power, Physicians very anciently attributed,
under a vague idea, to an agent in the system, which they call-
ed nature ; and  the language of a vis conservatrix et medicatrix
nature, has continued in  the schools of medicine  from the most
ancient times to the present.
  Dr. Stahl has explicitly founded his system on the supposition
that the power of nature, so much talked of, is entirely in the ra-
tional soul.   He supposes, that upon many occasions, the  soul
acts independently of the state of the body ;  and that, without
any  physical necessity arising from that state, the soul, purely
in consequence of its intelligence perceiving the tendency of nox-
ious powers  threatening, or of disorders any  wise  arising  in the
system, immediately  excites such motions  in the body as are
suited to obviate die hurtful or pernicious consequences which
might otherwise take  place.—Many of my readers may think it
was  hardly necessary for me to take notice of a system founded
upon so fanciful an hypothesis ; but there is often so much seem-
ing appearance of intelligence and design in die operations of the
animal oeconomy, that many  eminent persons,  as Perrault in
France, Nichols  and Mead in England, Porterfleld and Sims on in
Scotland, and  Gaubius in Holland,  have very much counten*-
anced the same opinion,  and it is therefore certainly entitled to
some regard.  It is not, however, necessary  for me here to en-
ter into any refutation of it.  Dr. Hoffman has done this fully, 
x                       PREFACE.
 in his Commentarius  de differentia inter Hoffmanni doctrinam  medico-
 mechanicam et G. E. Stahlii medico-organic am ;  and bodi Boerhaave
 and Haller, though no favorers of materialism, have mentioned
 a doctrine very opposite to that of Stahl.
   In my  Physiology I have offered some arguments against the
 same ; and I shall only  add now,  that whoever considers what
 has been said by Dr. Nichols in his Oratio de Anima Medica, and by
 Dr.  Gaubius in some parts of his Pathology, must perceive, that
 the admitting of such a capricious government of the animal oeco-
 nomy, as these authors in some instances suppose, would at once
 lead us  to reject all the physical and mechanical reasoning we
 might employ concerning the human body.  Dr. Stahl himself
 seems to have been aware of this ; and therefore in his preface to
 Juncker's  Conspectus Therapeia  Specialis, has acknowledged,  that
 his  general principle was not at all necessary ; which is in effect,
 saying that it is not compatible with any system of principles that
 ought to govern our practice.  Upon this footing, I might have
 at once rejected the Stahlion principle : but it is even dangerous
 to bring any such principle  into view ; for, after all Dr. Stahl had
 said in a passage just now referred  to, I find, that,  in the whole
of their practice, both he and his followers have been very much
governed by their general principle.  Trusting much to the  con-
 stant attention and wisdom of nature, they have proposed  the
Art of curing by expectation ; have therefore, for  the most part,
proposed only very inert and frivolous remedies ; have zealously
opposed the use of some of the most efficacious, such as opium
 and the  Peruvian "bark ;  and are extremely reserved  in the use of
general remedies, such as bleeding, vomiting, &c.
  Although these  remarks, upon a system  which may  now be
considered as exploded  or  neglected, may seem superfluous; I
have been willing to give these strictures on the Stahlion system,
 that I might carry my remarks a litde farther,  and  take this op-
portunity of  observing, that, in whatever manner we may explain
what have been called the operations of nature, it appears to me,
that the general doctrine of Nature  curing  diseases, the so much
vaunted Hippocratic method of curing, has often had  a baneful  in-
 fluence on the practice of physic ; as either leading physicians  in-
to, or continuing them in,  a weak and feeble practice ; and at the
 same time superseding or discouraging all  the attempts  of art.
 Dr.  Huxham has properly observed that even in the hands of Sy-
 denham it had this effect.  Although it may sometimes avoid
 the mischiefs of bold and rash practitioners, yet it certainly  pro-
 duces that caution and timidity which have ever opposed the  in-
 troduction of new and efficacious remedies.   The opposition to
chemical medicines in the sixteenth and seventeenth centuries, and
 the noted condemnation of  Antimony by the Medical Faculty of 
PREFACE.
Xl:
 Paris, are to be attributed chiefly to those  prejudices, which the
 physicians of France did not entirely get the better of for near an
 hundred years after.   We may take notice of the reserve it pro-
 duced  in Boerhaave, with  respect to the  use of the Peruvian
 bark. We have had lately published, under the title Cfnstitutiones
 Epidemic*, notes of the particular practice of the late Baron Van
 Swieten ; upon which the editor very properly  observes, That the
 use of the bark, in intermitting fevers,  appears very rarely in that
 practice ; and we know very well  where  Van Swieten learned
 that reserve.
   I might go farther, and show how  much the attention to the
 Autocrateia, allowed of, in one shape or other,  by every sect,  has
 corrupted the practice among all physicians, from Hippocrates to
 Stahl.   It must, however, be sufficiently obvious, and I shall con-
 elude the subject with observing,  that although this vis medicatrix
 nature, must unavoidably be received as a fact; yet whether it is
 admitted, it throws an obscurity upon  our system ; and it is only
 where the impotence of our art is very manifest and considerable,
 that we ought to  admit of it  in practice.
   To finish our remarks upon the Stahlion System, I shall shortly
 •bserve, that it did not depend entirely upon the Autocrateia, but
 also supposed a state of the body and diseases, that admitted of re-
 medies ;  which, under the power  and direction of the soul, acted
 apon the organization and matter of  the body,  so  as to cure its
 diseases.   Upon this  footing,  the Stahlion  pathology turned en-
 tirely upon Plethora and Cacochymy.  It was  with respect to the
 former that they especially applied their doctrine  of the Autocra-
 teia  in a very fantastical manner ;  and, with respect to die latter*
 they have been involved in a humoral  pathology  as much as the
 systematic physicians who had gone before them, and with a the-
 ory so incorrect as not to merit the smallest attention.   After all,
 I  ought not to dismiss 'die  consideration of die Stahlion system,
 without remarking, that as the followers of this system were very
 intent upon observing the method of nature, so they were very
 attentive in observing the phenomena of diseases,  and have given
 us in their writings many facts not to be found elsewhere.
   While  the doctrines of  Stahl were prevailing in the university
 ©f Halle, Dr. Hoffman,* a professor in the  same  university pro-.
 posed a system that was very different.   He received into his sys-
 tem a great deal of the mechanical, Cartesian, and chemical doc-

 * Frederick Hoffman was born at Halle in the year  1660.  He jiaiiuated in 1681; was mac!«
 professor of physic there in the year 1693; and tilled that chair till his death in 1742.  A very re-
 markable circumstance of his lite is, that he never took fees from his patients, but was content
 with his stipend. He was in high repute as a practitioner, aiM curing the Emperor Charles VI.
and Empress, and Trederick I. of Prussia, of inveterate diseases,-greatly increased his repufatioa.
His works are collected iuto six volumes, folio, published at different times from 1748 to 17M.
They abound with many useful practical directions; but atthe ;intc time con»..i» manv frico-
IniM remarks, and as abutKlaucc of cosjectural theory• 
xii
PREFACE.
trines  of the systems which had appeared before : but with re-
spect to these, it is of no  consequence to observe in what manner
he modified die doctrines of his predecessors, as his improvements
in these respects were no ways considerable, and no part of them
now remain ; and the real value of his works,  beyond what I am
just now going to mention,  rests entirely on the many facts
they contain.  The merit of Dr.  Hoffman and of his works is,
that lie made, or rather  suggested,  an  addition  to the system,
which  highly deserves  our attention.   Of this I cannot give a
clearer account than by giving it in the author's own words.   In
his Medicina Rationalis  Systematica, Tom III.  § 1. chap. iv.  he
has  given his Genealogia morborum ex  turbato solidorum et fluidorum
mechanismo ; and in the 47th and last paragraph of this chapter
he sums up his doctrine in the following words :  " Ex hisce au-
tem omnibus uberius hactenus  excussis,  per quam dilucide ap-
parere  arbitror, quod solus  spasmus  et simplex atonia, aequabi-
lem, liberum, ac proportionatum sanguinis omnisque generis flui-
dorum motum, quibus excretionum successus et integritas functi-
onum animi et corporis proxime nititur, turbando ac pervertendo,
universam viuilemocconomiam subruant  ac destruant;  atque hinc
universapathologialonge rectiusatque facilius ex vitio motuum
MICROCOSMICORUM IN SOLIDIS, quam  EX VARUS  AFFECTIONl-
bus vitiosorum  humorum, deduci atque explicari possit, adeo-
que omnis generis aegritudines  interna?,  ad pr^eternaturales
generis nervosi affectiones  sint referendae.   Etenim  laesis
qurcunque modo, vel nervis per corpus diseurrentihus, vel mem-
branosis  quibusvis  nervosis partibus, illico motuum anomaliae,
modo  leviores, modo graviores subsequuntur.  Deinde attenta
observatio docet, motus quosvis morbosos principaliter sedem fi-
gere et tyrannidem exercere in nervosis corporis partibus, cujus
generis prater omnes canales,qui systaltico et diastaltico motu pol-
lentes,  contentos succos tradunt, universui:i nimirum intestinorum
et ventriculi ab cesophago ad anum Ganalem, totum systema vaso-
rum arteriosorum, ductuum biliariorum, salivalium, urinariorum
et subcutaneorum, sunt quoque membranse nerveo-musculares ce-
rebri et medullae spinalis, praesertim hsec, quae dura mater vocatur,
organis sensoriis obductae, nee non tunicae illae ac ligament a, quae
ossa cingunt artusque firmant. Nam nullus dolor, nulla inflamma-
tio, nullus spasmus, nulla motus et sensus impotentia,  nulla febris
humoris  illius excretio, accidit, in qua non has partes patiantur.
Porro etiam omnes, quae morbos gignunt causae, operationem su-
am potissimam perficiunt in partes motu et sensu praeditas, et ca-
nales ex his coagmentatos, eorum motum, et cum hoc fluidorum
cursum,  pervertendo;  ita tamen, ut sicuti variae indolis sunt, sic
etiam varie in nerveas partes agant,  iisdemque noxam affiricent.
Demum omnia quoque eximix virtutis  medicamenta, non tam 
PREFACE.
xm
in partes fluidas, earum crasin ac intemperiem corrigendo, quanx
potius in solidas et nervosas, earundem motus alterando ac mode-
rando, suam edunt operationem : De quibus  tamen omnibus, in
vulgari usque eo recepta.morborum doctrina, altum est silentium."
   It is true, that Dr. Willis* had laid a foundation for this doc-
trine, in his Pathologia Cerebri et Nervorum ; and Baglivi had pro-
posed a system of this kind in his Specimen deflbra motrici et morbosa.
But in these writers it was either not extensively applied to dis-
eases, or  was still so  involved in many phisiological errors, that
they had  attracted little  attention; and Dr.  Hoffman  was the
first who gave any tolerable simple and clear  system on the sub-
ject, or pointed out any extensive application of it to the explana-
tion of diseases.
   There can be no sort of doubt that the phenomena of the ani-
mal oeconomy in health and in sickness, can only be explained by
considering the state and affections of the primary moving pow-
ers in it.   It is to me surprising that physicians  were so long in
perceiving this, and I diink we are  particularly indebted to Dr.
Hoffman for putting us into the proper train of investigation ;
and it every day appears that Physicians perceive the necessity of
entering more and more  into this inquiry.   It was this,  I think,
which, engaged Dr. Kaaw Boerhaave to publish his work entitled
Impetumfaciens ; as well as Dr. Gaubius to give the Pathology of
the Solidum vivum.  Even the Baron Van Swieten has upon the
same view  thought it necessary, in  at least one particular, to
make a very considerable change in the doctrine of his master, as
he has done in his Commentary upon the 775th Aphorism.   Dr.
Haller has advanced this part of science very much by his experi-
ments on irritability and sensibility.   In these and in many other
instances,  particularly in  the writings of Mr. Barthez of Mont-
pelier, of some  progress in the study of the affections in the  Ner-
vous  System,  we must perceive how much we are indebted to
Dr. Hoffman for his so properly beginning it.   The subject, how-
ever, is difficult:  the laws of the Nervous System, in the various
circumstances of the animal oeconomy, are by no  means ascer-
tained ; and from want of attention and observation with the view
to a system on this subject, the business appears to many as an in-
explicable mystery. There is no wonder therefore, that on such a
difficult subject, Dr. Hoffman's system was imperfect and incor-
rect ; and  has had less influence on the writings and practice of
Physicians since his time, than might have been expected.   He
  * This illus.rtous physician was born at great Bedwin in Wiltshire in 1621. He took the de-
gree or master of arts in 1642 at Oxford, where he was made professor of natural philosophy in
1600: and that same year he took the degree of M. D. His practice was extensive and success-
ful. He was one of the first members .of the royal society in London, whither he removed in.
1666°; and soon made his name as illustrious by liis writings, as he had already done by his prac-
tice. His works had been.often printed separately ;  but they were not collected till after his
'h-ath,  which happened on the 11th of November, 167b. One edition was published at Geneva
m 1676", and another at Amsterdam in 1682, both in quarto.
                                C 
AlV
PREFACE.
 himself has not applied his fundamental doctrine so extensively as

 he might have done ; and he has every  where intermixed  a Hu~

 moral  Pathology, as  incorrect  and  hypothetical as  any other.

 Though he differed from his colleague Dr.  Stahl in the fundamen-

 tal doctrines of his system, it is but too evident that  he was  very

 much infected with the Stahlion doctrines of Plethora and Ca-

 cochymy,  as may be  observed throughout the whole  course of

 his work ;  and particularly in his chapter De morborum generatione

 ex nimia sanguinis quantitate et humorum impuritate.

   But it is needless for me to dwell any longer upon the system

 of Hoffman ;  and I am next to offer some remarks on the system

 of Dr.  Boerhaave, the contemporary of both the other  Systema-

 tics, and who,  over all Europe,  and especially in this part ot the

 world, gained higher reputation  than either of the others.

   Dr.  Boerhaave* was a man of general erudition  ; and, in ap-

 plying  to   medicine,  he  had carefully studied  the   auxiliary

 branches of Anatomy, Chemistry,  and  Botany, so that he excel-

 led in each.   In forming  a system of Physic, he seems  to  have

 studied diligently all the several  writings of both  ancient and mo-

 dern  Physicians ; and, without prejudice in favor of any former

 systems, he endeavored to be a candid and genuine ecclectic.  Pos-

 sessed of an  excellent  systematic genius,  he  gave  a system  su-

 perior to any that ever before appeared.  As in the great extent*

 and seemingly perfect consistency, of system, he  appeared to im-

 prove and refine upon every thing that had before been offered ;

 and  as  in  his Lectures  he  explained  his  doctrines  with great

 clearness and elegance ;  he soon  acquired a very high reputation,

 and his system was more generally  received than any former had

 been  since the time of Galen.   Whoever  will consider the me-


  * Voorhoot, a small village about two miles from Leyden, gave birth to this eminent physician
 on the last day of the year 1668.  He was educated  at Leyden, and took his first degree in phi-
 losophy 1690.  His thesis on this occasion was a confutation of the doctrines of Epicurus*
 Hobbes, and Spinosa; in which  he shewed great  strength of  genius and  argument.
 Although he was at this  time  well  qualified to  enter  into the church,  which was  his fa-
 ther's intention, yet he was diffident of his abilities, and chose  to attend the  lectures of divinity
 longer.  His patrimony was however now exhausted, and he supported himself at the university
 by leaching mathematics, while he prosecuted his theological studies. This conduct was much
 approved by the eminent men both of the University and City, and procured for Boerhaave the
 friendship of Mr. Vanderburg the Burgomaster of Leyden.  Under the patronage,  and at the
 persuasion of this gentleman, Boerhaave applied himself to the study of physic with great ardor
 and indetatinaole diligence. In a short  time he became proficient in anatomy, chemistry, and the
 materia meuica, which indeed are the basis of physic.  Leaving Leyden he went to the univer-
 sity of Hardcrwick in Guelderland, and there look his degree of Doctor of Physic in July 1693.
 On his return to Leyden he still persisted in his intention of entering into the ministry, which
 luckily, for the sake of Physic, was frustrated by the following adventure: In a passage-boat
where Boerhaave was, a discourse was accidentally started aboutthe doctrines of Spinosa as sub-
versive of religion; and one of the passengers, with vague invectives of blind  zeal, opposed
this philosopher's pretended mathematical demonstration.  Boerhaave calmly asked him if he
 had read Spmosa's work, which he had so much  derided.  The bigot was suddenly struck dumb,
and became tireu with silent resentment. As soou as he arrived at Leyden,  he spread abroad a
 ru nor that Boerhaave was become a Spinosist. Boerhaave finding these  prejudices  to gain
 ground, thought it more prudent to pursue the  science ot physic, titan  risk the refusal  of a li-
cence for the pulpit.  He now joined the practice of Physic  to the theory,  on the I«th of
M.iv, 1701, he commenced his lectures on the Institutes of Physic. In 1709, he was created pro-
fessor of medicine and botany; and in 171fc, he succeeded Le Mort in the professorship of Che-
mistry.  In August 172-2, he was seized with the gout, and was obliged to resign his professorship
ot Chemistry and Botany in 1729. He continued for some time to practice, but was at length
 oOlijcd io <;uil mat aisoj and he died on U>e ZJd oi  September 1738. 
PREFACE.
xv
rlts of Dr. Boerhaave, and compare his system with that of for-
mer writers, must acknowledge that he was very justly esteemed,
and gave a system which was at that time deservedly valued.
  But, in the progress of an inquisitive and industrious age, it
was not to be expected that any system should  last so long as
Boerhaave's has done.  The elaborate Commentary of Van Swie-
ten on Boerhaave's system of  practice, has been only finished a
few years ago; and though this Commentator has added many
facts, and  made some corrections, he has not, except in the parti-
cular mentioned above,  made any improvement in the general
system.  It is even surprising  that Boerhaave himself, though he
lived near forty years after he  had first formed his system, had
hardly in all that time made any corrections of it or additions to
it; the following is the most remarkable.  In Aphorism 755, the
words forte et nervosi, tarn cerebri quam cerebelli cordi destinati inertia,
did not appear in any edition  before the fourth; and what a dif-
ference of system this points at, every physician must perceive.
   When I first applied to the  study of Physic,  I learned only the
system of Boerhaave ; and  even when I  came to take  a Profes-
sor's chair  in this university,  I  found that system here in its
full force; and as I believe it still subsists in credit elsewhere, and
that no other system of reputation had been offered to the world,
I think it necessary for me to  point out particularly the  imper-
fections and deficiencies  of the Boerhaavian  system, in order to
show the propriety and necessity of attempting a'new one.
   To execute this, however, so fully as I might, would lead me
into a detail that can hardly be admitted of here ; and I hope it
is not necessary, as I think, that every intelligent person, who has
acquired any tolerable knowledge of the present state of our sci-
ence, must in many instances, perceive its imperfections.  I shall
therefore touch only upon the great lines of this system ; and from
the remarks I am to offer, trust diat both the mistakes and defi-
ciencies which run tiirough the whole of his works will appear.
   Dr.  Boerhaave's treatise  of the diseases of the simple solid,
has the appearance of being very clear and consistent, and was
certainly considered by him as a fundamental doctrine ;  but, in
my apprehension,  it is  neither  correct nor extensively applica-
ble, not to mention the useless, and perhaps erroneous,  notion of
the composition of earth and gluten ; nor his mistake concerning
 the structure of compound membranes ; nor his inattention to the
state of the cellular texture ; all of  them  circumstances which
render his doctrine imperfect; I shall insist only upon the whole
being very-  litde applicable to the explaining the phenomena of
health or sickness.  The laxity or rigidity of the simple solid,
does, indeed, take place at the different periods of life, and may
perhaps, upon other occasions, occur as the cause of disease:  But 
xvi
PREFACE.
  I presume,  that the state of the simple solid is, upon few occa-
  sions, either changeable or actually changed ; and that, in ninety-
  nine cases of an hundred, the phenomena attributed to such a
  change, do  truly depend  on  the  state of the solidtm vivum ;
  a circumstance which Dr.  Boerhaave has hardly taken notice of
  in any part of his works.   How  much this shows the deficiency
  and imperfection of his system, I need not explain.  The learned
  work of Dr. Gaubius, above referred to, as well as many other
  treatises of late authors, point out sufficiently the defects and im-
  perfections of Boerhaave on this subject.
   After Dr.  Boerhaave has considered the diseases of die solids,
  he in the next place  attempts to explain the more simple diseases
 of the fluids ;  and there, indeed, he delivers a more correct  doc-
 trine of acid and alkali than had been given before :  But, after
 all, he has done it very imperfectly.   We have,  indeed, since his
 time,  acquired more knowledge upon the subject  of digestion;
 and so much as to know, that a great deal more is yet necessary
 to enable us to understand in what manner the  animal fluids are
 formed  from the aliments taken in.  And although Dr. Boer-
 haave has fallen into no considerable error with respect to a mor-
 bid acidity in  the stomach, he could not possibly be complete
 upon that subject; and his notion of  the effects of acidity in the
 mass of blood, seems to have been entirely mistaken, and is in-
 deed not consistent with what he himself has delivered elsewhere.
   His doctrine of alkali is somewhat better founded, but is  pro-
 bably carried too far ; and the state of alkalescency and putrefac-
 tion,  as well as all the other changes  which can take place in the
 condition of animal  fluids, are particulars yet involved in great
 obscurity, and are therefore still subjects of dispute.
   There is another particular, in which Boerhaave's doctrine con-
 cerning the fluids appears to me imperfect and unsatisfactory ; and
 that is,  in his doctrine de Glutinoso spontaneo.  The causes which
 he has assigned for it are by no means  probable, and the actual
existence of it is seldom  to be proved.   Some of  the proofs ad-
 duced for the existence of a phlegma calidum, are manifestly found-
 ed upon a mistake with respect to what  has been called the in-
flammatory crust, (See Van Sweiten's  Commentary, page 96.)
and the many examples given by Boerhaave of a glutinosum ap-
pearing in the human body,  (Aph. 75.) are all of them nothing
more than instances of collections or concretions found out of the
course of the circulation.
   If, then, we consider the imperfections of Dr. Boerhaave's
doctrine  with respect to the state and  various condition of the
 animal fluids ; and if at the same time we reflect how frequently
he and his followers have employed the supposition of an acrimo-
ny or lentor of the fluids, as causes of disease, and for directing 
PREFACE.
xvn
the practice; we must, as I apprehend, be satisfied, that his  sys-
tem is not  only deficient and incomplete,  but fallacious and apt
to mislead.  Although it cannot be denied, that the fluids of the
human body suffer various morbid changes ; and that upon these,
diseases may primarily depend; yet I must beg leave to maintain,
that the nature of these changes is seldom understood, and more
seldom  still is it  known when they have taken  place:  that  our
reasonings concerning them have been, for die most part, purely
hypothetical;  have therefore contributed nothing to improve, and
have  often misled, the practice of physic.   In this, particularly,
they have been hurtful,  that  they have withdrawn our attention
from, and prevented our study of,  the motions of the animal  sys-
tem, upon the state of which the phenomena of diseases do more
certainly and generally depend. Whoever, then, shall consider the
almost total neglect of the  state of the moving powers of the
animal body, and the prevalence of an hypothetical humoral pa-
thology, so conspicuous in every part of  the Boerhaavian system,
must  be convinced of its very great defects, and perceive the ne-
cessity of attempting one more correct.
   After giving this general view, it is not requisite to enter into
particulars; but, I believe, there are very few pages of his aphorisms
in which there does not occur some error  or defect;  although,
perhaps, not to be imputed to the fault of Boerhaave, so much as
to diis,  that since his time  a great collection of new  facts ha»
been acquired by  observation and experiment.   This, indeed, af-
fords  the best and most solid reason for attempting a new system:
for when many new facts have been acquired, it becomes requi-
site that these should be incorporated into a system, whereby not
only particular subjects may be improved, but the whole may  be
rendered more complete, consistent, and useful.  Every system,
indeed,  must be valued in proportion to the number of facts that
it embraces and  comprehends ; and Mons. Quesney could  not
pay a higher compliment to the system of Boerhaave,  than by
saying that it exhibited La medicine collective.
   But here it will, perhaps be suggested  to me, that the  only use-
ful work on the subject of physic, is the making a collection of
all the facts that relate to the art, and  therefore of all that expe-
rience has taught  us widi respect to the cure of diseases.   I agree
entirely in the opinion ; but doubt if it can ever be properly ac-
complished, without aiming at some  system of principles, by a
proper induction and generalisation of facts:  at least I am per-
suaded that it can be done not only very safely, but most usefully
in this way.  This, however, must be determined by a trial.  I
know that the late Mr. Lieutaud has attempted a work on the plan
of collecting facts without any reasoning  concerning their cau-
ses: And while I am endeavoring to give some account of  the 
XV111
PREFACE.
present state of physic, I cannot dismiss the subject without of-
fering some remarks upon the promising Synopsis universe medici-
ne, composed by the first physician  of a  learned and ingenious
nation.
   In this work there are many facts and much observation from
the Author's own experience, which may be useful to those who
have otherwise some knowledge and discernment; but, through-
out the whole work,  there is such total want of method, arrange-
ment,  system, or decision, that in my humble opinion, it can be
of little use, and may prove very perplexing to those who are yet
to learn.   The distinction of the genera of diseases,  the distinc-
tion of the species of each, and often even that of the varieties, I
hold to be a necessary foundation of every plan of physic, whe-
ther dogmatical or empirical.   But very little  of this distinction
is to be found in the work of Mr. Lieutaud ; and in his preface he
tells us, that he meant to neglect such arguta sedulitas. And indeed
his method of managing his subject  must certainly  interrupt and
retard all methodical nosology.   His arrangement  of diseases is
according to no  affinity, but that of the slightest and uninstruc-
tive kind, the place of the body which they happen to affect.   His
Generalia et incerte scdis, have hardly any connection  at all; the ti-
tles  Rheumatisms,  Hypocondriasis,  Hydrops, follow one  another.
When he does attempt any general doctrine, it is not till long af-
ter he has  treated.of the widely scattered particulars.  Under
each particular title which he assumes, he has endeavored to enu-
merate the whole of the symptoms that ever  appeared in a dis-
ease under that  title ; and this without aiming at any distinction
between  the essential and accidental symptoms,  or marking the
several combinations under which these symptoms do for the most
part steadily appear.  From the concurrence of accidental symp-
toms,  the  variety of die same disease is frequently considerable,
a circumstance  necessarily  perplexing and distracting to young
practitioners ; but it seems strange  to me, that an experience of
thirty years, in  considerable practice,  could do nothing to relieve
them.
   Mr. Lieutaud has  at the same time increased the  confusion
that  must arise from this want of distinction, by his considering
as primary diseases, what appear to  me to be the symptoms, ef-
fects,  and sequels, of other diseases  only.  Of this I think, the
JEstus morhosus,  Virum exolutio, Dolores,  Stagnatio  sanguinis, Pu-
rulentia,  Tremor, Pervigilium,  Raucedo, Suffbcatio,  Vomica,  Em-
pyema, Singultus, Vomitus, Dolor Stomachi, Tenesmus,  all treated of
under separate  titles,  are  examples.  A general  symptomato-
logia  may be a very useful work, with a view to a System of
Pathology ;  but with  a view to practice without any System, it
must  have bad effects as leading only to a palliative  practice, 
PREFACE.
xix
and diverting from the proper efforts towards obtaining a radical
cure.   Mr.  Lieutaud, indeed,  has endeavored  to  exhibit  the
symptoms above mentioned as scumany primary diseases : but he
has seldom succeeded in this ; and,  in delivering the practice he
commonly finds it necessary to consider them as sy*nptoms, and
that not without  some theory,  implied or  expressed,  with re-
spect to their proximate causes.   His title of Dolores may be tak-
en as an example of this ; and from which it may be readily per-
ceived how far such treatises can be really useful.
   In  establishing  a proper pathology, there is nothing that has
been of more service than the dissection of morbid bodies.   Mr.
Lieutaud has  been much and most commendably employed in
this way,  and in this Synopsis he has endeavored to communicate
his knowledge on the subject; but in my humble opinion,  he has
seldom done it in a manner that can be useful.  In the same way
that he has delivered the symptoms of diseases without any in-
structive arrangement; so  on the subject of the appearances af-
ter death, he  has  mentioned every morbid  appearance that had
ever been observed after the disease of which he is then treating :
but these appearances are strangely huddled together, without
any notice taken  of those which belong to one set  of symptoms
or to another ; and  with regard to the whole,  without any at-
tempt to distinguish between the causes of diseases and the causes
of death ; although the want of such distinction is the well known
ground o£ fallacy  upon this subject.   I take  for an example, the
appearances mentioned as having been observed after dropsy.
Here morbid  appearances, found, in every part of the body, in
every cavity of it,  and in every viscus contained in these cavities,
are enumerated : but which of these morbid states are more fre-
quent or more rare, and which has been more particularly con-
nected with the different causes or with  the different state of
symptoms  previously recited, we are not informed,  nor  has he
enabled us to  discover.  In short, the dissection of morbid bo-
dies has been, and may be, highly useful; but in order to be so, it
must be under a different management from  what we find either
in this Synopsis, or even in the Historia Anatomico-medica.
   I cannot dismiss this subject without remarking,  that the dis-
section of morbid bodies, is chiefly valuable  upon account of its
leading us to discover the proximate causes of diseases ; and die
great and valuable work of the illustrious Morgagni  is properly
intided De sidebus et causis.   It may well seem surprising, then,
that Lieutaud  should find the  whole of proximate  causes atra
caligine mersas ; and that he  should never have thought of ap-
plying his dissections towards the ascertaining at least some of
these.
  But let me now proceed to  consider the important part of every 
XX
PREFACE.
practical work, and of this  Synopsis  universe medicine-; that is,
the method of curing diseases.
   Here, again, upon the same plan as in giving the histories of
disease, the  method of cure  is delivered by enumerating the
whole of the remedies that have eT:er been employed in a disease
under the title prefixed ; without assigning  the species, or the
circumstances  to which the remedies, diough of a very  a'tfferent
and  sometimes opposite  nature,  are particularly  adapted.  On
the subject of  Asthma, he  very justly observes that physicians
have  been to blame in  confounding,  under  this title,  almost all
the species  of Dyspnoea ; and he  himself very properly  consi-
ders  Asthma  as a disease  distinct from all the other  cases of
Dyspncea.   Still,  however, he considers  Asthma  as of many
different species, arising from many different  causes, which till
we understand better, we cannot attempt to remove.  Notwith-
standing all this, he proceeds to deliver a very general  cure.
Parum ahest,  s:tys he, quia specifici titulo gaudeant pectoralia, vulne-
raria,  et incidcntia ! But from  such language I receive  no clear
idea ; uor can  I obtain any clear direction from the enumeration
of his medicines.   Bacce junipcri, gummi, tragacanthum vel ammo-
niacum, sapo aqua picea, terebinthina,  &c. que tamen haud indiscrimi-
natim  sunt usurpanda, sed pro re nata,  deluctu opus est.  Very justly.
indeed, deluctu  opus est; but here, as  in many other instances*
he gives us no  sort of assistance.
   From his endeavors, though not always successful,  to neglect
all  system, his practice is generally delivered in a very indecisive
manner ; or, what has die same effect,  in a way so conditional
as will render  it  always difficult,  and  often  impossible,  for a
young practitioner to follow him.  Let us take, for example, his
cure of Dropsy.   " The cure may be begun by blood-letting in
certain conditions ; but in others, it cannot be employed ivithout dan-
ger.   It gives relief in difficult breathing ;  but, after it  is practised,
the symptoms are aggravated,  and rendered more obstinate.   It  is not
to be concealed that some persons have been  cured by  repeated
blood-lettings,  or spontaneous haemorrhagies ;  but it is at the same-
time   known, that such a remedy inopportunely employed, has in many.
instances hastened on the fatal event."
   In the same manner he treats of vomiting, purging, sweating,
and the use  of mineral waters; but I must  confess, that he has
no where removed any  of my doubts or difficulties,  and indeed
he has sometimes increased  them.   He says, that hepatics, or
aperients, such as the lingua cervina, herbe capillares, tSr. deserve
commendation; but that when the disease has arisen to a certain
degree, they have been, for the most part, found to be useless.  He
observes, that the powder of toads given in wine, to the  quan-
tity of a scruple or more, has succeeded with severals. 
PREFACE.
xxi
   Such are commonly, the methods of cure  delivered by Mr.
Lieutaud,  longiori et forte felicissima praxi edoctus.
   It would be  tedious to enter further into that detail, which a
criticism of this immethodical and uninstructive work might lead
me into ; but,  if the  bounds proper for this preface did not pre-
vent me, I would particularly  show that the work is far from be-
ing  free from those  reasonings  which the author pretends to
avoid, and would affect even to despise.  He still holds the doc-
trines  Of the  CONCOCTION  and CRITICAL  EVACUATION of MOR-
BIFIC  matter ;  docrines  depending upon subtile  theories, and
which, in my opinion, can in no  wise be  ascertained as matters
of fact.  Mr.  Lieutaud  likewise is still very much upon the old
plan of following nature,  and therefore gives often what I con-
sider as a  feeble and inert practice.  The  hamectantia, diluentia,
demulcentia, et temperantia, are with him very universal remedies,
and often those which alone are to be employed.
   The mention of these medicines  might lead  me to take notice
of Mr. Lieutaud's second volume,  in which, ab insula remediorum
farragine qlienus,  he promises a great reformation upon the sub-
ject ; but this falls  so far short of the  idea of British physicians,
that I  need not make any remarks upon it.  With respect to his
list of simples, or Emporetica, as he is pleased  to term them,  an
English apothecary would  smile at it ; and with  respect to his
OJficinalia,  I believe they are to be found no where but  in  the
Codex  Medicamentarius of Paris ;  and in his Magistralia his doses
are generally such  as the most timid practitioner of this country
would hardly descend to ; and such as none of our practitioners
of experience would depend upon.  In short, the whole of the
work,  both with respect to the theories with which it abounds,
and to the facts which  it gives,  will not, in my  apprehension,
bear any serious criticism.  But I must conclude ; and shall only
say further, that such as I have represented it, is this work, ex-
ecuted by a man of the first rank in the profession.   It is indeed
for that reason I  have chosen it as the example of  a work, upon
the plan of giving facts only,  and of avoiding the  study or even
the  notice of  the  proximate causes of diseases ; and with what
advantage such  a  plan is pursued,  I shall leave my readers to
consider.
   In the following treatise I have followed a different course.  I
have endeavored to collect the facts relative to the  diseases of the
human body,  as  fully as the nature of the work and the bounds
necessarily prescribed to it would admit: but I have not been sa-
tisfied with giving the facts, without endeavoring to apply them
to the investigation of proximate causes, and upon these to esta-
blish a more scientific and decided measure of cure.  In aiming
at this, I flatter myself that I have avoided hypothesis* and what
                                B 
xxii                   PREFACE.
have been called theories.   I have, indeed, endeavored to esta-
blish my general doctrines,  both physiological and pathological;
but I trust that these are only a generalisation of facts, or con-
clusions from a cautious and full induction ; and if any one shall
refuse  to admit, or directly shall oppose, my general doctrines,
he must do it by showing that  I have been deficient or mistaken
in assuming and applying facts. I have, myself,  been jealous of
my being sometimes imperfect in these respects ; but I have ge-
nerally endeavored to obviate the consequences of this, by prov-
ing, that the proximate causes  which I have assigned, are true in
fact, as well as deductions from any reasoning that I may seem
to have employed.   Further, to obviate any dangerous fallacy in
proposing a method of cure, I  have always been anxious to sug-
gest that which, to the best  of my judgment, appeared to  be the
method approved of by experience, as much as it was the  conse-
quence of system.
  Upon this general plan I have endeavored to form a system of
physic  that should comprehend  the whole of the facts relating to
the  science, and that will,  1 hope,  collect  and arrange them  in
better  order than has been  done before, as well as point out in
particular those which are still wanting to establish general prin-
ciples.   This which I have  attempted may,  like other systems,
hereafter suffer a change ; but  I am confident that we are at pre-
sent in  a better train of investigation than physicians were in be-
fore the time  of Dr.  Hoffman.  The affections of the motions
and moving'powers  of  the animal economy,  must certainly be
the  leading inquiry in considering the  diseases of the human bo-
dy.   The inquiry may be difficult; but it must be attempted, or
die  subject must be  deserted  altogether.  I have therefore as-
sumed  the general  principles of Hoffman, as laid down in the
passage which  I have quoted above  ; and if I have rendered
them more correct,  and more extensive in their application ; and
more  particularly,  if I  have  avoided  introducing  the  many
hypothetical doctrines of the Humoral  Pathology which disfi-
gured both his and all the other systems which  have hitherto pre-
vailed  ; I hope I shall be excused for attempting a system, which
upon the whole may appear new.
Edinburgh,  Nov. 1789. 
     FIRST  LINES
                  OF THE
PRACTICE  OF  PHYSIC.
INTRODUCTION.
  1.] TN teaching the Practice of Physic,  we endeavor
      A to give instruction for discerning,  distinguishing,
preventing, and curing diseases, as they occur in particular
persons.
  2.]  The art of discerning and distinguishing diseases,
may be best attained by an accurate and complete observa-
tion of their phenomena,  as these occur in concourse and
in succession, and by constantly endeavoring to distinguish
the peculiar and inseparable concurrence of symptoms, to
establish a Methodical Nosology, or an arrangement of
diseases according to their genera and species, founded up-
on observation  alone, abstracted from all reasoning.  Such
an arrangement I have attempted in  another work, to which
in the course of the present 1 shall frequently refer.
  3.]  The prevention of diseases depends upon the know-
ledge  of their remote causes ;* which is partly delivered in
the  general Pathology,  and partly to be delivered in this
treatise.
  4.]  The cure of diseases is chiefly, and almost unavoid-
ably founded in the knowledge of their proximate causes.f
This requires an acquaintance with  the Institutions of Me-
dicine ; that is, the knowledge of the structure, action, and
functions of the human body ; of the several changes which
it may undergo; and of the several  powers by which it can

  * Remote causes are of two kinds, viz. the predisposing and the exciting, or, as it is some-
times called, the occasional.  The predisposing is (hat which renders the body liable or capable
of being affected by disease when the exciting cause is applied.  No disease can exist without
an occasional cause j yet it is necessary, that at the same time, the state of the body should be
such as to admit that cause to take effect, or act. The predisposing cause is inherent in the body;
but it may nevertheless be induced or changed by an external cause still more remote. Thus
plethora may be the )>redisposing cause of many diseases, yet that same plethora maybe induced
by various causes previously acting on the body. The prevention of diseases is to avoid the ex-'
citing cause, and to correct that state of the body, which renders it capable of being affected by
the exciting cause.
  + Proximate causes arc those which immediately produce the disease, and whose removal
cures the disease. 
24
PRACTICE OF  PHYSIC.
be changed.  Our knowledge of these particulars, however,
is still incomplete, is in many respects doubtful, and has of-
ten been involved in mistake and error. The doctrine, there-
fore, of proximate causes, founded upon that knowledge,
must be frequently precarious and uncertain.  It is, how-
ever, possible for a judicious  physician to avoid what is vul-
garly called theory, that is, all reasoning founded upon hy-
pothesis, and thereby many  of the errors which have for-
merly taken place in the Institutions of Medicine.  It is pos-
sible also for a  person who lias  an extensive knowledge of
the facts relative to the animal oeconomy in health and sick-
ness,  by a cautious and complete induction, to establish
many general principles which may guide his reasoning with
safety ;  and while at the same time,  a physician admits as
a foundation of practice those reasonings only which are
simple,  obvious and certain, and for the most part admits
as proximate causes those alone that are established as mat-
ters of fact rather than as deductions of reasoning,  he may
with great advantage establish a system of practice chiefly
founded on the doctrine of proximate  causes.  But when
this cannot be done with sufficient certainty, the judicious
and prudent physician will  have recourse to experience
alone ; always, however, aware of the hitherto incomplete
and fallacious state of Empiricism.
  5.]  With a strict attention to these considerations in the
whole of the following Treatise, I proceed to treat of par-
ticular diseases in the order of my Methodical Nosology.
                  PART  I.

   OF PYREXIAE,  OR FEBRILE DISEASES.  .

  6.]  T)YREXI/E, or febrile diseases, are distinguished
      JT  by the following appearances.   After beginning
with some degree of cold shivering, they show some  in-
crease of heat, and an increased frequency of pulse, with
the interruption and disorder of several functions, particu-
larly some diminution of strength in the animal functions.
  7.]  Of these Pyrexia; I have formed a class,  and have
subdivided it into five orders of fevers, inflammations,
erjjptions,  hemorrhages;  and fluxes.—See Synopsis
Nosologic Methodicie, Edit. 3. 1780. 
\
            25

     BOOK  I.

OF   FEVERS.
                   CHAPTER  I.

     OF THE PHENOMENA OF FEVERS.

  8.] rT,HOSE diseases are more strictly called Fevers,
       JL  which have the general symptoms of Pyrexia,
without having along with them any topical affection that
is essential and primary, such as the other  orders of the
Pyrexiae always have.
  9.]  Fevers,  as differing in the number and variety of their
symptoms, have been very  properly considered as of dis-
tinct genera and species.   But we suppose  that there are
certain circumstances in common to all the diseases com-
prehended under this order, which are therefore those essen-
tially necessary to, and properly constituting the nature of
fever.   It is our business especially, and in the first place,
to investigate these ;  and I expect to find them as they oc-
cur in the paroxysm, or fit, of an intermittent fever, as this
is most commonly formed.
  10.]  The phenomena to be observed in such a paroxysm
are the following.  The person is affected, first, with a lan-
guor or sense  of debility,  a sluggishness  in motion,  and
some uneasiness in exerting it, with frequent yawning and
stretching.  At the same time, the face and extremities be-
come pale ; the features shrink ; the bulk of every exter-
nal part is diminished ; and the skin  over the whoie body,
appears constricted,  as if cold had been applied  to it.   At
the coming on of these symptoms, some coldness  of the ex-
tremities, though little taken notice of by the patient, may
be  perceived  by another person.  At length, the patient
himself feels a sensation of cold, commonly first in his back,
but, from thence, passing over the whole body ; and now
his skin feels warm to another person.  The  patient's sense
of cold increasing, produces a tremor in all his limbs, with
frequent successions  or  rigors  of  the trunk  of the body.
When this sense of cold, and its effects, have continued for
some time, they become less violent, and are alternated with 
26
PRACTICE  OF PHYSIC.
 warm flushings.  -By degrees,  the cold goes off entirely ;
 and a heat, greater than natural prevails, and continues over
 the whole body.   With this heat, the color of the skin re-
 turns, and a preternatural redness appears> especially in the
 face.  Whilst the heat and redness comes on, the skin is re-
 laxed and smoothed, but for some time continues dry.  The
 features of the face, and other parts of the body, recover
 their usual size, and become even more turgid.  When the
 heat, redness, and turgescence have increased and continu-
 ed for some  time, a moisture  appears upon the forehead,
 and by degrees becomes a sweat, which gradually extends
 downwards over the whole body.  As this sweat continues
 to flow, the heat of the body abates ;  the sweat, after con-
 tinuing some time, gradually ceases ; the body returns to
 its usual temperature ; and most of  the functions are re-
 stored to their ordinary state.*
   11.]  This series of appearances gives occasion to divide
 the paroxysm into three different stages ; which are  called
 the cold, the hot, and the sweating stages or Fits.
   In the course  of these, considerable changes happen in
 the state of several other functions,  which are now to be
 mentioned.
   12.] Upon  the first  approach of languor,  the pulse be-
 comes sometimes slower,  and always weaker than before.
 As the sense of cold comes on, the pulse becomes smaller,
 very frequent, and often irregular. As the cold abates and
 the heat comes on, the pulse becomes more regular,  hard
 and full; and in these respects, increases  till  the  sweat
 breaks out.  As the sweat flows, the pulse becomes softer,
 and  less frequent, till the sweat ceasing altogether,  it re-
 turns to its usual state.
   13.] The respiration also suffers some changes.  During
the cold stage, the respiration is small, frequent and anxious,
 and is sometimes attended writh a cough : as the hot stage
 comes on,  the respiration becomes  fuller and  more free ;
 but continues still frequent and anxious,  till the flowing of
the sweat relieves the anxiety, and renders the breathing less
frequent and  more free.  With the ceasing of the sweat,
the breathing returns to its ordinary state.
   14.] The natural functions also suffer a change.   Upon
the approach of the cold stage, the appetite for food ceases,
and does not return till the paroxysm be over, or the sweat

   • Thil description of a paroxysm is truly admirable. The symptoms are most accurately de-
ttribed, and the order ot their succession most strictly attended to by the author. 
PRACTICE  OF  PHYSIC.
87
has flowed for some time.  Generally during the whole of
the paroxysm, there is not only a want of appetite, but an
aversion from all solid, and especially animal food.   As the
cold stage advances,  there frequently  comes on a  sickness
and nausea, which often increase to a vomiting of a matter
that is for the most part bilious.  This vomiting commonly
puts an end to the cold stage,  and brings on the hot.   As
the hot stage advances, the nausea and vomiting abate ; and
when the sweat breaks out, they generally cease altogether.
   15.]  A  considerable degree of  thirst is commonly  felt
during the whole course of the  paroxysm.  During  the cold
stage, the thirst seems to arise from the dryness and clam-
miness of  the mouth and fauces, but during the hot stage,
from the heat whicli then prevails over the whole body ; and
as the sweat flows,  the mouth becomes moister,  and the
thirst, together with the heat gradually abates.*
   16.]  In the course of a paroxysm, there is often a  con-
siderable  change  in the state of the  secretions.  The cir-
cumstances just now mentioned, show it in the secretion of
the saliva and mucus of the mouth ;  and it is still more re-
markable with respect to the urine.   During the cold stage,
the urine is almost colorless, and without cloud or sediment.
In the hot stage it becomes high colored, but is still with-
out sediment.   After the sweat has flowed freely, the urine
deposits a sediment, commonly lateritious,  and continues
to do so for some time  after the paroxysm is over.
   17.]  Excepting in certain uncommon cases which are  at-
tended throughout with a diarrhoea, stools seldom occur till
towards the end of a  paroxysm,  when commonly a stool
happens, which is generally of a loose kind.f
   18.]  Analogous to these changes in the state of the secre-
tions,  it frequently happens, that tumors subsisting on the
surface of the body, suffer during  the cold stage of fevers,
a sudden  and considerable detumescence ; but generallv,
though not always,  the tumors return  to their  former size
during the sweating stage. In like manner, ulcers are some-

   * The thirst in the cold and hot stages of the paroxysm seems to be a provident design of
nature, and has  been held forth as  an argument for the existence of the vis medicatrix naturx.
The paroxysm concludes with a profuse sweat; the production of this sweat requires an addi-
tional quantity of fluidity; and nature, by means of the thirst, seems anxious to supply the quan-
tity of fluid matter necessary for the perspiration tliat is requisite to remove the disease.
   + The author's expression is here somewhat aukward: the meaning of the passage is, that
stools seldom occur in the two first  stages of a paroxysm, except in peculiar cases attended with
diarrhoea ; and if a stool happens about the end of  the paroxysm, it is generally of a loose kind.
   A spontaneous diarrhoea always increases the violence or the symptoms, and the obstinacy of
the disease. Hence the absurd practice of prescribing purges in agues, which never fail to exa-
cerbate the paroxysms, and prolong  their continuance.  If any uneasiness arise* from accunwla*
fcd fa-tes in the colon or rectum, they may be removed by emollient clysters. 
28
PRACTICE OF  PHYSIC.
 times dried up during the cold stage ;  and return again to
 discharge matter during the sweating stage,  or after the
 paroxysm is over.
   19.] Certain changes appear also in sensation and thought.
 During the cold stage,  the sensibility is often greatly im-
 paired; but when  the hot stage is formed,  the sensibility
 is recovered, and often considerably increased.
   20.] With  respect to the intellectual functions, when the
 cold stage comes on, attention and recollection become dif-
 ficult, and continue more or less so during the whole pa-
 roxysm.   Hence some  confusion of thought takes place,
 and often arises to a delirium, which  sometimes comes on
 at the beginning of the cold stage, but more frequently not
 till the hot stage be formed.
   21.] It belongs also to this place to remark, that the cold
 stage sometimes comes  on  with a drowsiness and  stupor,
 which often increase to a degree that may be  called coma-
 tose, or apoplectic.
   22.] We have still to  add, that sometimes, early in the
 cold stage, a headach comes on ;  but which, more  com-
 monly, is not felt till the hot stage be  formed, and  then is
 usually attended with a throbbing of the temples.  The
 headach  continues  till  the sweat breaks out; but as this
 flows more freely,  that gradually goes off.   At the  same
 time with the headach,  there are commonly pains of the
 back, and of some of the great joints ;  and these pains have
 the same course with the headach.
   23.] These are nearly the whole, and are at least the chief
 of the phenomena which more constantly appear in the pa-
 roxysm of an intermittent fever ;  and we  have pointed out
 their  ordinary concourse and succession.  With respect to
 the whole of  them,  however, it is to be observed,  that in
 different  cases,  the several phenomena are in different de-
 grees ; that the series of them is more or less complete  ; and
 that the several parts or  stages in the time they occup}*, are
in a different proportion  to one another.
   24:] It is very seldom that a fever consists of a  single pa-
 roxysm, such as we have now described ; and it more gene-
 rally happens, after a certain length of time has elapsed from
the ceasing of the paroxysm, that the same series  of pheno-
 mena again arises, and observes the same course as before ;
 and these states of  fever and apirexia often continue to
 alternate  with one another for many times.  In such cases,
 the length of time from the end of one  paroxysm  to the be- 
PRACTICE OF  PHYSIC.
29
winning of another,  is  called  an  intermission; and the
length of time from the beginning of one paroxvsm to the be-
ginning of another next succeeding,  is called an interval.
  25.] VViien the disease consists of a number of paroxysms,
it is generally to  be observed, that  the intervals between
them are  nearly equal; but these intervals are of different
lengths in'different cases.   The most usual interval is  that
of forty-eight  hours, which is named the tertian  period.
The next most  common is that of seventy-two  hours, and
is named  the quartan period.   Some other intervals are
also observed,  particularly one of twenty-four hours, nam-
ed therefore, the quotidian  ; and  the appearance of this
is pretty frequent.  But all other intervals longer than that
of the quartan are extremely rare,  and probably are only
irregularities of the tertian or  quartan periods.*
   26.]  The paroxysms of pure intermittent fevers  are al-
ways finished in less than  twenty-four hours : and  though
it happens that there are fevers  which consist of repeated
paroxysms, without any entire intermission betweem them;
yet in such  cases it is observed, that  though the hot and
sweating  stages of the paroxysm do not entirely cease be-
fore the twenty-four hours from their beginning have ex-
pired, they suffer, however, before that time, a considera-
ble abatement or remission of their violence ; and at the
return  of the  quotidian  period, a  paroxysm  is in  some
shape renewed, which runs the same course as before.  This
constitutes what is called a remittent fever.
   27.]  When in these remittents the remission  is consider-
able,  aud the return of a new paroxysm is distinctly mark-
ed by the symptoms of a cold stage at the beginning  of it;
such fevers retain strictly the  appellation  of remittents.
But  when it happens, as  it does in certain cases, that the
remission is not considerable, is perhaps  without sweat,
and that the returning paroxysm is not marked by the most
usual symptoms of a cold stage, but chiefly by the aggra-
vation or exacerbation  of a hot stage,  the disease is cal-
led a continued fever.
   28.] In some cases of  continued fever,  the remissions
and exacerbations are  so inconsiderable as not to be easily
  * Of the quotidian, tertian, and quartan intermittents there are manv varieties and forms; at
the double tertian,having a paroxysm every day, with the alternate paroxysms similar to one
another. The double tertian, with two paroxysms every other dav. The trple tertian, with
two paroxysms on one day,and another on the next. The double quartan wnn two paroxysms
•n the hrst day, none on the second and third, and two again on the fourth day.  The double
«|ii..rtan, with a paroxjsm on the first day, another on tie second, but none on the third. The
triple quartan, with three paroxysms every fourth dav. The triple quartan, with a paroxvjm
every day, every fourth paroxjsm being similar.
                            E 
 30            PRACTICE  OF PHYSk'.

 observed or distinguished ; a-id  this has led physicians tct
 imagine, that there is  a species of fever subsisting for se-
 veral days together, and seemingly, consisting of one pa-
 roxysm only.   This they have called a continent fever ;
 but^ in a  long course  of practice, I  have not had an op-
 portunity of observing such a fever.
   29.] 'It is, however, to be observed here, that the fevers
 of a continued form are to be distinguished from one ano-
 ther ; and that, while some  of  a very continued form do
still belong to  the section of intermittents, there are others
 which, though still consisting of separate and repeated pa-
roxysms, yet as different from their causes an J circumstan-
 ces from intermittents, are to be distinguished from  the
whole of these, and are more strictly to be called and con-
 sidered as  continued.*   Such are  most of  those which
have been   commonly  supposed to  be  continent;  and
those which by most writers have been simply named con-
tinued; and  which term I have employed  as the title of
a section, to be distinguished from that of intermittent.
  I shall here  add the marks by which, in practice, these
different continued fevers may be distinguished from one
another.
  Those fevers of a continued form, which, however, still
belong to the section of Intermittents, may be distinguish-
ed by their  having  passed  from an intermittent  or remit-
tent form, to that of a continued ; by their showing some
tendency to become intermittent, or at least remittent; by
their being known to have been occasioned by marsh mias-
mata ;  and for the most part, by their having but one pa-
roxysm, or  exacerbation and remission,  in the course of
twenty-four hours.
   On the other hand,  Continued Fevers, to be more strict-
ly so called, may be  distinguished by their  showing  little
 tendency to become intermittent or remittent in any part
of their course, and especially  after the first week of their
continuance; by their being occasioned by human contagi-
on, at least  by other causes than the marsh miasmata ; and
by their having pretty constantly  an exacerbation and re-
mission twice in the course of twenty-four hours.   In both
 cases, the knowledge of the nature of the epidemic for the
time prevailing, may have a great share in deter iiiinino- the
nature of the particular fever.
 * This passage is very obscure : the author's meaning is, that some continued fevers put on the
appearance of tnteimttrents j but bein; d fcrent, in some peculiar and material circumstances.,
fcom intermittents, are notto be classed wub them. 
PRACTICE OF PHYSIC.
31
   30.]  With respect  to  the  form, or type of fevers,  this
further  maybe observed, That the quartan, while it has
the longest interval, has at the same time, the longest and
most violent cold stage ; but, upon the whole, the shortest
paroxysm: That  the tertian, having  a shorter  interval
than the quartan,  has at the same time, a shorter  and less
violent cold stage; but  a longer  paroxysm: And lastly,
that the quotidian, with  the shortest interval, has the least
of a cold stage ; but  the longest paroxysm.
   31.]  The type of fevers is sometimes changed  in  their
course.   When this happens, it is generally in the follow-
ing  manner : Both tertians and quartans change into quo-
tidians, quotidians into remittents,  ar.d these last  become
often of the most  continued  kind.   In  all these cases, the
fever has its paroxysm protracted longer than usual, before
it changes into a type of more frequent repetition.
   32.]  From all this a presumption arises, that every fever
consists of repeated paroxysms, differing from others chiefly
in the circumstances and repetition of the paroxysms; and
"therefore, that it was allowable for  us to take  the paroxysm
of a pure intermittent  as an example  and  model  of the
whole.



                    CHAPTER II.

   OF  THE PROXIMATE CAUSE OF FEVER.

   33.] r I^HE proximate cause* of fever seems hitherto to
         A  have  eluded the research  of physicians ; and
I shall  not pretend  to  ascertain it in a manner that  may
remove every difficulty; but 1 shall endeavor  to  make an
approach towards it,  and such as I hope, may be of use ki
conducting the  practice in this disease :  while at the same
time I  hope to avoid several errors which have formerly
prevailed on this subject.
   34.]  As  the hot stage of fever is so constantly preceded
by a cold stage, we presume that the latter is the cause  of
the former; and therefore that the cause of the cold stage

  • The author, in this chapter, delivers his favorite doctrine of universal spasm. It is by no
means new, as he himself confesses in the preface, but borrowed from Hoffman. The author,
however, greatly improved the original idea, and brought the system to a greater degree of per-
fection than it had been before. That there are weighty objections against it, cannot indeed be
.-denied ; it contains, however, much ingenuity ; and Dr. Cullen (by introducing it in tht* unj
versify), raised his name high ia the annals ot medical tame. 
32
PRACTICE  OF PHYSIC.
 is the cause of all that follows in the course of the  parox-
 ysm.----See Boerh.  A ph.  1756.
   35.] To discover the cause of the cold stage  of fevers,
 we may observe, that it is always preceded by strong marks
 of a general debility prevailing in the system.  The small-
 ness and weakness of the pulse,  the  paleness and coldness
 of the extreme  parts, with the shrinking of the  whole bo-
 dy,  sufficiently show that the action of  the heart  and larger
 arteries  is, for the time,  extremely weakened.   Together
 with this,  the languor, inactivity,  and debility of  the ani-
 mal motions, the imperfect sensations, the feeling of cold,
 while  the body is truly warm, and some other symptoms,
 all shew that the energy of the  brain is, on this occasion,
 greatly weakened ;  and I presume, that as the weakness of
 the action of the heart can hardly be  imputed to any other
 cause, this weakness also is a proof  of the diminished ener-
 gy of  the brain.
   36.] I  shall hereafter  endeavor  to show,  that the most
 noted  of the remote causes of fever, as contagion,  mias-
 mata,  cold and fear,  are of a sedative  nature ;  and there-
 fore render it probable that a debility is induced.  Like-
 wise, when the paroxysms of  a fever  have ceased to be re-
 peated, they  may again be  renewed, and  are most com-
 monly renewed  by the application  of debilitating powers.
 And further, the debility which subsists in the animal mo-
 tions and other functions through the whole  of fever,  ren-
 ders it pretty certain that sedative or debilitating powers*
 have been applied to the body.
   37.] It is therefore evident, that there are three states
 which always  take place  in fever  : a  state of debility, a
 state of cold, and a state of heat; aad as these three states
 regularly and constantly succeed each other in the order we
 have  mentioned  them, it is presumed that they  are in the
 series of cause and effect with respect to one another. This
 we hold  as matter of fact, even although we should  not
 be able to explain in what manner,  or by what mechanical
 means these states severally produce each other.
   38.] How the state  of debility  produces some of the
 symptoms of the cold stage, may  perhaps be readily ex-
 plained ;  but  how it  produces all  of them, I cannot ex-
 plain  otherwise than  by referring the matter to  a  general
law of the animal oeconomy, whereby it happens,  that pow-
 * A purge administered six or seven days after the appearance of any paroxysm, has frequently
•ccas.oned a relapse, and is a practice that ought to be  carefully avofdecI  1  iIuve Veiwra W
found that purges gtven ia the beginning of the disease, increase t£e difficulty of curing h. 
              PRACTICE OF PHYSIC.            33

ers which have a tendency to hurt  and destroy the system,
often excite such motions as are suited  to obviate the ef-
fects of the noxious power.  This is the vis medicatrix
nature, so  famous in the schools of physic ; and it seems
probable, that many of the motions excited in fever are
the effects of this power.
   39.]  That the increased action of the heart and arteries,
which takes place in the  hot stage of fevers, is to be consi-
dered as an  effort of the vis medicatrix  natura, has been
long a common  opinion  among physicians ; and I am dis-
posed to assert, that some part of the cold stage may be
imputed to the same power.  I judge so, because the cold
stage appears to be  universally a means of producing  the
hot; because cold,  externally  applied, has very often si-
milar effects ; and more certainly still, because  it seems to
be in proportion to the degree  of tremor in the cold stage,
that the hot stage proceeds more or less quickly to a ter-
mination of the paroxsym, and to a more compleat solu-
tion and longer intermission.  See 30.
   40.]  It is to be particularly observed, that during the cold
stage of fever, there seems to be a spasm induced every-
where on the extremities of the arteries, and more especi-
ally of those upon the surface of the body.  This appears
from the suppression of all excretions, and from the shrink-
ing  of the external parts; and although this may perhaps
be imputed  in part  to the weaker  action of the heart in
propelling the blood into the extreme vessels; yet, as these
 symptoms often continue after  the action of the heart is re-
 stored, there is reason to believe that a spasmodic constric-
 tion has taken place ; that it  subsists for some  time, and
 supports the hot stage ; for this stage ceases with the flowing
 of the sweat, aivi the return of other excretions, which are
 marks of the relaxation of vessels  formerly  constricted.
 Hoffman. Med.  rat. System. Tom. 4. P. 1.  Sect.  i. Cap.
 -}. art. 4.
   41.] The  idea of fever, then, may be that a spasm of the
 extreme vessels,  however  induced,  proves  an irritation to
 the  heart and arteries; and that this continues till the spasm
 is relaxed or  overcome.   There  are  many appearances
 which support this  opinion; and there is little  doubt  that
 a spasm does take place, which proves an irritation to the
 heart,  and therefore may be considered  as a principal part
 in the proximate cause of fever.  It will  still, however,  re-
 main a question, what is the cause of this spasm; whether 
SI-
PRACTICE  OF PHYSIC.
it be directly produced bv the remote cause of fever, or tf
itbe onlv a part of the operation of the vis medicatrix natura?.
  42.] 1 am disposed to be of the latter opinion, beeausein
the firsl place, while it remains still certain that a debility
lays the foundation of fever, it is not obvious in what man-
ner the debility produces the spasm, and what seems to be
its effect, the increased action of the heart and arteries ;  and
secondly, because,  in almost all the cases, in which an effort
is made by the vis medicatrix natur.r, a cold fit and a spasm
of the extreme vessels are almost always the beginnings of
such an effort.  See Gaub.  Pathol. Medicin. art.  750.
  43.] It is therefore presumed, that  such  a cold fit and
spasm,  at the beginning of fever, is a part of the operation
of the vis medicatrix ;  but,  at, the same time, it seems to
me probable, that during  the whole  course of the fever,
there is  an atony subsisting in the extreme vessels, and  that
the relaxation of the spasm  requires  the restoring of the
tone arid action of these.
  44.]  This it may  be difficult to explain; but I  think it
may be  ascertained as a fact, by  the consideration of the
-symptoms which take place, with respect to the functions of
the stomach in fevers, such  as the anorexia, nausea,  and
Tomiting.   G4.)
  From  many circumstances it is  sufficiently certain,  that
there is a consent between the stomach and the surface of the
body: and  in all cases of the consent of distant parts,  it is
presumed to be by the connection of the nervous  system,
and that the consent which  appears, is between the  sentient
and moving  fibres of the one part with those of the other, is
such, that a certain condition prevailing in the one part, oc-
casions a similar condition in the other.
   In  the case of the stomach  and surface of the  body, the
consent  particularly appears by the connexion which is ob-
sened between the state of the perspiration, and the  state
of  the appetite  in healthy  persons; and if it may  be  pre-
sumed  that the appetite depends  upon the state  of tone in
the muscular  fibres of the  stomach, it will follow,  that the
connexion of appetite and perspiration depends upon a con-
sent  between the  muscular fibres  of the stomach,  and the
muscular fibres of the extreme vessels, or of the organ of
perspiration, on the surface of the body.
   It is further in proof of the connexion between the appe-
tite and perspiration, and  at the  same time of the circum-
stances on which it depends, that cold applied to the surface 
PRACTICE  OF PHYSIC.
35
of the body, when it does not stop perspiration, but proves
a stimulus to it, is always a powerful means of exciting ap-
petite.
  Having thus established the connexion or consent mention-
ed, we argue, that as the symptoms of anorexia,  nausea,
and vomiting, in many cases, manifestly  depend  upon a
a state of debility or loss of tone in the muscular fibres of
the stomach ; so it may be presumed, that these symptoms
in the beginning  of fever, depend upon an atony commu-
nicated to the muscular fibres of the stomach, from the mus-
cular fibres of the extreme vessels on the surface of the body.
   That the debility of the stomach which produces vomiting
in the beginning of fevers, actually depends upon an atony of
the extreme vessels on the surface of the body, appears par-
ticularly from a fact observed by Dr. Sydenham.  In the at-
tack of  the plague, a vomiting happens, which prevents any
medicine from  remaining on the  stomach ; and  Dr. Sy-
denham tells us,  that in such cases he could not overcome
this vomiting but  by external means applied to produce a
sweat; that is,  to excite  the action of the vessels on  the
surface of the body.
   The same connexion between the state of the stomach and
that of the extreme vessels on the surface  of the body, ap-
pears from this also, that the vomiting, which  so frequently
happens in the cold stage of fevers, commonly ceases upon
the coming on of the hot,  and very  certainly upon any
sweat's coming but (14.)   It is indeed probable, that the vo-
miting in the cold stage of fevers, is one of the means em-
ployed  by nature for restoring the  determination to  the
surface  of the  body ; and it  is a circumstance affording
proof,  both of this, and of the general connexion between
the stomach and surface  of the body, that emetics thrown
into the stomach, and operating there, in the time of  the cold
stage, commonly put an end to it, and bring on the hot stage.
   It also affords a proof of the same connexion,  that cold
water,  taken into the stomach produces an increase of heat
on the surface of the body,  and is very often a convenient
and effectual means of producing sweat.
   From the whole we have now said on this subject, I think it
is sufficiently probable, that the symptoms of anorexia, nau-
sea, and vomiting, depend upon, and are a proof of, an ato-
ny subsisting  in the  extreme vessels on the surface of the
body j and that this atony therefore,  now ascertained as a 
 36            PRACTICE  OF PHYSIC.

 matter of fact, may be  considered as a principal circum-
 sta::c? in the proximate cause of fever.
   45.] This atonv*we supppose to depend upon a diminu-
 tion of the energv of the brain ; and that this diminution
 takes pliee in fevers, we conclude, not only from the debility
 prevailing  in  so many functions of the  body,  mentioned
 above (35.) but particularly from symptoms which are pe-
 culiar to the braii  itself.   Delirium is a frequent symptom
 of f<-. er; and as from the physiology and pathology we learn
 that this svmptom  commonly depends upon some inequality
 in the excitement of the brain or intellectual organ; we hence
 conclude, that, in fever, it denotes some diminution in the en-
 ergy of the brain.  Delirium,  indeed, seems often  to de-
pond upon an  increased impetus of the blood, in the vessels
 of the brain, and then.lore attends phrenitis.   It frequently
appears also in the  hot stage of fevers, accompanied with a
 headacl: and throbbing of the temples.  But as the impetus
 of the blood in  the vessels of the head is often considerably in-
rreased  by  exercise,  external   heat,  passions,  and other
 causes,  without  occasioning any delirium ; so,  supposing
 that the same impetus,  in the case  of fever,  produces deli-
rium, the reason must be, that at the  same time, there is
some cause which  diminishes the energy of the brain, and
prevents a free communication between the parts concerned
in the intellectual functions.  Upon the same principles al-
so, 1 suppose  there is another species of delirium, depend-
ing more-entirely  on  the diminished energy of the brain,
and which may therefore arise,  when there is no unusual in-
crease of the impetus of the blood in the vessels of the brain.
 Such seems to be the delirium occurring at the beginning of
 the cold stage of fevers,  or in the hot stage of such fevers
 as show strong marks of debility in  the whole svstem.
   46.] Upon the whole,  our doctrine of fever is explicitly
 this.  The remote causes (Z6.)  are  certain  sedative  powers
 applied to the nervous system,  which  diminishing the ener-
 gy of the brain, thereby produce a debility in the whole  of
 the functions, (35.) and  particularly in the action of the
 extreme vessels, (43. 44.) Such, however,  is,  at the same
 time,  the nature of the animal economy, (38.) that this de-
 bility proves an indirect stimulus to the sangu.ferous system ;
 whence,  by the  intervention of the cold'stage, and spasm
 connected with  it, (39.  40.) the action of tue heart and

 lheticaTreaderW'U perceive'thatthe whQleof the doctrine delivered in this chapter is hypo- 
PRACTICE  OF PHYSIC.
37
larger arteries is increased, (40) and continues so (41.) till
it has had the effect  of restoring the energy of the brain, of
extending this  energy to the extreme vessels, of restoring
therefore  their  action, and thereby especially overcoming
the spasm affecting  them; upon the removing of which,
the excretion of sweat, and  other marks of the relaxation
of excretories,  take place.
  47.] This  doctrine will, as I  suppose,  serve to explain
not only the nature of fever in general, but also the various
cases of it which occur.  Before proceeding, however, to
this, it  may  be proper to point  out the opinions,  and as
I apprehend, the mistakes, which have formerly  prevailed
on this subject.
  48.] It  has been supposed, that a lentor or viscidity pre-
vailing in the mass of blood,  and stagnating in the extreme
vessels, is the cause of the cold stage of fevers and its con-
sequences.  But there is no evidence of any such viscidity
previously subsisting in the fluids; and as it is very impro-
bable that such a  state of them can be very quickly pro-
duced, so  the suddenness with which paroxysms come on,
renders it more likely that the phenomena depend upon some
cause acting upon the nervous system, or the primary mov-
ing powers of the animal economy.  See Van Swieten apud
Boerh. Aph. 775.
  49.] Another opinion, which has been almost universally
received,  is, that a noxious matter introduced into,  or ge-
nerated in, the body, is the proximate cause of fever; and
that the increased action of the heart and arteries,  Avhich
forms so great a part of the disease, is an effort of the vis
medicatrix naturae to expel this morbific matter ; and parti-
cularly to change or concoct it,  so as to render it either al-
together innocent,  or at least, fit for being  more  easily
thrown out of the body.   This doctrine, however, although
of as great antiquity as any of the records  of  physic now
remaining, and  although it has been received by almost eve-
ry school of medicine, yet appears to me to rest upon a very
uncertain foundation.  There are fevers produced by cold,
fear, and  other causes,  accompanied with all the essential
circumstances of fever, and terminating by sweat ; but, at
the same time,  without any evidence  or suspicion of mor-
bific matter.
  There have been fevers suddenly cured by a hemorrhagy,
so moderate as could not carry out any considerable portion
of a matter diffused over the whole mass of blood ; nor can
                          ..F 
33
PRACTICE  OF PHYSIC.
 we conceive how the morbific matter could be  collected or
 determined  to  pass off by such an outlet as in  that case is
 opened.
   Even supposing a morbific matter were present,  there is
 no explanation given, in what manner  the concoction of it
 is performed ; nor is it shown that any such change does in
 fact take place.   In certain cases, it is  indeed evident,  that
 a noxious matter is introduced into the  body, and proves
 the cause of fever; but, even in  these cases, it appears
 that the noxious matter is thrown out again, without having
 suffered any change ; that the fever often terminates before
 the matter  is  expelled ;  and that,  upon many occasions,
 without waiting the supposed time of concoction,  the fever
 can be cured,  and that by remedies which  do  not seem to
 operate upon the fluids, or to produce any evacuation.
   50.] While we thus reason against the notion  of fever be-
 ing an effort of nature, for concocting and expelling a mor-
 bific matter ; 1 by no means intend to deny  that the cause
 of fever frequently operates  upon the fluids, and particular-
 ly produces a putrescent state of them.   I acknowledge that
 this is frequently the case ; but, at the same time, I main-
 tain, that such a change of  the fluids  is not commonly the
 cause of fever ; that very  often it is an effect only ;  and
 that there is  no reason to believe the terminatiou of the fe-
 ver to depend upon the expulsion of the^putrid matter.
   51.] Another opinion which has prevailed, remains  still
 to be mentioned.  In intermittent fevers, a great quantity of
 bile is commonly thrown out by vomiting ; and  this is so
 frequently the case, that many have supposed an unusual
 quantity of bile, and perhaps a peculiar quality  of it, to be
 the cause of intermittent fevers.  This however, does not
 appear to be well founded.  Vomiting, by whatever means
 excited, if too often repeated, with violent straining, seems
 to be powerful in emulging the biliary ducts, and common-
 ly throws out a great deal of bile.   This will happen espe-
 cially in the case of intermittent fevers.   For, as in the state
 of debility  and cold  stage of these fevers, the blood is not
 propelled in the usual quantity into the extreme  vessels, and
 particularly into those on the surface of the body, but is ac-
cumulated in the vessels of the internal parts, and particu-
larly in the vena  protarum; so this may occasion a more
 copious secretion of bile.
   These considerations will, in some measure,  account for
 the appearance of an unusual quantity of bile in intermittent 
PRACTICE OF PHYSIC.            89
fevers;  but the  circumstance which  chiefly occasions the
appearance of bile in these cases,  is the influence of warm
climates and seasons.   These seldom fail to produce a state
of the human body, in which the bile is disposed to pass off,
by its secretories, in greater quantity  than usual ; and per-
haps also changed in its quality, as appears from the disease
of cholera, which so frequently  occurs in warm  seasons.
At the same time, this disease occurs often without fever ;
and we  shall hereafter render it sufficiently probable, that
intermittent fevers, from  the most part arise from another
cause, that is, from marsh effluvia;  while on the other hand,
there is  no evidence of their  arising from the  state of the
bile alone.   The marsh effluvia  however,  commonly ope-
rate most  powerfully in the same season that produces the
change  and  redundance of the bile ;  and therefore consi-
dering  the vomiting, and other circumstances of the inter-
mittent  fevers which  here concur,  it is not surprising that
autumnal  intermittents  are so often attended with effusions
of bile.
  This  view of the subject does not lead us to consider the
state of the bile as the cause of intermittents, but merely as
a circumstance accidently concurring with them, from the
state of the season in which they arise.   What attention this
requires in the conduct of the disease, I shall consider here-
after.
  52.]  From this view of the principal hypotheses which
have hitherto been maintained with respect to the proximate
cause of fever, it will appear, that fevers do not arise from
changes in the state of the fluids; but that, on the contrary,
almost  the whole of the phenomena of fevers lead us to be-
lieve, that they chiefly depend upon changes in the state of
the  moving powers  of the  animal system.  Though  we
should  not be able to  explain all the circumstances of the
disease, it is at least of some advantage  to be led into the
proper  train  of investigation.  I have attempted to pursue
it; and shall now endeavor to apply the doctrine already de-
livered, towards explaining the diversity of fevers. 
40
PRACTICE OF PHYSIC.
                  CHAPTER III.

OF THE DIFFERENCE OF FEVERS,  AND ITS
                       CAUSES.

  53.] HpO  ascertain  the difference of fevers, I think it
        A  necessary to observe, in the first place, that eve-
ry fever of more than one day's duration, consists of repeat-
ed,  and in some measure separate paroxysms ; and that the
difference of fevers taken notice of above  (from 25. to 30.)
appears to consist in the different state of paroxysms, and in
the different circumstances  of their repetition.
  54.] That fevers generally consist of distinct, and in some
measure  separately  repeated paroxysms, I  have  alledged
above to be matter of fact;  but I shall here endeavor to con-
firm it,  by assigning the cause.
  55.] In  every fever,  in which we can distinctly  observe
any number of separate paroxysms, we constantly find that
each paroxysm is finished  in less than twenty-four hours ;
but as I cannot perceive any thing in the cause of fevers de-
termining to this, I must presume it to depend on some ge-
neral law* of  the animal economy.   Such a law seems to be
that which subjects the economy, in many respects  to a di-
urnal revolution.   Whether this depends  upon the original
conformation of the  body,  or upon certain powers constant-
ly applied to  it,  and inducing a habit,  I  cannot positively
determine ; but the returns of sleep and watching, of appe-
tites and excretions,  and the changes which regularly occur
in the state of the pulse, show sufficiently,  that in the hu-
man body a diurnal revolution takes place.
  56.] It is this diurnal revolution which, I suppose deter-
mines the  duration  of the paroxysms  of fevers;  and the
constant and universal limitation of these paroxysms, (as ob-
served in 55.)  while no other cause  of it can be assigned,
renders it sufficiently probable,  that their duration depends
upon, and is  determined  by,  the revolution mentioned.
And that  these paroxysms  are connected  with  that diurnal
revolution, appears further  from this, that though the inter-
vals  of paroxysms  are different in different cases, yet the
times of the accession of paroxysms are generally  fixed to

  * The reader will find entertainment in admiring the ingenuity of the author, in contriving
several articles for maintaining his doctrine. One hypothesis piled on the top of another, almost
without end. 
PRACTICE  OF PHYSIC.
41
one  time  of the day ; so that Quotidians come on in the
morning,  Tertians at noon, and Quartans in the  afternoon.
  57.] It  remains to be  remarked, that as Quartans  and
Tertians are apt to become Quotidians, these to pass into
the state of Remittents, and these last to become Continued ;
and that,  even in the Continued form, daily exacerbations
and  remissions are  generally to be  observed ; so all  this
shows, so  much the power of diurnal  revolution,  that when
in certain cases,  the daily exacerbations and remissions are
with difficulty distinguished, we may still presume, that the
general tendency  of the economy prevails, that  the dis-
ease  still  consists  of repeated  paroxysms,  and,  upon the
whole, that there is no such disease as that which the schools
have called a Continent Fever.  I expect that  this doctrine
will be confirmed by what I shall say hereafter, concerning
the periodical movements observed in continued fevers.
   58.]  It being thus proved, that every fever, of more than
one day's duration, consists of repeated paroxysms ; we,  in
the next place, remark,  that the repetition  of paroxysms
depends upon the  circumstances of the paroxysms which
have already taken  place.  From what was observed (in 30.
and 31.) it appears, that the longer paroxysms are protract-
ed,  they are the sooner  repeated ; and therefore, that the
cause of the frequent repetition is tobe sought for in the cause
of the protraction of paroxysms.
   59.]  Agreeably to what is laid down in 46. and to the opi-
nion of most physicians,  I suppose, that in every fever there
is a power applied to the body, which has a tendency  to
hurt and destroy it, and produces in it certain motions which
deviate from the natural state ; and at the same time, in eve-
ry fever which has  its full course, I suppose, that in conse-
quence of the constitution of the animal economy, there are
certain  motions excited, which have a tendency to obviate
the effects of the noxious power, or to correct and remove
them.  Both these  kinds of motion are considered as con-
stituting the disease.
   But the former is perhaps strictly the morbid state, while
the latter  is to be considered as the operation of the vis me -
dicatrix nature of salutary  tendency, and which I shall
hereafter call the reaction of the system.
   60.]  Upon the supposition that these two states take place
in every paroxysm of fever, it will appear to be chiefly in the
time of the hot stage that the reaction  operates in removing
the  morbid state ; and therefore as this  operation succeeds 
42
PRACTICE  OF PHYSIC.
more or less quickly,  the hot stage of paroxysms will  be
shorter or longer.   But as the length of paroxysms depends
chiefly upon the duration of the hot stage, so the longer du-
ration of this and of paroxysms, must be owing either to the
obstinacv of resistance in the  morbid state, or to the weak-
ness of the salutary reaction ; and it is probable that some-
times the one,  and sometimes the other of these circumstan-
ces takes place.                                     ,
  61.]  It seems to be  only by the state of the spasm, that
we can judge of the resistance of the morbid state of fever;
and with respect to this spasm I observe, that either the cause
exciting it may be  different in different cases ; or, tn°«gh
the cause should be the same in different persons, the differ-
ent degree  of  irritability, in each may  give occasion to  a
greater or lesser degree of spasm ; and therefore, the  reac-
tion in fever being given, the continuance of the hot stage,
and of the whole paroxysm, may be longer or shorter,  ac-
cording to the degree of spasm that has been formed.
   62.] One cause of the obstinacy  of spasm in fevers may
be  clearly  perceived.  In inflammatory diseases, there is a
diathesis phlogistica prevailing in the body, and this diathe-
sis  we suppose to consist in an increased tone of the whole
arterial system.  When,  therefore, this diathesis accompa-
nies fever, as it sometimes does, it may be supposed to give
occasion to the febrile spasm's being formed more strongly,
and thereby to produce more protracted paroxysms.   Ac-
 cordingly we find, thatall inflammatory fevers are of the con-
tinued kind; and that all the causes  of the diathesis phlogis-
tica have a tendency to change intermittent into continued
fevers.  Continued fevers, then, being often attended with
the diathesis phlogistica, we conclude, that,  in many cases,
 this is the cause of  their continued form.
   63.] In many fevers, however, there is no evidence of any
diathesis phlogistica being present, nor of any other cause of
 more considerable spasm; and, in such cases, therefore, we
 must impute the  protraction of paroxysms, and the continu-
 ed  form  of the fever,  to the weakness  of reaction.   That
 this cause takes place, we  conclude from  hence, that, in
 many cases of fever,  wherein the  separate paroxysms, are
 the longest protracted, and the most difficultly observed, we
 find the. most considerable symptoms of a general debility:
 and therefore we infer, that in such cases, the protracted pa-
 roxysms,  and continued form,  depend upon a weaker reac-
 tion ; owing either to the causes of debility applied having 
PRACTICE OF PHYSIC.
40
been of a more powerful kind, or from circumstances of the
patient's constitution favoring their operation.
  64.] Upon these principles we  make a  step towards ex-
plaining in general, with some probability, the difference of
fevers;  but must own, that there is much doubt and difficul-
ty in  applying the doctrine to particular cases.  It applies
tolerably well to explain the different states of  intermittents,
as they are more purely such,  or as  they approach more
and  more to the  continued  form:  but several  difficulties
still remain with respeet to many circumstances of intermit-
tents ; and more still with respect  to the difference of those
continued fevers, which we have distinguished in our Noso-
logy as different from intermittents,  and as more especially
entitled to  the appellation  of  Continued, (see  Syn. Nos.
Meth. P. V.  Ch. I.  Sect. II.  ) and explained more fully
above.
   €5.]  From  the view given (63  and 64.) of the causes of
the protraction of paroxj^sms,  and therefore of the form of
Continued Fevers, strictly so called, it seems  probable, that
the remote causes of these operate by  occasioning either a
phlogistic diathesis,  or a weaker  reaction ; for we can ob-
serve, that the  most obvious difference of continued fevers
depends upon  the prevalence  of one  or other  of  these
states.
   66.]  Continued fevers have  been accounted  of great di-
versity ; but physicians have not been successful in marking
these differences, or in reducing them to any general heads.
The distinctions made by the ancients are not well under-
stood ;  and, so far as  either they  or the modern nosologists
have distinguished continued fevers by a difference of dura-
tion, theirdistinctions are not well founded, and do not ap-
ply in such a manner as to be of any use.  We think it agree-
able to observation,  and to the principles  above laid down,
(63. 64.)to distinguish continued fevers according  as  they
shew eitheran  inflammatory  irritation or a weaker reaction.
   67. ] This distinction is the same with that of fevers into
the inflammatory and nervous ; the distinction at pre-
sent most generally received in Britain.  To the first as a
genus, I  have given the name of  Synochus ;  to the second,
that of Typhus ; and little studious whether these names be
authorised by the ancient use of the same  terms,  I depend
upon their being understood by the characters* annexed to

  * These characters are, Syuocha. Calor plurirnum auctus ; pulsus frequens, validus, et d»-
(us; urina rubra ; tcnsorii functiones plurirnum turbata?; vires multura imaunuuc 
4i
PRACTICE OF PHYSIC.
 them in our Nosology, which I apprehend to be founded on
 observation.
   68.]  By these characters I think continued fevers ma}' in
 practice be distinguished ; and if that be the case, the prin-
 ciples above laid down will be confirmed.
   69.]  Besides these  differences of continued fever,  now
 mentioned, I am not certain of having observed any other
 that can be considered as fundamental.  But the most com-
 mon form of continued fevers, in  this climate, seems to be
 a combination of these two  genera ; and I have therefore
 given such a genus a place in our Nosology,  under the ti-
 tle of Synochus.  At the same time, 1 think that the limits
 between the Synochus and Typhus  will be with difficulty
 assigned ; and I am disposed to believe, that the Synochus
 arises from the same causes as the Typhus, and is therefore
 only a variety of it.
   70.]  The Typhus seems to be  a  genus comprehending
 several species.   These,  however, are not yet well ascer-
 tained by observation ; and  in the mean time we can  per-
 ceive that many of the different cases observed, do not im-
 ply any specific difference, but seem to be merely varieties
 arising from a different degree of power in the cause, from
 different circumstances of the climate or season in which
 they happen, or from different circumstances in the consti-
 tution of the persons affected.
  71.] Some of the effects arising from these circumstances
 require  to be particularly explained.
  One is, an  unusual  quantity of bile appearing in the
 course of the disease. This abundance of bile may possibly
 attend some continued fevers,  strictly so called ; but, for
 the reasons  above explained, it more commonly attends
 intermittents,  and we believe, it might have been enume-
 rated (29.) among the marks distinguishing the latter kind
 of fevers from the former.  But though an unusual quantity
 of bile should  appear  with continued fevers, it is consider-
 ed in this case, as in that of intermittents,  to be a coinci-
 dence only,  owing to the state of  the season, and produc-
 ing no different  species  or  fundamental distinction,  but
 merely a variety of the disease.  I think  it proper to ob-
 serve here, that it is probable that the most part of the con-
 tinued fevers named Bilious, have been truly such as belono-
 to the section of Intermittents.                         °
  72.] Another effect of  the circumstances  occasionally
varying the appearance of typhus, is  a putrescent state of 
PRACTICE  OF PHYSIC.
45
 the fluids.  The ancients, and likewise the moderns,  who
 are in general much disposed to follow  the former, have
 distinguished fevers,  as  putrid, and non putrid : but the
 notions of the ancients, on this subject, were not sufficient-
 ly  correct to deserve much notice; and it is only of late
 that the matter  has  been more accurately observed, and
 better explained.
   From the dissolved state of the blood, as it presents itself
 when drawn out of the veins, or as it appears from the red
 blood's being disposed to be effused and run off  by various
 outlets,  and from several other symptoms to be hereafter
 mentioned, I have now no  doubt,  how much soever it has
 been  disputed by some ingenious men, that a putrescency
 of  the fluids, to a certain degree, does really take place in
 many cases of fever.  This putrescency, however,  often
 attends intermittent, as well as continued fevers, and of the
 continued kind, both the synochus and typhus, and all  of
 them in very different degrees ; so that whatever attention
 it may deserve in practice,  there is no fixing such limits to
 it as to admit of establishing a species under the title  of
 putrid.
  73.]  Beside differing by the circumstances already men-
 tioned, fevers differ also  by their being accompanied with
 symptoms which belong  to  diseases of the other orders  of
 pyrexiae. This sometimes happens in such a manner, as  to
 render it difficult to  determine which of the two is the pri-
 mary disease. Commonly, however,  it may be ascertained
 by  the knowledge of the  remote cause,  and the prevailing
 epidemic, or by observing  the series and succession  of
 symptoms.
  74.]  Most of our systems of physic have marked, as  a
  rimary one, a species of fever under the title of hectic ;
  ut as it is described, I have never seen it as a primary dis-
 ease.   I have constant!}'  found it as a symptom of some to-
 pical affection, most commonly of an internal suppuration;
 and as such it shall be considered in another place.
  75.] The distinction of the several cases  of intermittent
fever I have not prosecuted here ; both because we cannot
assign the causes of the differences  which appear ; and be-
cause I apprehend that the differences which in fact occut
may be readily understood from what is said above (25. 26.
and 27.)  and more  fully from our  Methodical Nosology,
Ch. 1. Sect.  I.
£
c 
4b
PRACTICE OF PHI SIC.
                  CHAPTER IV.

    OF THE REMOTE CAUSES OF FEVER.

  76.]   AS fever has been held to consist chiefly in an in-
       ii  creased action of the heart and arteries, phy-
sicians have supposed its remote causes to be certain direct
stimulants fitted to produce this increased action.  In ma-
ny cases, however, there is no evidence of such stimulants
being applied ; and in those in which they are applied, they
either produce only a temporary frequency of the pulse.
which cannot be  considered as a disease ; or, if they do
produce a permanent febrile state, it is by the intervention
of a topical inflammation, which produces a disease differ
entfrom what is strictly called fever.  (8.)
  77.]  That direct stimulants are the remote causes of fe-
ver, seems farther improbable ;  because the supposition
does not account  for the phenomena attending the acces-
sion of fevers, and because other remote causes can  with
greater certainty be assigned.
  78.]  As fevers are so generally epidemic,  it is probable,
that some matter floating in the atmosphere, and applied to
the bodies of men, ought to be considered as the remote
cause of fevers:  And these matters present in the atmos-
phere, and thus acting upon men, may be considered either
as contagions, that is, effluvia arising directly or original-
ly from the body of a man under a particular disease, and
exciting the same kind  of  disease in the body of the per-
son to  whom  they are applied  ; or  miasmata,  that  is,
effluvia arising from  other  substances than the bodies of
men, producing a disease in the person to whom they are
applied.
   79.] Contagions have been  supposed to be of great va-
riety ; and it is possible this may be the case ; but that they
truly are  so, does not appear clearly from any thing  we
know at present.   The genera and  species of  contagious
diseases, of the class of the Pyrexias at present known, are in
number not very great. They chiefly belong to the order of
Fevers, to that of Exanthemata, or that of Profluvia.  Whe-
ther there be any belonging to tire order of Phlegmasia, is
doubtful ; and though  there should, it will not much  in-
crease the number of contagious pyrexiae.  Of the conta-
gious exanthemata and profluvia, the  number of species is 
PRACTICE OF PHYSIC.
nearly ascertained ; and each of them is so far of a deter-
mined nature, that though they have now been observed
and distinguished for many ages, and in many different parts
of the world, they have been always found  to retain  the
tame general character, and to differ only in circumstances,
that may be imputed to season,  climate,  and other exter-
nal causes, or to the peculiar constitutions of the several
persons affected.  It seems, therefore probable, that in each
of these species, the contagion is of  one specific  nature  ;
and that the number of contagious exanthemata or proflu-
via is hardly greater than the number of species enumerat-
ed in the systems of  nosology.
   80.] If, while the contagious exanthemata and profluvia
are thus limited, we should suppose the contagious pyrexias
to be still of great and unlimited variety, it must be with
respect to the genera and species of continued fevers.   But
if I be right in limiting, as I have done, the genera of these
levers (67.—70.) it will appear likely that the contagions
which produce them are not of great  variety:  and this will
be much confirmed, if  we can render it probable that there
is one principal, perhaps one common, source of such con-
tagion.
   81.] To this purpose it is now well  known, that the efflu-
via constantly arising from the living  human body, if long
retained in the same place, without being diffused in the at-
mosphere,  acquire a singular virulence ; and, in that state,
being applied to the bodies of men, become the cause of a
fever which is highly contagious.
   The existence of such a cause is fully proved by the late
observations on jail and hospital fevers: and that the same
virulent matter may be produced in many other places, must
be sufficiently obvious  : and it is probable that the conta-
gion arising in this manner,  is not, like many other conta-
gions, permanent and constantly existing ; but that,  in the
circumstances mentioned, it is  occasionly generated.  At
the same time, the nature of the fevers from thence, upon
different occasions, arising, renders it probable that the vi-
rulent state of human effluvia is the common cause of them,
as they differ only in a state of their symptoms ; which may
be imputed to  the circumstances of  season,  climate,  &c.
concurring with the contagion,  and modifying its force.
   82.] With respect to these contagions, though we have
spoken of them as of a matter floating in the atmosphere,
it is proper to observe, that they are never found to art 
48
PRACTICE  OF PHYSIC.
but when they are near to  the sources from whence they
arise ;  that is, either near to the bodies of men, from which
they immediately issue; or near to some substance* which,
as having been near to the bodies of men, are imbued with
their effluvia, and in  which substances these  effluvia are
sometimes retained in an active state for a very long time.
   The substances thus imbued  with an active and infec-
tious matter, may be called,  Fomites ,-  and it appears to
me probable, that contagions, as they arise from fomites,
are more powerful than as they arise immediately from the
human body.
   83.]  Miasmata are next to be considered.   These may
arise from various sources, and be of different kinds ; but
we know little of their variety, or of their several effects.
We know with certainty only one species of miasma, which
can be  considered as the cause of fever; and, from the uni-
versality of this, it may be doubted if there be any other.
   84.]  This miasma, so universally the cause  of fever, is
that which arises from marshes or moist ground, acted upon
by heat.  So many observations have now been made with
respect to this, in so many different regions of the earth, that
there is neither any doubt  of its being in general a cause
of fevers, nor of its being very universally the cause of inter-
mittent fevers, in all their different forms.  The similarity
of the  climate, season, and soil,  in the different countries
in which intermittents arise, and the similarity of the. dis-
eases, though arising in different regions, concur in prov-
ing, that there is one common cause of these diseases, and
that this is  the marsh miasma.
   What  is  the particular nature of this miasma, we know
not; nor do we certainly know whether or not it differs  in
kind ; but it is probable that it does not;  and that it varies
only in the degree of its power, or perhaps as to its quan-
tity, in a given space.
   85.]  It has been now rendered probable, that the remote
causes of fevers  (8.) are chiefly Contagions or Miasmata,
and  neither of them of great  variety.  We have supposed
that miasmata are the cause of intermittents, and contagions
the cause of continued   fevers, strictly so named ; but we
cannot with propriety employ these general terms.  For,
as the cause of continued fevers may arise from fomites, and
may, in such cases, be called a Miasma; and as other mias-
mata also may produce contagious  diseases ; it will be pro-
per to  distinguish the causes of  fevers, by  using the terms 
              PRACTICE OF PHYSIC.            49

Human or Marsh Effluvia, rather than the general ones of
Contagion or Miasma.
  86.]  To render our doctrine of fever consistent and com-
plete, it is necessary to add  here,  that those remote causes
of fever, human and marsh effluvia, seem to be of a debilitat-
ing or sedative quality.  They arise from a putrescent mat-
ter.  Their production is favored,  and their power increas-
ed, by circumstances which favor putrefaction ; and  they
often prove putrefactive ferments with respect to the animal
fluids.   As putrid matter, therefore, is always with respect
to animal bodies, a  powerful sedative,  so it can hardly be
doubted, that human and marsh effluvia are of the same
quality  : and it is confirmed by this, that the debility which
is always induced, seems  to be in proportion to the other
marks that appear of the power of those causes.
  87.]  Though  we have endeavored  to  show  that fevers
generally arise from marsh or human effluvia,  we  cannot,
with any certainty, exclude  some other  remote causes,
which are commonly supposed to have at  least a  share in
producing  those diseases.   And I proceed,  therefore, to
enquire concerning  these causes ;  the first of which that
merits attention, is the power of cold applied to the human
body.
  88.]  The operation of cold on a living body, is so differ-
ent in different circumstances, as to be of difficult explana-
tion ; it is here,  therefore, attempted  with some diffidence.
  The  power of cold may be considered as absolute or
relative.
  The  absolute  power is that by which it can diminish the
temperature of  the body to which it is applied. And thus,
if the natural temperature of the human body is, as we sup-
pose it  to be, that of 98 degrees of Farenheit's thermome-
ter ;* every degree  of temperature less than  that,  may be
considered as cold with respect to the human body ;  and,
in proportion to its degree, will have a tendency to diminish
the temperature of the body.  But as the living human bo-
dy has in itself a  power of  generating heat, so it can sustain
its own  proper heat to the degree above mentioned, though
surrounded by air or other bodies of  a lower temperature
than itself; and  it appears from observation,  that, in this
climate, air, or other bodies applied to the living man, do
not diminish the temperature of his body,  unless the tem-
 * In ever)' instance of our mentioning degrees of heat or cold, we shall mention them by the
degrees in Farenheit's scale : and the expression of higher or lower shall ahvavs be according to
that scale. 
 50           PRACTICE OF PHYSIC.

 perature of the bodies applied be below 62 degrees. From
 nence it appears, that the  absolute power of cold in this
 climate, does not act upon the living human body,  unless
 the cold applied be below the degree just now mentioned.
   It appears also that the human body's being surrounded
 by air ot a lower temperature than itself, is necessary to its
 being retained in its proper temperature of 98 degrees: for,
 in this climate, every temperature of the air above 62 de-
 grees, applied to the human body, though still of a lower
 temperature than itself, is found to increase the heat of it.
 And from  all this it appears, that the  absolute  power of
 cold with respect to the human body, is very different from
 what it  is with respect to inanimate bodies.
   89.] The relative power of cold with respect to the liv-
 ing human body, is  that power by which it produces a sen-
 sation of cold in it; and with respect to this, it is agreeable
 to the general principle of sensation, that the sensation pro-
duced, is not in proportion to the absolute force of impres-
sion,  but according as the  new impression is stronger oi'
 weaker than that which had been  applied immediately be-
fore.  Accordingly, with respect to temperature, the sensa-
 tion produced by any degree of this,  depends upon the
 temperature to which the body had been immediately be-
 fore exposed ; so that whatever is higher than this feels
 warm, and whatever is lower than it, feels cold ; and it will
 therefore happen that the opposite sensations of heat and
 cold  may on different occasions arise from the same tem-
 perature,  as marked by the thermometer.
   With respect to this, however, it is to be observed, that
though  every change of  temperature gives a sensation of
cold or  heat as it is lower or higher than the  temperature
 applied  immediately before, the sensation produced  is, in
 different cases,  of different duration.  If the  temperature
at any time applied is under 62 degrees, every increase of
 temperature applied will  give a  sensation of heat; but  if
 the increase of temperature docs not arise to  62 degrees,
 the sensation produced will not continue long,  but be soon
 changed to a sensation of cold.   In like manner,  any tem-
perature, applied to the human body, lower than that of
the body itself, gives a sensation of cold ; but if  the tem-
perature applied does not go below  62 degrees, the sensa-
 tion of cold will not continue long, but  be soon changed to
 a sensation of heat.
   It will appear hereafter, that the effects of the sensation 
              PRACTICE  OF PHYSIC.            51

of cold will be very different, according as it is more per-
manent or transitory.
  90.] Having thus explained the operation of cold, as ab-
solute or relative, with respect to the human body, I pro-
ceed to  mention the general effects of cold upon it.
  1. Cold, in certain circumstances, has manifestly a seda-
tive power.   It can extinguish the vital principle entirely,
either in particular parts,  or in the whole body ;  and con-
sidering how much the vital principle  of animals depends
upon heat, it cannot be doubted that the power of cold is
always more or less directly sedative.
  This effect may be said to take place from every degree
of absolute cold ; and when the heat of the body has upon
any  occasion been preternaturally increased,  every lower
temperature may be useful  in diminishing the activity of
the system ;  but it cannot diminish the natural vigor of the
vital principle,  till the cold applied is  under .62  degrees ;
nor even then will it have this effect, unless the cold applied
be of an intense degree, or be applied for some  length of
time to a large portion of the body.
  2.  It is equally manifest,  that in certain circumstances,
cold proves a stimulus to the living body, and particularly
to the sanguiferous system.
  It is probable, that this effect takes  place in every  case,
in which the temperature applied produces a sensation of
cold ; and this,  therefore, as depending  entirely on the re-
lative power of cold,  will be in proportion to the  change of
temperature that takes place.
   It appears to me probable, that every  change of tempe-
rature, from a higher to  a  lower degree, will prove more
or less  stimulant; excepting when the  cold  applied is so
intense, as immediately to extinguish the vital principle in
the  part.
   3. Beside the sedative and stimulant powers of cold, it is
manifestly also a powerful astringent, causing a contraction
 of the vessels on the surface of the body, and thereby pro-
 ducing a paleness of the skin, and a suppression of perspi-
 ration ;  and it  seems to have similar effects when applied
 to internal parts.  It is likewise probable, that this con-
 viction, as it takes place especially in consequence of the
 sensibility of the parts to which the cold  is applied,  will in
 some measure be communicated to other parts of the bo-
 dy ; and that thereby the application of  cold proves a tonic
 power with respect to the whole system. 
52
PRACTICE OF PHYSIC.
   These effects of tonic and astringent power seem to take
place both from the absolute and relative power  of cold ;
and therefore every application of it, which gives a sensa-
tion of cold, is in its first effect, both astringent and stimu-
lant, though the former may be often prevented from being
either considerable or permanent, when the latter immedi-
ately takes place.
   91.]  It  will be obvious, that these several effects of cold
cannot all take  place at the same time, but may in succes-
sion be  variously  combined.  The stimulant power taking
place obviates the effects, at  least  the permanency of the
effects,  that might otherwise have arisen from the sedative
power.  That the same  stimulant  power prevents these
from the astringent, 1 have said above ; but the stimulant
and tonic  powers  of cold are commonly,  perhaps always,
conjoined.
   92.]  These  general effects of cold now pointed out are
sometimes salutary,  frequently morbid ; but it is the latter
onlv 1 am  to consider here, and they seem to be chiefly the
following.
   1.  A  general inflammatory disposition of  the system,
which is commonly accompanied  with Rheumatism,  or
other Phlegmasia-.
   2.  The  same inflammatory disposition accompanied with
Catarrh.
   3.  A Gangrene  of particular parts.
   4.  A Palsy of a single, member.
   5.  A  Fever,  or Fever strictly so called (8)  which it of-
ten produces by its own power alone, but more common-
ly it is only an exciting cause of fever by concurring with
the operation of human or marsh effluvia.
   93.]  Cold is often applied to the human bodv without
producing any of  these morbid effects, and it is cufricult to
determine  in what circumstances it especially  operates in
producing them.  It appears to me,  that the morbid effects
of cold depend partly  upon certain circumstances of the
cold itself, and partly  on certain circumstances of the per-
son to whom it is applied.
   94.]  The  circumstances of the cold applied, which seem
to give it effect, are, 1. The intensity or degree of the cold :
2. The length of time  during  which it is applied ; 3. The
degree of  moisture at  the same time accompanying it; 4.
Its being  applied  by a wind or current of air ; 5.  Its be- 
PRACTICE OF PHYSIC.
S3
 ing a vicissitude, or sudden and considerable change of
 temperature, from heat to cold.
   95.]  The circumstances of persons rendering them more
 liable  to be affected by cold, seem to be, 1. The weakness
 of the  system,  and particularly the lessened  vigor of the
 circulation, occasioned by fasting, by  evacuations, by fe-
 tigue, by a last night's  debauch, by excess in venery, by
 long watching,  by much study, by rest immediately  after
 great exercise, by sleep, and by preceding disease.   2. The
 hody, or its parts, being deprived of their accustomed co-
 verings.  3. One part of the body  being exposed to cold,
 while the rest is kept in its usual or a greater warmth.
   96.]  The power of these circumstances  (95) is demon-
 strated by the circumstances enabling persons to resist cold.
 These are  a certain vigor of constitution, exercise of the
 body, the presence of active  passions,  and the use of cor-
 dials.
   Besides these,  there are other circumstances which, by  a
 different operation, enable persons to resist  cold acting as a
 sensation ;  such  as, passions engaging a close attention  to
 one object,  the use of narcotics, and that state of the body
 in which sensibility is greatly diminished, as in maniacs.  To
 all which is to be added,  the power of habit with respect to
 those parts of the body to which cold is more constantly ap-
 plied,  which both diminishes  sensibility and increases the
 power of the activity generating heat.
   97.]  Besides cold, there are other powers that seem to be
 remote causes of fever ; such as fear, intemperance in drink-
 ing, excess  in venery, and other circumstances, which evi-
 dently weaken the system.   But whether any of these seda-
 tive powers be alone the remote cause of fever, or if they
 only operate either as concurring with the operation of marsh
 or human effluvia, or as giving an opportunity to the opera-
 tion of  cold, are questions not to  be positively answered :
 they may possibly of themselves produce fever,  but most
 frequently they operate as concurring in one or other of the
 ways above mentioned.
   98.]  Having  now  mentioned the  chief of  the  remote
 causes of fevers,  it may be further observed, that these will
 arise more or less readily,  according as miasmata and con-
 tagions are more or less prevailing and powerful, or as these
 are more or less favored by the concurrence of cold and other
sedative powers.
                           H 
>4
PRACTICE  OF PHYSIC.
                       CHAPTER  V.

          OF  THE PROGNOSIS  OF FEVERS.

   "•"]  A S fevers  (by 60) consist of both morbid and salu-r
        J\ tary motions and symptoms,  the tendency of the
   disease to a  happy or fatal issue, or the  prognostic in fevers,
   has been established by marking the prevalence of the morbid
   or of the salutary symptoms ;  and  it might be properly so
   established,  if we could certainly  distinguish between the
   one and the other of these kind of  symptoms: but the ope-
   ration of the reaction, or salutaiy efforts of nature in curing
   fevers,  is'still  involved in so much obscurity, that I cannot
   explain the  several symptoms of it so clearly as to  apply
   them to the establishing prognostics ; and this, I think, may
   be done better, by marking the morbid symptoms which shew
   the tendency to death in fevers.
      100.] This plan of the prognostics in fevers must proceed
   upon our knowledge of the causes of death in general, and
   in fevers more particularly.
      The causes of death, in general, are either direct  or  in-
   direct.
      Tlie first  are those which directly attack and  destroy  the
   vital principle, as lodged in the nervous system ; or destroy
   the organization  of the brain  immediately necessary to  the
   action of that principle.
      The second, or the  indirect causes of death, are those
   which interrupt such functions as are necessary to the circu-
   lation of the blood,  and thereby necessary to the due con-
   tinuance and support of the vital principle.
      10 J.] Of these general causes, those which operate more
i   particularly in' fevers seem to be, first, The violence of reac~
    tion; which either by repeated violent excitements, destroys'
    the vital power itself ; or, by its violence, destroys the  or-
    ganization of the brain necessary to the action of that pow-
    er ; or, by the same violence, destroys the organization of
    the parts more immediaitely  necessary  to the circulation of
    tlie blood.
      Secondly, The cause of death in fevers may be a poison,
    that is,  a power  capable of destroying the vital principle ;
    and this poison may be either the miasma or contagion which
    was the remote cause of the fever,  or it  mav  be a  putrid
    matter generated  in the course of the fever," In both cases, 
PRACTICE  OF PHYSIC.
the operation of such a power appears either as acting chief-
ly on the nervous system, inducing the symptoms of debility;
or as acting upon the fluids of the body,  inducing a putre-
scent state in them.
   102.] From all this it appears, that the symptoms show-
ing the tendency to death in fevers, may be discovered by
their being either the symptoms
   Of violent reaction;
   Of great debility;
   Or, of a strong .tendency to putrefaction in the fluids.
   And upon this supposition, I proceed now to mark those
symptoms more particularly.*
   103.]  The  symptoms which denote the violence of reac-
tion, axe  1. The increased force, hardness, and frequency,
of  the pulse.   2. The increased heat of the body.   3.  The
symptoms which are  the marks of a general inflammatory
diathesis, and more especially of a particular determination
to  the brain,  lungs,  or other  important  viscera.   4.  The
symptoms which are the marks of the cause of violent re-
action ; that is of a strong stimulus applied,  or of a strong
spasm formed,  the latter appearing in a  considerable  sup-
pression of the excretions.
   104.]  The symptoms which denote a great degree of de-
bility, are,
   In the  animal functions :  I.  The weakness of the vo-
luntary motions ; II. The irregularity of the voluntary mo-
tions,  depending on their  debility  ;  III.  The weakness of
sensation ;  IV. The weakness and irregularity of the intel-
lectual operations.
   In the vital functions : I. The weakness of the pulse;
II. The coldness and shrinking of the extremities ; III. The
tendency to a deliquium animi in an erect posture ; i V. The
weakness of respiration.
   In the natural functions :  I.  The  weakness of r the
stomach, as appearing  in  anorexia, nausea, and vomiting;
II.  Involuntary excretions, depending upon a palsy of the
sphincters ;  HI. Difficult  deglutition, depending  upon  a
palsy of the muscles of the fauces.
    105.]  Lastly, The symptoms denoting the putrescent state
of the fluids, are,

  * No part of medical knowledge is so serviceable in the practice of physic as prognostics.  It
wonderfully assists in the cure of all diseases, but more especially fevers, and other acute disor-
ders. Tne young reader, therefore, ought  to be particularly attentive to this part of the work.
 What the author advances is very different from whathas gone before.  We have here no hy-
 pothesis or fancies, no supposition! unsupported by facts ; but on the contrary, truths deduced
 from a careful observation of nature, and  arranged in a distinct and perspicuous manner.
• 
56             PRACTICE OF  PHYSIC.
   I. With respect to the stomach ; the loathing of animal
food, nausea, and vomiting, great thirst, and a desire of acids.
   II. With respect to the fluids ; 1.  The blood drawn out
of the veins not coagulating as usual;  2.  Hemorrhagy from
different parts, without marks of increased impetus ;  3.  Ef-
fusions under the skin or cuticle, forming patechiae,  macu-
lae, and vibices ; 4. Effusions of a yellow serum under the.
cuticle.
   III.  With respect  to the  state of the excretions ; fetid
breath, frequent loose and  fetid stools, high colored  turbid
urine,  fetid sweats, and the fetor and livid color of blistered
places.
   IV.  The candaverous smell of the whole body.
   106.] These several symptoms  have very often, each of
them singly, a  share in determining  the prognostic ;  but
more especially by their concurrence and  combination  with
one another ; particularly  those of debility  with  those of
putrescency.*
   107.] On the subject of the prognostic, it is proper to ob-
serve,  that many physicians have been of  opinion  there  is
something in the nature of fevers which generally determines
them to be of a certain duration ; and therefore that their ter-
minations,  whether  salutary or fatal, happen at certain pe-
riods of the disease, rather than at others.   These periods are
called  the critical days ; carefully marked by Hippocrates
and  other ancient physicians, as well as by moderns  of the
greatest eminence in practice ; whilst at the same time  ma-
ny other moderns, of no inconsiderable authority, deny their
taking place in the fevers of  these northern  regions which
we inhabit.
   108.] I am of opinion that the doctrine of the  ancients,
and particularly that  of Hippocrates, on this subject,  was
well founded ; and that it is applicable to the fevers  of our
climate.
   109.] I am of  this opinion, first, Because I observe  that
the animal economy, both  from its  own constitution,  and
from habits which are easily produced  in  it,  is  readily
subjected to  periodical  movements.   Secondly,   Because,
in the  diseases of  the human body,  I  observe periodical
movements to take place with great constancy and exact-

 * It may not be amiss to explain this circumstance a little more fullv. Coldness of the extre-
mities may alone be sufficient to induce practitioners to think the issue of the disease fatal; yet
if this symptom be combined with a weakness and irregularity of the intellectual  operations
and these two accompanied with involuntary, loose, and t'tid evacuations of stool,  and urine!
DEATH may be pronounced to be a/ no great distance. 
PRACTICE  OF PHYSIC.
57
ness; as in the case of intermittent fevers, and many other
diseases.
  110.] These considerations render it probable, that exact
periodical movements may take place in continued fevers ;
and I think there is evidence of  such  movements actually
taking place.
  111.] The critical days, or those on which we suppose the
termination of continued fevers  especially to  happen, are,
the third,fifth, seventh,  ninth, eleventh, fourteenth, seven-
teenth, and twentieth.  We mark none beyond this last; be-
cause, though fevers  are sometimes protracted beyond this
period, it is,  however, more rarely ; so that there  are  not a
sufficient number of observations to ascertain the course of
them ; and further, because it is probable that, in fevers long
protracted, the movements become less  exact and  regular,
and therefore less easily observed.
   112.]  That the days now mentioned are the critical days,
seems to be  proved  by  the particular facts which are found
in the writings of Hippocrates.  From these facts, as collect-
ed from the several writings of that author by M. de Ilaen,
it appears, that of one hundred and sixty-three instances of
the termination of fevers, which happened on one or other of
the first twenty days  of the disease, there are  one hundred
and seven, or more than two-thirds of the whole number,
which happened on  one or other  of  the eight days above
mentioned ;  that none happened on the second or thirteenth
day ; and upon the  eighth, tenth,  twelfth,  fifteenth, six-
teenth, eighteenth, and nineteenth, there are but eighteen
instances of termination, or one ninth of the whole.
   113.]  As the terminations which happen on the seven days
Jast mentioned, are,  upon the whole,  few ;  and, upon any
one of them, fewer  that those which happen on any of our
supposed critical days; so there are therefore nine days which
may be called noncritical ; while, on the other hand, the
many terminations which happened  on the seventh,  four-
teenth,  and twentieth days,  afford a proof both of critical
days in  general, and  that these are the chief of them.   Here-
after  1 shall mention an analogy that renders the  power of
the other critical days sufficiently probable.
   114.]  It appears  further, that as, of the terminations
which were final and salutary, not a tenth part happened on
the noncritical days  ; and of the terminations which were
final and fatal, though the greater number happened on the
critical days, yet above a third of them happened on the non- 
 58             PRACTICE OF PHYSIC.

 critical;  so it would appear that the tendency of the animal
 economy is to observe the critical days, and that it is by the
 operation of some violent and irregular cause that the course
 of things is sometimes turned to the noncritical.
   115.]  What has been said gives sufficient ground  for pre-
 suming, that it is the general tendency of the animal econo-
 my to determine the periodical  movements in fevers to  be
 chiefly on the critical days.  At the same time,  we must ac-
 knowledge it to be a general tendency only ; and that in par-
 ticular cases,  many circumstances may occur to disturb the
 regular course of it.  Thus, though the chief and  more re-
 markable exacerbations in continued fevers happen on  the
 critical days,  there are truly exacerbations happening every
 day ; and these from certain causes, may become considera-
 ble and critical.   Further,  though intermittent fevers are
 certainly very strongly determined to  observe  a tertian  or
 quartan period,  we know there are  certain circumstances
which prevent them from  observing these  periods exactly,
and which render them either anticipating or postponing  so
much, that the days of paroxysms come to be quite changed ;
and it is allowable to suppose,   that  die like may  happen
with respect to the exacerbations of continued fevers, so  as
thereby to disturb the regular appearance of critical days.
   A particular instance of this  occurs with respect to  the
sixth day of fevers.   In the writings  of Hippocrates,  there
are many instances of terminations happening on  the  sixth
day ; but it is not  therefore reckoned among  the  critical
days ; for of the terminations happening on that day,  there
is  not one which  proves finally of  a salutary kind ;  the
greater number are  fatal ;  and all  the  rest are imperfect,
and followed with a relapse.  All this shews, that some vio-
lent cause had, in these cases, produced a deviation from the
ordinary course of nature  ; that the terminations on the sixth
day are nothing more than anticipations of the seventh, and
therefore a proof of the power of this last.*
   116.] The  doctrine of critical days has been much em-
barrassed by some dissonant accounts of it,  which appear in
the writings imputed to  Hippocrates.f  But this may  be

 * This idea of the general tendency of nature to preserve a regularity in the animal motions.
is a most ingenious explanation of the apparent irregularities in the termination of fevers  It is
perhaps one of the best defences of the critical days that ever appeared, because it explains in
a most satisfactory manner, why the termination on the sixth day should not be salutary  The
violence of the disturbing cause excites motions which nature has not the power of withstand-
ing, and which are either the immediate causes of death or induce such morbid affections as
prove ultimately fatal.
 + To enter into a critical enquiry, whether the works handed down to us  as the writings of
 Hippocrates are reahy the productions of That great man, or compilations from various pbysi- 
PRACTICE OF PHYSIC.
5£)
justly accounted  for  from  these  writings  being  truly the
works of different persons, and from the  most  genuine of
them having suffered  many corruptions ; so  that,  in  short,
every thing which is inconsistent with the facts above  laid
down, may be ascribed to one or other of these causes.
   117.] This, further, has especially disturbed the doctrine
of critical days, that  Hippocrates himself attempted perhaps
too hastily, to establish general  rules, and to bring the doc-
trine to a general theory, drawn from Pythagorean opinions
concerning the power of numbers.  It is  this which  seems
to have produced the idea of odd days, and of  a quaternary
and septenary period, doctrines which appear so often in the
writings of Hippocrates.  These, however, are inconsistent
with the facts above laid down ; and indeed,  as Asclepiades
and Celsus have observed, are inconsistent with one another.
   118.]  Upon the whole, therefore, it is apprehended,  that
the  critical days  above assigned are truly the critical days of
Hippocrates,  and may be consistently explained in the fol-
lowing manner.
   119.] From the universality of tertian or quartan periods
in intermittent  fevers, we cannot doubt of there  being, in
the  animal economy,  a tendency to observe such  periods ;*
and the critical  days above mentioned are consistent with
this tendency of the  economy,  as all of  them mark either
tertian or quartan periods.   These periods, however, are
not promiscuously mixed, but occupy constantly their seve-
ral portions in the progress of the disease ; so that, from the
beginning to the eleventh day,  a tertian period takes  place,
and, from the eleventh to the twentieth, and perhaps longer,
a quartan period is as steadily observed.
   120.] What  determines the periods to be changed about
the eleventh day, we have not clearly  perceived ; but the
fact is certain :  for there is no instance of any termination
on the thirteenth,  that is,  the tertian period next following
the eleventh ; whereas, upon the  fourteenth,  seventeenth^
and twentieth, which mark quartan periods, there are forty-
 three instances of terminations,  and six only on all the in-
 termediate days  between these.
 cians, would be foreign to  the design of this work. The style of them is, if I may be allowed tht
 expression, homogeneous; the same provincial dialect prevails through the whole of them; and
 they are extremely remarkable, especially such of them as respect the critical days, for being ra-
 ther a detail of observed  facts, than reasonings brought to support a favorite hypothesis. It i*
 probable indeed that Hippocrates, who has got the credit of the work, might have been indebted
 to many of his cotemporaries for some of the materials that coni]>ose them; but the sameness of
 the style is a strong presumptive argument that they are the production of one person, or at
 least of their having been reduced to their present form by one and the same hand. Pr. Cullen's
 other supposition, of their having suffered many, and, he might have added, material corruptions,
 seems highly probable.
  * The Author might have added, or periods compounded of these two. 
€0
PRACTICE  OF PHYSIC.
   This prevalence of a quartan period leaves  no room for
 doubting that the twentieth, and not the twenty-first, is the
 critical day marked by Hippocrates, though the last is men-
 tioned as such in the common  edition of the Aphorisms,
 taken  from an erroneous  manuscript,  which Celsus  also
 seems to have copied.
   121.]  A consistency with the general tendency of the sys-
 tem renders the series of critical days we  have mentioned,
 probably the true one ; and the only remaining difficulty in
 finding what we have  delivered to be the same with the
 genuine doctrine  of Hippocrates, is the frequent mention
 of the fourth as a critical day.
   It is true there are more  instances  of terminations  hap-
 pening on  this day,  than on some of those days we have as-
 serted to be truly critical:  but its  inconsistency with the
 more general tendency, and some other considerations,  lead
 us to deny its being naturally a critical day ;  and to think
 that the instances of terminations,  which have really  occur-
 red on the  fourth  day,  are to be reckoned among the other
 irregularities that happen in this matter.
   122.]  I have thus endeavored to support the doctrine of
 critical days, chiefly upon the particular facts to be found
 in the writings of  Hippocrates: And although  I might  also
 produce many other testimonies of both ancient and modern
 times; yet it must be  owned, that some  of these testimo-
 nies may be suspected to have arisen rather from a venera-
 tion of Hippocrates, than from accurate observation.
  123.] With respect to the opinions of many  moderns
 who deny the prevalence of  critical days, they are to be lit-
 tle regarded,  for the observation of the course  of continued
 fevers is known to be difficult and fallacious ;  and therefore
 the regularity of that course may have often escaped inat-
 tentive and prejudiced observers.
  124.] Our own observations amount to this, That fevers
 with moderate symptoms, generally the. cases  of the syno-
 eha, frequently terminate in nine days, or sooner, and  very
 constantly upon one or other of  the critical days which fall
 within that period :  but it is very rare,  in this climate,  that
 cases of either the typhus or synochus terminate before the
eleventh day ; and when they do terminate on this day, it
is for the most part fatally.   When they are protracted be-
yond this time, I  have very constantly found, that their ter-
 minations Mere upon the fourteenth, seventeenth, or  twen-
 tieth day. 
              PRACTICE  OF PHYSIC.            61

  In such cases, the salutary terminations are seldom attend-
ed with any considerable evacuation.  A sweating frequent-
ly appears, but is  seldom considerable; and I  have hardly
ever observed critical and decisive terminations attended with
vomiting, evacuations by stool, or remarkable changes in the
urine.   The solution of the disease is chiefly to be discerned
from some return of sleep and appetite, the ceasing of deli-
rium, and an abatement of the frequency of the pulse. By
these symptoms we can  often mark a crisis of the disease :
but it seldom happens suddenly and entirely ; and it is most
commonly from some  favorable symptoms occurring  upon
one critical day, that  we can announce a more  entire solu-
tion upon the next following.
   Upon the whole, I am persuaded,  that if observations
shall be made with attention, and without prejudice, I shall
be allowed to conclude with the wot;ds  of the  learned and
sagacious Gaubius, " Fallor, ni sua constiterit Hippocrati
auctoritas, Galeno fides, naturae virtus et ordo."



                   CHAPTER  VI.

   OF THE  METHOD OF CURE IN FEVERS.

                       SECT. I.

            Of the Cure  of Continued Fevers.

    125.]  A S it is allowed, that in every fever which has
         jLX. its full course, there is an effort of nature of
 a salutary tendency,  it might be supposed that the cure of
 fevers should be ieft to  the operations of nature, or that
 our art should  be only  directed  to support and  regulate
 these  operations, and that  we should form the indications
 accordingly.  This plan, however, I cannot adopt, because
 the operations of nature are very precarious, and not so well
 understood as to enable us to regulate them properly.   It
 appears to me,  that trusting to these  operations has often
 given occasion to a negligent and inert practice ; and there
 is reason to  believe, that an  attention to the operations of
 nature may be often  superseded by art.
    126.] The plan which  to me appears tobe most suitable
 is that which forms the indications of cure upon the view
                           I 
 62            PRACTICE OF PHYSIC.

 of obviating the tendency to death ; while at the same time
 the means of executing these indications are directed  by a
 proper attention to the proximate cause of fevers. ■
   Upon this plan,  in consequence of what has  been laid
 down above on the subject of the prognostic, we form three
 general indications in the cure of continued fevers;  and the
 one or other of these is  to  be  employed according as the
 circumstances of the fever  (102.)  shall direct.
   The first therefore is,  To moderate the violence of reac-
 tion.
   The second is, To remove the causes or obviate the effects
 of debility.  And,
   The third  is,  To obviate  or  correct  the  tendency of the
fluids to putrefaction.
   127.]  The first indication may be answered, that is, the
 violence of reaction may be moderated,
   1. By all  those means which diminish the action of the
 heart and arteries.
   2. By those means which take off the spasm of the extreme
 vessels, which we suppose to be the chief cause of  violent
 reaction.
   128.]  The action of the heart and arteries maybe di-
 minished,
   1, By avoiding or moderating those  irritations, which in
 one degree or other, are almost constantly applied  to  the
 body.
   2. By the  use of certain sedative powers.
   3. By diminishing the tension and tone of the  arterial
 system.
   129.]  The irritations (128. 1.) almost constantly applied,
 are the" impressions made upon our senses ; the exercise of
 the body  and mind; and the taking in of aliments.  The
 avoiding these as much as possible, or the moderating their
 force,  constitute what is  rightly called the  antiphlogistic
 regimen, proper to be employed in almost every continued
 fever.
   130.]  The conduct of this regimen is to be directed by the
 following rules and considerations.
   1. Impressions on the external senses, as being stimulant
 to the system, and a chief support of its activity, should be
 avoided as much as possible  ; those especially of more con-
 stant application", those of a stronger kind, and those which
 give pain and uneasiness.
   No impression is to be more carefully  guarded  against 
               PRACTICE OF PHYSIC.             6J

than that of external heat; while at the  same time, every
other means of increasing the heat of the body is to be shun-
ned.   Both these precautions are to be observed as soon  as
the hot stage is fully formed, and  to be attended to during
its continuance ; excepting in certain cases, where a deter-
mination to sweating  is necessary, or  where  the  stimulant
effects of heat may be compensated by circumstances which
determine it to produce a relaxation and revulsion.
   2.  All motion of the body is to be avoided, especially
that which requires the exercise of its own  muscles; and
that posture of the body is to be chosen which employs the
fewest muscles,and which keeps none of them  long in a state
of contraction.  Speaking, as it accelerates respiration, is
particularly to be refrained from.
   It is to be  observed,  that every motion of the body is the
more stimulant,  in proportion as the body is weaker.
   3.  The exercise of the mind also is  a stimulus  to the bo-
dy; so  that  all impressions,  which lead to  thought, and
those especially which may excite emotion or passion, are
to be carefully shunned.
   With respect to avoiding impressions of all kinds, an ex-
ception is to be  made in the case of a delirium coming on,
when the  presenting of accustomed objects may have the
effect of interrupting and diverting the  irregular  train of
ideas then arising  in the mind.
   4.  The presence of recent aliment in the stomach proves
always a stimulus to the system, and ought therefore to be
as moderate as possible.   A total abstinence  for  some time
may be of service;  but as this  cannot be long  continued
with safety we must avoid the stimulus of aliment,  by choos-
ing that kind which gives the least.*  We suppose that ali-
mentary matters  are more stimulant, according  as  they
are more  alkalescent;  and this leads to avoid all animal,
and to use vegetable food only.
   As our  drinks also may prove stimulant, so all aromatic
and spirituous liquors are to be avoided ; and in  answering
the present indication,  all fermented liquors,   excepting
 those of the lowest quality, are to be abstained from.f

  •In addition to these directions, it may be mentioned, that if  the patient have a desire for
food, which is seldom the case, he ought to make very sparing  and frequent meals. Much
food taken at once, proves a greater stimulus than the same quantity taken at  several different
 times; especially if sufficient quantities of diluting mucilaginous drink, such as lintseed tea,
 barley-water, water-gruel, Sec. be taken along with it.
  + Thin liquors are the best in cases of this kind : of these we may either use water alone, or
weak lintseed tea, thin barley-water, toast and water, whey, currant-jelly dissolved in water,
with a variety of such like mucilaginous acescent drinks. They ought to be taken in small quanti •
ties, and often. 
64
PRACTICE OF PHYSIC.
   131.] Besides these stimulant powers more constantly ap-
plied, there are others which, although  occasionally ouly,
yet, as commonly accompanying fevers, must be attended
to and removed.*
   One is, the sense of thirst, which, as a powerful stimu-
lus, ought always, in one way or other to be removed.f
   Another stimulus frequently arises from crudities, or cor-
rupted humors in the stomach ; and it is to be removed by
vomiting, by dilution, or by the use of acids.J
   A third stimulus often arises from the preternatural reten-
tion of faeces in the intestines ; and ought to  be removed by
frequent laxative  glysters.||
   A fourth stimulus to be constantly suspected in fevers, is
a general acrimony of the fluids,  as produced by the  in-
crease of motion  and  heat, joined with an  interruption of
the excretions.  This acrimony is  to be obviated or remo-
ved by the taking in of large quantities of  mild antiseptic
liquors.§
   132.] The avoiding of irritation in all these particulars,
(130.  and 131.) constitutes the  antiphlogistic  regimen ab-
solutely necessary for moderating the violence of reaction;
and, if  1 mistake not, is proper in  almost every circum-
stance of continued fevers; because the propriety and safe-
ty of employing stimulants is often uncertain;  and because
several of those above mentioned, beside  their stimulant
powers, have other qualities by which they may  be hurtful.
   It appears to me,  that the supposed utility of stimulants,
in certain cases of fever, has often arisen from a mistake in
having ascribed to their stimulant,  what really depended
upon  their antispasmodic power.
   133.] A second head of the means (128. 2.) for moderat-
ing the violence of reaction,  comprehends certain sedative
powers,  which may be employed to diminish the activity
of the whole body,  and particularly that of the  sanguifer-
ous system.
  * This passage might have been more clearly expressed thus: beside* the  stimulant power5
more constantly applied, others, only occasionally accompanying fevers, must be attended to and
removed.
  + The drinks mentioned in the former note are best adapted to this purpose.
  t The vegetable acids are the most suitable, especially the juices of acid  fruits, as the juices of
oranges,  lemons, currants or apples, diluted with water. In some cases the mineral acids have
been much extolled, expecially the nitrous, when united with the spirit of wine. The spiritus
xtherts nitrosi of the last London Pharmacopoeia is used with success in  these cases.  It may be
given in  barl'-y water, to the quantity of twenty or twenty-five drops within the hour.
  II The preference of giysters to purging medicines is obvious.-—The action even of the most
gentle laxatives is always attended with some degree of  stimulus, while giysters, especially the
mild ones, seldom produce that effect. The best glyster in these cases,  is half a point of milk
with as much water, two ounces of oil, and one ounce cf brown sugar, or, what is better than*
sugar, two ounces of manna.
  } The chief of these are the acid fruits diluted with water: to which we  may add the decoc-
tion of malt, of radix graminis, (the Triticura reuens of Linne,) infusions of sage, mint, and
other plants of that natural  order which Linne calls Spiraitia. 
PRACTICE  OF PHYSIC.
65
  The first of these to  be mentioned is the  application of
cold.
  Heat is the chief  support of the activity  of the animal
system; which is therefore provided in itself with  a power
of generating heat.   But,  at  the same  time we observe,
that this would go to excess, were it not constantly moder-
ated by a cooler temperature in thesurroundingatmosphere.
When, therefore, that power of the system generating heat
is increased,  as is commonly the  case in fevers, it is neces-
sary not  only to avoid all means of increasing it further,
but  it seems  proper also to apply air of a cooler tempera-
ture; or at least to apply it more entirely and freely, than
in a state of health.
  Some late experiments in the small pox and in continued
fevers, show that the free admission of cool air to the body,
is a powerful  remedy in moderating the violence of reaction;
but what is the mode of its operation, to what circumstances
of fever it is peculiarly adapted,  or what limitations it re-
quires, I shall not venture to determine, till more particular-
ly instructed  by further experience.
   134.]  A second sedative power which may be employed
in fevers,  is that of  certain medicines, known, in the writ-
ings on the Materia Medica,  under the title of refrige-
rants.
  The chief of these are acids  of all kinds, when sufficient-
ly diluted; and they are, in several respects, remedies adapt-
ed  to  continued fevers.  Those especially in use  are, the
Vitriolic and  Vegetable;  and, on many accounts,  we pre-
fer the latter.*
   135.]  Another set of refrigerants are,  the  Neutral Salts,
formed of the vitriolic, nitrous or vegetable acids;  with al-
kalines, either fixed or volatile.   All these neutrals, while
they are dissolving in water, generate cold; but as that cold
ceases soon after the solution is finished, and as the  salts are
generally exhibited  in a  dissolved state, their refrigerant
power in the animal body  does  not at all  depend upon
their power of generating cold with  water.  The neutral
chiefly  employed as a  refrigerant, is  Nitre;  but all the

  • The vitriolic acid is harsh to the taste, and frequently acts as an astringent: it is therefore
not always admissible. The best vegetable acids lor this purpose, are as was said above, the na-
turaljuices of acid fruits. The acid of tartar is the best refrigerant we have: there  is an excel-
lent formula of it in the Swedish Pharmacopoeia, under the title of Pulvis refrigerans, which con-
sists chiefly of the essential salt of tartar and sugar. The dose of the acid of tartar, prepared ac-
cording to Scheele's prescription, is half a scruple, or fifteen grains, in the hour, largely diluted
wiiha mucilaginous liquor.                                , 
66
PRACTICE OF PHYSIC.
others compounded as  above mentioned, partake more or
less of the same quality.*
  136.] Besides these neutrals,  some  metallic  salts also
have been employed as refrigerants in fevers; and particu-
larly  the Sugar of Lead.   But the refrigerant powers  of
this are not well ascertained; and its deleterious qualities
are too well known to admit of its being freely used.
  131.] Under the third  general  head (128.  3.)  of the
means to be employed for moderating the violence of reac-
tion,  are comprehended the several means of diminishing
the tension, tone, and activity, of the sanguiferous system.
As the activity of this system depends, in a great measure,
upon the tone, and this again upon the tension of the ves-
sels,  given to them by the quantity of fluids they contain,
it  is evident,  that the diminution of the quantity of these
must diminish the activity of the sanguiferous system.
   138.]  The  quantity of fluids contained in the sanguifer-
ous system, may be diminished most conveniently  by the
evacuations of blood-letting and purging.
   139.]  Nothing is more evident,  than that blood-letting
is one of the most powerful means of diminishing the activ-
ity of the whole body, especially of the sanguiferous system;
and it must therefore  be the most effectual means of moder-
ating  the violence  of reaction in fevers.   Taking this as a
fact^I omit inquiring into  its mode of operation and shall
only  consider in what circumstances of fevers it  may  be
most properly employed.
   140.]  When  the violence  of reaction,  and its constant
attendant, a phlogistic diathesis, are sufficiently manifest;
when these constitute the principal part of  the disease, and
may  be expected to continue throughout the whole of it as
in the cases oVsynocha; then blood-letting is the principal
remedy, and  may be employed as far as the symptoms of
the disease may seem to  require,  and the constitution of
the patient will bear.  It is, however, to be attended to, that
a greater evacuation than is necessary,  may  occasion a
slower recovery, may render the person more liable to are-
lapse, or may bring on other diseases.
   141.] In the case  of synocha, therefore,  there  is  little
doubt about  the propriety of blood-letting : but there  are
 other species of fever, as the synochus, in  which a violent

  * Nitre has been long used as a refrigerant. In too large quantities, however, it has  often
 done harm.  It may therefore be necessary to guard the younsj practitioner against giving nitre
in a larger quantity than two drachms mine twenty-four hours, tior in doses of above ten grainSi
 we,l diluted with mucilaginous drinks. 
              PRACTICE OF PHYSIC.             67

reaction and phlogistic diathesis appear,  and  prevail  du-
ring some part of the course of the disease ; while  at the
same time, these circumstances do not constitute the prin-
cipal part of the disease, nor are to be expected to continue
during the whole course of it, and it is well known, that in
many cases, the state of violent reaction is to be succeeded,
sooner or later, by a state of debility from  the excess of
which the danger of the disease is chiefly to arise.  It is,
therefore,  necessary, that, in many  cases, blood-letting
should be avoided, and even although, during the inflam-
matory state of the disease, it may be proper, it will be ne-
cessary to take care that the evacuation be  not so large as
to increase the state of debility which is to follow.
   142.] From all this it must appear,  that the employing
blood-letting, in certain fevers, requires much discernment
and skill, and is to be governed by the consideration of the
following circumstances;
   1. The nature of the prevailing epidemic.
   2. The nature of the remote cause.
   3. The season and climate in which the disease occurs.
   4. The degree of phlogistic diathesis present.*
   5. The period of the disease.
   6. The age, vigor, and plethoric state of the patient.
   7. The patient's former diseases and habits of blood-let-
ting.
   8. The appearance of the blood drawn out.
   9. The effects of the blood-letting that may have  been
already practised.
   143.]  When  after the consideration  of  these circum-
stances,  blood-letting is  determined  to be  necessary, it
should be observed, that it is more effectual,  according as
the blood is more suddenly drawn off, and as the body is at
the same time more free from all irritation, and consequently
when in a posture in which the fewest muscles are  in action.
   144.] Another evacuation whereby the quantity of fluids
contained in the body can be  considerably  diminished,  is
that of purging.
   145.]  If we consider  the quantity  of fluids constantly
present in the  cavity of the intestines,  and the quantity
which may be drawn from the innumerable excretories that
open into this cavity, it will be obvious, that a very great
evacuation can be made by purging; and, if this be done
by a stimulus applied to the intestines, without being at the
             * The phlogistic diathesis is explained in art. 9*7. 
68
I PRACTICE OF PHYSIC.
same time communicated to the rest of the body, it may,
by emptying both the cavity of the intestines, and the arte-
ries which furnish the excretions poured into it,  induce a
considerable relaxation in the whole system ; and therefore,
purging seems to be a remedy suited to moderate the vio-
lence of reaction in fevers.
  146.] But it is to be observed,that as the fluid drawn from
the excretories opening into the intestines, is not all drawn
immediately from the arteries, as a part of it is drawn from
the mucous follicles only ;  and what is even  more immedi-
ately drawn from the arteries, is drawn off  slowly,  so  the
evacuation will not, in proportion to its quantity,  occasion
such a sudden depletion of the red vessels, as blood-letting
does ;  and therefore cannot operate so powerfully in taking
off the phlogistic diathesis of the system.
   147.]  Auhe same time, as this evacuation may  induce
a considerable degree of debility ; so, in  those cases, in
which a dangerous state of debility is likely to occur, purg-
ing is to be employed with a great deal of  caution; and more
especially as the due measure  of the evacuation is more
difficult to be applied than in the case of blood-letting.
   148.]  As we shall presently have  occasion  to observe,
 that it is of great importance, in the cure of fevers, to re-
 store the determination of the blood to the  vessels  on the
 surface of the body ; so purging, as in some measure tak-
 ing off that determination, seems to be an  evacuation not
 well adapted to the cure of fevers.
   149.] If, notwithstanding these doubts,  (146. 147.  and
 148.) it shall be asserted,  that purging,  even from the ex-
 hibition of purgatives, has often  been useful  in fevers ; I
 would beg leave to maintain,  that this  has not happened
 from a large evacuation ;  and therefore, not by  moderating
 the violence of reaction, excepting in the  case of  a more
 purely inflammatory fever, or of exanthemata of an inflam-
 matory nature.   In other cases of fever, I have seen a large
 evacuation by purging, of mischievous consequence ; and if
 upon occasion, a more moderate evacuation has appeared
 to be useful, it is apprehended to have been only by taking
  off the irritation of  retained fasces, or by  evacuating cor-
  rupted humors, which happened to be present in the intes-
  tines ; for both of which purposes, frequent laxatives may
  be properly employed.*
   * Purges ought to be very cautiously administered in fevers ; and such only are to be used as
  operate with the least irritation. In fevers'attended with local inflammation, we may be under no
  apprehension of danger even from the brisker purges, as Glauber's salt, e:ven in the quantity of 
PRACTICE  OF PHYSIC.
63
   150.]  Another set of means (127. 2.) for moderating the
riolence of reaction in fevers, are those suited to take  off
the spasm of the extreme vessels, which we believe to  be
the irritation that chiefly supports the reaction.
   Though I have put here this indication of taking off the
spasm of the extreme vessels, as subordinate to the general
indication of moderating the violence  of  reaction ;  it is,
however, to be observed here,  that  as fever universally
consists in an increased action of the heart, either in  fre-
quency or in force, which in either case is supported by a
spasm of the extreme vessels, so  the indication for remov-
ing this is a  very general one, and applicable in almost eve-
ry circumstance of fever, or at least, with a few exceptions,
to be taken  notice of hereafter.
   151.]  For taking off the spasm of  the extreme  vessels,
the means to be employed are either internal or  external.
   152.]  The internal means (151.) are,
   1.  Those which determine the force of the circulation to
the extreme vessels on the surface of the body, and, by re-
storing the tone and activity of these vessels, may overcome*
the spasm on their extremities.
   2.  Those  medicines which have the power of  taking  off
spasm in any part of the system,  and which are known un-
der the title  of antispasmodics.
   153.]  Those remedies which are fit to determine to the
surface of the body, are,
   1.  Diluents.
   2.  Neutral Salts.
   3.  Sudorifics.
   4.  Emetics.
   154.]  Water enters,  in a large proportion, into the com-
position of all the animal fluids, and a large quantity of it
is always diffused through the whole of the common  mass.
Indeed, in a sound state,  the fluidity of the wriole mass de-
pends upon  the quantity qf  water present in  it.  Water,
therefore is the proper diluent of our mass of  blood ;  and
other fluids  are diluent  only in proportion to the quantity
of water they contain.

an ounce,or an ounce and a half, or three or four ounces of the infusum sennas, with half an
ounce of Glauber's salt and a drachm or two of tincture of jalap; but in fevers where no topical
inflammation appears, the purgesf if necessary, must be of the mildest kind, such as manna, cas-
sia, ice. and  they must be given in small and often repeated dozes.  Inmost  fevers the intes-
tine:, may be sufficiently evacuated by taking half an ounce of manna, and a scruple of cream of
tartar, every hour till it operates, diluting plentifully at the same time with barley-water.  The
phosphorated soda, lately introduced into practice by the ingenious Dr. Pearson of London, ia
well calculated for these cases. The dose of it is an ounce or ten drachms in barley-water or Broth.
                             K 
70             PRACTICE OF  PHYSIC.

   155. Water may be said to be the vehicle of the several
matters  which ought to be excerned ;  and  in  a  healthy
state the fulness of the extreme vessels, and the quantity of
excretions, are nearly in proportion to the  quantity of wa-
ter present in the body.  In fever, however,  although  the
excretions are in some measure interrupted,  they continue
in such quantity as to exhale the mdre  fluid parts  of  the
blood  ; and while a portion of them is at the same time  ne-
cessarily retained in  the larger vessels, the smaller and  the
extreme vessels, both from the deficiency of fluid, and their
own contracted state, arc  less filled, and therefore  allowed
to remain in that condition.
   156.]  To remedy this contracted state,  nothing is more
necessary than a large supply of water or watery fluids, ta-
ken in by drinking or otherwise ;  for as any superfluous
quantity of water is forced off  by the several  excretories,
such a  force  applied, may  be a means of dilating the  ex-
treme vessels, and  of overcoming the spasm affecting their
extremities.
   157.]  Accordingly the throwing in of a large quantity of
watery fluids has been, at all times, a  remedy  much em-
ployed in fevers ;  and in  no instance  more remarkably,
than by the Spanish and Italian physicians, in  the  use of
what they call the  Diccta aquea.
   158.]  This practice consists in taking away every other
kind of aliment and drink, and in giving in divided portions
every day, for several days together, six  or eight pounds
of plain water, generally  cold,  but sometimes warm.  All
this, however, is to be done only after the disease has con-
tinued for some time, and, at least, for a week.*
   159.]  A second  means (153. 2.) of determining  to  the
surface of the body, is by the use of neutral salts.   These,
in a certain dose taken into the stomach, produce, soon af-
ter, a sense of heat upon  the surface  of the body ; and,  if
 the body be covered close and kept warm, a sweat is readi-
ly brought out.   The same medicines, taken during the
cold stage of a fever, very  often put  an  end  to the  cold

  * Simply as a diulent, water is undoubtedly the best drink than can  be used, but by addir*
a r-mall quantity of mucilage  to it, iwo intentions arc answered at the same time, viz. diluting
and overcoming the acrimony; hence the propriety of barley-water, water-gruel,linsteed tea, j
made extremely weak; otvery slight decoctions, of malt, of bread-crusts, or f ven the gelatinou-
 parts of  young anima'is, as calf's feet, or the more solid hartshorn shavings, &c. These  animal
 substances iniist however, be used in great moderation, and only in those cases where the pa-
 tient requires nourishment.  When this watery regimen is carried to a great length, the  patient
 turns anasarcous; but this effect may be prevented by some of the neutral salts, of which Kali
 acetatum of the London Pharmacopoeia is most preferable, or> account of its diuretic quality.
 The do!>e of it may be carried as far as half an ounce or six drachms in the day. The same in-
 tention may also be answered by eating water-creases, radishes if in season, or a  I rt!e of t!.*
 out rinJ of turnips j all which are diuretics. 
                PRACTICE OF  PHYSIC.             «n

 stage, and bring  on the hot; and they are also remarkable
 for stopping the  vomiting which  so frequently attends the
 cold stage of fevers.  All this shows, that neutral salts have
 a power of determining the blood to the surface of the bo-r
 dy, and may therefore be of use  in taking off  the  spasm
 which in fevers subsists there.
   160.]  The neutral most commonly employed in fevers,
 is that formed of an alkali with the  native acid of vegeta-
 bles,* but all the other neutrals have  more or  less  of the
 same virtue ; and perhaps some  of them, particulary the
 amnioniacal  salts, possess it in a stronger degree.f
   161.]  As cold  water taken into the stomach,  often shows
 the same diaphoretic effects with the neutral salts, it is pro-
 bable that the effect of the latter depends upon their refri-
 gerant powers mentioned above,  (134.)  What is the effect
 of the neutral salts, given when they  are forming and in  a
 state of effervescence ? It is probable that this circumstance
 may increase the refrigerant power of these salts, and may
 introduce into the body a quantity of fixed air ; but for
 these purposes it would seem proper  to  contrive that  the
 whole of the effervescence should take place in the stomach. J
   162.]  A third means (153. 3)  of determining to the sur-
 face  of the body, and taking off the spasm subsisting there,
 is by the  use of sudorific medicines,  and of sweating.
   163.] The propriety of this remedy has been much disput-
 ed ;  and specious arguments may be  adduced both for and
 against this practice.
   In favor of the practice it may be  said,
   1.  That, in healthy persons, in  every  case  of increased
 action of the  heart and arteries,  a sweating takes place, and
 is seemingly the means of preventing the  bad effects of such
 increased action.

  * The following is the usual dose of it every three or four hours:
           R. Sal. Absinth. 9i.
               Succ. Limon. §ss.  vel. q. s. ad. saturationem ;
               Adde Aq. Fontame Biss.
               Syrup, commun. 3m
               M. f. haust.
  + The form and dose of this is the same with the foregoing, only using the volatile alkali in -
 stead of the fixed.  The aqua ammonia acetata of the  London Phaimaiopceia is one of the
 ammoniacal salts, and may  ue given in doses of two drachms every tour hours, diluted with an
 ounce and a half ot water.
  t It is certainly extremely useful in suppressing vomitings in fevers. The method of produc-
 ing the effervescence in the stomach is as follows:  Let the patient take the acid first, diluted
with a sufficient quantity of water, and immediately after let him swallow trie alkali,,also dilut-
ed.  The proportion of the alkali to the acid mu>t be learned from chemistry. If die tnild ii-
ed alkali is good, it will saturate about twelve times its weight of lcmMjuice. 
72            PRACTICE OF PHYSIC.
  2. That, in fevers, their most usual solution and termina-
tion is by spontaneous sweating.
  3. That, even when excited by art, it has been found ma-
nifestly useful, at certain periods,  and in certain species of
fever.
  164.]  Upon the other hand, it may be urged against the
practice of sweating,
  1. That as in fevers a spontaneous sweating does not im-
mediately come on, so there must be in these some circum-
stances different from those in a state of health, and which
may therefore  render it doubtful whether the sweating can
be safely excited by art.
  2. That in many cases,  the practice  has been attended
with bad consequences.  The means commonly  employed
have a tendency  to produce an  inflammatory  diathesis;
which, if not  taken off by the  sweat following their use,
must be increased with much  danger.  Thus, sweating em-
ployed to prevent the accessions of intermitting fevers, has
often changed them into a continued form,  which is always
dangerous.
  3. The utility of the practice is further doubtful, because
sweating, when it happens,  does not always give a final
determination ; as must be manifest in the case of intermit-
tents, as well as in many continued fevers,  which are some-
times in the beginning attended with  sweatings that do not
prove final; and,  on the contrary, whether spontaneous or
excited by art, seem often to aggravate the disease.
  165.]  From these considerations, it is extremely doubt-
ful  if the practice of sweating can be ad mi ted very gener-
ally ; but at the same time, it is also doubtful, if the failure
of the practice, or the mischiefs said to have arisen from it,
have not been owing to the improper conduct of the prac-
titioner.   With  respect to this last, it is almost agreed
among physicians,
   1. That sweating has been generally hurtful, when ex-
cited by stimulant, heating,  and inflammatory medicines.
   2. That it has been hurtful,  when  excited by much ex-
ternal heat, and continued with a great increase of the heat
of the body.
  3. That it is always hurtful, when it does not soon re-
lieve, but  rather increases, the frequency and hardness of
the pulse, the anxiety and difficulty of breathing, the head-
ach, and delirium.
   4. That it  is always hurtful, if it be urged when the 
PRACTICE OF  PHYSIC.
73
sweat is not fluid, and when it is partial,  and on the supe-
rior parts of the body only.
  166.] In these cases, it is probable, that either an inflam-
matory diathesis  is produced,  which increases the spasm
on the extreme  vessels; or  that, from other  causes, the
spasm is too much fixed to yield easily to the increased ac-
tion of the heart and  arteries;  and, upon either supposi-
tion, it must be obvious, that urging the sweat, as ready to
produce a hurtful determination to some of  the internal
parts, may be attended  with very great danger.
  167.] Though the doubts started (164.) are to be attend-
ed to  ; and although the practices (165.) having been found
hurtful, are therefore to be rejected; it still remains true,
  1. That sweating has certainly been often useful in pre-
venting the accession of fevers, when the times of this have
been  certainly foreseen, and a proper conduct employed.
  2.  That, even after fevers have in  some measure come
on, sweating, when properly employed,  either at the very
beginning of the disease,  or during its approach and  gra-
dual formation, has often prevented their further progress.
  3.  That, even after pyrexiae have continued for  some
time, sweating has been successfully employed in curing
them, as particularly in the case of rheumatism.
  4. That certain fevers, produced by  a very  powerful
sedative contagion, have been generally  treated, so far as
we yet know, most successfully by sweating.
  168.] These instances (167.) are in favor of sweating,
but give no general rule; and  it must be left to further ex-
perience  to determine how far any general rule can be es-
tablished in this matter.  In the mean time, if the practice
of sweating is tobe attempted,  we can venture to lay down
the following rules for the conduct of it.
   1.  That it should be excited without the use of stimulant
inflammatory medicines.
   2.  That it should be  excited with as little external heat,
and with as little increase of the heat of the body, as possible.
   3.  That when excited, it should be continued for a due
length of time,  not less then twelve hours, and sometimes
for twenty-four or forty-eight hours ; always however, pro-
viding that it proceeds without the circumstances mention-
oned(l65. 3. 4.)
   4.  That for some part of the time, and as long as the per-
son can easily bear, it should be carried on without admitting
of sleep.*
* This direction is not always absolutely neces»ary. 
74
PRACTICE  OF  PHYSIC.
    5.  That it should be rendered universal over the whole bo-
 dy ; and, therefore, particularly, that care  be taken to bring
 the sweating to the lower extremities.
    6.  That the practice should be rendered  safer by moderate
 purging, excited at the same time.
    7. That it should not be suddenly checked by cold any how
 applied to the body.
    169.]  When attention  is to be  given to  these rules, the
 sweating may be excited,  1.  By warm bathing, or a fomen-
 tation of the lower extremities.   2. By frequent draughts of
 tepid liquors  chiefly water,  rendered  more  grateful by the
 addition  of the  light  aromatic,* or more  powerful by that
 of a  small  quantity of  wine.   3.  By giving some doses  of
 neutral  salts.f   4.  Most effectually, and perhaps most  safe-
 ly, by a large  dose of an opiate, joined  with a portion of neu-
 tral salts, and  of an  emetic!
   In what cases  may  cold water,  thrown  into the stomach
 in large  quantities,  be employed  to  excite sweating ?  See
 Celsus, Lib.  III. Cap. vii—ix.
    170.] The fourth means (153.  1.)  of determining to the
 surface  of the body, and thereby taking off the spasm affect-
 ing the extreme vessels, is by  the use of emetics.
   171.]  Emetics, and particularly  antimonial emetics, have
 been employed in the  cure of  fevers ever since the  introduc-
 tion of chemical  medicines:  but for a long time, they were
 employed by chemists and chemical practitioners only: and
 although of late the use of  them  has  become very general,
 their efficacy is still disputed, and their manner of operating
 is not commonly explained.|j
  * The light aromatics here mentione.l are sage, mint,  ba!m, ice.  For the purpose of sweat-
 ing, while wines answer best, especially the thin fresh  wines ; as also Rhenish wines, particu-
 larly Hock.  They must be taken warm and plentifully diluted.  Wine whey  is also a very
 powerful sudorific, as are also wheys made with vinegar, cream of tartar, the juices of acid fruits
 »r wiih cluldhed spirit of nitre.
  + Neutral salts may be given in the quantity of two  scruples or a drachm: but the patient
 must nevertlieless drink large quantities ot warm water. The tartarous ta/tarisatus is the neu-
 tral most frequently used for producing sweats; its dose is generally one scruple, but it may be
 increased to two dracluns.
  % This is the well known Dover's powder, now called in  the London Pharmacopoeia, pulvis
 i|>ecacuanha: compositus. It consists of eight parts of neutral salt, one of opium, and one of
 ipecacuhana; so that 10 grains of it are an orninary dose: But it has been given  to the  quan-
 tity of a scruple without any bad consequences, and that dose repeated every two or three
 hours, till the effect was produced  lngener.il, however, doses of 12 or 15 grain:, are the most
 usual, and arc found by experience tobe the Ixm. The  Dover's powder, when given in larger
 ijuantilies./otten nauseates, and is rejected by vomit. In the Edinburgh Pharmacopeia, the Do-
 ver', powder consists of 9 parts of neutral salt, one of opium, and one of ipecacuanha. The dose
 of mis, therefore, will be nearly the same as the dose  of  the turnier ;  11 grains of the Edinburgh
 Dover's powder being equivalent to 10 of the London. In administering this powder, it mav be
 necessary to observe, that the patient ought to refrain from drinking for at least an hour after
 inking it, because it nauseates more readily if much diluted in the stomach j and if the nausea
 be so great as to produce vomiting, its effects as a sudorific are considerably diminished : when,
 however, a swe.it is produced, chin diluting drinks may and ought to be plentifully given: for in
Michcase3, it is evident from the effect, that the medicine has  passed out of the  stomach, and
that no material nausea can then be produced by it.
 - All the antimonial emetics are violent in their effects, and are sometimes attended withdis-
a.: ^.tble consequences. Emetic tartar is found from experience tg be the safest  of them ; bu< 
PRACTICE  OF PHYSIC.
75
   172.] Vomiting is, in many respects, useful in fevers;
as it evacuates the contents of the stomach ; as it emulges
the biliary and pancreatic ducts ; as it evacuates the contents
of the  duodenum, and perhaps, also of a larger portion of
the intestines ; as it agitates the whole of the abdominal vis-
cera, expedes the circulation in them,  and promotes their
several secretions ; and lastly, as agitating also the viscera of
the thorax,  it has like effects there.  All these several effects
are in  many cases and circumstances of fever, procured with
advantage; but  do not  properly  fall under our view  here,
where we are to consider only the effect of vomiting in deter-
mining to the surface of the body.
   173.]  This effect we do not impute to the exercise of vom-
iting in  agitating the whole frame; but to the particular
operation of emetics upon the muscular fibres of the stomach,
whereby  they excite the action of the extreme arteries on
the  surface of the body,  so as thereby effectually to de-
termine the blood into these vessels,  remove the atony, and
take off  the spasm affecting them.
   174.]  That such is the power of emetic,  will appear from
the several considerations mentioned above  (44) ; and there-
fore, that they are remedies well suited to the cure of fevers.
   175.] Emetics, for that purpose, are  administered in two
different ways :  that is,  either in such doses as may excite
full  and  repeated vomitings ; or in such doses as may excite
sickness and nausea only, with little or no vomiting at all.
   176.]  Full  vomiting is best suited  to the several purposes
mentioned (172.) and is  also well  suited to  determine to the
surface of the body, so as thereby to obviate the atony and
spasm which  lay the foundation of fever.   Thus vomiting,
excited a little before the expected accession of the paroxysm
of an intermittent,  has been found to prevent the paroxysm
altogether.   And it has  been observed also, that when con-
tagion has been applied to a person, and first discovers its
operation,  a vomit given will prevent the fever, which was
otherwise  to  have been expected.  See  Lixd on Fevers and
Infection.
   111.]  These are advantages  to be obtained  by  exciting
vomiting at the first approach of fevers, or of the paroxysms
of fevers ;  and after fevers are formed, vomiting may also be

it is not always of the same strength, unless peculiar attention be paid to the making of it. The
prescription for it in the last Edinburgh Pharmacopoeia is preferable to that in ihe London. Some
demists think that it would be better to use boiling water alone, and omit the alkaline salt, al-
ledging that the alkali renders the precipitation variable in point of strength : But this opinion
is erroneous. The alkali is used in order to free the  precipitate more completely from any re-
mains of the muriatic acid, making u the-."by a milder powder and a more perfect calx. 
 76            PRACTICE OF  PHYSIC.

employed to take off, perhaps entirely, the atony and spasm,
or at least to moderate these, so that the fever may proceed
more gently and safely.
   178.] It  is seldom, however, that vomiting is  found to
produce  a  final solution of fevers; and  after they are once
formed, it is commonly necessary  to repeat the vomiting se-
veral times;  but this is attended  with  inconvenience,  and
sometimes with disadvantage.   The operation of full vomit-
ing commonly  soon ceases, and the exercise of vomiting is
often a debilitating power; and therefore, when the vomit-
ing does not  remove  the  atony and  spasm  entirely, it
may give occasion to their recurring  with greater force.
   179.] For these reasons, after fevers are fully formed, phy-
sicians have thought proper to employ emetics in nauseating
doses only.  These arc capable of exciting the action of the
extreme vessels, and their operation is more permanent.  At
the same time, they often show their power by exciting some
degree of sweat, and their operation is  rendered more safe,
by their commonly producing  some  evacuation by stool.
   180.] Such are the advantages to be procured by nauseat-
ing doses of emetics ; and it only remains to  mention,  Avhat
are the medicines most fit to be  employed in that  manner,
what are the most  proper times for exhibiting, and what is
the best manner of administering them.
   181.] The emetics at present chiefly in use,  are, Ipeca-
cuanha and Antimony.
   The former may be employed for  every purpose of eme-
tics, particularly those mentioned  (172.) It may likewise be
employed,  either in larger or smaller doses for determining
to the surface of the body ; but,  even  in very small doses,
it  so readily excites vomiting, as  to be  with difficulty em-
ployed for the purpose of nauseating only  ; and  however
employed there is reason to believe,  that its  effects are less
permanent, and less powerfully communicated from the sto-
mach to the rest of the system than those of Antimony.
   182."] This therefore, is generally preferred ; and its pre-
 arations, seemingly  various, may all be referred to two
 eads; the one comprehending those in which the reguline
part is in a condition to be acted upon by acids ; and there-
fore, on meeting with acids in the stomach becomes active ;
and  the  other  comprehending those preparations  in which
the reguline part is already joined  with an acid, rendering it
active.
I 
                PRACTICE OF PHYSIC.             77

   183.]  Of each kind there are great numbers, but not dif-
fering essentially from one another.   It will be enough for
us to compare the Calx  Antimonii Nitrata of the Edinburgh
Dispensatory with the Emetic Tartar of the same.   The for-
mer, as I judge,  is nearly  the  same with what is called
James' Powder.*  Which of these is best suited to the cure
of fevers, as above explained, seems doubtful; but it appears
to me,  that, although  the former  may  have  some advan-
tages from its slower operation, and may thereby seem to be
more certainly  sudorific and purgative, yet  the uncertainty
of its dose renders it inconvenient,  has often given occasion
to the timid to be disappointed,  and to the bold to do mis-
chief.   On the other hand,  the dose of  the Emetic Tartar
can  be exactly ascertained; and I think it may be exhibited
in such a manner as to produce all  the  advantages of the
other.
   184.]  Whichsoever of these preparations be employed,  I
judge the most proper time for exhibiting them, to be the
time of accessions ;  or a little before, when that can be cer-
tainly known*  In continued fevers, the exacerbations are
not  always very observable; but there is reason to think,
that one commonly happens about noon, or soon after it,
and  another in the evening; and that these, therefore, are
the most proper times for exhibiting emetics.
   185.]  With respect to the manner of administration, that
of the Calx Nitrata is simple, as the whole of what is judg-
ed a proper dose is given at once, and no more can properly
be given till the time, of the next accession.f
   The administration of the  Emetic Tartar  is different.  It
is to be given in small doses, not sufficient to excite vomiting;
and  these doses, after short intervals, are to  be repeated for
several times, till sickness, nausea, and some, but not much,
vomiting, come on.  The difference of this administration
must depend upon the dose, and the length of the intervals at
which it is given.  If it be intended  that the medicine should
certainly operate by stool, the doses are made  small, and
the intervals long.  On the contrary,  when vomiting is pro-
per, or when much purging ought to be avoided, and there-

  * The pulvis antimonialis of the London Pharmacopoeia is intended as a substitute for, or imi-
tation ol, James' powder. The dose of it is 7 or 8 grains.  It is by no means so sure in its ope-
 rations as the emetic tartar ; yet it has been much extolled by several eminent modern practi-
tioners.
  + The dose is ten or twelve grains.  This calx, however, is very unrertain in its operations,
sometimes acting with great violence, and sometimes scarcely producing any percept I'x
L 
78
PRACTICE OF  PHYSIC.
fore some  vomiting must be admitted,  the  doses are made
larger and the intervals shorter.*
  186.] With respect to both kinds of preparations,  the re-
petition is to be made at the times of accession, but not very
often : for if the first exhibitions duly  managed, have little
effect, it is seldom that the after exhibitions have much, and
it sometimes happens that the repeated vomitings, and espe-
cially repeated purges, do harm by weakening the patient.
   187.]  The other set of internal medicines,  (152. 2.) which
I suppose may be useful in taking off the spasm of the ex-
treme vessels, are those  named  Antispasmodic.   How many
of these may be properly  employed,  I am uncertain ; and
their mode of operation  is involved in great obscurity.   It is
certain, however, that opium, camphor, musk, and  perhaps
some others, have been employed in fevers  with advantage ;
but the  circumstances in  which they  are especially proper
and safe, I find  difficult to ascertain ;  and therefore cannot
venture  here to lay down  any general doctrine concerning
them.
   188.]  The external  means  (151.) suited to take off the
spasm of  the extreme vessels,  are blistering  and warm
BATHING.
   189.]  What  are the effects  of Blistering, so frequently
employed in fevers, is  not yet  agreed upon among physi-
cians ; and many different  opinions have been maintained on
this subject, drawn not only from reasoning, but also from
presumed experience.  I  must  not,   however,  enter  into
controversy; but shall  deliver my own opinion in  a few
words.
    190.] I  am  persuaded, that the small  quantity of can-
tharides absorbed from a blistering plaster, is not sufficient
to change the consistence of the mass of blood ;  and there-
fore that such a quantity can neither do good,  by resolving
phlogistic  lentor, if it exists;  nor do harm, by increasing
 the dissolution  of the blood arising from a putrid tendency in

   * The dose of the Antimonium tartarisatum should never exceed three grains. The best
 method of  giving it is, to dissolve three grains in six ounces of water ; and of this mixture give
 two table spoonfuls: if no vomiting ensues within twenty  minutes, repeat the dose, aud con-
 tinue to give a table spoonful every ten minutes, till the vomiting is excited,  which mu-t be
 encouraged by drinking plentifully of camomile tea, or a thin water gruel. If the emetic tar-
 tar be intended for a sudorific, two table spoonfuls of the following solution every two or i.ve*
 hours will peihaps be more proper than small doses of the other.
               R. Antimonii tartarisati gr. ii.
                  Aq. Cinnamon, simpl. 3n\
                  —. Font. Bvi.
                   M. F. Julap. 
              PRACTICE  OF PHYSIC.            7§>

it.  I therefore  neglect  entirely the  effects of cantharides
upon the fluids.
  191.] The inflammation produced by the application of
cantharides to the skin, affords a certain proof of their stim-
ulant power; but in many persons, the effect of that stim-
ulus is not considerable; in many it is not communicated to
the whole system ; and even when the effect does take place
in the whole system, it seems to be taken off entirely, by
the effusion and  evacuation of serum from the blistered part.
I conclude, therefore, that neither much good is to be  ex-
pected, nor  much harm to be apprehended, from the stim-
ulant power of blistering;  and the certainty of this conclu-
sion is established, by the great benefit arising from the pro-
per practice of blistering in inflammatory diseases.
   192.]  Much has been imputed to the evacuation occasion-
ed by blistering; but it  is never so considerable as to affect
the whole system ; and therefore can neither, by sudden de-
pletion, relax the sanguiferous vessels,  nor, by  any revul-
sion, affect the general distribution of the fluids.
   193.]  The evacuation, however, is so considerable as to
affect the neighboring vessels; and the manifest  utility of
blistering near the part  affected,  in inflammatory diseases,
leads me to believe,  that blistering, by deriving to the skin,
and producing  an  effusion there, relaxes  the spasm of the
deeper seated vessels.  I apprehend it to be in this manner,
that the tumor of a  joint, from an effusion into the cellular
texture under the skin, takes off the rheumatic pain affect-
ing that joint.
   194.] Analagous to this, it may be held, that the good ef-
fects of blistering in continued fevers, arise from its relaxing
 the spasm  of the extreme vessels, by a communication  of
the blistered part with the rest of the skin ; and this is illus-
trated by the effect of blistering in cholic and dysentery.
   195.] It appears  to me, that blistering may be employed
at  any period of continued fevers;  but that it will be  of
most advantage in the advanced state of such fevers, when
 the reaction being weaker, all ambiguity from the stimulant
 power of blistering is removed,  and when it may best  con-
 cur with  other  circumstances  tending to a final solution  of
 the spasm.
    196.] From the  view of this  matter  given  in  (193. and
 194.) it will appear, that the part of the body to which blis-
ters  ought to be applied, is  indifferent, excepting upon the 
80
PRACTICE  OF PHYSIC.
suspicion of topical affection, when the blistering ought to
be made as near as possible to the part affected.
   197.]  Whether sinapisms and other rubefacients,  act
in a manner analogous to what we have supposed of blister-
ing, may be doubtful ; but their effects in rheumatism, and
other inflammatory diseases render it probable.
  198.]  The other external means of taking off the spasm
of the extreme vessels,  is  Warm Bathing.   This was fre-
quently, and in various circumstances, employed by the an-
cients ;  but till very lately has  been neglected by  modern
physicians.  As the heat of the bath stimulates the extreme
vessels, and, with the concurrence of moisture,  also relaxes
them,  it seems  to be a safe stimulus, and well suited to take
off the spasm affecting them.
  199.]  It may be applied to the whole body by immersion ;
but this  is, in many respects, inconvenient; and whether
some of the inconveniences of immersion might not be avoid-
ed by a  vapour-bath, I have not learned  from  experience.
I know,  however, from much experience, that  most of the
purposes of warm bathing can be obtained by a fomentation
of the legs and feet, if properly administered, ^nd continu-
ed for a due length of time, which ought not to be less than
an hour.
  200.] The marks of the good effects of such a fomentation,
are,  the  patient's bearing it easily, its  relieving  delirium,
and inducing sleep.
  201.]  Having pow considered the several means of satisfy-
ing the first general indication in the cure of fevers, I pro-
ceed to the second (126.) which is,  To remove the cause, or
obviate the effects of debility.
  202.}  Most  of  the sedative powers inducing debility,
cease to act soon after they have  been first applied; and,
therefore, the removing them is not an object of our present
indication.  There is only one which may be supposed to con-
tinue to act for a long time ; and that is, the contagion applied:
but we know nothing of the nature of contagion that can lead
us to any measures for removing or correcting it.   We know
only its effects as a sedative power inducing debility, or as a
ferment  inducing a tendency  to putrefaction in the fluids.
The obviating  the latter will be considered under our third
general indication, and the former alone is to be considered
here.
  203.]  The debility induced in fevers by contagion,  or
other causes, appears especially in the weaker energy of the 
              PRACTICE OF PHYSIC.             81

brain; but in what this consists, or how it may be directly
restored, we do not well know.  As nature, however, does,
seemingly for this purpose, excite the action of the heart
and arteries,  we ascribe the continuance of debility  to  the
weaker  reaction of the sanguiferous, system  ; so that  the
means to be employed for obviating debility, are immediate-
ly directed to support and  increase the action of the heart
and arteries ; and the remedies used  are tonics  or  stimu-
lants.
   204.]  In contagious diseases, both from the effects which
appear,  and from  dissections,  it  is known that the tone of
the heart and arteries is considerably diminished ; and  that
tonic remedies, therefore,  are properly indicated.
   These are to be considered as of two kinds ; the first  be-
ing the power of cold, the second that of tonic medicines.
   ^205.]  The power of cold, as a tonic,  I have mentioned
above;  (90.) and  it is employed,  in fevers, in two ways;
either  as the cold matter is thrown into the stomach, or as
it is applied to the surface of the  body.
   206.]  As it has been  shown above,  that the tonic power
of cold can be  communicated from any one  part to every
other part of the system ;  so it will readily be allowed,  that
the stomach is a part as fit for this communication as  any
other; and that cold drink, taken  into the stomach, may,
therefore, prove an useful  tonic in fevers.
   207.]  This the experience of all ages has confirmed ; but,
at the same time,  it has been frequently observed, that., in
certain circumstances, cold drink, taken into the stomach,
has proved very hurtful; and, therefore, that the use of cold
drink in fevers requires some limitations.   What these limi-
tations should be, and what are all the circumstances which
may forbid the use of cold drink, is difficult to determine;
but it seems clearly forbidden, in all cases  where a phlogistic
diathesis prevails in the system,  and more especially when
there are topical affections of an  inflammatory nature.
   208.]  The other method of employing cold as a tonic,
 is, by applying it to the surface of the body.  The appli-
 cation of cold air to the surface of the body, as  a  refrige-
 rant power fit to moderate the violence of reaction,  I have
spoken of  above;  (133.) but probably it  may also be  con-
 sidered here as a tonic, and useful in cases of debility.
   209.] Not only cool air, but cold water also, may be ap-
 plied to the surface of the body,  as a refrigerant, and  per-
haps as a tonic.   The  ancients frequently applied it  with 
8 J
PRACTICE  OF  PHYSIC.
advantage, to particular parts, as a tonic ; but it is a disco-
very of modern times, that in the case of putrid fevers,  at-
tended  with much debility, the body  may  be  washed  all
over with cold water.
   210.]  This was first practised at Breslew in Silesia, as ap-
pears from a dissertation, under the title of  Epidemia ver-
na qua? Wratislaviam,  anno  1737,  ajjlixit,  to  be found in
the appendix to the Acta. Nat.  Curios. Vol. X.   And from
other writers we find, that the practice has passed into some
of the neighboring countries ;  although  in  this  island,  so
far as I know, we have hitherto had no experience of it.
   211.]  The medicines which have been employed in fevers,
as tonics, are various.  If the Saccharum Saturni has  been
found useful, it is,  probably, as a  tonic, rather  than as a
refrigerant; and the Ens  Veneris, or other  preparations of
iron which  have been  employed, can act  as  tonics  only.
The preparations of  copper,  from their effects  in  epilepsy,
are presumed to possess a tonic  power ;  but whether  their
use in fevers be  founded  upon their  tonic  or their  emetic
powers may be uncertain.   The use of arsenic and of alum,
in intermittent fevers, seems manifestly to depend upon their
tonic  power.   And,  upon the whole, there may occur cases
of continued fevers,  which may be  cured by tonics taken
from the fossil kingdom ;  but the use of these has  been rare,
as well as the effects   uncertain ; and  physicians  have em-
ployed, more commonly,  the vegetable tonics.
   212.]  A great variety of these has been employed in  the
-cure of intermittent fevers;  but how many  of them may be
employed in continued fevers, or in what circumstances of
these fevers is not well ascertained;  and I  shall  now only
consider the question with respect to the most celebrated of
these tonics,  the Peruvian Bark.*

  * When or how the inhabitants of Peru first  discovered the febrifuge powers of thisb3rk is
involved in fable and uncertainty. They appear, however, to  have long known its virtue
although we have no proofs of their revealing it to the Europeans before the middle of the last
century. The Spaniards call the tree which produces it Palo de Calenturas, or fever tree Linne
calls it Cinchona r-fficinalis, in memory of the Countess of Cihchon,  the Spanish  viceroy'*
lady in Peru, who was the hist European that had been cured by it.  It was first brought into
Italy by a Jesuit about the year 1649, and distributed through Europe  by the fathers of that or-
der ; hence the names Cortex and Pulvis Jcsuiticus, Pulvis Patrum.  By Cardinal de Lueo's in-
fluence a cargo ot it was procured and brought to Rome soon after  : whence it received the
name of Pulvis Cardmahs de Lugo.
  As this bark is a medicine of considerable importance, it may not be improper to join a short
description of the external qualities of the best sort.  It is in concave  pieces, scarcely ever ex-
ceeding the fourth part of a cylinder cut longitudinally.  It breaks short, and when broken evi-
ciemly appears to be composed of three distinct and separate coats, viz. one  outer thin coat
that is somewhat rugged, often covered with  moss of different kinds, and is of a reddish brown
color like cinnamon. The middle coat is considerably thicker, of a closer texture and deener
color than the first, and is less brittle but more resinous than any other part  The third orin!
nermostcoat is woody and fibrous, and of a brightish red, at least considerably brighter than
either of the others.  From this description of the bark, great care must be taken in powdering
it, not to leave much gross powder, but to pass the whole of it through the neve "because thi 
               PRACTICE OF PHYSIC.             83

  213.]  This bark has been commonly considered as a spe-
cific, or as a remedy of which the operation was not under-
stood.  But it is certainly  allowable  to inquire into this
matter ; and I apprehend it may be explained.
  214.]  To this purpose it is to be remarked, that  as,  in
many cases, the effects of the bark are perceived soon after
its being taken into the stomach,  and before it can possibly
be conveyed to the mass of blood, we  may conclude,  that
its effects do not arise from its operating  on  the fluids ;
and  must, therefore,  depend upon  its  operating  on  the
nerves of the stomach, and being thereby  communicated
to the rest of the nervous  system.  This operation seems to
be a tonic power,  the bark being a remedy in many cases
of debility,  particularly in gangrene ;  and, as the recur-
rence of the paroxyms of intermittent fevers depends upon
a recurrence of atony, (35. and 36.) so probably the bark,
by its tonic  power, prevents  the recurrence of these pa-
roxysms ;  and this is greatly confirmed by observing,  that
many other tonic medicines answer the same purpose.
   215.] If the operation  of the bark may be thus explain-
ed,  from its possessing a tonic power,  it is easy to perceive
why it is improper when a phlogistic diathesis prevails ; and
from the same view, we can ascertain in what cases of con-
tinued fever it may be admitted.  These  are either  after
considerable remissions have appeared, when  it  may  be
employed to prevent the return  of exacerbations, on the
same footing that it is used in intermittent fevers,  or in the
advanced state of fevers, when all suspicion of an inflamma-
 tory state is removed, and a general debility prevails in the
 system ; and its being then employed  is sufficiently agree-
 able to the present practice.
   216.]  With respect to the use of the bark, it is proper to
 add, that good effects are to be expected from it, almost
 only when given in substance and in large quantity.*
   217.]  Another set  of  Medicines to  be employed for ob-

 most resinous, and consequently the most effectual, part of the bark is the longest and most
 difficult to powder.
  With respect to the two kinds  of bark so much talked of and noticed a few years ago, it
 may be proper to observe, that they seem to be the production of the same tree.  The Spaniards
 always selected such pieces as those above described out of the original packages, and rejected
 the thin, pale, and quilled sort, v/hich  the English preferred.  It  is certain that both the red,
 pale, quilled, and a variety of gradation between them, all occur in the same chest as originally
 imported; and it is extremely improbable that the bark of different kinds of trees should be
 packed together.  Be this matter however as it may, experience gives the preference to what
 it called the red bark, and this sort ought surely to be used.
  •The doses of the bark can only be determined from the state of the patient's stomach and
 the violence or" the disease :  It is usual to give a drachm of the powder at a dose, and repeal
 it eve;y two or three hours, according to the exigency of the case, or the state of the patient's
 bowels. It frequently passes off by stool when given too liberally ; tins inconvenience isobvi.
 atrd by giving a few drops, 8 or 1° of laudanum, with each dose. 
84
PRACTICE OF PHYSIC.
viating debility and  its effects,  are the  direct stimulants
(203.) These, in some measure, increase the tone of the mov-
ing fibres; but they are different from the tonics, as more di-
rectly exciting and increasing the action  of the heart  and
arteries.  This mode of their operation renders the  use of
them ambiguous ; and when an inflammatory  diathesis  is
present, as  so often happens in the beginning of fevers,
the effects of these stimulants may be  very hurtful ;  but it
still remains probable,  that in the  advanced state of fevers,
when  debility prevails, they may be useful.
   218.]  What are the stimulants that may be most pro-
perly employed, I am uncertain, as  the use of them in  this
age has been rare ; but I am  disposed to believe that, of all
kinds, wine is the best.
   219.]  Wine has the  advantage  of being grateful to the
palate and stomach, and of having  its stimulant  parts so
much diluted, that it can be conveniently given  in  small
doses ; so that it may be employed  with sufficient caution ;
but it is  of little service, unless taken pretty largely.*
   220.]  It may be supposed, and on  good grounds, that
wine has an operation  analogous  to that of  opium,  and
some other narcotic  medicines.   It  may  indeed  be  said,
that we can distinctly mark its stimulant power only, which
renders its effects in  the phrenitic delirium manifestly hurt-
ful, and, in the mild delirium, depending on debility, as re-
markably useful.   But in all  this the analogy  with opium
is still obvious ; and it is probable, that both wine and opi-
um are more useful by their sedative   and antispasmodic,
than by  their stimulant powers.
   221.]  These are the means of answering our second ge-
neral indication ;  (126. 2.) and I now proceed to the  third,
which is, To obviate or to correct the tendency of the fluids la
putrefaction.
   222.]  This may be done,
   1.  By avoiding any new application of putrid or putres-
cent matter.
   2.  By evacuating the putrid or putrescent matter  alrea-
dy present in the  body.
   3.  Bv correcting the putrid or putrescent matter remain-
ing in the body.
  * Wine is a valuable cordial, and is much superior to  most other stimulants; it rai^ the
pulse, supports the vis vita?, promotes diaphoresis, and resists putrefaction.  With respect to the
medical differences of wines, it may suffice to observe, that the effects of full bodied wines are
more lasting than those of the thinner.  Red wines are sub.istringent, and consequently posses
a tonic virtue, and are hence more proper in fevers of all  kinds where wine is at all admissable.
than white wines are. All sweet wines are nutritive and in general more stimulating that!
others; but they heat much and are apt to turn sour on the storriacl'. 
PRACTICE  OF PHYSIC.
85
   4. By supporting the tone of the vessels, and thereby re-

sisting further putrefaction,  or obviating its effects.

   223.] The further application  of putrid  or  putrescent

matter may be avoided,

   1. By removing the patient from places filled  with cor-

rupted air.

   2. By  correcting ithe air  fromwhicbhecannot.be  re-

moved.

   3. By preventing the  accumulation of the patient's own

effluvia, by a constant ventilation, and by a frequent change

of bed-clothes and body  linen.

   4. By the careful and speedy removal of all excremental

matters from the patient's chamber.

   5. By avoiding animal food or  correcting  it.

   224.] The putrid or putrescent  matter, already  present

in the  body, may be evacuated partly by  evacuating  fre-

quently the contents of  the intestines,* and more effectual-

ly still, by supporting the excretions  of perspiration  and

urine, by the plentiful use of diluents.f

   225.] The putrid or putrescent matter, remaining$n  the

body,  may  be rendered  more mild and innocent  by the  use

of diluents; or may be corrected by the  use  of antiseptics.

These last are of many and various kinds ;  but which  of

them are conveniently applicable, or more particularly suit-

ed to the case of fevers, is  not  well  ascertained.   Those

most certainly applicable and useful, are, acescent aliments,

acidsj of all kinds, neutral  saltsj|  and  fixed air,§


  * The evacuants to be used in these cases are, the milder purges, sucji as manna, &c. Rheu-
barb and senna may also be used; but  we must avoid the drastic purges, sudh as jalap, scara-
mony, aloes, and similar resinous purges.  Calomel has  been found very useful in these cases:
It may be .given to the quantity of 8 or 10 grains, and 3 ounces of the iufusum sennre, with
half an ounce of Glauber's salt may be given, about 10 or i-hours after it,  to accelerate its
operation.
  + The diluents necessary in these cases must all be snixt with a little port wine or claret. Warm
port wine and water is the best diluent.
  t Whether all kinds of acids are to be used as antiseptics is somewhat doubtful.  The mineral
acids, especially the vitriolic, have been much recommended; but the vegetable acids seein much
more efficacious.  As their mildness-allows  us to give them in very large quantities, and as
they more easily enter into a union with the animal fluids than the fossile acids do, they seem
more suitable antiseptics in these cases. Whether there is any difference between the native
vegetable acids and vinegar, with respect to their antiseptic qualities, was formerly much dis-
puted by practitioners. Physicians, however, have now settled this question : and are generally
of opinion, that in cases of putrescence arising from fevers, the fermented acid is most proper;
but in cases of putrescence wiiliout fever, they prefer the native acid juices.
  H The antiseptic power of the  different neutral salts is extremely various.  According to the
reasoning in the foregoing note, those consisting of a vegetable acid "base ou»ht to be preferred ;
and indeed experience confirms the opinion. The Spiritus Mindereri would perhaps be useful,
if it could be prevented from passing two hastily off by sweat and urine. In doses of a drachm
every two hours, it is less •subject  to promote sweat and urine,than when given in the usual dose
of half an ounce.  Lemon juice, saturated with volatile alkah, has often been successfully used
in these cases; especially when they are taken either  in the act of effervescence, or separately,
the one immediately after the other.
 i The antiseptic qualities of fixed air are much doubted by  several eminent physicians.  The
giving it is frequently very difficult, and sometimes even impossible. The author might  have
added several other antiseptics to the short list he has given : What he has mentioned, however,
ire such as are generally used, or approved of by practitioners.  Camphor is a considerable aa-

                                 M 
86             PRACTICE  OF PHYSIC.
  226.]  The progress of putrefaction may be considerably
retarded, and its effects obviated, by supporting  the tone
of the vessels ; and this may be done by tonic remedies ;
the chief of which are,  Cold,  and  Peruvian  Bark,  both
sufficiently treated of above, (205. et seqj
  227.]  I have now  finished the consideration of the three
general indications to be formed in  the cure of continued
fevers ; and have  mentioned most  of the remedies  which
have  been,  upon any occasion, employed in this  business.
It was necessary, in the first place, to consider these indica-
tions  and remedies separately, and to explain the operation
of the latter more  generally ; but from what has been now
delivered, compared  with  what  was said above,  concerning
the difference of fevers, and the signification of their seve-
ral  symptoms in forming the prognostic,  I  expect it  will
not be difficult  to assign the indication, and to select and
combine the several remedies mentioned, so as to adapt them
to the several species and circumstances of continued fevers.

I think it may be useful for  my Readers to  have the whole
  of  the cure  of  continued  fevers brought under one
  View, as in the following table.

   IN THE CURE  OF  CONTINUED FEVERS,

                 THE INDICATIONS ARE,

         I.  To  moderate  the violence of reaction.

Which may be done by,
   1.  Diminishing the action of the heart and arteries, by
A. Avoiding or moderating those irritations  which are almost
       constantly applied to the body ;  as,
     a.  The impressions made upon our senses, particular^
       a. Increased heat,  whether arising from

 tiseptic, but it is of too heating a quality to be given in such quantities as seem necessary.  The
 common dose ot it is from 1 to 10 grains, and it is best exhibited in the form of a bolus -r in which
 form it ffnv also be joined with some other antiseptic, as
                R.  Camphor, gr. viii.
                   Spt. Vini. gutt. x.
                   Pulv. Rad. Contrayerv. 9ii.
                   Syr. Simpl. q. s.
                   M. f. bol.
 This dose may be repeated every 6 houFs, or oftcner, especially if the pulse be low or weak. In
 using camphor the practitioner ought to remember that this medicine, when given in  large
 quantities, frequently occasions delirium.  Peculiar attention must  therefore be paid to that
 '.vmrtora, and the dos*s of camphor regulated with cauiion. 
PRACTICE  OF  PHYSIC.
81
         *o» External heat,  or,
         @B. The accumulation of the heat of the body.
     b. The exercise of the body,
     c. The exercise of the mind,
     d. The taking in of aliment,
     e. Particular irritations arising from
       a. The sense of thirst,
       0. Crudities, or corrupted humors,  in the stomach,
       y. The preternatural retention of fatces,
       & A general acrimony of the fluids.
B.  Employing certain sedative powers ; as,
     a. Cold,
     b. Refrigerants ; the chief  of  which are,
       v. Acids of all kinds,
       fi. Neutral salts,
       y. Metallic salts.
C.  Diminishing the tension and tone of the arterial system, by
     a. Blood-letting,
     b. Purging.
  2. Taking off the spasm of the extreme vessels, by
A.  Internal means ; which are,
     a. Those remedies which determine to the surface, as,
       a. Diluents,
       /?. Neutral salts,
       y. Sudorifics,
       & Emetics.
     b. Those remedies named antispasmodics.
B. External means ; as,
     a. Blistering,
     b. Warm bathing.

    II.  To remove the causes, or obviate the effects,  of
                        debility,  by

  1. Supporting and increasing the action of the  heart and arte-
       ries,  by
A. Tonics,  as,
    a. Cold,
    b. Tonic medicines, which are either,
       a. Fossil,  as,
         <*«. Saccharum saturni, &c. or,
       &. Vegetable, as,
         »a. Peruvian Bark.
B. Stimulants,  as,
     a. Aromatics, &c.
     b. Wine. 
8S             PRACTICE OF  PHrsiC.

  HI. To obviate or correct the tendency of the fluids to
                    putrefaction, by

  1. Avoiding the application of putrid or putrescent matter, by
A.  Removing the patient from places filled With corrupted air.
B. Correcting the air, from which he cannot be removed.
C. Avoiding  the accumulation of the patient's own effluvia, by
    a. A constant ventilation,
    b. Frequently changing the bed-clothes and body-lihen.
D.  Removing carefully and speedily all excrernental matters.
E. Avoiding  animal food* or correcting it.
  2. Evacuating the putrid or putrescent matter already present
      in thebody,"-byj
A.  Evacuating frequendy the intestines.
B. Supporting the excretions of perspiration and Urine, by
    a. Diluents,
    b. Neutral salts.
  3. Correcting the putrid or putrescent matter remaining in the
      body,  by
A.  Diluents,
B. Antiseptics,
C. Fixed air.
  4. Resisting farther putrefaction, or obviating its effects, by
    Supporting the tone of the vessels, by
    Tonic remedies.
                      SECTION  II.

        Of the  Cure of Intermittent  Fevers.

   228.] IT still remains  to consider the cure of intermit-
tent fevers; and with respect to these,  we form also three
general indications.
   1. In the time of intermission, to  prevent the recurrence
of paroxysms.
   2. In the time of paroxysms, to conduct these so as to ob-
tain a final solution of the  disease.  ■
   3. To take, off certain circumstances which might prevent
the fulfilling of the two first indications.
   229.] The first indication may be  answered in two ways;
   1. By increasing the action of the  heart and arteries some
time before the period of accession, and supporting that in-
creased action  till  the  period of the accession be over,  so
as thereby to prevent the recurrence  of  the atony and spasm 
              PRACTICE OF PHYSIC.            89

of the extreme vessels which give occasion to the recur-
rence of paroxysms.
  2. Without increasing the action of the heart and arte-
ries, the recurrence Of paroxysms may be prevented, by
supporting the tone of the vessels and thereby preventing
atony, and the consequent spasm.
  230.] For the purpose mentioned in 229. 1. the action of
the heart and arteries may be increased,
  1. By various  stimulant remedies, internally given,  or
externally applied, and that without exciting sweat.
  2. By the same remedies, or others so managed as to ex-
cite sweating, and to  support that sweating till the period
of accession be for some time past.
  3. By nauseating doses  of emetics, given about  an hour
before the time of accession, thereby supporting  and in-
creasing' the tone and action of the extreme vessels.
  231.]  The tone of the extreme vessels may be supported
without increasing the action of the heart and arteries (229.
2.) by various tonic medicines; as,
  1. Astringents  alone.
  2. Bitters alone.
  3. Astringents and bitters conjoined.
  4. Astringents and aromatics conjoined.
  5. Certain metallic tonics.
  6. Opiates.
  Lastly, an impression of horror.
  A good deal of exercise, and as full a diet as the condi-
tion of the patient's  appetite and digestion may allow of,
will be proper during the time of intermission, and may be
considered as belonging to this head.
  232.]  Of all the  tonic remedies mentioned (231.) the
most celebrated,  and perhaps the  most certainly effectual,
is the Peruvian bark, the tonic power of which we have en-
deavored to demonstrate above (214.) and have at the same
time explained its use in continued fevers.
   The same observation as made in 216. is especially pro-
per in the case of intermittents: and  further, with respect
to these, the following observations or rules are offered here.
   1. That the  bark may  be  employed with safety at any
period of intermittent  fevers, providing that, at the sam»
time, there be neither a phlogistic diathesis prevailing in the
system, nor any  considerable or fixed congestion  present
in the abdominal  viscera.
  2. The proper time for exhibiting the bark in intermit- 
 9Q                PRACTICE  OF  PHYSIC.


 tent fevers, is during  the  time of intermission; and where

 intermissions are to  be expected,  it is to be abstained  from

 in the time of paroxysms.

    3.  In remittents,  though no entire apyrexia occurs,  the

 bark  may be given during  the remissions; and it  should be

 given even  though  the  remissions  be  inconsiderable, if,

 from   the  known  nature  of  the  epidemic,  intermissions

 or  considerable  remissions,  are  not  to  be  soon expected,

 and  that  great danger  is  apprehended from  repeated  ex-

 acerbations.

    4.  In the case of genuine intermittents, while a due quan-

 tity of bark is to  be employed, the exhibition  of it ought to

 be brought as near to the time of accession as  the condition

 of the patient's stomach will  allow.

    5.  In general,  in all cases  of intermittents,   it is  not suf-

 ficient  that the recurrence of paroxysms  be  stopped  for

 once by the use of the bark ;   a relapse is commonly to  be

 expected, and should be prevented  by the exhibition of the

 bark, repeated  at proper intervals.*


  ♦The quantity of bark to be given in the intermission must be as great as the stomach can pos-
 sibly bear.  It is very common to give 2 ounces during the intermission, in doses of half a drachm
 or two scruples every hour, especially in quartans. But it has been found more successful in its
 operations, when we begin  with small doses, viz. one scruple in the commencement of (he in-
 termissions, and increase the dozes to one drachm towards the end of it.  The baric  sometimes
 sits better on the stomach by adding to it about an eighth or a fourth of its weight of some aro-
 matic antiseptic.  Virginian snake root answers this intention very  well.   An ounce of red baric
 and '2 drachms of snake root taken during the intermission of a tertian, if the stomach can bear
 it, or if no diarrhcea comes on, generally prevents the next paroxysm.  In  case of diarrhoea  being
 produced by bark, ten or twelve drops of laudanum arc to be given three or four times with
 each dose of the bark.  The substances generally joined with the bark in prescription, seem cal-
culated  either to promote  its efficacy or reduce it to the intended form, without having re-
gard to the agreeablene^s of the composition. This, liowever, is a point of great consequence,  as the
 taste of the bark, and the large quantity of it necessary for the cure, make the patient frequently
loath it before its use ought  to be discontinued.  When made inio  an electuary or bolus with sy-
 rups, it sucks about the mouth and fauces; whence its taste remains a long while ;  but when
 made into an electuary with mucilage, it passes down  freely, scarcely leaving any taste behind
it. The taste of the bark i»  very effectually concealed by liquorice root in a decoction, or by the
extract in an electuary.  The extract of lo»wood also conceals the taste of the bark, and an elec-
tuary made wiih it, and a sufficient quantity of mucilage, is a very elegant form. Decoctions,
infusions, and tinctures of the bark are much less  efficacious  than the substance. The  extract
 and the resin are seldom employed in the cure  of intermittents, except when other forms will
 not sit on the stomach. The formula in the last London Pharmaco]weia is  the best, being a com-
 pound of both the extract and resin ; for the watery extract is strong in bitterness, but weak  in
astringency, and the resin is strong in astnngency, but weak in bitterness, and both qualities are
necessary for curing intermittents. About 10 or 12 grains of the extract are equivalent to half a
drachm of the powder. When a paroxysm has been stopped by the  bark, it  is by no means safe to
abandon the use of this medicine altogether, as a ielapse is always to be apprehended.  The  doses
are gradually to be diminished, and the intervals between the times of giving them are to be in-
creased : A fter tertians, we may diminish the quantity daily one half, till we arrive at 2 drachms:
and these 2 drachms ought to be continued in doses of 2 scruples thrice a day for eight days; after
which period, 2 scruple^ ought to be given night and morning for  a week longer : after quar-
tans, when the dose is reduced to two drachms a day, it will be prudent to continue giving thit
quantity daily for a fortnight, and half a drachm night and morning for a fortnight longer.  la
order the more effectually to prevent a relapse, great attention must be paid to  diet and  regi-
men.  Patients are generally extremely voracious after the cure of intermittents; and  indeed
they require considerable nutrition to supply the waste occasioned by the fever. Small quan-
tities of food are to be taken at once and to be often repeated j and the must nutritive, and at
the same time, easily digestable food, must be chosen, as broths with barley and white flesh meat
roast lamb, veal, chickens, new laid eggs, broiled fresh fish, &c  Acrid, acescent, and irritatuif
aliments, and acids are to be carefully avoided.  The drink ought to be in moderate quantity,
but rich and strong j as mild ale, port wine and water. With respect to the regimen proper for
convalescents from intermittents, it may suffice to observe, that sleep may be indulged in. Ex.
ercise without fatigue is of great use, either by walking, by riding on hor>eback, or in a carriage, 
PRACTICE  OF  PHYSIC.             <u
   233.]  Our second general indication for conducting the
 f>aroxysms of intermittent fevers, so as to obtain a final so-
 ution of the disease, may be answered,
   1.  By exhibiting emetics during  the  time of the cold
stage, or at the beginning of the hot.
   2.  By opiates given during the time of the hot stage.*
   234.]  The circumstances which may  especially prevent
the fulfilling of those too indications,  and therefore give
occasion to  our third, are a phlogistic diathesis  prevailing
in the system, and congestions fixed in  the abdominal vis-
cera.  The first must be removed  by blood-letting and
the antiphlogistic  regimen ;   the second by vomiting and
purging.
   Where these measures are not immediately effectual,  I
hold it safer to attempt  the  cure of the  disease  by the
tneans pointed out in general in 229,  rather than by those
in article second of the same paragraph.
according to the strength of the patient.  But above all, cold must be carefully avoided ; for no-
thing more effectually produces a relapse than an imprudent exposure to cold damp air, or a
neglect in keeping the body properly clothed.  The practice of giving purges after the cure of
intermittents is highly blameable, and is frequently the cause of a relapse.  Should costiveness
be troublesome, it may be removed by very mild emollient giysters.
  • This practice of giving vomits in the end of the cold stage and an opiate after their opera-
tion, is old.  It is mentioned by Sydenham, Boerhaave, Van Swieten, and most practical wri-
ters. It must not, however, be indiscriminately used. It is seldom attended with any salutary
effect, except in vernal intermittents, and in the earlier periods of the disease; and it is constant-
ly attended with disadvantage when the disease has been of long continuance.
                   BOOK   II.
OF INFLAMMATIONS, OR PHLEGMASIA.
                     CHAPTER I.

      OF INFLAMMATION IN GENERAL.
                       SECTION  I.

         Of the Phenomena of Inflammation.

235.] TT7HEN any part upon the surface of the body is
       VV  affected with unusual  redness, heat, pain  and
tumor, we name the disease an Inflammation or  Phlegma-
sia.   These symptoms of inflammation are never consider- 
 92            PRACTICE OF PHYSIC.

 able, without the whole system being, at the same time, af-
 fected with p3Trexia*
   23G.] As the external, so likewise the internal parts may
 be affected with inflammation; and we judge them to be so,
 when, together with pyrexia,  there is a fixed pain in any
internal part,  attended with some interruption in the exer-
cise of its functions.
   237.] We judge of the  presence of inflammation also
from the state  of the blood drawn out of the veins.  When
the blood, after cooling and concreting, sliows a portion of
the gluten separated from the rest of the mass, and lying
on the  surface of the crassamentum;  as such separation
happens in all cases of more evident phlegmasia; so, in
ambiguous cases, Ave,  from this appearance, joined  with
other symptoms, infer  the  presence of inflammation.  At
the same time, it must be  observed  that as several cir-
cumstances in blood-letting, may  prevent this  separation
of gluten  from taking place in blood otherwise disposed to
it; so, from the absence of such appearance, we cannot
always conclude against the presence of inflammation.
   238.] I cannot easily give any other general  history of
the phenomena of inflammation than what is contained in
the three preceding paragraphs ; and the variations which
 may take place in its circumstances, will occur to be  more
properly taken notice of under the several heads of the par-
ticular genera and species to be hereafter mentioned, I pro-
 ceed, therefore, to inquire into the proximate cause of in-
 flammation in  general.
                   SECTION II.

     Of the Proximate Cause  of Inflammation.

  239.] The pheaomena of inflammation (235.) all concur
in showing, that there is ah increased impetus of the blood
in the  vessels  of the part affected;  and as,  at the same
time, the action of the heart is not always evidently increas-
ed, there is reason to presume,  that the increased impetus
of the bloud in the particular part is owing especially to
the increased action of the  vessels of that part itself.
  240.] The cause of this increased action in the vessels of
a particular part is, therefore, what  we  are to consider as
the proximate  cause of inflammation. 
              PRACTICE OF PHYSIC.             93

  In many cases, we can manifestly perceive, that inflam-
mation arises from the application of stimulant substances
to the part.   When the application  of such stimulants,
therefore, is evident, we seek for no other cause of inflam-
mation ;  but as, in many cases, such application is neither
evident,  nor, with any  probability,  to be  supposed,  we
must in such  cases, seek for some other cause of the increas-
ed impetus of the blood in the vessels of the part.
   241.]  Many ph)Tsicians have supposed, that an obstruc-
tion of the extreme vessels, any how produced, may prove
a cause of inflammation; and particularly, that this may
arise from an obstruction formed by a matter stopping up
these vessels. But many difficulties attend this doctrine.*
   1. The opinion seems chiefly to have arisen from the ap-
pearance of  the blood described in (237.)  when the sepa-
rated gluten was considered as a preternatural and morbid
matter;  but we now know very certainly, that  this gluten
is constantly a  constituent part of the human blood; and
that it is only  a peculiar separation of the parts  of the
blood that happens in  consequence of inflammation and
some other circumstances, which gives occasion to the ap-
pearance that was falsely considered as a mark of a mor-
bid lentor in the blood.
   2. There are no experiments directly in proof of a pre-
ternatural lentor prevailing  in the mass 1 of blood;  nor is
there any evidence of certain parts of the blood occasion-
ally acquiring a greater density and force of cohesion than
ordinary; neither is there any proof of the denser or more
 coherent parts being present  in the mass of blood, in such
 greater  proportion than usual, as to occasion a dangerous
 spissitude.   The experiments of Dr. Browne Langrish on
 this subject  afford no conclusion, having  been  made on
 certain parts of the blood separated from the rest, without
 attending to the circumstances of blood-letting, which very
 much alter the state of the separation and coucretion of the
 blood drawn out of the veins.
   3. The supposition of a preternatural lentor or viscidity
 of the blood, is not well founded ;  for it is probable, that
 nature has specially provided against a state of the fluids,
 so incompatible with  the exercise  of the most  important
functions of the animal economy.  While motion continues
to prevent any  separation of parts, and heat continues to
  • This is the Boerhaavian doctrine which the author here refutes, many objections might be
made against several parrs of this refutation; but toexamine it minutely, is foreign to my pur-
pose, and would require more room than the narrow limits of these notes can possibly allow. 
94
PRACTICE OF  PHYSIC.
preserve the fluidity of the more viscid, there seems to  be
always so large a proportion of water present as to give a
sufficient fluidity to the whole.  1 must own that this is not
absolutely conclusive ; but I still repeat it, as giving a pro-
babilitv to the general argument.
  4. In the particular case of inflammation, there are se-
veral circumstances which render it probablethat the blood
is then more fluid than usual.
  5. I presume that no such general lentor, as Boerhaave
and his disciples have  supposed, does ever take place ; be-
cause if it did, it must shew more considerable effects than
commonly appear.
  6. Besides the supposition of an obstructing lentor, phy-
sicians have supposed, that an obstruction may be formed
by an impermeable matter of another kind,  and that  such
an obstruction  may  also be  tire  cause of inflammation.
This supposition is what is well known in the schools un-
der the title of  an  error loci; but it is an opinion that 1
cannot find to be at  all probable ; for the motion of the
blood in the  extreme  vessels is so weak and slow, as rea-
dily to admit a retrograde course of it; and  therefore, if
a particle of blood should happen  to enter a  vessel whose
branches will not allow of  its passage, it will  be  moved
backwards, till it meet with a vessel fit for transmitting it;
and the frequent ramifications and anastomoses  of the ex-
treme arteries are very favorable to this.  I must own in-
deed, that this argument is not absolutely conclusive; be-
cause I allow it to be  pretty certain that error loci,  does
actually upon occasion happen ; but for the reasons I have
given, it is  probable  that it seldom happens,  and is there-
fore rarely the cause of inflammation ; or if it  be, that it
is  not merely by the obstruction that it  produces ; as,
among other reasons,  I conclude particularly  from the fol-
lowing argument.
  7. Though an obstruction should be supposed to  take
place, it will not be sufficient  for producing  the effects,
and exhibiting the phenomena, that appear in  inflamma-
tion.  The theory that has  been commonly employed on
this occasion is by no means satisfying ;  and, in fact, it
appears, from many observations  and experiments, that
considerable obstructions may be formed,  and  may  sub-
sist, without producing the symptoms of inflammation.
  242.] Obstruction,  therefore, from a matter stopping up
the vessels, Gaub. Pathol. 249. i.  is not to be considered as 
               PRACTICE OF PHYSIC.            95

the primary cause of inflammation ; but at the same time,
it is sufficiently probable, that some  degree of obstruction
does take place in every case  of inflammation.   The dis-
tension, pain, redness and tumor,  attending inflammation,
,are to be explained only by supposing, that the extremities
of the arteries do not readily transmit the unusual quantity
of blood impelled into them by the increased action in the
course of these vessels.   Such an obstruction may be sup-
posed to happen  in every case of an increased impetus of
the blood ; but it is probable, that in the case of inflamma-
tion , there is also a preternatural resistance to the free pas-
sage of the fluids.
   243.]  From the doctrine of fever, we are led to believe,
that an increased action of the heart and arteries is not sup-.
ported for any length of time by any other means than  a
spasm affecting the extreme vessels; and that the same spasm
takes place in inflammation seems likely, because that eve-
ry considerable inflammation is introduced by a cold stage,
and is accompanied  with that and other circumstances of
pyrexia.  It seems also probable, that  something analo-
gous to this occurs even in the case of those inflammations
which appear less considerable, and to be purely topical.
   544.]  From all this, the nature of inflammation may in
many cases be explained in the following manner.   Some
causes of inequality in  the distribution  of  the blood .may
throw:an unusual quantity of it upon particular vessels, to
which it must necessarily prove a stimulus.   But, further,
it is probable, that, to relieve the congestion,  the vis  me-
dicatrix naturae increases still more the action of these ves-
sels ; and which, as in all other febrile diseases,  it effects
by the formation of a spasm on their extremities.
   245.]  A spasm of the extreme  arteries., supporting an
increased action in the  course of them,  may  therefore be
considered as  the proximate cause of inflammation ; at least,
in all cases not arising  from  direct*, stimuli applied ; and
even  in this case the stimuli may be supposed to produce a
spasm of the extreme vessels.
   246.]  That, in inflammation,  there is the concurrence
of a constriction  of the extreme vessels, with an  increased
action in the other parts of them, seems probable, from the
consideration  of  Rheumatism.   This is a species of inflam-
mation which is often manifestly produced, either by  cold
applied to over distended vessels, or  by causes of an in-
creased impetus,  and over distention  in vessels previously 
96             PRACTICE OF PHYSIC.

constricted.  Hence the disease especially appears at sea-
sons liable to frequent and considerable vicissitudes of heat
and cold.
  To this we may add,  that the parts of the body most fre-
quently affected with inflammation, are those exposed, both
to over distention, from a change in  the distribution of the
fluids,  and, at the same time,  to the immediate action of
cold.  Hence,  quinsies, and pneumonic inflammations, are
more frequent than any  others.
  247.] That a spasm of the extreme vessels takes place in
inflammation, is to be further presumed from  what is at the
same time  the state of the whole arterial system.   In  every
considerable inflammation,  though arising in one part only,
an affection is communicated to the whole system, in conse-
quence of which  an inflammation  is  readily produced  in
other parts beside that first affected.   This general affection
is well known  among physicians, under the name of the
diathesis  phlogistica.   It appears  most commonly  in
persons of  the most rigid fibres : is often manifestly  indu-
ced by the  tonic or astringent powers of cold ; is increased
by  all tonic and stimulant powers applied to the body ; is
always attended with a hardness  of the pulse ; and is most
effectually taken off by the relaxing power of blood-letting.
From these  circumstances,  it seems probable, that the dia-
thesis phlogistica consists hi an increased tone, or contracti-
lity, and perhaps in an increased contraction of the muscu-
lar fibres of the whole arterial system.  Such a state of the
system seems often to arise,  and subsist for some time, with-
out the apparent inflammation  of any particular part; but
such a state of the system renders it likely, that a spasm may
at the same time readily arise in any of the extreme vessels,
and  a  particular inflammation be there produced. It does,
however, appear also, that the general diathesis  frequently
arises from inflammation begun in a particular part.
  248.] I have  thus endeavored, in  the case of  inflamma-
tion, to explain the state of the whole system, as well as that
of the  part more particularly affected.  The latter I have
considered  as when in its first formation ; but after  it has
subsisted for some time, various changes  take place in the
part affected ; and of these I must now take notice.
6 
PRACTICE  OF PHYSIC.            91
                    SECTION III.

       Of the Terminations of Inflammation.

  249.] IF an inflammation be cured  while the state  and
texture of the part remain entire, the disease is said to be
terminated by7 resolution.
  This happens when the previous congestion and spasm
have been in  a moderate degree, and the increased impetus
of the blood  has been sufficient to overcome the spasm, to
dilate the vessels and to remove the congestion  so  that the
part is restored to its ordinary and healthy state.
  A resolution takes place also when the increased impetus
of the fluids has produced an increased exhalation into the
adjoining  cellular  texture, or an  increased excretion in
some neighboring  part, and has thereby relaxed the spasm,
and relieved  the congestion, in the vessels of the part more
particularly affected.
  Lastly,  A resolution may take .place, when the increased
impetus of the blood in the whole system occasions an eva-
cuation,  which, though in a distant part, may prove suffi-
cient to take  off the phlogistic diathesis of the whole system,
and thereby  relieve the congestion and spasm of the parti-
cular part affected by inflammation.
 . 250.]  The tumor which appears in inflammation may be
imputed  in part to the congestion of fluids in their proper
vessels ; but is owing chiefly to an effusion of matter into the
adjoining  cellular  texture; and, accordingly,  tumors sel-
dom  appear  but in parts adjoining to a lax cellular texture.
If,  in this case,  the matter effused be only a larger quantity
of the ordinarv exhaling fluid, this, when the free circula-
tion in the vessels  is restored, will  be readily absorbed, and
the state of the part will  become the same as before.  But,
if the increased impetus of the  blood  in an inflamed part,
dilate the exhalant vessels to such a degree, that they pour
out an entire serum,  this will not be so readily  reabsorbed ;
and,  from the experiments  of Sir John Pringle, and espe-
cially from those of Mr. Gaber, Miscell. Taurin. Vol. II.
we learn,  that the serum, under stagnation, may suffer a
particular change,  by having the gluten present in  it chang-
ed  into  a white,  opaque, moderately viscid, mild liquor* 
93
PRACTICE OF PHYSIC.
 which we name pus.  When this change takes place in the
 inflamed part, as it is  at the same time  attended with an
 abatement of the redness, heat, and pain, which before dis-
 tinguished the inflammation, so the disease is said to be ter-
 minated by suppuration ;  and an inflamed part, contain-
 ing a collection of pus, is called an abscess.
   251.] In inflammation, the tendency of it to suppura-
 tionmay be discovered by the long continuance of the in-
 flammation, without the symptoms of resolution; by some
 remission of the pain of distention; by the pain becoming of
 a throbbing kind, more distinctly connected with the pul-
 sation of the arteries being fuller  and softer ;  and often by
 the patient's being frequently affected with cold shiverings.
 The  period at which this takes place is not determined,
 but may be sometimes sooner, sometimes later.  When the
 tendency is determined, the time necessary to a complete
 suppuration is different in different cases.
   When pus is completely formed, the pain in  the  part
 entirely ceases, and a  weight is felt in it.   If the collection
 be formed immediately under  the skin, the  tumor  be-
 comes pointed, the part becomes soft,  and the fluctuation
 of the fluid within can commonly be perceived;  while  at
 the same time, for the most part, the redness of the skin
 formerly prevailing  is  very much gone.
   252.]  In abscesses, while  the pus is formed of one  part
 of the matter which had been effused, the other and thin-
 ner parts are reabsorbed, so  that in the abscess, when open-
 ed, a pus alone appears.  This pus, however,  is not the
 converted gluten alone ; for the conversion of this being
 the effects of a particular fermentation, which may affect
 the solid substance of  the part, and perhaps every solid of
 animal bodies; so it most readily, and particularly, effects
 the cellular texture, eroding much of it, which  thereby
 becomes a part of the pus.   It generally happens also, that
 some  of the smaller red vessels are eroded,  and thereby
 some red blood often appears mixed with the pus in absces-
ses.   Upon the whole, the internal surface of an abscess
is to be considered as an ulcerated part.
   253-3  This account of suppuration explains, why an ab-
scess, when formed, may either spread into the cellular
texture of the neighboring parts ; or by eroding the incum-
bent teguments, be  poured  out upon the surface of the bo-
dy, and produce an  open ulcer.
  25 K]  We have here given the idea of an abscess  as a 
PRACTICE  OF PHYSIC.
99
collection of matter following inflammation ; but the term
has been applied to every collection of.matter effused, and
changed by stagnation in an inclosed cavity.
  The  matter of abscesses, and of the ulcers following
them is various, according to the nature of what is effused,
and which may be,
  1. A matter thinner than serum.
  2. An entire and pure serum.
  3. A quantity of red globules.
  4. A matter furnished by particular glands seated in the
part.
  5. A mixture of matters from different sources, changed
by peculiar fermentation.
  It is the second only which affords a proper pus; the ef-
fusion whereof, whether in  suppurating parts  or  ulcers,
seems to be the peculiar effect of an inflammatory state of
the vessels ; and for this reason it is, that, when ulcers do
not produce a proper pus, a circumstance always absolute-
ly necessary to their healing, we in many cases, bring the
ulcers to a state of proper suppuration,  by the application
of  stimulants  exciting inflammation,  such  as balsams,
mercury, copper, &c.
  255.]  When the matter effused into the cellular texture
of an inflamed part, is tainted with a putrid  ferment, this
produces in the effused matter, a state approaching  more
or less to that of  putrefaction.   When this is  in a mode-
rate degree, and  effects only the fluids  effused, with the
substance of the cellular texture,  the part is said to be af-
fected with gangrene ; but if the putrefaction affect also
the vessels and muscles of the part, the disease is said to be
a sphacelus.
  256.]  A gangrene, and its consequences, may arise from
a putrid ferment  diffused in the  mass of  blood, and poured
out with the serum effused, which it operates upon  more
powerfully while the serum  is stagnant, and retained in the
heat of the body : but it may also arise from the peculiar na-
ture of the matter effused being disposed to  putrefaction ;
as particularly seems to be the case  of the red globules of
the blood effused in a large  quantity.  In a  third manner
also,  a gangrene seems frequently to arise from the violent
excitement of the inflammation  destroying the tone of the
vessels ; whereby the whole  fluids stagnate and run into pu-
trefaction, which taking place in any degree,  destroys still
further the tone of the vessels, and spreads the gangrene. 
100
PRAOtlCE  OF PHYSIC.
  257.] In inflammation, the tendency to gangrene may be
apprehended from an extreme violence of pain  and heat in
the inflamed part, and from a great degree of pyrexia at-
tending the inflammation.
  The actual coming on of gangrene may be perceived by
the color of the inflamed part changing from a clear to a
dark red  ; by blisters arising upon the part; by the part be-
coming soft, flaccid, and insensible; and by the ceasing of
all pain while these appearances take place.
   As the gangrene  proceeds, the color of the  part becomes
livid, and'by  degrees quite black ;  the heat of the part en-
tirely ceases ; the softness and flaccidity of the part inci ease;
it loses its consistence, exhales a cadaverous smell, and may
then be considered as affected with  sphacelus.
   258.]  Gangrene is thus  a third manner in which inflam-
mation terminates ;  and the schools have commonly marked
a fourth  termination of inflammation ; which is, by a  scir-
rl'ius, or  an indolent hardness of the part formerly  affected
with inflammation.   This  however, is  a  rare occurrence,
and does not seem to depend so much upon  the nature of
inflammation, as upon the  circumstances of the part affected.
It is in glandular parts chiefly  that scirrhosity is  observed ;
and it is probably owing to the parts readily admitting  a
stagnation of the fluids.  I have observed,  that  inflamma-
tion seldom induces scirrhus ; but that this more commonly
 arises from other causes; and when inflammation supervenes,
 which it is sooner or later apt to do, it does  not so common-
 ly increase, as change the scirrhosity into some kind of ab-
 scess. From these considerations it does not seem necessary
 to take any further  notice of scirrhus as a termination of in-
 flammation.
   259.] There are,  however, some other  terminations  of
 inflammation, not  commonly taken notice of, but now  to-
 be mentioned.
   One is, by the effusion  of a portion of the  entire mass  of
 blood,  either by means of rupture or  of anastomosis, into
 the adjoining cellular texture.  This happens especially in
  inflammations of the lungs, where the effused matter, by
  compressing  the vessels,  and  stopping the circulation, oc-
 casions  a fatal suffocation ; and this is perhaps the manner
  in which pneumonic inflammation most commonly proves
  fatal.
    260.] Another kind of termination is, that of certain
  inflammations on the surface  of  the  body,  when there is 
PRACTICE OF  PHYSIC.
101
poured out under the cuticle a fluid, which being too gross
to pass through its  pores, therefore separates  it from the
skin,  and raises it up into the form of a vesicle containing
the effused  fluid ; and  by which effusion the previous in-
flammation is taken off.
  261.]  Beside these already mentioned,  I believe there is
still  another manner in which inflammation terminates.
When the  internal  parts  are affected with  inflammation,
there seems to have been almost always upon their surface,
en exudation, which appears partly as a viscid concretion
upon their surface ;  and partly as a thin serous fluid effused
into the cavities in which the  inflamed viscera are placed.
Though we have become acquainted with these appearances
only, as very constantly accompanying those inflammations
which have proved fatal, it is however  probable, that like
circumstances may have attended  those which  were  termi-
nated by  resolution, and may have contributed to that event.
It is in favor of this supposition that there are instances of
pneumonic inflammation terminating in a hydrothorax.
                    SECTION IV.

      Of  the  Remote  Causes of Inflammation.

   262.] THE remote causes of inflammation may be  re-
duced to five heads.
   I.  The application of stimulant substances ; among which
are to be reckoned the action of fire, or burning.
   2.  External violence  operating mechanically  in wound-
ing, bruising, compressing, or overstretching the parts.
   3.  Extraneous substances, lodged in any  part of the bo-
dy, irritating  by their  chemical acrimony  or  mechanical
form, or compressing by their bulk or gravity.
   4. Cold, in a certain degree, not sufficient immediately
to produce gangrene.
   5. An increased impetus of the  blood determined to a
particular part.
   It will not be difficult to understand how these  remote
causes,  singly, or in concurrence,  produce  the  proximate
cause of inflammation.
  263.]  It does not appear, that in different cases of inflam-
mation,  there is any difference in the state of the  proximate*
                           o 
102            PRACTICE OF PHYSIC,
cause, except in the degree of it;  and though some differ-
ence of inflammation may arise from the difference  of the
remote  causes, yet this is not  necessary  to be taken  notice
of here; because the different appearances which  attend
different inflammations may be referred, for the  most part,
to the difference of the part affected ; as will  appear when
we shall consider the several genera and species  marked in
the Nosology.   When I come  to treat of these,  I shall find
a  more proper occasion  for taking  notice of the  different
states of the proximate, or of  the differences of  the remote
cause,, than by treating of them in general here.
                     SECTION V.

            Of the Cure of Injlammation.

  264.]  THE indications of cure in  inflammation are dif-
ferent, according as it may still be capable of resolution,  or
may have taken a tendency to the several other terminations
above  mentioned.   As the tendency  to these  terminations
is not always immediately evident, it is always proper, upon
the first appearance of inflammation,  to attempt the cure of
it by resolution..  For thi& purpose,  the indications of cure
are,
   1. To remove the remote causes,  when they are evident,
and continue to operate.
 , 2. To take off the phlogistic diathesis affecting either the
whole system, or the particular part.
  3. To take off the spasm  of the  particular part,  by re-
medies applied either to the whole system,  or to  the part
itself.
   265.]   The means  of removing the remote causes will
readily occur, from considering the particular nature and
circumstances of the  different kinds.   Acrid matters  must
be  removed,  or their action must be prevented, by  the ap-
plication of correctors or  demulcents.*  Compressing and
overstretching powers must be taken away ;  and, from their
several circumstances, the means of doing so will be obvious.

  * If the matter causing the inflammation be an acid, then the application Of an alkaline sub-
stance will be proper : If, on the contrary, the inflammation'be produced by an alkali/then an
acid must be applied. In many oases, however, the acrid substances causing inflammation
are neither alkafine nor acid : and, in such cases, or when we cannot find a proper corrector*
we must use demulcents, which by their outunding quality, sheath the acrimony, or defend
 the parts to which they are apphed from being irritated orCorroded   •^"'"«ur» « unwu* 
                     PRACTICE  OF PHYSIC.              103


     266.]  The means  of taking  off the  phlogistic  diathesis

  of the system,  are the same with  those for moderating the

  violence  of reaction  in  fever,  which  are  mentioned  and

  treated of  from  (127  to 159,)  and therefore need not be re-

  peated here.   I  only  observe,  that in the  use of those reme-

.  dies,  there is less occasion  for any  reserve  than  in  many

  cases  of fever ;  and   more particularly, that  topical bleed-

  ings*  are here particularly indicated and proper.

     267.]  The means  of taking off the spasm  of the  parti-

  cular part  are nearly the same  as those mentioned above, for

  taking  off  the spasm of the  extreme  vessels in  the case of

  fever, and  which are treated of from  (150. to 200.)   Only

  it  is observed here,  that some  of  these  are  here  especially

  indicated,  and  that  some  of  them are to be directed more

  particularly to the part especially affected ; the management

  of which will be more properly considered when  we shall

  treat  of particular inflammations.f

     268.]  When a tendency to suppuration  (251.) is distinct-

  ly perceived, as we suppose it to  depend upon  the effusion



   * The  advantages of topical bleedings, in most cases of local inflammation are very great.
  They may be. performed by cupping, or what is in many cases more preferable,  by leeches.
 -Cuppingacts sometimes as a stimulus, especially on parts which are tendonous  or fleshy, or
  where the cellular substance is tliin, and thus frequently increases  the inflammation which we
  would wish to resolve
   + The resolution of an inflamed pirt is considerably assisted  by the, application of discuti-
  ents; and in most cases when the general system is not  affected,  these  discutients alone fre-
  ■quently  succeed in dissolving an incipient phlegmon.  Solutions of lead in vinegar are the ap-
  plications which the best modern practitioners generally approve.  Goulard's extract  was sup-
  posed by the vulgar to be a new remedy ;  and  his panegyric on it, tended in  a considerable
  degree to render the use of lead more universal  than it had been before his time. There are,
  however, many weighty objections against the formula used by that gentleman ; the chief one
  is, that on account of the different strength of the vinegar employed, and of the degree of heat
  used in the process, we can nevei accurately ascertain the quantity  of lead  dissolved in. the
  acid ; and consequently the efficacy of this preparation must  be uncertain. The Saccharum
  Saturni,  which is always of the same strength, is  therefore preferable to Goulard's extract: and
  as  vinegar is a powerful discutient itself; it has  been usual to add a quantity of vinegar to
  the solution of the sugar  of lead in distilled water. The following proportions bave Been
  -found in general to be the-best:
                  ft.  Sacchar. Saturn. §i.

                      Acet. Gallic, opt. §iv.

                      Aq. font, distillatac Sxxxii.

                      M.
  In the application of this solution, it is of great consequence that tire parts affected should be
  continually moistened with it. Poultices made of fresh bread crumb, and as much of the'above
  solution as is necessary, are in general preferable to any other mode of applying it; but it
  sometimes happens that the inflamed part is so extremely painful and tender, as not to bear
  the great weight of a poultice ; and in such cases we must nave recourse to pieces of soft linen,
  moistened with the solution.  Both these applications, viz. poultices, or wet pledgets, must al-
  wavsbe applied cold, and be frequently renewed when they become warm, hard or stiff. This
  is the most approved method of applying lead for the purpose of resolving inflammations; yet
  it frequently happens that practitioners meet with patients whose prepossessions  for a popular
  remedy are so great that there is no persuading them  from using it.  The method of making
  Goulard's extract and Vegeto-Mineral Water are therefore subjoined,
                    Take Litharge of Gold,  one pound,
                    French White-Wine Vinegar, a quart,
  Boil them in an earthen vessel, on't slow fire, for an hour and an half; constantly stirring them
  with a wooden spathula, and wherf cold, pour off the clear liquor, which must be kept m well
  stopped glass phials.  The Vegeto-Mineral water is  made by adding a hundred drops oi the
  above extract to a o,i»it of water, and four tea-spoonfuls of French ilrandy. 
104             PRACTICE OF  PHYSIC.

of a fluid which cannot be easily reabsorbed,  so it becomes
necessary that  this fluid be converted into  pus,  as the only
natural means of obtaining its evacuation ; and as  the effu-
sion  is, perhaps, seldom made without some rupture of  the
vessels, to the healing of  which a  pus  is  absolutely neces-
sary  ;  so, in the case   of a tendency  to suppuration,  the
indication of cure always is, to promote the  production of
a perfect pus as quickly as  possible.
   269.]  For this  purpose,  various  remedies, supposed to
possess a specific power, have been proposed; but I can per-
ceive no such power in any of them; and in my opinion,
all that can  be done is, to favor  the  suppuration by such
applications as may  support a proper  heat in the part, as
by some tenacity, may confine the perspiration of the part,
and as, by an emollient quality, may weaken the cohesion
of the teguments, and favor their erosion.*
   270.] As, in  the case of  certain effusions,  a suppuration
is not only unavoidable, but desirable,  it may be supposed,
that  most of the means of resolution  formerly  mentioned
should  be avoided ;  and  accordingly our practice is  com-
monly so directed.   But as we observe,  on the  one  hand,
that  a certain degree of increased  impetus, or of the origi-
nal circumstances of inflammation,  is  requisite to  produce
a proper suppuration ;  so  it is then especially necessary to
avoid those  means of resolution that may diminish  too much
the  force of the circulation.   And as, on the  other hand,
the impetus of  the blood, when violent, is found to prevent
the proper suppuration ;  so, in such cases, although a ten-

  f Poultices of various kinds have been recommended for this purpose? It is however,  of
little consequence what their ingredients arc, provided they be emollient,  and applied warm.
The white bread poultice is in common-use, and answers in general very well; the addition of
a little oil keeps it from becoming hard, and is at the same time serviceable as an emollient.
A poultice of bruised lintseed well boiled with  milk and water is strongly recommended by
some writers, and indeed not  without reason, on account of its very great emollient quality.
  As heat is absolutely necessary for the production of-matter in tumors, it is of great  conse-
 quence that the poultices should not be suffered to cool on the part, and that they should be
 often renewed.  Mr. Bell has given  excellent directions for applying poultices, with the  inten-
 tion of promoting suppuration.                                      I
  " Warm fomentations and poultices,  (says that rational practitioner) are the means usually
 employed for the application of heat to an inflamed  part; and when these are regularly and
frequently renewed, nothing, it,is probable, can more effectually answer the purposif.  But  in
 ihe ordinary manner in which they are applied, and as the cataplasms are renewed <|nly once,
 or at most twice a day, they mus^ always, it is imagined, do more harm  than gooif.  For as
 soon as the degree of heat they at first possessed is dissipated, the moisture kept up by them,
 with the consequent evaporation that ensues, must always render the part much colcerthan if
 it had been merely wrapped up in flannel, without the use of any such application.
   " In order to receive all theadvantages of such remedics,the part aflected should be well
 fomented with flannels, pressed out of any warm emollient decoction, applied as warm  as the
 patient can easily bear them, continued at least half an hour at once, and repeated four or five
 times a day.
   «' Immediately after the fomentation is over, a large emollient poultice should likewise  be
 applied warm, and renewed every second or third hour at farthest. Of all the torms recom-
 mended for emollient cataplasms, a common bread and milk poultice, with a due proportion of
 butter or oil, is perhaps the most eligible ; as it not only possesses all the advantages  of the
 others, but can at an times be more easily procured."—Treatise on Ulcers, Edition of 1787, p. 67. 
                  PRACTICE  OF  PHYSIC.            10S

dency to suppuration may have begun, it may be proper to
continue those means of resolution which moderate the force
of the circulation.
  With  respect  to the opening of abscesses, when com-
pletely formed,  I refer to the writings on surgery.*
   271.]  When  an inflammation has taken a  tendency  to
gangrene,  that event is to be prevented by every possible
means;  and  these must be different, according to the na-
ture of  the several  causes occasioning that tendency,  as
may be  understood  from what has been already said  of
them.   After a grangrene has, in some degree, taken place,
it can  be  cured only by the separation  of the dead from
the living parts.   This,  in certain circumstances,  can be
performed by the knife,  and always most properly, when
it can be so done.
   In other cases, it  can be done by exciting a suppuratory
inflammation on the verge of the living part, whereby its
cohesion with the dead may be every where broken off, so
that the latter may  fall off by itself.   While this is doing,
it is proper to prevent the further putrefaction of the part,
and its spreading wider.   For  this purpose, various anti-
septic applications have  been proposed:  But it appears to
me, that,  while the teguments are entire,  these applications
can hardly have any effect;  and,  therefore,  that the  fun-
damental  procedure must be  to scarify the  part so as to
reach the living substance, and, by  the wounds made there,
to excite the suppuration required.  By  the same incisions
 also, we give access  to  antiseptics,  which may  both  pre-
 vent the progress  of the putrefaction in the dead,  and ex-
 cite the inflammation necessary on the verge of the living
 part.f

  • Fora particular account of knowing when abscesses are completely formed, at what perioj
they ought to be opened, and the manner of opening them, the reader can consult no author
.preferable 10 Mr. Bell.
  + The author mentioned in the preceding note treats this subject in his usual rational man-
 ner; and with noiess perspecuity than judgment. Contrary to the opinion of all former wri-
 ters on gangrene, he disapproves of scarifications, and the subsequent application of antiseptics
 and stimuants.   Mr. Bell's reasoning against this practice is to the following purport: The de-
 gree of inflammation requisite,  and indeed necessary, for the separation of the dead parts, is
 only very slight, and when too violent, it fails to produce the desired effect. Scarifications, and
 the'subsequent application ot stimulants, which increase the inflammation too much, are there-
 fore hurtful. Again, in scarifying, there is a considerable risk of wounding large blood vessel.*,
 nerves or tendons; besides the disadvantage of allowing the putrescent fluids of the gangrene
 fo enter more freely the sound parts,by increasing the surface of the wound.  With respect to
 the application of antiseptics, it is justly remarked, that although these medicines have the qua-
 lity of preserving dead animal substances from corruption, they by no means produce the same
 effect on living animal substances. But the concluding argument is of much greater  weight,
 viz that, in a long course of extensive practice, no advantages ever accrued from scarification.
  These objections against promiscuous scarification were firs; proposed by Mr. Bell in his Trea-
 tise on Ulcers, about Yl years ago; and the novelty of the opinion excited the attention of al-
 most every practitioner.  At present, however, it is universally adopted, and would of itself,
 independent of the many improvements Mr. Bell has made in surgery, perpetuate his justly ac-
 quired fame. 
 106           PRACTICE OF  PHYSIC.

   272.] When the gangrene proceeds from a loss of tone;
 and when this, communicated to the neighboring parts,
 prevents that inflammation  which, as I have said, is neces-
 sary  to the  separation of the dead  part from the living ;
 it will be  proper to obviate this loss of tone, by tonic medi-
 cines  given  internally; and,  for this purpose,  the Peru-
 vian bark has been found to be especially effectual.   That
 this medicine operates  by a tonic power, 1 have endeavor-
 ed to prove  above,  (214.)  and from what is said  in 215.
 the limitations to be observed  in employing it may also be
 learned.  When the gangrene arises from the violence  of
 inflammation,  the  bark may not only fail  of  proving a
 remedy,  but may  do harm:  and its power as  a tonic  is
 especially suited to those cases of gangrene which proceed
 from an original loss of tone,  as  in the case of palsy and
 oedema; or to those  cases of  inflammation  where a loss
of  tone takes place,  while  the original  inflammatory
 symptoms are removed.*
   273.] The other terminations of inflammation either do
not admit of any treatment, except that of preventing them
by the means of resolution ;  or they belong to a treatise  of
surgery, rather than to this place.
   Having thus, therefore, delivered  the  general doctrine,
I proceed  now to consider the particular genera and species
of inflammation.
   It has been hinted above (263.)  that the difference of in-
flammation arises  chiefly from the difference of the part
affected :  I have therefore  arranged  them as  they  are cu-
taneous,  visceral, or articular;  and in this  order they
are now to be considered.
                     CHAPTER  II.

    OF INFLAMMATION,  MORE STRICTLY
                     CUTANEOUS.

  274.] /CUTANEOUS inflammations are of two kinds,
        V>> commonly distinguished by  the  names  of
phlegmon and erysipelas.

 * The bark must be given in these cases in large quantities ; and as the pulse is in general
rery small, Port wine must be used along with it. Beside the use of these remedies a good
nourishing diet is absolutely requisite, with such a quantity of strong generous wine as is suffi-
cient to keep up the pulse, and induce the necessary slight degree of inflammation  When in-
deed the patient is extremely languid, and much reduced, the warm stimulating cordials, as
camphor, confectio cardiaca, spiritus aromaticus volatilis,  ice. may be used with advantage. 
PRACTICE  OF PHYSIC.
107
  Of the latter there are two cases, which ought to be dis-
tinguished by different appellations.   When the disease is
an affection of  the skin alone, and very little of the whole
system, or when the affection of the system is only symptom-
atical of the  external inflammation, I shall give the disease
the name of erythema ; but when the external inflamma-
tion is an exanthema, and symptomatica! of an affection of
the whole system, I shall then name the disease erysipelas.*
  275.] It is the erythema only that I am to consider here.
  For the distinction between Erythema and Phlegmon, I
have  formerly referred to the characters given of  them in
our Nosology.   See Synops. Nosolg. Meth. Vol.  II. p. 5.
gen.  vii. spec. 1. and 2.   But I think it proper now to de-
liver the characters of them  more fully and exactly here, as
follows.
  A phlegmon is an  inflammatory affection of the skin, with
a swelling, rising generally to a more considerable eminence
in the middle of it;  of a bright  red color ; both the swel-
ling  and  color  being  pretty exactly circumscribed ;  the
whole being  attended with a pain of distention, often of a
stounding or throbbing kind, and frequently ending in sup-
puration.
   An Erythema, Rose, or St. Anthony's fire,  is an inflam-
matory affection of the skin, with hardly any evident swel-
ling ; of a  mixed and  not very bright red color, readily
disappearing upon pressure,  but quickly returning  again ;
 the  redness of no regular  circumscription, but spreading
 unequally and  continuing almost constantly to spread upon
 the neighboring part; with a pain like to that from burning -r
 {)roducmg blisters,  sometimes of a  small, sometimes of a
 arger size; and always ending in a desquamation of  the
 scarf-skin, sometimes in  gangrene.
   This subject  I am not to prosecute here, as properly  be-
 longing to surgery,  the business of which I  am seldom to
 enter upon in this work ;  and shall therefore observe only
 as necessary here, that the difference of these appearances
 seems to depend  on the different  seat of the  inflammation.
 In the phlegmon, the inflammation seems to affect especially
 the vessels on the internal surface of the skin communicating
 with the lax subjacent  cellular  texture ; whence a more
 copious effusion, and  that of serum convertible into pus,
 takes place.  In the erythema,  the  inflammation  seems to
 have its scat in the vessels on the external surface of  the
           * The Erysipelas is particularly described in article 696,  et seqi
                              * 
 108           PRACTICE OF  PHYSIC.

 skin,  communicating with the rete mucosum, which, does
 not admit of any effusion,  but  >yhat  separates the cuticle,
 and gives occasion to the formation of a blister, while the
 smaller size of the vessels admits only the effusion of a thin
 fluid, very seldom convertible into pus.
   Besides these differences in the circumstances of these two
 kinds  of inflammation, it is probable that they also differ
 with respect to  their causes.  Erythema is the effect of  all
 kinds of acrids externally applied to  the skin ;  and, when
 ariang from an internal cause, it is from an  acrimony, pour-
 ed out on the surface of the skin under the  cuticle.  In the
 phlegmon an acrimony is not commonly evident.
   276.] These differences  in the seat and causes  of the
 phlegmon and erythema being admitted,  it will  be evident,
 that when an erythema affects any internal  part,  it can take
 place in those only whose surfaces are covered with an epi-
 thelion, or membrane analogous to the cuticle.
   277.] The same distinction between the seat  and causes
 of the two diseases  will, as I judge,  readily explain what
 has been delivered by practical writers, with respect to the
 cure*  of  these different cutaneous inflammations.   But I
 shall not,  however,  prosecute this  here, for  the  reason
 given  above; (275.) and, for  the same reason, shall not
 say any thing of the  variety of  external inflammation, that
 might otherwise be  considered  here.f



                   CHAPTER  III.

 OF OPHTHALMIA,  OR INFLAMMATION OF
                      THE EYE.

   278.] r I THE inflammation  of the eye may be consider-
         X.  ed as of two kinds; according as it has  its
 seat in the membranes of the ball of the eye, when I would
 name it ophthalmia membranarum ; or  as it has its seat
in the  sebaceous glands placed in the tarsus, or edges of
the eyelids, in which case it may be termed ophthalmia
 tarsi.

 * The method of curing an erysipelas is delivered in article 708, et sequent.
 + The cure of erythema is chiefly effected by the antiphlogistic regimen already sufficiently
described.  Although bleeding, purging, and the general remedies for resolving ah inflamma-
tion, will in most cases, cure an erythema,  yet as it is a disease frequently depending on a pe-
culiar acrimony, we sliall always find great advantage from the external use of emollients  ap-
pled cold, or mucilaginous diluents taken internally. The disease, however, is seldom daneer-
•us, and generally terminates favorably. 
PRACTICE OF PHYSIC.
109
  These two kinds are very frequently combined together,
as the one may readily excite the other; but they are still
to be  distinguished according as the one or the other may
happen to be  the primary affection, and properly as they
often arise from different causes.
  279.]  The inflammation of the membranes of the eye,
affects especially, and most frequently, the adnata, appear-
ing in a turgescence of its vessels ; so that the red vessels
which are naturally  there,  become not only increased  in
size, but there appear many more than did in  a natural
state.   This turgescence of the vessels is attended with
pain,  especially upon the  motion  of the ball of the eye;
and this like every other irritation  applied to the surface
of the eye, produces an effusion of tears from the lachry-
mal gland.
  This inflammation commonly, and chiefly, affects the
adnata spread on the anterior part of the bulb of the eye ;
but usually  spreads also along  the continuation  of that
membrane on  the  inside  of the  palpebrse  ; and as that is
extended on the tarsus palpebrarum, the excretories of the
sebaceous glands opening there are also frequently affect-
ed.  When  the affection of the  adnata is considerable, it
is frequently communicated to the subjacent membranes of
the eye, and even  to the retina itself, which thereby ac-
quires so  great a  sensibility, that the slightest impression
of light becomes painful.
  280.]  The inflammation of the membranes of the eye is
in different degrees, according  as the adnata is more  or
less affected, or according as the inflammation is either of
the adnata alone, or of the subjacent membranes also ; and
upon these differences, different specieshave been establish-
ed, and different appellations given to them.  But I shall
not, however, prosecute the consideration  of these,  being
of opinion,  that all the cases of  the Ophthalmia membra-
narum differ only in degree, and are to be  cured by reme-
dies of the same kind, more or less employed.
  The remote causes of  Ophthalmia are many and vari-
ous; as,
  I. External violence, by blows, contusions, and wounds,
applied to the eyes; and even very slight impulses applied,
whilst the eyelids  are open, to the ball of the eye itself,
are sometimes sufficient for the purpose.
  2. Extraneous bodies  introduced under  the eyelids, ei-
                         P 
no           PRACTICE OF PHYSIC.

therof an acrid quality, as smoke and other acrid vapors,*
or of a bulk sufficient to impede  the  free motion of the
eyelids upon the surface of the eyeball.
  3. The application of strong light, or even of a mode-
rate light long continued.
  4. The application of much heat, and particularly of
that with  moisture.
  5. Much exercise of  the eyes in viewing minute objects.
  6. Frequent intoxication.
  7. Irritation from other and various diseases of the eyes.
  8. An acrimony  prevailing  in  the mass of blood,  and
deposited in the sebaceous glands on the edges of the eye-
lids.
  0. A change in the  distribution of the blood, whereby
either a more than usual quantity of blood,  and with more
than usual force,  is impelled into the vessels of the head,
or whereby  the free return of  the venous blood from the
vessels of  the head is interrupted.
  10. A certain consent of the eyes  with the other parts
of the system, whereby from a certain state of these parts,
either  a simultaneous, or an alternating affection of the
ej'es, is produced.
  281.] The proximate cause of Ophthalmia, is not dif-
ferent from that of inflammation in general; and the  dif-
ferent circumstances of Ophthalmia  may be explained by
the difference of its remote causes,  and by  the different
parts of the eye which  it happens to affect.   This may be
understood from  what has been already said ;  and I shall
now therefore proceed  to consider the cure.
  282.] In the cure of  Ophthalmia, the first attention will
by always due to the removing of the remote causes,  and
the various means necessary for this purpose will be direct-
ed by the consideration of these causes enumerated above.
  The  Ophthalmia membranarum requires  the remedies
proper for inflammation in general; and when the deeper
seated membranes are affected, and especially when a py-
rexia is present, large general bleedings maybe necessary.
But this is  seldom  the case; as the  Ophthalmia, for the
most part, is an affection purely local, accompanied with
little or no pyrexia.  General bleedings, therefore, from
the arm or foot, have little effect upon it; and the cure is
chiefly to be obtained by topical bleedings,  that is,  blood
processes where copious noxious vapors artse.
much as possible. 
PRACTICE  OF  PHYSIC.
ill
drawn from vessels near the inflamed part;  and  opening
the jugular vein or the temporal artery, may be consider-
ed as  in some measure of this kind.   It is commonly suf-
ficient to apply a number of leeches* round the eye; and
it  is perhaps  better still  to  draw blood  from the temples,
by  cupping and scarifying.f   In many cases,  a very effec-
tual remedy  is,  that  of scarifying the internal  surface of
the inferior eyelid;  and more so still,  is cutting the turgid
vessels upon the adnata itself4
   283.]  Besides blood-letting, purging,  as a  remedy suit-
ed  to  inflammation in general, has been  considered as pe-
culiarly adapted to inflammations in any of the parts of the
head,  and  therefore to Ophthalmia;  and  it  is sometimes
useful ;  but,  for  the  reasons given before with respect to
general bleeding, purging in the case of  Ophthalmia does
not prove useful in  any degree in proportion to the evacu-
ation  excited.
   284.]  For the relaxing  the spasm in the part, and taking
off the determination of the fluids to it,  blistering near the
part has commonly been  found useful.§
   285.]  Electrical sparks taken  from the eye will  often
suddenly discuss the inflammation  of the adnata; but the
effect is seldom permanent, and even  a frequent repetition
seldom gives an entire cure.
   286.]  Ophthalmia,  as  an external inflammation, admits
of topical applications.   All those, however,  that increase
the heat and relax the vessels of the part, prove common-
ly hurtful; and  the admission  of cool air to the  eye, the
proper application  of cold  water immediately to the ball
of  the  eye,  and  the application of  various  cooling and
astringent medicines, which at the same time do not pro-
 * Ten or twelve may be applied at once, and when many are employed together, they gene-
rally produce a better effect, than if fewer be employed repeatedly : That is twelve at once are
more efficacious than three at a tune repeated four timesa day.
 + Cupping and scarifying the temples ought to be performed with very great caution, because
of tire numerous ramifications of considerable branches of arteries in those places.
 t These operations require great nicety. For the particular method of performing them, the
reader is referred to the wiiters on Surgery.
 Much harm ensues from these operations when injudiciously performed :  they ought there-
fore to be refrained from, except when a  very skillful and expert surgeon can be procured.
They are seldom serviceable, except they be repeated several times. Cutting the vessels of the
adnata is perhaps the best preventative of an opacity of the Cornea that we know: and where-
ver there is the least "tendency to an opacity, the practice should be put in execution. '1 he ope-
ration ought to be repeated daily tor two, three, or four weeks, or even longer, if a cure is not
accomplished sooner.
 i The part where blisters are usually applied in Ophthalmia are behind the ear, or the nape of
the neck.  The blisters ought to be kept open by the subsequent application of the mild blister-
ing ointment, if ihey assume appearances of healing.
 Setons in the neck are sometimes recommended; out where speedy relief is required, they aie
pf little service, because they seldom begin to discharge till the expiration of a few days ; besides
they are extremely troublesome to the patient: and if the phlogistic diathesis be considerable,
they sometimes become so exceedingly inflamed as to produce many disagreeable circumstances
that might have been avoided. 
112
PRACTICE  OF  PHYSIC.
duce much irritation, prove generally useful;  even spiritu-
ous liquors, employed  in  moderate quantity, have  often
been of service.*
   287.] In the cure of  Ophthalmia, much care is requisite
to  avoid all irritation,  particularly that of light ;  and the
only safe and certain means of doing this is by confining the
patient to a very dark chamber.
   288.] These are the  remedies of the Ophthalmia niem-
branarum ; and in the Ophthalmia tarsi,  for as it is produ-
ced by Ophthalmia membranarum,  the same remedies may
be necessarv.   As, however, the  Ophthalmia  tarsi  may
often depend  upon an acrimony deposited in the sebaceous
glands of the part, so it may require various internal reme-
dies according to  the nature of the acrimony  in fault;  for
which I must refer  to the consideration of scrophula, syphilis,
or other diseases with which this Ophthalmia  may be con-
nected ; and when the nature of  the acrimony is not ascer-
tained, certain remedies,  more  generally  adapted  to the
evacuation  of acrimony,  such,  for instance,  as mercury,
may be employed.f
   289.] In the Ophthalmia tarsi,  it  almost constantly hap-
pens that some ulcerations are formed on the tarsus.   These
require the application of  mercury or copper,  either  of
which may by itself sometimes  entirely cure the affection ;
and these may even be useful when the disease depends upon
a  fault of the whole system.
   290.] Both in the Ophthalmia membranarum, and in the
Ophthalmia tarsi, it is  necessary to obviate that gluing  or
sticking  together  of the eye-lids which commonly happens
in sleep ;  and  this may be done  by insinuating a  little of
any mild unctious medicine,  of' some tenacity between  the
eye-lids  before the patient shall go to sleep.J

  * A solution of a scruple of sugar of lead in four ounces of distilled water, is a very effectual
application ; some authors recommend equal parts of white vitrol and sugar of lead dissolved in
distilled water.  These collyria, as they are called,  do infinite mischief if they are too strong.
   If, therefore, the patient complains of the least smarting on their application, it will be neces-
sary to dilute them with the addition of more distilled water.  They ought to be applied cold,
and pledgets moiatned wiih them ought to be frequently renewed when they grow hot or dry.
An additional direction maybe added, viz. that the solution of saccharum saturni be always
made in Jistti.id water, especially when it is to be used as a collyrium, because the least impreg-
nation ff any mineral acid, however combined, decomposes the sugar of lead.
   Cold poultices of rasped raw potatoes or turnips  are sometimes very efficacious.  They may
be applied in a fine muslin bag, and ought to be renewed whenever they grow warm.
   + If the ophthalmia be venereal, mercury is the only remedy, and external applications have
little effect.  If scrophula is  the cause, relief is often speedily procured by  an application of the
 Coagulum a luminis, or the unguentum citrinum, now called unguentum hvdrargyri nitratum
 in the London Pharmacopoeia. The unguentum tutix hasbeen used in manv cases with advan-
 tage, as has also the unguentum cerussae acetaue.  But these topical applications never eftecta
 permanent cure.
   t Ho?'s lard, fresh pressed lintseed-oil, or oil of almonds, answer this intention very well, or
 the unguentum spermatls ceti, of the London Pharmacopoeia.                 • 
PRACTICE OF PHYSIC.
113
                  CHAPTER  IV.

        OF PHRENZY, OR PHRE NIT IS.

  291.] r I ^HIS disease is an inflammation of the parts
         X contained in the cavity of the cranium ; and
may affect  either the membranes of the brain,  or the sub-
stance of the brain itself.  Nosologists have apprehended,
that these two cases might  be distinguished by different
symptoms, and  therefore by different appellations: but
this does not seem to be confirmed by observation and dis-
section ;  and therefore I shall treat of both cases under the
title of Phrenzy, or Phrenitis.
   292.] An idiopathic  phrenzy is a  rare  occurrence, a
sympathic more frequent;  and the ascertaining either the
one  or the other is, upon many occasions, difficult.   Many
of the symptoms by which  the disease is most commonly
judged  to be present, have appeared,  when from certain
considerations, it was presumed,  and even from dissection
it appeared, that there had been no internal inflammation ;
and  on the other hand,  dissections have shown, that the
brain had been inflamed, when few of the peculiar symp-
toms of phrenzy had before appeared.*
  293.] The symptoms  by which  this disease may be most
certainly known, are a vehement pyrexia, or a violent deep-
seated headach, a redness and turgescence of the face and
eyes, an impatience of  light and noise, a constant watch-
ing and a delirium impetuous and furious.  Some nosolo-
gists have thought these symptoms peculiar to an inflam-
mation of the membranes,  and that the inflammation  of
the substance of the brain was to be distinguished by some
degree of coma  attending it. It was for  this  reason that
in the Nosology I added the  Typhomania to the character
of Phrenitis ;  but upon further reflection, I  find no proper
foundation  for this ; and if  we pass from  the characters
above delivered, there will be no means of fixing the va-
riety that occurs.
  I am here, as in other analogous cases, of opinion, that
the symptoms  above  mentioned of an acute inflammation,
always mark inflammations of membranous parts; and that

 * This sentence is very obscure j the  Author meant to sav, that the diagnostic svmptoms of
this disease are uncertain.                    '        »     .  r 
114
PRACTICE OF PHYSIC.
an inflammation of the parenchyma or substance of  visce-
ra, exhibits,  at least commonly, a more chronic affection.
   294.]  The remote causes of phrenzy,  are all those  which
directly stimulate the membranes or substance of the brain ;
and  particularly all those which increase the impetus  of  the
blood in the vessels of  the  brain.  Among these the  expo-
sure of  the naked head  to the direct rays of  a very warm
sun,  is a  frequent cause.   The  passions of the mind,  and
certain poisons, are amongst the remote causes of phrenzy ;
but in what manner they operate  is not well  understood.*
   295.]  The cure of phrenzy is  the  same with that  of in-
flammation in general; but in phrenzy the most powerful
remedies  are to be immediately employed.  Large and re-
peated blood-letting  is  especially necessary ; and the blood
should be drawn from vessels as near  as possible  to  the part
affected.   The opening of the temporal artery has  been re-
commended,  and  with some reason : but the  practice is at-
tended with inconvenience ; and I apprehend that  opening
the jugular veins may prove more effectual; but at the same
time, it  will be  generally proper to draw  blood  from  the
temples by cupping  and scarifying.
   296.]  It is probable, that purging,  as it may  operate by
revulsion, may be  of more use in  this than in some other in-
flammatory affections.
   For the same purpose  of revulsion, warm pediluvia are
a remedy; but at the same time somewhat ambiguous.   The
taking off the force of the blood in the vessels of the head by
an erect posture, is  generally useful.
   297.]  Shaving of the head is always proper and necessary
for the admission of other remedies.  Blistering is commonly
  * Practitioners have in general admitted two kinds of phrenzy, viz.  the  idiopathic or true
phren/.v, and the symptomatic.  The former is what the author describes in the text; and, as
he has omitted  to describe the  latter, which in article 292, he acknowledges to be the more
frequent ot the two, I shall enumerate its symptoms.
  The symptomatic phrenzy is constantly preceded by some very acute inflammatory fever.  Its
approach may be suspected by a suppression of the  excretions, by colorless stools,  by a black
dry, and rough tongue, by pale and  watery urine, which sometimes has black or dark brown
clouds floating in it. by a desire but inability to sleep, by picking the bed clothes,  by the eyes
appearing tierce, and the vessels of the albuginea becoming turgid, and by a few drops of blood
distilling from the nose.
  When most of these symptoms appear in inflammatory fevers, we justly apprehend an attack
of the phrenzy, and ought to have immediate recourse to such remedies as will lessen its violence,
or altogether prevent its access.   Large bleedings, if the pulse permits, must be made  on the
lower extremities, emollient giysters are to be frequently injected, laxatives administered, fo-
mentations applied to the feet and legs, cupping glasses applied on the thighs, and the patient must
be forced to drink plentifully, for he is seldom thirsty in these cases, although  his tongue be
parched. Besides these general remedies, peculiar attention must be paid to the primary disease;
and the treatment of the symptomatic phrenzy will vary according to the natuie of  the disease
by which it is produced.
  No part of the practice of physic requires more judgment and segacity in the practitioner.
than ascertaining the proper mode of treating the symptomatic phren/.y in different fevers. To
enter fully into the subject, would require more room than these notes allow.   I can  only there-
fore recommend the young practitioner to pay great attention to it.  He will find many useful
practical directions lor the treatment of these cases, in most of the medical writers, both ancient
and modern, especially Sydenham and Van Sweiten. 
PRACTICE OF PHYSIC.
115
useful in this disease, but chiefly when applied near the part

affected.*
  298.]  Every part of  the antiphlogistic  regimen is here

necessary, and particularly the admission of cold air.   Even

cold substances, applied close to the head, have been found

safe and highly useful;  and the application of such refrige-

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

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

observed,  that,  from the  ambiguity mentioned  in   (292.)

the accounts of practitioners,  with  regard to  the juvantia

and laedentia in this disease, are of very uncertain applica-

tion.
                     CHAPTER V.


       OF THE QUINSY,  OR CYNANCHE.


   300.]  nHHIS name is applied to every inflammation of
          JL  the internal fauces ;  but these inflammations
are different, according to the part of the fauces which may
be affected, and according to the nature of the inflammation.
In the Nosology, therefore, after  giving the character of the
Cynanche as  a genus, I have distinguished  five  different
species,  which must here likewise be separately considered.
                       SECTION  I.



             Of the Cynanche  Tonsillaris.



   301.]  THIS is an inflammation of the mucous membrane

of the fauces, affecting especially that  congeries of mucous

follicles which forms the tonsils,  and spreading from thence

along the velum and uvula, so as frequently to affect every

part of the mucous membrane.

  * It has been usual to apply a large blistering plaister over the whole heid, and suffer it to
remain on for eight and forty hours.  This, however, hinders the application of other very
powerful remedies.  Shaving the head of a frantic patient is always a troublesome operation;
out the very great benefit arising from it, renders it absolutely necessary in all cases; and the
physician aught therefore to advise it on the first suspicion of an approaching phrenzy.
  t Many eminent practitioners have dissuaded the use of these refrigerant applications to the
newly shaven head; the immediate relief which the mere shaving generally procures seems to
indicate the propriety of the practice: and experience has not discovered any material disaoV
advantages attending it, but on the contrary, much benefit accruing from it. 
116
PRACTICE  OF PHYSIC.
  302.]  The disease appears by some tumor,  sometimes
considerable, and by a redness of the parts  ; is attended  with
a painful and difficult deglutition ;  with  a pain sometimes
shooting into the ear ; with a troublesome  clamminess of the
mouth and throat;  with a frequent, but difficult, excretion of
mucous;  and the whole is accompanied with a pyrexia.
   303 ]  This species of quinsy  is never contagious.   It
terminates frequently by resolution,*  sometimes by  suppu-
ration,  but hardly ever by gangrene;  although in this dis-
ease some sloughy spots commonly supposed to be forerun-
ners of gangrene, sometimes appear upon  the fauces.
  304.]  This disease is commonly occasioned by cold ex-
ternally  applied, particularly  about  the  neck.   It affects
especially the young and sanguine, and a  disposition to it is
often acquired  by  habit;  so that from every considerable
application of cold to any part of the body, this disease is
readily induced.  It occurs especially  in spring and autumn,
when vicissitudes  of heat and  cold  frequently take place.
The inflammation  and tumor are commonly at  first  most
considerable in one tonsil;  and afterwards abating  in  that,
increase in the other.
  305.]  In the cure of this inflammation, some bleeding may
be  proper:  but large general  bleedings will seldom be ne-
cessary.  The opening of the ranular veins seems to be an
insignificant remedy ;  and leeches set upon  the external
fauces are of more efficacy.
  306.]  At  the beginning of the disease, full  vomiting has
been frequently found to be of  great  service.f
  307.]  This inflammation may be often  relieved by mode-
rate astringents, and  particularly by acids  applied to  the
inflamed parts.J   In many cases, however, nothing has been
found to give  more relief than  the  vapor of warm  water
received into the fauces by a proper  apparatus.
   308.]  The other remedies of this disease  are  rubefacient
or blistering medicines, applied externally to the neck  ; and
with these,  the  employment  of antiphlogistic purgatives,§

  * As the most frequent termination of this disease is by  resolution,  this mode of cure must
alwavs be attempted, and will seldom fail of proving successful.
  + The formula of an emetic may be seen in the note on art. 185.
  t Various have Lven the opinions of physicians respecting the kind of gargles proper  in these
cases. A pint of tincture of roses, with two drachms of honey,  has often been found service-
able.  The following gargle is frequently used with success. Boil an ounce of oak-bark, bruised
in a quart of water, tili half is evaporated, and to the strained liquor add an ounce of honey of
roses, and a drachm of allum. Sage tea, with honey, is in common use, and frequently answers
every purpose.
  i Glauber's Salts answer the end of purges in these cases very well, especially if the patient
drinks copiously during the operation. 
PRACTICE OF PHYSIC.
117
as well as every part of  the antiphlogistic regimen, except-
ing the application of  cold.
  309.] This disease,  as we have said, often terminates by
resolution, frequently accompanied with sweating ; which is
therefore to be prudently favored and encouraged.*
  310.] When this disease shall have taken a tendency  to
suppuration, nothing will be more useful, than the frequent
taking into the fauces the steams of  warm water.f   When
the abscess is attended with  much swelling,  if it  break not
spontaneously, it should be opened by  a lancet;  and this
does not require much caution, as even the inflammatory
state may be relieved  by some scarification of the  tonsils.
  I have  never  had  occasion  to  see any  case  requiring
bronchotomy.
                         SECTION  II.

                Of  the  Cynanche Maligna.

   311.]  THIS is a contagious disease, seldom sporadic, and
commonly  epidemic.  It  attacks persons of all ages  but
more commonly those in a  young and infant state.  It at-
tacks persons of every constitution when exposed to the con-
tagion,  but most readily the weak and infirm.
   312.] This disease is usually attended with a  considera-
ble pyrexia; and the symptomsof the accession of this, such
as frequent cold shiverings, sickness,  anxiety, and vomit-

  * Dover's powder is an excellent sudorific in these  cases.  The method of giving it has been
described in a former note, in art. 169. Many other sudorifics, however, are found to answer
tolerably well, as wine-whey, whey made with dulcified spirit of nitre, vinegar-whey, sage tea,
with several other drinks of a similar kind.  The following bolus is often very effkacioui, espe-
cially when the patient drinks largely of sage or balm tea.
            R. Camphor, gr. viii.
                Opii pur. gr. i.
                Tart. Vitriolat. 9i.
               Tere in mortario marmoreo ; et adde
               Confect. cardiac. 3i-  vel. q. s. ut fiat bolus.
  Small doses of tartar emetic taken in such quantities as to produce a  slight  nausea without
vomiting, are also good sudorifics. Two table-spoonfuls of the following julep may be taken
every half hour, till the effect be produced, drinking, at the same time, plentifully of some warm
diluent.
              R. Tartar,  emetic, gr. iii.
                 Aq. font. Bvii.
                 Syr. Papaveris rubri, %\.
                 M. f. julap.
 4- Very convenient apparatus for tins purpose are made by most tin-workers. Beside the steam.
of warm water here recommended, external applications to the throat and sides of the  neck
have a considerable effect in forwarding the suppuration, as warm poultices, fomentations, &cv
                              Q 
113
PRACTICE OF PHYSIC.
ing, are often the first appearances of the disease.   About
the same time, a stiffness is felt in the neck, with some un-
easiness in the internal fauces,  and some hoarseness of the
voice.   The internal fauces, when viewed appear of a deep
red color, with  some tumor; but this last is seldom con-
siderable, and deglutition is seldom difficult or painful.  Ve-
ry soon a number of white or ash  colored  spots  appear
upon the inflamed parts.  These spots  spread  and unite,
covering almost the whole fauces with thick1 sloughs;  which
falling  off,  discover  ulcerations.  While these  symptoms
proceed in the fauces,  they are generally attended with a
coryza which pours out a thin acrid and fetid matter, exco-
riating the nostrils and lips.  There is often also,  especially
in infants,  a frequent  purging; and a thin  acrid  matter
flows from the anus excoriating this and the neighboring
parts.
  313.] With these symptoms, the pyrexia proceeds with
a small, frequent, and irregular pulse; and there occurs a
manifest exacerbation every evening, and some remission
in the mornings.  A great debility appears in the animal
functions ; and the  sensorium  is  affected with delirium,
frequently with coma.
  314.] On the second day, or sometimes later,  efflores-
cences appear upon the skin, which are sometimes in small
points hardly eminent; but, for the most part,  in patches
of a red color, spreading and uniting so as to cover the whole
skin.  They appear first about the face and neck, and in
the course of some days spread by degrees to the lower ex-
tremities.   The scarlet redness is often considerable on the
hands and extremities of the fingers, which feel stiff  and
swelled.  This eruption is often irregular,  as to the time
of its appearance, as to its steadiness, and as to the time
of its duration.  It  usually continues four days, and goes
off by  some desquamation of the cuticle; but neither on
its first appearance, nor on its desquamation, does it always
produce a remission of the pyrexia, or of the other symp-
toms.
   315.] The progress of the disease depends on the state
of the fauces and of the pyrexia.   When the ulcers on the
fauces, by their livid and black color, by the fetor of the
breath, and by many marks of  acrimony in the fluids, show
a tendency to gangrene,  this takes place to a considerable
degree; and the symptoms of a putrid fever constantly in-
creasing, the patient dies, often on the third day,  some- 
               PRACTICE OF PHYSIC.           n$

  times later, but for the most part before the seventh.   The
  acrimony poured out from the diseased fauces must neces-
  sarily, in part, pass into the pharynx,  and there spread
  the infection into the oesophagus,  and sometimes through
  the whole of the alimentary canal, propagating the pu-
  trefaction, and often exhausting the patient by a frequent
  diarrhoea.
    The acrid matter  poured out in  the fauces being again
  absorbed, frequently occasions large swellings of the lym-
  phatic glands about  the  neck,  and sometimes to such a
  degree as to occasion suffocation.
    It is seldom that the organs of respiration escape entire-
  ly unhurt, and very often the inflammatory affection is com-
  municated to them.   From dissections it appears, that,  in
  the Cynanche maligna," the larynx and trachea are often af-
  fected in the same manner as in the Cynanche trachealis ;
  and it is probable, that, in consequence of that affection,
  the Cynanche maligna often proves fatal by such a sudden
  suffocation  as happens in the proper Cynanche trachealis;
  but there is reason to suspect, that upon this subject dissec-
  tors have not always distinguished  properly between the
  two diseases.
    316.]  These are the several fatal terminations of the Cy-
  nanche maligna ; but they do not always take place.  Some-
  times the ulcers of the fauces are of a  milder  nature ; and
•  the fever is more moderate, as well as of a less putrid kind.
  And when, upon  the appearance of  the efflorescence on the
  skin, the fever suffers a  remission ; when the efflorescence
  continues for three or four  days, till it has spread over the
  whole body, and then ends by a desquamation,  giving a
  further  remission of the fever ; this often entirely termi-
  nates, by gentle sweats, on or before the seventh day ; and
  the rest of the disease terminates in a few days more, by an
  excretion of sloughs from the fauces; while sleep, appetite,
  and the other marks of health retura.
    From what is said in  this and the preceding paragraph,
  the prognostics in this disease may be readily learned.
    317.]  In the cure of this disease, its septic tendency  is
  chiefly to be kept in view.  The debility, with which  it  is
  attended, renders  all evacuations by bleeding and purging
  improper, except in a few instances where the debility  is
  less,  and the inflammatory symptoms more  considerable.
  The fauces are tobe preserved from the effects of the acrid
  matter poured out upon them, and are  therefore to be  fre- 
120                PRACTICE  OF  PHYSIC.

quently washed out  by antiseptic  gargles*  or  injections ;
and  the  septic  tendency  of the  whole  system should be
guarded against and  corrected by internal antiseptics,  espe-
cially  by the Peruvian bark given in  substance, from  the
beginning, and continued through the course of the disease.f
Emetics,  both by  vomiting  and nauseating,  prove useful,
especially when employed early  in the disease.    When  any
considerable  tumor occurs, blisters applied  externally  will
be of  service,  and  in any  case  may be fit to moderate the
internal inflammation.^
  * When the violence of the symptoms is moderate, and when the ulceration is slight, sage tea,
or tea made of rose leaves, or both together, may be sufficient.  A gargle rnade of a pint ot
sage and rose tea, three spoonfuls of  vinegar, and one spoonful of honey, has been found as
efficacious as any of the sharper antiseptics with the mineral acids.  Dr. Fothergill s gargle is,

           R.  Decoct, pectoral. Bxii. cui inter coquendum adde

                Rad. contrayerv. contus.  §ss.

                Liquori colato  admisce,

                Acet. vin. alb.  §ii.

                Tict. myrrh.  Si.

                Mel. opt. 3vi.
But he often used it with a drachm of the Mel Egyptiacum dissolved in two ounces of it.
  The Mel Egyptiacum is a very harsh application, and ought to be  cautiously  used. If the
sloughs cast off so slowly as to require a powerful application, it is better practice to touch them
with Mel Egyptiacum by means of an armed probe, than to use gargles in which it is an ingredi-
ent.  In thisdisease, astrict attention must be given to the use of gargles  and injections for the
throat, because the cure seems to depend in part on procuring a discharge from the glands of
the fauces which these gargles induce, and also because they are  the only means of retarding
the progress of the ulcers.
  + The quantity of bark given ought to be very considerable, viz. as much as the stomach and
intestines can possibly bear; half a drachm or two scruples  every hour, with a glass of  good
Port wine.  A scruple of confectio cardiaca, joined with each dose of the bark, has a double ef-
fect of making the bark less nauseous, and of preventing in some measure, a tendency to a diar-
rhoea, but opium is a sovereign remedy for removing this symptom when it is actually present.
  In administering the bark, great care must be taken to avoid a diarrhcea, which is a very dan-
gerous symptom m any period of the disease, but especially after the third or fourth day, when
the patient is in a considerable state of debility.
  Cnildren are more frequently attacked with this disease than adults ; and it is sometimes ex-
tremely difficult to prevail on them to take a sufficient quantity of this necessary and valuable,
though nauseous medicine. In these cases giysters with powdered bark have been  used with
very  great success. Two drachms of the fine powder may be given in five or six ounces of bar-
ley-water, every 3 or 4 hours to very young children, and half an ounce or 6 drachms to chil-
dren of 8 or 10 years old, in three quarters of a pint of barley-water.  If the first  glyster comes
away too speedily, two or three grains of opium may be added to the subsequent giysters.
   t In addition to the method of cure here delivered, it may be  proper to observe,  that as the
cure depends much on the removal of every thing putrid from the patient, it is absolutely  ne-
cessary to have the room well ventilated, but not with cold air.  The  reason for this  precaution
is, that the patient always complains of the least admission  of cold air, becoming sick and op-
pressed, probably in consequence of the sudden  disappearance of the efflorescence which al-
ways accompanies the disease. The linen ought frequently to be changed,  the patient kept
clean, the mouth and throat frequently washed, and great plenty of liquid vegetable nutriment
must be given, with generous wine.
  A  hemorrage from the nose, mouth, or ears; very frequently occurs in the later stages of a
malignant sore throat.  This discharge is by no means critical, but always a dangerous symptom,
and must be stopped with  the utmost expedition. It is the  consequence of some arterial
branch being corroded by the mortification.  If the hemorrhage withstands the usual means of
tents dipped in vinegar, or a solution  of alum,, &c. recourse must be  had to opium and baik :
 and tne  Port wine must be given sparingly.
   In the advanced stages, a diarrlitra frequently appears,  especially  in  children ; it proceeds
 frqrn the putrid and acrid matter of the ulcers being received into the intestines.  It can only I e
 prevented, or effectually removed, by a careful attention to keep the mouth as clean as possible. 
PRACTICE  OF PHYSIC.
121
                     SECTION III.

            Of the  Cynanche  Trachealis.

  318.] THIS* name has been given to an inflammation of
the glottis,  larynx, or upper part of the trachea whether it
affect the membranes of these parts, or the muscles adjoin-
ing.  It may arise  first in these parts, and continue to sub-
sist in them alone ; or it may come to affect these parts from
the Cynanche tonsillaris or maligna  spreading  into them.
  319.] In either way it has  been  a rare occurrence,  and
few instances of it  have been  marked and recorded by phy-
sicians.  It  is  to be known by a peculiar ringing sound of
the voice, by difficult respiration,  with a sense of straitening
about the larynx, and by a pyrexia attending  it.
  320.] From the nature of these symptoms, and from the
dissection of the bodies of persons who had died of this dis-
ease, there is no  doubt of  its being of an  inflammatory
nature.  It does not, however, always run the course of in-
flammatory affections,  but frequently produces such  an ob-
struction  of the passage of the air, as suffocates, and thereby
proves  suddenly fatal.
  321.]  If we judge rightly of the  nature of this disease, it
will be obvious, that the cure of it requires  the most power-
ful remedies of inflammation, to be  employed  upon the very
first appearance of the symptoms.  When  a suffocation is
threatened, whether any remedies  can be employed to  pre-
vent it, we have not had experience to determine.
   322.] The accounts which  books have hitherto given us
of  inflammations of the larynx, and the parts connected with
it,  amount to what we have now said; and the instances re-
corded have almost all of them happened in adult persons ;
but there is a peculiar affection of this kind  happening espe-
cially to infants, which till lately has been little taken notice
 of.  Dr. Home is the first who has given any distinct account
 of  it;  but,  since he  wrote, several  other authors have taken
 notice of it,  (see Michaelis De  angina polyposa  sivc mem-
 oranda,  Argentorati  1778)  and have given  different  opi-
 nions  with regard  to it.   Concerning this diversity of
  * This d sease has been supposed to be new, and confined chiefly to infants.  It is, however,
 described by manv of both the antient and modern writers. Boerhaave describes it in his 801st
 and 802d Aphorism.  It is, indeed, uncommon in adults, and most frequent in infants,  it was
 never rightly understood, however, till Dr. Home, the Professor of the  Materia Medica in this
 University, invest.gated its naiuic, and pointed out the only effectual method of cure. 
 122           PRACTICE OF PHYSIC.

 opinions I shall not at present inquire ; but shall deliver the
 history and cure of this disease, in so far as these have arisen
 from my own  observation,  from that of Dr. Home,  and of
 other skilful persons in this neighborhood.
   323.] This  disease seldom attacks infants till  after they
 have been  weaned.  After this period, the younger they
 are, the more  they are liable  to  it.  The frequency of it
 becomes less as children become more advanced ; and there
 are no instances of children  above twelve years of age being
 alTected with it.  It attacks children of  the midland coun-
 tries, as well as those  who  live near the sea.  It does not
 appear to be contagious, and  its attacks are frequently re-
 peated in the same child.   It is often manifestly the effect
 of cold applied to the body; and  therefore appears  most
frequently in the  winter and spring seasons.  It  very  com-
monly comes on with  the ordinary symptoms of  a catarrh;
but sometimes the peculiar  symptoms of the disease  show
themselves at the very first.
   324.] These peculiar symptoms are  the  following :  A
 hoarseness,  with some shrillness and ringing sound, both in
speaking and  coughing, as if the noise came from a bra-
zen tube.  At  the same time, there is a sense of  pain about
the larynx,  some difficulty of respiration,  with a whizzing
sound in inspiration, as if the passage of the air were strait-
ened.  The cough which attends it, is commonly dry; and if
 any thing be spit up, it is a matter of a purulent appearance,
 and sometimes films resembling portions  of a membrane.
 Together with these symptoms, there is a frequency of pulse,
 a restlessness,  and an uneasy sense  of heat.
   When the internal fauces are viewed,  they are sometimes
 without any appearance of  inflammation : but  frequently a
 redness and  even  swelling, appear ; and sometimes in the
 fauces there is  an appearance of matter like to that rejected
 by coughing.  With the symptoms now  described and par-
 ticularly with great difficulty of breathing,  and a sense of
 strangling in the fauces, the patient is sometimes suddenly
 taken off.
   325.] There have been many dissections made of  infants
 who had died of this disease ; and  almost  constantly  there
has appeared a preternatural membrane lining the whole in-
 ternal  surface of the  upper  part of the trachea, and ex-
 tending in  the same  manner downwards  into some of its
 ramifications.  This preternatural membrane may be easily
 separated,  and sometimes has been found separated in  part, 
PRACTICE OF PHYSIC.
from the subjacent proper membrane of  the trachea.  This
last is commonly found entire,  that is, without any appear-
ance  of erosion or ulceration ; but  it frequently shows the
vestiges of inflammation, and is covered  by a matter resem-
bling pus, like to that rejected by coughing ;  and very often
a matter of the same kind is found in the bronchia-, some-
times in considerable quantity.
  326.]  From the remote causes of this disease ; from the
catarrhal symptoms commonly attending it;  from the py-
rexia constantly present with  it; from the same  kind of
prete rnatural membrane being found in the trachea when
the cynanche maligna is communicated  to it; and,  from
the vestiges of inflammation on the  trachea discovered up-
on dissection ; we must conclude, that the disease consists
in an inflammatory affection of the mucous membrane of
the larynx and trachea, producing an exudation analogous
to that found on  the surface of inflamed viscera, and  ap-
pearing  partly in a membranous crust,  and partly in a
fluid resembling  pus.
  327.]  Though  this disease manifestly consists  in an in-
flammatory affection, it does not commonly end either in
suppuration or gangrene.   The  peculiar and troublesome
circumstance of  the disease seems to  consist in a spasm of
the muscles of the glottis, which by  inducing a suffocation,
prevents the common consequences of inflammation.
  328.]  When this disease terminates in health,  it is by a
resolution of the inflammation, by a ceasing of the spasm of
the glottis, by an  expectoration of the matter exuding from
the trachea, and of the crusts formed  there ; and frequent-
ly it ends without any expectoration, or at least  with such
only as attends an ordinary catarrh.
   329.]  When the disease ends fatally,  it is by a suffoca-
tion ; seemingly,  as we have said, depending upon a spasm
affecting the glottis; but sometimes,  probably, dependin"-
upon a quantity of matter filling the bronchia?.
   330.]  As we suppose the disease to be an inflammatory
affection, so we attempt the cure of it by the usual remedies
of inflammation, and which for the  most part I have found
effectual.  Bleeding, both general and topical,*  has often
  * The topical bleeding is best performed by leeches. Three or four may be applied at once
on each side ot the irachea, or on the trachea itse.f. Notwithstanding this recommendation of
topical bleeding, previous general bleeding is absolutely necessaiy in every case, and ought ne-
ver to be oiuiu'ed. It frequently produces relief even while the blood is flowing from the vein;
but, in these cases, it is imprudent to stop the evacuation, even on the total removal of the symp-
toms.  A much blood must be drawn as the infant can bear to lese, and leeches ought moreo-
ver to be app'ied, as above directed ; for it frequently happens, that, when all the symptoms sud-
denly disappear, the disease  returns in a few hours with redoubled violence, and speedily puts
an ead to tiie Unld's life. 
 124           PRACTICE OF  PHYSIC.

given immediate relief;  and by being repeated, has  en-
tirely cured the disease.  Blistering also, near to the part
affected,  has  been found useful.   Upon the first attack of
the disease, vomiting, immediately after bleeding, seems to
be  of considerable\ise, and sometimes suddenly removes
the disease.  In every stage of the disease,  the antiphlo-
gistic regimen is necessary, and particularly the frequent
use of laxative giysters.*   Though  we  suppose  that  a
spasm  affecting the  glottis is often fatal in this  disease,  I
have not found antispasmodic medicines to be of any use.
                    SECTION IV.

            Of the Cynanche Pharyngcea.

  331.] IN the Cynanche  tonsillaris,  the inflammation of
the mucous membrane often spreads upon the pharynx, and
into the beginning of  the oesophagus,  and thereby renders
deglutition more difficult and uneasy ;  but such a case does
not require to be distinguished as a  different  species, from
the common Cynanche tonsillaris ;  and only  requires  that
bloodletting, and  other remedies, should be employed with
greater diligence than  in ordinary cases.   We  have never
seen any  case, in which  the inflammation  began  in the
pharynx,  or in which this part alone was inflamed; but
practical writers have  taken notice of such a  case;  and to
them,  therefore,   I must refer, both for the  appearances
which distinguish it, and for the method of cure.
                      SECTION V.

             Of the Cynanche Parotidcea.

  332.]  THIS is a disease known to the vulgar,  and among
them has got a peculiar appellation, in every  country  of
Europe ;f but has  been little  taken notice of by  medical
writers.   It is often  epidemic, and manifestly  contagious.
 * Laxative giysters are to be carefully distinguished from purging giysters, which generally
irritate too violently, and thus inciease the inflammatory diathesis. It is of little consequence
what the compositions of giysters be, urovided they contain some Glauber's or Epsom s-.lt, and
are sufficiently large.  The common giyster with milk and water, and a little tpsom sa',  an-
swers sufficiently well.
 + It is called here, and in many parts cf Great-Britain, The Mumps. 
               PRACTICE OF PHYSIC.           125

It comes on with the usual symptoms of pyrexia, which  is
soon after attended with a considerable tumor of the exter-
nal fauces and neck.—This tumor appears first as a glandu-
lar moveable tumor at the corner of the lower jaw ;  but the
swelling soon becomes uniformly diffused over a great part
of the neck, sometimes on one side only, but more common-
ly on both. The swelling continues to increase till the fourth
day ; but from that period it declines, and in a few days more
passes off  entirely.   As the swelling of the fauces recedes,
some tumor affects the testicles in the male sex, or the breasts
in the female.  These tumors are sometimes large, hard, and
somewhat painful; but in this climate are seldom either ve-
ry painful or of long continuance.  The pyrexia attending
this disease is commonly slight,  and recedes with the swell-
ing of the fauces ; but sometimes, when the swelling of the
testicles does not succeed to that of the fauces,  or when the
one  or the other has  been suddenly repressed, the pyrexia,
becomes more considerable, is often attended with delirium,
and has sometimes proved fatal.
  333.] As this disease commonly runs its course without
either dangerous or troublesome s3miptoms, so it hardly re-
quires any remedies.   An antiphlogistic regimen and avoid-
ing cold,  are all that will  be  commonly  necessary.  But
when, upon the receding of the swellings of  the testicles  in
males, or of the breasts in females, the pyrexia comes to be
considerable, and threatens an affection of the brain, it will
be proper, by warm  fomentations, to bring back the swell-
ing ; and by vomiting, bleeding, or blistering, to  obviate;
the consequences of its absence.


                  CHAPTER VI.

OF PNEUMONIA, OR PNEUMONIC INFLAM-
                      MATION.

  334.] T TNDER this title I mean  to comprehend the
         vJ whole  of the inflammations affecting  either
the viscera of the thorax, or the membrane lining the inte-
rior surface  of  that cavity : for neither do our diagnostics
serve to ascertain exactly the seat of the disease ; nor does
the difference in the seat of the disease exhibit any consider-
able variation in the state of the  symptoms, nor lead  to any
difference in the method of  cure.
R 
126
PRACTICE OF PHYSIC.
  335.] Pneumonic inflammation, however various  in its
seat,  seems to me to be always known and distinguished by
the following symptoms : pyrexia, difficult breathing, cough
and pain in some parts of the thorax.   But these symptoms
are, on different occasions, variously modified.
  336.] The  disease  almost  always comes on with a cold
stao-e, and is accompanied with the other symptoms of py-
rexia ; though, in a few instances, the pulse may not be more
frequent,  nor the  heat of the body increased beyond what is
natural.   Sometimes the pyrexia is from the beginning  ac-
companied  with the other symptoms ;  but frequently  it is
formed for some hours before the other symptoms become
considerable,  and particularly before the pain be felt.  For
the most part, the pulse is frequent,* full, strong, hard, and
quick ;f but  in a few instances, especially in tiie advanced
state  of the disease, the pulse is Aveak and soft,  and at the
same time irregular.
   337.] The difficulty of breathing is always present, and
most considerable in inspiration; both because the lungs do
not easily admit of a  full dilatation, and because the dilata-
tion aggravates the pain attending the disease.  The diffi-
culty of breathing is  also greater, when the patient is in one
posture of  his body rather than  another.  It is  generally
greater when he lies upon the side affected ; but sometimes
the contrary  happens.   Very often  the patient cannot lie
easy upon either side, finding  ease only  when lying on his
back ;  and sometimes he cannot breathe easily, except when
in somewhat  of an erect posture.
    338.]  A cough always attends this disease;  but in differ-
 ent cases,'  is more or less urgent and painful.  It is some-
 times dry, that is, without any expectoration, especially in
 the beginning of the disease; but more commonly it is, even
 from the first, moist, and the matter spit up various both
 in consistence and color; and frequently it is streaked with
 blood.}
    339.]  The pain attending this disease, is in different ca-
 ses, felt in different parts of the thorax, but most frequent-
 ly  in  one side.   It  has been said  to affect the right side
  * A frequent pu'.se is when there is a great number of strokes in a given time.
  + A quick pulse is when the stroke itselt is quick, although the number in a given time benot
 •very great.
   It is therefore no tautology to  mention both frewent and qnici, as they are really distinct,
 arid may be both present at once ; but, if the pulse be above an hundred in a minute, the phy-
 sician  must have a very nice sense of reeling to distmgiris'i between a quick and a slow beat.
   } Young practitioners should  not he alarmed at ihis symptom ; nor should they  suppose it a
 dan?erousone: it is, on the contrary, a salutary symptom, and ought not to be restrained,
 either bv too rigorous an a*Ili«r«u«e to the antiphlogistic regimes, or by the osc of strr.u*. anil
 e;:.er astrii-.ieats. 
PRACTICE OF  PHYSIC.
127
more frequently than the left; but this is not certain ; while
on the other hand, it is certain that the left side has been
very often affected.  The pain is felt sometimes as if it were
under  the sternum;  sometimes in the  back between  the
shoulders; and  when in the sides, its place has been higher
or lower,  more forward or backward:  but the place of all
others  most frequently affected, is about the sixth or se-
venth rib,  near the middle of its length, or a little more
forward.  The pain is often severe and pungent; but some-
times more dull and obtuse, with a sense of weight rather
than of pain.   It is  most especially severe and pungent
■when occupying the  place last mentioned.  For the most
part it continues fixed in one place ; but sometimes shoots
from the side to the scapula on one hand, or to the ster-
num and clavicle on the other.
  340.] The varying state of symptoms  now mentioned,
does not always ascertain precisely the seat of the disease.
To me it seems probable, that the disease is always seated,
or at least begins, in some part of  the pleura;  taking that
membrane in is greatest extent, as now commonly under-
stood ;  that is, as covering not only the internal surface of
the cavity of the thorax, but also as forming the mediasti-
num, and as extended over the pericardium, and over the
whole surface of the lungs.
  341.] There is,  therefore, little foundation for distin-
guishing this disease by different appellations taken from
the part which may be supposed to be chiefly affected.
The term Pleurisy, might with propriety be applied to ev-
ery case of the disease; and has  been very improperly li-
mited to that inflammation which begins in, and  chiefly af-
fects the pleura costalis.   1 have no doubt that such a case
does truly occur; but,  at the same time, I apprehend it to
be a rare occurrence ; and that the disease much more fre-
quently begins in,  and chiefly affects, the pleura invest-
ing the lungs, producing  all  the symptoms  supposed to
l>eTong to what has been called the  Pteuritis vera.
  342.] Some physicians have imagined, that there is a case
of pneumonic inflammation  particularly entitled to the
appellation of Peripneumony ; and that is, the case of an
inflammation beginning in the parenchyma or cellular tex-
ture of the lungs, and  having its seat  chiefly there.  But
it seems to me very  doubtful, if any acute inflammation
of the  lungs or any disease which has been called  Perip-
neumony be of that kind.   It seems probable,  that every 
128           PRACTICE OF  PHYSIC.
acute inflammation begins in membranous parts ;  and, ia
every dissection of persons dead of peripneumony, the ex-
ternal  membrane of the lungs, or some part of the pleura,
has appeared to have been considerably affected.
   343.]  An inflammation of the pleura covering the upper
surface of the diaphragm,  has been  distinguished by  the
appellation of Paraphrenitis, as supposed  to be  attended
with the peculiar symptoms  of delirium, risus sardonicus,
and other convulsive motions :  but it is certain, that an in-
flammation of that portion of the pleura, and affecting also
even the muscular substance  of the  diaphragm, has  often
taken place without any of these  symptoms ; and I have not
met with either dissections, or any accounts of dissections,
which  support the opinion, than an  inflammation of  the
pleura covering the  diaphragm,  is attended  with delirium
more commonly than any other pneumonic inflammation.
   344.]  With respect to the seat of pneumonic inflamma-
tion,  I must observe further, that although  it may arise
and subsist chiefly in one part of the pleura only, it is how-
ever frequently communicated to other parts of the same,
and commonly communicates  a  morbid  affection through
its whole extent.
   345.]  The  remote cause of pneumonic inflammation, is
commonly cold applied to the body, obstructing perspira-
tion, and determining to the lungs ;  while at the same time
the lungs themselves are exposed to the action  of cold.
These circumstances operate especially, when an inflamma-
tory diathesis prevails in the system ; and, consequently,
upon persons of the greatest vigor ; in cold climates in the
winter season; and particularly in the spring, when vicissi-
tudes of heat and  cold are frequent.  The disease, how-
ever, may arise in any season when such  vicissitudes occur.
   Other remote causes also may have a share in this mat-
ter ; such as every means of obstructing,  straining,* or
btherwise injuring,f the pneumonic organs.
   Pneumonic inflammation may happen to persons of any
age, but rarely to those under  the age of puberty : and
most commonly it  affects persons somewhat advanced in
life, as those between forty-five and sixty years ; those too,
especially of  a robust and full habit.
 * Violent exertions in speaking, singing, plaving on wind instruments, runnin» un hill, or in
Short, any exercise lhat increases the action of  the lunsjs.               * H  '
 + Xeccivmg noxious vapois into the lunss is sometimes the cause of pneumonic inflammation:
especially corrosive or mher acrid poisonous vapors, as the fumes of arsenic, of sulphur, of the
murine a.-id, and similar caustic and destructive exhalations.  Chemists, therefore, in ma" Z
♦x^eruntnts, ci aitiMs who work on substances yielding such vapors, s,liould be careful to avouj 
             PRACTICE OF PHYSIC.           12§

  The pneumonic inflammation has been  sometimes so
much an  epidemic,  as to occasion a suspicion of its de-
pending  upon a  specific  contagion; but 1 have not met
with any  evidence in proof of this.—See  Morgagni de
causis et sedibus morborum, epist.  xxi. art. 26.
  346.] The pneumonic,  like other inflammations, may
terminate by resolution, suppuration, or  gangrene ; but it
has also a termination peculiar to itself,  as has been hinted
above (259) ; and that is, when it is attended with an effu-
sion of blood into the cellular texture of the lungs, which
soon interrupting the circulation of the  blood through this
vise us, produces a fatal suffocation.  This,  indeed, seems
to be the  most common termination of pneumonic inflam-
mation, when it ends fatally; for, upon  the dissection of
almost every person dead of the  disease, it has appeared
that such an effusion had happened.
   347.] From these dissections also we learn, that pneumo-
nic inflammation commonly produces an exudation from
the internal surface of the pleura ; which appears partly a*
a soft viscid crust, often of a compact,  membranous form,
covering every where the surface of the pleura,  and parti-
culary those parts where the lungs  adhere  to the pleura cos-
talis, or mediastinum; and this crust seems always to be
the cement of such adhesions.
   The same exudation shows itself, also,  by a quantity of
at serous whitish fluid, commonly found in  the cavity of the
thorax ; and some exudation or effusion  is usually found
to have been made likewise into the cavity of the pericar-
dium.
   348.] It seems probable, too, that a like effusion is some-
times made into the  cavity of the bronchiae : for, in some
persons who have died after laboring under  a pneumonic
inflammation for a few days only,  the bronchia? have been
found  filled with a  considerable quantity of a serous and
thickish fluid ; which, I think, must be considered rather
as the effusion mentioned, having had its thinner parts tak-
en off by respiration, than as a pus so suddenly formed in
the inflamed part.
   349.] It is, however, not improbable, that this effusion,
as well as that made into the cavities of  the thorax and pe-
ricardium, may  be a matter of the same kind with that
which, in  other  inflammations is poured into the cellular
texture of the parts inflamed, and there converted into pus;
but, in the thorax and pericardium, it doe* not always as- 
130
PRACTICE OF PHYSIC.
 sume that appearance, because the crust covering the sur-
 face prevents the absorption of the thinner  part.  This
 absorption, however, may be compensated in the bronchiie
 by the drying power of the air ; and therefore the effusion
 into them may put on a more purulent appearance.
   In  many  cases of pneumonic  inflammation, when  the
 sputa are very copious, it is difficult to suppose that the
 whole of them proceed from the mucus follicles of the bron-
 chise.   It seems more probable that a great part  of them
 may proceed from the effused serous  fluid we have been
 mentioning ; and this too will  account for the sputa being
 so often of a purulent appearance.   Perhaps the same thing
 may account for  that  purulent expectoration, as well as
 that purulent matter found in the bronchia?, which the learn-
 ed Mr.  de  Haen says he had often observed,  when there
 was no  ulceration of the lungs : and this explanation is at
 least more probable than Mr. de Haen's  supposition of a
 pus formed in the circulating blood.
  350.] To conclude this subject,  it would appear, that
 the effusion into the bronchiae which we have  mentioned,
 often concurs with the effusion of red blood in  occasioning
 the suffocation, which fatally terminates pneumonic inflam-
 mation ; that the effusion of serum alone may have this ef-
 fect ; and that the serum poured out in a certain quantity,
 rather than any debility in the powers of expectoration, is
 the cause of that ceasing of expectoration which very con-
 stantly precedes the fatal event.  For, in  many cases, the
 expectoration has ceased, when no other symptoms of de-
 bility have appeared, and when upon dissection, the bron-
 chiae have  been found  full  of liquid  matter.   Nay, it is
 even probable,  that  in some cases, such an effusion may
 take place,  without any symptoms of violent  inflamma-
 tion ; and in other cases, the effusion taking place, may
 seem to remove the symptoms of inflammation which had
 appeared before,  and thus account for those unexpected
 fatal terminations which have  sometimes happened.  Pos-
 sibly this effusion may account also for many of the pheno-
 mena  of the Peripneumonia Notha.
  351.] Pneumonic inflammation  seldom terminates  by
resolution,  without being attended with some evident eva-
 cuation.  An hasmorrhagy from the nose happening upon
 some of the first days of the disease, has sometimes°put an
 end to it; and it is said that an evacuation from the hemor-
 rhoidal veins, a bilious evacuation by stool, and an evacu- 
PRACTICE OF  PHYSIC.
131
ation of urine with a copious sediment, have severally had
the same effect: but such occurrences have been rare and
unusual.
  The evacuation most frequently attending, and seeming
to have the greatest effect in promoting resolution, is an
expectoration of a thick, white, or yellowish matter, a little
streaked with blood,  copious, and brought up without ei-
ther  much or violent coughing.
  Very frequently the resolution of this disease is attended
with, and perhaps produced by a sweat, which is warm,
fluid, copious over the whole body, and attended with an
abatement of the frequency of the pulse, of the heat of the
body and of other febrile symptoms.
  352.]  The prognostics in  this disease are formed from
observing the state of the principal symptoms.
  A violent pj^rexia is always dangerous.
  The danger,  however, is chiefly denoted by the difficul-
ty of breathing.  When the patient can lie on one side on-
ly; when he can lie on neither side,  but upon his back on-
ly ; when he cannot  breathe with tolerable ease, except
the trunk of his body be  erect;  when, even in this pos-
ture, the breathing is very difficult, and attended with a
turgescence and flushing of the face, together with partial
sweats about the head and neck, and an irregular pulse;
these circumstances mark the difficulty of breathing in pro-
gressive  degrees,  and, consequently,  in proportion,  the
danger of the disease.
  A frequent violent cough aggravating the pain is always
the symptom of an obstinate disease.
  As I apprehend that the disease is hardly ever resolved,
without some expectoration; so a dry cough must be al-
ways an unfavorable symptom.
  As the expectoration formerly described,  marks that the
disease is proceeding  to a resolution ; so an expectoration
which has not the conditions  there mentioned, must denote
at least a doubtful state of the disease; but the marks taken
from the color of the matter, are for the most part falla-
cious.
  An acute pain,  very much interrupting  inspiration, is
always the mark of a violent disease; though not of one
more dangerous,   than an  obtuse  pain,  attended with
very difficult respiration.
  When the pains, which at  first had affected one side on-
ly,  have afterwards spread into the other ; or when leav- 
 132             PRACTICE  OF  PHYSIC.

ing the side first affected, thev entirely pass into the other ;
these are always  marks of an increasing, and therefore ot
a dangerous, disease.                       ■  •  a
  A delirium coming on during a pneumonic inflammation,
is constantly a symptom denoting much danger.
  353.]  When  the termination of this disease  proves fatal,
it is on one or other of the days of the first week, from the
third to the seventh.   This is the most common case  ;  but,
in a few instances, death has happened at a later period of
the disease.
  When the disease is violent, but admitting of resolution,
this also happens frequently in the  course of the first week ;.
but,  in a more  moderate state of the disease,  the resolution
is often delayed to the second week.
  The  disease, on some of  the  days  from the third to the
seventh, generally suffers a remission ;  which, however, may
be  often fallacious,  as the disease does sometimes  return
again with as much violence as before, and then with great
danger.
  Sometimes the  disease disappears on the second or third
day, while an erysipelas makes its appearance on  some ex-
ternal part:  and  if this continue fixed,  the pneumonic in-
flammation does not recur.
   354.]  Pneumonia,  like  other inflammations,  often  ends
in suppuration  or gangrene.*
   355.]  When a pneumonia, with symptoms  neither  very
violent nor very slight,  have continued for many days,  it is
to  be feared it  will end in a suppuration.   This,  however,
is not to be determined precisely by the number  of days :
for,  not only after the fourth,  but even after the tenth day,
there have been examples of a pneumonia ending by  a re-
solution ; and  if the  disease has suffered some intermission
 and again recurred, there  may be instances of a  resolution

                                      •
  *  As this lermination of Pneumonia is always fatal, it is highly necessary that the physician
 should be able to know  when a gangrene is to be suspected,  that he may take the proper mean*
 for  preventing it; or, when it is absolutely formed, that he may save Jiis reputation, by inform-
 ing  the patient's relations of the impending danger, and the fatal consequences with which such a
 termination is attended : I shall therefore add some of the more remarkable diagnostics of an in-
 cipient gangrene in this disease.
  A purulent spitting, streaked with deep colored blood, or  with a blackish matter; a fetid
 breath ; a rattling in the throat; a dejected countenance ; a dim eye ; a languid quick pulse ;
 the  biood drawn from a vein void of the inflammatory crust; fetid green stools in abundance ;
 urine of a bright flame color, or depositing a black sediment of a scaly appearance.
  More symptoms of ihis fatal lermination are unnecessary; for, if most of those above mention-
 ed be present, the physician has no other duty to perform than warn the friends of  the patienC
 that death may be soon expected.
  It may be farther remarked, that, when a gangrene is begun, the patient is considerably freed
 from pain, an.1 both himself and his attendants have great hopes of his recovering ; a few'hours,
 however, soon undeceives them, and raises the reputation of the physician, who has pronouncca
 a true prognosis. See some other diagnostics of gangrene in the notes on article 359. 
PRACTICE  OF PHYSIC.
133
  happening at a much later period from the beginning of the
  disease, than that just now mentioned.
    356.] But if a moderate disease, in spite of proper re-
  medies employed, be protracted to the fourteenth day with-
  out any considerable remission,  a suppuration is pretty cer-
  tainly to be expected ; and it will  be still more certain,  if
  no signs of resolution have appeared, or if an expectoration
  which had appeared shall have again ceased, and the difficul-
  ty of breathing has continued or increased, while the other
  symptoms have rather abated.
    357.] That in  a pneumonia,  the  effusion is made, which
  maX. 'ay tne f°undati(>n of a suppuration, we conclude from
  the  difficulty  of  breathing becoming greater when the pa-
  tient is  in  a horizontal  posture,* or when he can lie more
  easily upon the affected side.
    358.] That in  such cases,  a suppuration has actually be-
  gun, may  be concluded from  the patient's being frequently
 affected with slight cold shiverings, and with a sense of cold
 felt sometimes in  one, and sometimes in another part of the
 body.  We form the same conclusion also from the state of the
 pulse, which is commonly  less  frequent and softer, but
 sometimes  quicker and fuller than before!
    359.]  That a suppuration is already formed,  may be in-
 ferred from there being a considerable remissionf  of the
 pain which had before subsisted, while along with this, the
 cough,  and especially the dyspnoea, continue,  and are ra-
 ther augmented.   At the same time, the  frequency of the
 pulse is  rather increased ;% the feverish state suffers consi-
 derable exacerbations  every  evening,  and by degrees, a
 hectic in all its circumstances  conies to be formed.
   360.] The  termination of  pneumonia  by  gangrene,  is
 much more rare than has been imagined ; and when  it does
 occur, it is usually joined  with  the termination bv effusion
 (346.)  and the symptoms of the one are  hardly to  be dis-
 tinguished from fhose of the other.
   361.]  The cure  of pneumonic inflammation, must pro-
 ceed upon the general plan (264.) but the importance of the

  • In all Pneumonic affections, the breathing is generally more difficult when the patient lies in
 an horizontal posture; it cannot therefore be admitted as a diagnostic of an effusion
  + the young physician must be on his guard with respect to this symptom : for it is also a
 !?,m£.,°.,m;0'*nmaPle,,l'ora» already formed gangrene; he ought therefoie to be  peculiarly
V.IZ1Z1,?„^^Tlf^f sJmP'««ns which the author enumerates, viz  the continuance or
nefr ora econi,^nlh,CUlty°,1 bre",]lng and the cough, both of which either totally disap-
pear, or are considerably lessened on the supervention of gangrene.                v
  t l lie increased frequency of the pulse is also a symptcm of a gangrene being formed; but. if
 ni '"C'TCd 'refluen7 be a«e»°ecl with febrile exacerbations in the evenings, then and then
 grene?    phyuclan be sure th»t «** ^ase ««« lermuiawa io suppuration, and not in g"n"
,S 
134,           PRACTICE  OF PHYSIC.

part affected, and the danger to which it is exposed, require
that  the remedies be fully, as well as early employed.
  362.] The remedy chiefly to be  depended upon,  is that
of bleeding at the arm ;  which will be performed with most
advantage in the arm of  the side most affected, but may be
done in either arm,  as may be most convenient for the  pa-
tient or the surgeon.   The  quantity drawn must be suited
to the  violence  of the disease, and to the vigor of the pa-
tient ;  and generally ought to be as large as this last circum-
stance  will allow.  The  remission of pam, and the relief of
respiration, during the flowing of the blood, may limit the
quantity to be then drawn ; but if these symptoms of relief
do not  appear, the bleeding  should be continued  till the
symptoms of  a beginning syncope come on.   It  is  seldom
that  one bleeding however large,  will prove a cure  of  this
disease ; and although the pain and difficulty of breathing
may be much relieved by the first bleeding,  these symptoms
commonly, and after no long interval, recur,  often  with as
much violence as before.  In the  event of such recurrence
the bleeding is to be repeated, even in the  course of the
same day, and perhaps to the same quantity as before.
  Sometimes the second bleeding may be larger than the
first.  There are persons who, by their constitution, are
ready to faint even upon a small bleeding ; and in such per-
sons this may prevent the drawing so much blood at first as
a pneumonic inflammation might require ; but, as the same
persons are frequently found  to bear after-bleedings better
than the first, this allows the second and subsequent bleed-
ings to be larger, and to such a quantity as the symptoms
of the disease may seem to demand.
  363.] It is according  to the state of the symptoms,  that
bleedings are to be repeated ; and they will be more effec-
tual when practised in the course of the first three days, than
afterwards ; but they are not to be omitted,  although four
days of the disease may have already elapsed.  If the physi-
cian shall not have been called in sooner ; or if the bleedings
practised  during the first days shall  not have been  large
enough, or even although these bleedings shall have procured
some remission ;  yet upon the recurrence of the urgent symp-
toms,  the bleeding should be  repeated at  any period of the
disease, especially within the first fortnight; and even after-
wards, if a tendency to  suppuration be not evident,  or if,
after a seeming solution, the disease shall have again returned.
   364.]  With respect to the quantity of blood which ought., 
PRACTICE OF PHYSIC.           135
 or which with safety may be taken away, no general rules
 can be delivered, as  it must be  very  different, according
 to the state of  the disease and constitution of the patient.
   In an adult male of tolerable strength, a pound of  blood,
 avoirdupois, is a full bleeding.  Any quantity above twenty
 ounces, is a large,  and any quantity below twelve a small,
 bleeding.   A quantity  of from four  to five pounds,  in the
 course of two  or three  days, is generally as much as such
 patients will safely bear ; but, if the intervals between the
 bleedings and the whole of the time during which the bleed-
 ings have been  employed have  been long, the  quantity
 taken upon the whole may be greater.*
   365.] When a large quantity  of  blood has been already
 taken from the arm,  and  when it is doubtful  if more  can
 with safety be drawn in that manner,  some blood  may still
 be taken by cupping  and scarifying.   Such a measure  will
 be more particularly  proper, when the continuance or re-
 currence  of pain,  rather than  the  difficulty of breathing,
 becomes the urgent symptom ; and  then the cupping  and
 scarifying should be made as near to the pained part as can
 conveniently be done.
   366.] An expectoration takes place sometimes very early
 in this disease ; but if, notwithstanding  that,  the urgent
 symptoms should still Continue, the expectoration must not
 supersede the bleedings  mentioned;  and during the first
 days of the disease, its solution is not  to be  trusted to  the
 expectoration alone.  It is in a more advanced stage only,
 when the proper remedies have been before employed, and
 when the symptoms have suffered a considerable remission,
 that the entire cure may  be trusted to a copious and free
 expectoration.
   367.] During  the  first days of the  disease, I  have  not
found that bleeding stops expectoration.  On the contrary,
I have often observed  bleeding promote it; and it is m  a
more advanced stage of the disease only, when the patient,

  * Bleedings produce'the best efect when the blood is drawn off as quickly as possible in a
large full stream ;and,in orderto prevent syncope, the patient ought to be laid horizontally, or
even with his head lower than his trunk.  With respect to the quantity of blood tobe  drawn at
once, or in the whole course of the disease, no general directions can be given ; it must depend
entirely on the circumstances of the disease and of the  patient.  In general, it is usual to conti-
nue the discharge until the patient can either breathe more freelv. or feels a considerable abate-
ment of the pain. If, however, the pain does not abate while the" blood continues to flow, but
signs ot tinning appear, the blood must theu be immediately stopped.
 If the pain and other symptoms continue violent, or return  after the first bleeding, it will
men De necessary to have recourse to the operation ; and it must be repeated frequently through
tne course ottne disease; avoiding, however, so large an  evacuation at once as may induce
fainting.  I he reason of this precaution is evident, viz. that while the motion of the heart is sus-
pcuueu during fainting, the blood stagnates in the right side 01" the heart, and is afterwards
fliawii wub.grcaicj-impetuosity thro^h t'.it lurgs.                       «wwUS 
136
PRACTICE OF PHYSIC.
by large evacuations and the continuance of the disease, has
been already exhausted, that bleeding seems to stop expec-
toration.  It appears to me, that even then bleeding  does
not stop expectoration so much by weakening the powers
of expectoration,  as  by favoring the serous  effusion into
the bronchia;, (348) and thereby preventing it.
   368.] While the bleedings we have mentioned shall  be
employed, it will  be  necessary  to employ also every  part
of the antiphlogistic regimen, (130—132)  and particularly
to prevent the irritation which might arise from any increase
of heat.   For this purpose, it  will be proper  to keep the
patient out  of bed, while  he' can bear it easily; and when
he. cannot, to cover him very lightly while he lies in bed.
The temperature  of  his chamber ought not to exceed sixty
degrees of Farenheit's  thermometer ; and whether it may
be at any time colder,  I am uncertain.
   369.] Mild and diluent drinks, moderately tepid, at least
never cold,  given by small portions at a time, ought to be
administered plentifully.  These drinks may be impregnated
with vegetable acids.*  They may be properly accompani-
ed also with nitre, or some other neutrals; f but these salts
should be given separately from the drinks.J
   It has been alledged, that both acids and nitre are ready
to excite coughing, and in some persons they certainly have
this effect; but except in persons of a peculiar habit, I have
not found their effects in exciting cough so considerable or
troublesome as to  prevent our seeking the advantages other-
wise to be obtained from these  medicines.
   370.]  Some practitioners have doubted,  if purgatives
can be safely employed in this  disease ; and indeed a spon-
taneous  diarrhoea occurring in the  beginning of the dis-
ease has seldom proved  useful: but I have found the mo-
derate use  of cooling laxativesjj generally safe, and  have
always found it useful to keep the belly open by frequent
emollient giysters.
   371.]  To excite full vomiting by emetics, I judge to be
a dangerous practice in  this disease : but I have found it
useful to exhibit  nauseating doses ; and in a somewhat ad-

  * See the note on article 131. acids.          + See the note on article 160.
  t These salts generally render the drink nauseous; and, as plentiful dilution is absolutely neces-
sary in these cases,so far from rendering the patient's common drink nauseous, by impregnating
it with ill-flavored medicines, we ought, by every possible means, to endeavor to make it as
agreeable as we can, that he may be the more easily prevailed on to take it plentifully.
  ilThe cooling laxatives are, salts, manna, ice. but, in these cases, three or four ounces of in
 sum senna?, with half an ounce of Glaubers rait may be given without danger. 
PRACTICE  OF  PHYSIC.
137
vanced state of the disease, I have found such doses prove
the best means of promoting expectoration.*
   372.]  Fomentations and poultices applied to  the pained
part  have  been  recommended, and may be  useful; but
the application of them is often inconvenient, and may be
entirely omitted for the sake of the more effectual remedy,
blistering, f
   Very early  in the disease, a blister should be applied  as
near to the  pained part as possible.   But as, when the irrita-
tion of a blister is present, it renders bleeding less effectu-
al ; so the  application of the blister should be delayed till
a  bleeding  shall have  been employed.   If the disease be
moderate,  the blister may be applied immediately after the
first bleeding; but if the disease be violent, and it is presum-
ed that  a second bleeding may be necessary soon after the
first, it will then be proper to delay the  blister  till after
the second  bleeding, when it may be  supposed that any fur-
ther bleeding  may be postponed till the  irritation  arising
from the blister shall have  ceased.  It may be frequently
necessary in this disease to repeat the blistering: and in that
case the  plaisters should always be applied somewhere on
the thorax;J for, when applied to more distant parts, they
have little  effect.  The  keeping the blistered  parts open,
and making what is called  a perpetual blister, has much
less effect than a fresh blistering.
   373.] As this disease often terminates by an expectora-
tion, so various means of promoting this have been propos-
ed :  but none  of them appear to be  very effectual; and
some of them being acrid stimulant  substances, cannot be
very safe.
   The gums usually employed seem too heating: squills
seem to  be less so; but  they are not very powerful, and
sometimes inconvenient by the constant nausea they induce. |J
  • The tartar emetic is the medicine generally employed for this purpose. The dose of it in
these cases must be verv small, and well diluted, as in the following formula:
              R. Antimon. tartarisat. gr. ii.
                 Aq. font. Bviiss.
                 Syr. papaveris rubr. §ss.
                 M.
  The dose of this mixture ought not to exceed three table-spoonfuls, when given with this
intention.
  + The application of a blister to the part affected, ought to be the first prescription in all
complaints of the thorax, except some remarkable or urgent cause forbid the practice, because
it is a most efficacious remedy, and is as necessary as bleeding.
  t They ought, however, to be applied as near to the pained part as possible.
  II All the liquid lorms of squills which we have in the shops are nauseating. Pills made of the
dry powder, with an electuary or conserve, or honey, is the form in whiovt squills affect the
stomach least. The dose is 4 or 5 grains of the dry powder : 10 grains generally, if not con-
stantly produce vomitings.  To prevent the  nauseating eflectsof squills, die addition of some 
138
PRACTICE  OF PHYSIC.
  The volatile alkali may be of  service as an expectorant;
but it should be reserved for an advanced  state of the dis-
ease.
  Mucilaginous and oily demulcents appear  to be useful,
by  allaying that acrimony of  the mucus  which  occasions
too frequent coughing; and which  coughing prevents the
stagnation and thickening of the mucus,  and thereby its
becoming mild.
  The receiving into the lungs the steams of warm water
impregnated with vinegar, has often proved  useful in pro-
moting expectoration.*
  But, of all  other remedies  the most powerful for this
purpose, are antimonial  medicines,  given in nauseating do-
ses,  as in (179).   Of these,  however,  I have not found the
kermes mineral more efficacious than emetic tartar,  or an-
timonial wine ; and the  dose of the kerrnes is much more
uncertain than that of the others.
  374.] Though a spontaneous sweating  often proves the
crisis of this disease, it ought not to be excited by art, un-
less  with much caution.  At least  I have not yet found it
either so effectual or safe, as some  writers have  alledged.
When, after some remission of the symptoms, spontaneous
sweats  of a proper  kind arise they may  be encouraged ;
but it ought to be without  much heat, and without stimu-
lant medicines.   If, however,  the sweats be partial and
clammy only, and a great difficulty, of breathing still re-
main, it wili be very dangerous to encourage them.
  375.] Physicians have differed much in opinion with re-
gard to the use of opiates in pneumonic inflammation.   To
me it appears, that, in the beginning of the disease, and be-
fore bleeding and blistering have produced some remission
of the pain and of the  difficulty  of breathing, opiates have
a very bad effect, by their increasing the difficulty of breath-
ing, and  other inflammatory  symptoms.   But in a  more
advanced state of the disease,  when thedifliculy of breath-
ing has abated, and when the urgent symptom is a cough,
proving the chief cause of the  continuance of the pain and
grateful aromatic is of material use. The pilul.t? silitica? of the Edinburgh Pharmacopoeia is a
good formula, except that the dose of it must be large, in order to lake a sufficient quantity of
the squills,  10 grains ot it containing only 1 grain of dry squills, supposing no syrup to be used
in making the mass.  One convenience indeed, attends this formula, viz. that we can give
imall doses with more precision than if we used the  powder alone.  The gum ammoniac is an
expectorant; and therefore, when given along wilh the squills in these pills, may render a less
do.-e of the squills necessary.  If ti.e extract of liquonce be omitted, the proportion ot the
squills to ilie whole will be increased.
 ** s line practitioner, propose the steam of vinegar alone : but it proves in general too irritat-
■ !»>.  The sin.e objection  may be made against  using the steam of wine, which some piacii-
n.Kwrs have recommended instead ot the steam ot vinegar.  Plain  water is the be.t, as the
waiai \apur Only acts by'relaxing the internal surface of u.e lu.^a. 
             PRACTICE  OF PHYSIC.            139

of the want of sleep, opiates may be employed with great
advantage and  safety.  The  interruption  of the expec-
toration, which  they seem to occasion, is for a short  time
©nly ; and they  seem often to promote it, as they occasion
a stagnation of  what was by frequent coughing dissipated
insensibly,  and therefore give the appearance  of  what
physicians have called Concocted Matter.



                 CHAPTER  VII.

   OF  THE PERIPNEUMONIA NOTHA,  OR
         RASTARD PERIPNEUMONY.

   376.] A   DISEASE under this  name is  mentioned in
       x\. some medical  writings of the sixteenth cen-
tury; but it is very  doubtful if the name was then applied
to the same disease to which we now apply it. It appears
to me,  that unless some of the cases described  under the
title of Catarrhus Suffocativus be supposed  to have  been
of the kind I am now to treat of,  there was no description
of this disease given before that by Sydenham, under the
title I have employed here.
  377.] After Sydenham, Boerhaave was the first who in a
system took  notice of  it as a distinct disease; and he has
described it in his aphorisms, although with  some circum-
stances different from those in the description of Sydenham.
Of late, Mr. Lieutaud has with great confidence asserted,
that Sydenham  and  Boerhaave had,  under the same  title,
described different diseases ; and  that, perhaps, neither of
them had on this subject delivered any thing but hypothesis.
  37S.] Notwithstanding this  bold assertion, I am humbly
of opinion, and  the Baron Van Swieten seems to have been
of the same, that Sydenham and Boerhaave did describe
under the same title,  one and  the same  disease.   Nay, I
am further of opinion, that the disease described by Mr.
Lieutaud himself, is  not essentially different from that des-
cribed by both the other authors.  Nor will  the doubts of
the very  learned, but modest Morgagni, on this  subject,
disturb us, if we consider, that while very few describers of
diseases cither have it in their power,  or have been suffici-
ently attentive in distinguishing between the  essential and
accidental symptoms of disease; so, in a disease which may 
140
PRACTICE  OF PHYSIC.
 have not  only different, but  a greater number of  symp-
 toms,  in one person than it has in another,  we need  not
 wonder that the descriptions of the same disease by differ-
 ent persons should come out in some respects different.  I
 shall, however, enter no further into this controversy ;  but
 endeavor to describe the disease as it has appeared to my-
 self: and, as I judge, in the essential symptoms, much the
 same as it has appeared to all the other authors mentioned.
   379.] This disease appears at the same seasons that other
 pneumonic and catarrhal affections commonly do ; that is,
 in autumn and spring.   Like these diseases also, it is seem-
 ingly occasioned by sudden changes of the  weather from
 heat to cold.  It appears, also,  during the prevalence of
 contagions catarrhs ; and it is frequently under the form of
 the Peripneumonia Notha that these catarrhs prove fatal to
 elderly persons.
   This disease attacks  most commonly  persons  somewhat
 advanced in life, especially those of a full phlegmatic habit;
 those who have  before been frequently  liable to  catarrhal
 affections ; and those who have been much addicted to  the
 large use of fermented and spirituous liquors.
   The disease commonly comes on with the same symptoms
 as other febrile diseases ; that is, with alternate chills and
 heats ; and the symptoms of pyrexia are sometimes suffi-
 ciently evident;  but in most cases these are very moderate,
 and in some hardly at all appear.   With the first attack of
 the disease, a cough comes on ;  usually accompanied with
 some expectoration,  and in many cases, there is a frequent
throwing up of a considerable  quantity of a viscid opaque
 mucus.   The cough often becomes frequent and violent; is
 sometimes accompanied with a rending head-ach ;  and, as
 in other cases of cough, a vomiting is sometimes excited by
 it.  The face is  sometimes flushed, and  some giddiness or
 drowsiness often attends the disease.  A difficulty of breath-
ing,  with a sense of oppression, or straitening in the chest,
 with some obscure pains there, and a sense of lassitude over
the whole body,  very constantly attend  this disease.   The
blood drawn in this disease,  sliows  a buffy surface,  as in
other inflammatory affections.
  The disease has often the appearance only of a more vio-  -'
lent catarrh, and after the employment of some remedies is
entirely relieved by  a free and copious expectoration.   In
other cases, however, the  feverish and catarrhal symptoms
are at fir!>t very moderate, and even slight; but after a  few 
PRACTICE OF PHYSIC.
141
days, these symptoms  suddenly become considerable,  and
put an  end  to the patient's life when the  indications of
danger  were before very little evident.
  380.] From the different circumstances in  which this dis-
ease appears, the pathology of  it is difficult.   It is certainly
often no other at  first  than a catarrhal affection, which, in
elderly persons, is frequently attended with a large afflux of
mucus  to the lungs ;  and  it was on this footing that Syden-
ham considered it as  only differing in degree from his Febris
Hyemalis.   A catarrh, however, is strictly  an affection of
the mucus membrane and follicles of  the bronchiae  alone :
but it may readily have, and  frequently has, a degree of
pneumonic inflammation joined to it; and in that case may
prove more properly the peculiar disease we  treat of here.
But, further, as pneumonic inflammation very often produ-
ces an  effusion of serum into the bronchiae  (348.) so this,
in elderly persons,  may  occur  in  consequence of a  slight
degree of inflammation ;  and Avhen it does happen, will give
exquisite and fatal cases of the peripneumonia notha.
   381.] After this attempt to establish  the pathology,  the
method of cure in the different circumstances of the disease
will not be difficult.
   In case the fever, catarrhal  and pneumonic  symptoms,
are immediately considerable,   a blood-letting will certainly
be proper and necessary  :  but,  where these symptoms are
moderate,  a  blood-letting will  hardly be  requisite ;  and
when an effusion is to  be feared, the repetition of blood-let-
ting may prove extremely hurtful.*
   In all cases the remedies chiefly to be depended upon, are
vomitingf and blistering.£
   Full vomiting may  be  frequently repeated, and nauseat-
ing doses||  ought  to  be constantly employed.
   Purging may perhaps  be useful ; butas it is seldom so in

  * The intention of bleeding in this disease is merely to facilitate the circulation through the
lungs, and to relieve the oppression in the breast; when this intention is therefore answered, and
when the shortness of breath and oppression about the breast are removed, there is no farther
need of the lancet.  As this disease chiefly attacks elderly persons, and such as are of a phleg-
matic habit, much harm may be done by repeated bleedings, which always increase debility and
retard the cure.                                                '
  + Vomiting, in this disease, has been thought by many practitioners to be a doubtful remedy.
The action ot vomiting always oppresses the breast, and sometimes even increases the svmu-
toms of the disease.                                               v
  X This is the chief remedy : and the blisters ought to be applied as near the part affected as
  II In several of the former Notes we have fully described the method of giving the emetic tar-
tar in nauseating doses. Their principal effect  is to piocure a perspiration : and, when this
h«i«™WUCe ^.tl?Pa'',en.,m"St  drink largely of any diluent or attenuating liquor, as thin
pane) water, with the addition of the juice of some of the acid fruits, or infusions of some of
ike gent.e aromatics, as sage, balm, mint, &c. or even a thin wine whey. 
142            PRACTICE OF  PHYSIC.

pneumonic affections, nothing but gentle laxatives are here
necessary."
   In all the circumstances of this disease, the antiphlogistic
regimen is proper ;  cold is to be guarded against; but much
external heat is to be  as carefully avoided.
   382.]  If a person  sweats easily,  and it can be brought
out by the use of mild tepid liquors only,  the practice may
in such persons be tried.   See Morgagni  de Sed. et Caus.
Epist. xiii. Art.  4.
   383.]  I might here, perhaps, give a separate section  on
the Carditis and  Pericarditis,  or  the inflammations  of the
Heart and Pericardium ;  but  they hardly require a particu-
lar consideration.  An acute inflammation of the pericardi-
um is almost always a part of the same pneumonic affection
I have been treating of ; and  is not always distinguished by
any different symptoms :  or,  if  it be, does not require any
different treatment.   The same may be said of an acute in-
flammation of the  heart  itself ;  and when it happens that
the one or other is discovered by the symptoms of palpita-
tion or syncope, no more will be implied than that the reme-
dies of pneumonic inflammation  should  be  employed with
greater diligence.
   From  dissections,  which shew the  heart and pericardium
affected  with erosions, ulcerations, and abscesses, we disco-
ver,  that these parts  had  been before affected with  inflam-
mation :  and that in  cases where no symptoms of pneumo-
nic inflammation had  appeared ;  it may therefore be alledg-
ed, that those inflammations of  the heart and  pericardium
should be considered  as  diseases  independent of the pneu-
monic.    This indeed is just ; but the history of  such cases
proves that those inflammations had been of  a chronic kind,
and hardly discovering themselves by any  peculiar  syrrip-

  * Purging is surely hurtful in this disease, by inducing too great a state of debility : the intes-
tines, however, are to be emptied in the beginning ot the du>easc, which is best done by a
p irging glyster, and kept open by the subsequent use of gentle laxatives, or by repetitions of
mild emollient giysters  The purging ghster may be made as follows:
              R. Aq. font. lb. 1.
                 Fol.  Senn. §ss.
                 Coque leniter, et colaturx adde
                 Sal.  Cathart. ama. |i.
                 Mel. B".      t
                 M. f. Enema.
The subsequent giysters ought to consist ot nothing- more than simple barley-water, or milk" and
water. The laxatives, if they ate used, should be very gentle and mild j as cream of tartar,
whey, manna, tamarinds, ice.  Half an ounce of manna dissolved in half a pint of crcain of
larta'r whey, makes an agreeable opening mixture ; half a  tea-cupful of it may be taken three
or four times a day, so as to procure at least two or three stools in the twcn^-iour hours. 
PRACTICE OF PHYSIC.           143
toms ; or if attended with symptoms marking an affection
of the heart, these were however such as have been known
frequently to arise from other causes than  inflammation.
There is, therefore, upon the whole, no room for our treat-
ing more particularly of the  inflammation of the heart or
pericardium.


                 CHAPTER  VIII.

OF THE  GASTRITIS,   OR  INFLAMMATION
               OF THE STOMACH.

   384.]  A MONG the  inflammations  of the abdominal
        II region,  I have given a place in our Nosology
to the Peritonitis; comprehending under that title,  not on-
ly the inflammations affecting the peritonaeum lining the ca-
vity of the abdomen,  but also those affecting the extentions
of this membrane in the omentum and mesentery. It is not,
however, proposed to treat of them here, because it  is ve-
ry difficult to say by what symptoms they are always to be
known; and farther, because when known, they do not re-
quire any remedies beside those of inflammation in gener-
al.  I  proceed  therefore, to treat of those inflammations,
which  affecting viscera of peculiar functions, both give
occasion to  peculiar symptoms, and requires some peculi-
arities in the method  of cure; and I shall begin with the
inflammation of the stomach.
   385.]  The inflammation of the stomach is of two kinds,
Phlegmonic, or Erythematic*   The first may be seated in
what is called the Nervous Coat  of the stomach,  or in the
peritonaeum investing it.   The second is always seated  in
the villous coat and cellular texture immediately subjacent.
   386.]  The phlegmonic inflammation of the stomach,  or
what has been commonly treated of under the title of Gastri-
tis,  is  known by an acute pain in some part of the region
of the stomach, attended with pyrexia, with frequent vom-
iting,  especially upon occasion  of any thing being taken
 down into the stomach, and frequently with hickup.   The
 pulse is  commonly small and hard; and there is a greater
loss of strength in all the functions of the body, than in the
 case of almost  any other inflammation.
 .r^S,!$ t^LTIV butwh°ever considers what is said in 274, will, I expect, perceive the
 T'jpnety, and even the necessity, of it.                     v 
144           PRACTICE OF PHYSIC.
  387.] This inflammation may be produced by various
causes; as, by  external contusion; by acrids of various
kinds taken into the stomach;  frequently by very  cold
drink taken into it while the body is very warm ; and some-
times by over-distension, from the having taken in a  large
quantity of food of difficult digestion.  All these may be
considered as external  causes;  but the disease sometimes
arises also from internal causes not so well understood.  It
may arise from inflammations of the neighboring parts com-
municated to the stomach,  and is then to be considered as
a symptomatic affection only.   It may arise also from va-
rious acrimonies generated within the  body, either in  the
stomach itself, or in other parts,  and poured into the cavity
of the  stomach.  These are causes more  directly applied
to the  stomach; but there are perhaps others originating
elsewhere,  and affecting the stomach only sympathetical-
ly.   Such may be supposed to have acted in the case of pu-
trid fevers andexanthematic pyrexia;  in which, upon dis-
section, it has been discovered  that the stomach had been
affected with inflammation.
  388.] From the sensibility of  the stomach, and its com-
munication with the rest of the system, it will be obvious,
that the inflammation  of  this organ,  by whatever causes
produced,  may be attended  with fatal consequences.  In
particular,  by the great debility  which such an inflamma-
tion suddenly produces, it may quickly prove fatal,  with-
out running the common course of inflammations.
  When it lasts long enough to  follow the ordinary course
of other inflammations, it  may  terminate  by resolution,
gangrene,  or suppuration.  The scirrhosities which are of-
ten discovered affecting the stomach,  are seldom known to
be the consequences of inflammation.
  389.] The tendency of  this disease  to admit of resolu-
tion, may be known, by its having arisen from no violent
cause ; by the moderate state of the symptoms ; and by a
gradual remission of these, especially in consequence  of re-
medies employed  in the course of the first, or at farthest,
the second week of the disease.
  390.] The tendency  to  suppuration may be known by
the symptoms continuing, in a moderate degree,  for more
than one or two weeks ; and likewise by a considerable re-
mission of the pain, while  a sense of weight and an anxiety
still remain.
  When an abscess has been formed, the frequency  of the 
              PRACTICE OF PHYSIC.            145

pulse is at first abated ; but soon after, it is again increased,
with frequent cold shiverings, and with marked exacerba-
tions  in the afternoon  and evening, followed  by  night
sweatings, and other symptoms of hectic fever.  These at
length prove fatal, unless the abscess open into the  ca-
vity of the  stomach, the pus be evacuated by  vomiting,
and the ulcer soon heal.
  391.]  The tendency to gangrene may be suspected from
the violence of the symptoms not yielding to the remedies
employed during  the first days of the disease : and that a
gangrene has already begun, may be known from the sud-
den remission of the pain, while the frequency of the pulse
continues, and at the same time becomes weaker,  accom-
panied with other marks* of an increasing debility  in the
whole system.
   392.]  From the  dissection of dead  bodies it appears,
that the stomach very often has been affected with inflam-
mation, when the characteristic symptoms of it  (386.) had
not appeared ; and therefore it is very difficult to lay down
any general rules for the cure of this disease.
   393.] It is only in the case of phlegmonic inflammation, as
characterised in (386.) that wecan advisethe cure or resolu-
tion to be attempted by large and repeated bleedings em-
ployed early in the disease: and we are not to be deterred
from these  by the  smallness of the pulse; for after bleed-
ing, it commonly becomes fuller and s.ofter.   After bleed-
ing, a blister ought to be applied to the region of the sto-
mach ; and the cure will be assisted by fomentations of the
whole abdomen, as  well as by frequent emollient and lax-
ative giysters.
   394.] In  this disease,  the irritability of the stomach will
not admit  of any  medicines being thrown into it;  and if
any internal medicines  can be supposed  necessary, they
must be exhibited in giysters.  The giving of drink may
be tried ; but it  ought to be of the very mildest kind, and
in very small  quantities at a time.f
   395.] Opiates,  in  whatever manner exhibited, are very
hurtful during the first days of  the disease ;  but when its
violence  shall have abated, and when the  violence of the
pain and vomiting recur at intervals  only, opiates given in

  * A delirium is one of the most general concomitants of the increasing debility of the system,
and may be considered as a diagnostic.
  + Chicken broth is extremely mild; it may be taken in small quantities, with about eifcht or
ten grains of nine in every pint of it. Lintseed tea is also a very mild drink ; and, if the in-
flammation be owing to the presence of any acrid matter irritating the stomach, it is of great
seivitc by tts sheathing quality. 
146
PRACTICE OF PHYSIC.
giysters may be cautiously tried, and sometimes have been
employed with advantage.
  396.] A tendency to suppuration, in this disease, is to
be obviated  by the  means just now proposed.  After a
certain duration of the disease, it cannot be prevented  by
any means whatever ; and when actually begun  must be
left to  nature ; the business of the physician being only to
avoid all irritation.
  397.] A tendency  to gangrene  can be obviated in  no
other way than by the means suggested, (393.) employed
early in the disease ;  and, when it does actually supervene,
admits of no remedy.
  398.]  Ery thematic inflammations of the  stomach,  are
more frequent than those  of the phlemonic kind.   It ap-
pears at least, from dissections, that the stomach has often
been affected with inflammation, when neither pain nor py-
rexia had before given any notice  of it; and such inflam-
mation I apprehend to have been chiefly of the ery thematic
kind.  This species of inflammation also is especially to be
expected from acrimony of any kind thrown into the sto-
mach ;  and would certainly occur more frequently fromsuch
a cause, were not the interior surface of this organ common-
ly defended  by mucus exuding in large quantities from the
numerous follicles placed immediately under the villous
coat.  Upon many  occasions,  however, the exudation of
mucus is prevented, or the liquid  poured out is of a less
viscid kind,  so as to  be less fitted to  defend  the subjacent
nerves ; and it is in such cases that matters even of mode-
rate acrimony, may produce an ery thematic affection of
the stomach.
  399.] From  what  has been said, it must appear that an
erythematic inflammation of the stomach may frequently
occur ; but  will not always discover itself, as it sometimes
takes place without pyrexia, pain, or vomiting.
  400.] There are cases, however, in which it may be dis-
covered.  The affection of the stomach sometimes spreads
into the oesophagus,  and appears in the pharynx, as well
as on the whole internal  surface of the mouth.  When,
therefore, an erythematic inflammation affects the mouth
and fauces,  and when at the same time there shall  be in  the
stomach an unusual sensibility to all acrids, with a frequent
vomiting, there can be little doubt of the  stomach being
affected with the same inflammation that has appeared in
the fauces.  Even when no inflammation appears  in  the 
PRACTICE  OF PHYSIC.           147
Fauces yet if some degree of pain be felt in the stomach,
if there be a want of appetite,  an anxiety, frequent vom-
iting, an unusual sensibility, with respect to acrids, some
thirst, and frequency of pulse,  there will then be room to
suspect an  erythematic inflammation of the stomach ; and
we have known such symptoms, after some time, discover
their cause more clearly by the appearance of the inflam-
mation in the fauces or mouth.  Erythematic inflamma-
tion is often disposed to spread from one place to another
on the same surface ; and, in doing so, to leave the place
it had at first occupied.  Thus, such an inflammation has
been known to spread successively along the whole course
of the alimentary canal,  occasioning in the intestines diar-
rhoea, and in the stomach vomitings; the diarrhoea ceasing
when the vomitings  came on, or the  vomitings upon the
coming on  of the diarrhoea.
  401.]  When an erythematic inflammation of the sto-
mach shall  be discovered, it is to be treated differently, ac-
cording to  the difference of its  causes and symptoms.
  When it  is owing to acrid matters taken in by the mouth,
and when these may be supposed still present in the stom-
ach, they  are to be  washed  out by throwing in a large
quantity of warm and mild liquids,  and by  exciting vomit-
ing.  At the same time, if the  nature of the acrimony and
its proper corrector be  known, this should be thrown in ;
or if a specific corrector be not known, some general de-
mulcents should be employed.
  402.]  These measures, however,  are more suited to pre-
vent the inflammation, than to cure it after  it has taken
place.   When  this last may be supposed to be the case, if
it be attended with a  sense of heat,  with pain and pyrexia,
according to the degree of  these symptoms,  the  measures
proposed in (393) are to be  more or Jess employed.
  403.]  When an erythematic inflammation of the stomach
has arisen from internal  causes,  if pain and  pyrexia accom-
pany the disease, some bleeding in  persons not otherwise
weakened,  may be employed; but, as  the affection often
arises in putrid diseases, and in convalescents  from fever;
so in these cases, bleeding is inadmissible; all that can be done
being to avoid  irritation, and  to throw into  the stomach
what quantity  of acids, and of acescent aliments, it shall
be found to bear.
  In some  conditions of the body,  in  which this disease
arii-e.-;, the Peruvian bark and bitters may seem to be indi- 
148           PRACTICE OF  PHYSIC.

cated: but an erythematic state  of the  stomach  does not
commonly allow of them.
CHAPTER IX.
OF THE  ENTERITIS,  OR INFLAMMATION
               OF THE INTESTINES.

  404.]  HHHE inflammation of the intestines, like that of
          X  the  stomach,  may  be  either  phlegmonic  or
erythematic ; but, on  the subject  of the latter, I have no-
thing  to add to what has been said in the last chapter; and
shall here therefore treat of the phlegmonic inflammation only.
  405.]  This inflammation may be  known  to  be  present,
by  a  fixed  pain  of the abdomen, attended with pyrexia,
costiveness,  and vomiting.   Practical  writers mention  the
pain  in  this case  as felt  in  different parts of the abdomen^
according to the different seat of the inflammation ; and so,
indeed,  it sometimes happens ;  but very often  the  pain
spreads  over the  whole  belly, and is felt more  especially
about the navel.
  406.]  The Enteritis and  Gastritis arise from like causes ;
but the former, more readily than the latter, proceeds from
cold applied  to the lower extremities,  or to  the belly  itself.
The enteritis has likewise its own peculiar causes, as super-
vening  upon the  spasmodic colic, incarcerated hernia, and
volvulus.
   407.] Inflammations of the intestines have the same ter-
minations as those of the stomach; and, in  both cases, the
several  tendencies are to be discovered by the same  symp-
toms (389. 391.)
   408.] The cure of the enteritis is, in general, the same
with that  of the  gastritis;  (393. and seq.)  but in the ente-
ritis,  there is commonly more access to the introduction of
liquids, of acid, acescent,  and other cooling remedies,  and
even of laxatives.*   As, however a vomiting so frequently

  » In this disease, we ought to be extremely cautious in the administration either of medi-
cines or diluents. The reason is evident from the following considerations. In every case of
inflammation of a canal, the bore of that canal is  diminished,  and frequently quite shut. A
miantity of any kind of ingesta being forced against this obstruction, must necessarily increase
the irritation, and consequently aggravate all the symptoms. The same reason may be eiven
tor the caution necessary in prescribing laxatives, which always iiriiate; for their action gene-
rally denends upon the irntaHon they produce. Large bleedings, emollient giysters frequently
repeated, fomentations, the warm bath, and small anodvne giysters  occasionally injected, arc
■be most effectual remedies in tlie first stage of this violent disease. When the pain remits, and 
PRACTICE OF  PHYSIC.
149
 attends  this disease, care  must  be taken not to excite that
 vomiting by either the quantity or the quality,  of any thing
 thrown into the stomach.
   The  same observation with respect to the use of  opiates
 is to be made here as in the case of gastritis.
   409.]  Under the title of Enteritis, it has been usual with
 f>ractical  writers to treat of the remedies proper for the cho-
 ic* and its higher degree named Ileus: but, although it be
 true that  the enteritis  and cholic do frequently accompany
 eaeh other, I still hold them to be distinct diseases, to be of-
 ten occurring separately, and accordingly to require and ad-
 mit  of different  remedies.   I shall  therefore delay speaking
 of the remedies proper for the  cholic, till I shall come to
 treat of this disease in its proper place.
   410.]  What might be mentioned with respect to the sup-
 puration or gangrene occurring in the enteritis, may be suf-
 ficiently understood from what nas been said on the same sub-
ject with respect to the gastritis.
CHAPTER  X.
 OF THE HEPATITIS,  OR  INFLAMMATION
                    OF THE LIVER.

  411.] HT^HE inflammation of the liver seems tobe of
          X  two kinds ;  the one acute, the other chronic.
  412.] The acute is attended with pungent pain; consid-
erable  pyrexia;  a frequent, strong, and  hard pulse;  and
high colored urine.
  413.] The chronic hepatitis very often does  not exhibit

1 u^ v.'.olence of the symptoms abates, mild diluents may then be admitted, as chicken-broth,
thin lintseed tea, ice.; and, if such liquors be retained without aggravating the symptoms, we
may then venture to give an ounce ot manna every three or four hours, till it procures a pas-
 The internal use of opium has been extolled by several practitioners in these cases; but ex-
perience shews that it generally does harm in every case of inflammation, especially in the
early stages of it.                                     >  r   /
 The anodyne glyster is the safest method of using opium; but giysters of this kind are said to
wstruct: This objection is, however, ill founded;  for, by diminishing the irritation, they evi-
raU   d • W r   ve the lnflair>mation.  The foUowing  formula of an anodyne glyster is gene-

                R. Decoct, hord. Biv.
                   Opii puri gr. iv.
                   M.
S/\Vi'rri?Mfe.T,te"'paitiCUlar caje mustbe taken to aroid every thing mat has the least tenden,
reraedfe'sTI'in vair^™6'1  M°K ^ Ph*rician be Mlled« as » t0° frequently the case, then all
 • See article 435. 
150           PRACTICE  OF PHYSIC.

any of these symptoms ;  and it is only discovered to have
happened,  by "our  finding  in the liver,   upon dissection,
large abscesses, which are presumed to be the effect of some
degree of previous  inflammation.  As this chronic inflam-
mation is seldom to be certainly known,  and therefore does
riot lead to any determined practice, we  omit treating of it
here,  and shall only treat of what relates to the acute spe-
cies of the hepatitis.*
  414.] The acute  hepatitis may be known by a pain more
or less acute in the right hypochondrium, increased by pres-
sing upon the part.   The pain is very often in  such a part
of the side as to make it appear like that of a pleurisy;  and
frequently,  like  that too,  is increased on respiration.   The
disease is,  in some instances, also attended with a cough
which is  commonly dry, but sometimes humid: and when
the pain thus resembles that of a pleurisy,  the patient can-
not lie easily except upon  the side affected.
  In every kind  of acute hepatitis, the pain is often extend-
ed to  the clavicle, and to the top of the shoulder.  The dis-
ease in attended sometimes with hickup, and sometimes with
vomiting.  Many practical writers have mentioned the jaun-
dice,  or a yellow color of the skin and eyes, as a very con-
stant  symptom of the hepatitis ; but experience has shown,
that it may  often occur without  any  such symptom, f
  415.]  The remote causes  of  hepatitis are  not always to
be discerned, and many have been assigned on a very uncer-
tain foundation.   The following seem to be frequently evi-
dent.  1.  External violence from contusions or falls, and es-
pecially  those  which  have  occasioned  a  fracture of  the
cranium.   2.  Certain  passions  of the mind.  3. Violent
summer heats.   4.  Violent exercise.  5. Intermittent and
remittent fevers.  6. Cold applied externally,  or internal-
ly ; and therefore in many cases the same causes which pro-
duce  pneumonic inflammation,  produce hepatitis;  and
whence also the  two diseases are sometimes joined together.
7. Various  solid concretions or collections of  liquid  mat-
ter, in the  substance of the liver, produced  by  unknown
causes.   Lastly, The  acute is often induced by  a chronic
inflammation of this viscus.
  416.]  It has been supposed, that the hepatitis may bean
affection either of the  extremities of the  hepatic artery, or

  * It is doubtful whe her this chronic hepatitis ever exists.
  + This svmptoru generally appears, however, after the disease has continued for three or four
days ; perhaps, indeed, it might have been present in the beginning, for it rs frequently so sleht
as to escape observation.                                 ■»   <   *■ 
PRACTICE OF PHYSIC.          151,
of those of the vena potarum ; but of the last supposition
there is neither evidence nor probability.
  417.] It seems  probable, that the acute hepatitis is al-
ways an affection of  the  external membrane  of  the liver;
and that the  parenchymatic is of the  chronic  kind.   The
acute disease may be seated either on the  convex or on the
concave  surface of the liver.   In the former  case, a more
pungent  pain and hickup  may  be produced, and the res-
piration is more considerably affected.  In the latter, there
occurs less pain ; and a  vomiting is produced, commonly
by some inflammation communicated to the stomach.   The
inflammation  of the concave  surface of the liver, may be
readily communicated to the gall bladder and biliary ducts;
and this perhaps is the only case of idiopathic hepatitis at-
tended with jaundice.
   418.]  The hepatitis, like other inflammations, may end
by resolution, suppuration, or gangrene  ; and the  tenden-,
cy to the one or the  other of these events, may be known
from what has been delivered above.
   419.] The resolution of hepatitis is often  the  conse-
quence of, or is attended  with,  evacuations of different
kinds.  A hemorrhagy, sometimes from  the* right nostril,
and  sometimes from the hemorrhoidal vessels, gives  a so-
lution  of the  disease.  Sometimes a bilious diarrhoea  con-
tributes to the same event; and  the resolution of the hepa-
titis, as of other inflammations,  is attended with sweating
and with an  evacuation of urine, depositing a copious se-
diment.   Can this disease be resolved  by expectoration ?
It would seem to be sometimes  cured by an erysipelas ap-
pearing in some external part.
   420.]  When this disease has ended  in suppuration, the
pus collected may be discharged by the biliary ducts ; or,
if the  suppurated part does not any  where adhere closely
to the  neighboring parts, the pus may be discharged into
the cavity of  the abdomen; but if, during the first state of
inflammation, the affected part of  the liver shall  have
formed a close adhesion to some of the neighboring parts,
the discharge of the pus after suppuration mav be various,
according to the different seat of the abscess. " When  seat-
ed on  the convex  part  of the liver,  if the  adhesion be to
the  peritonaeum lining  the common teguments, the p
us
such hem rrha£«««„»"?» a fa1Cy °lCalcn 5 ,Jhat inflammatory fcTen were only resolved by
^\ycd2TX^S^S!nYheU^afka/dL Thus an •"•morrtugefrom the right nonr.I,
•oleen   """^maiion of the liver; but a discharge from the left, an ioflammaiVo* ot the 
 152          PRACTICE OF  PHYSIC.

 may make its way  through these, and be discharged out-
 wardly; or, if the  adhesion should have been to the dia-
 phragm, the  pus may penetrate through this,  and into the
 cavity of the thorax, or  of  the lungs ; and  through the
latter may be discharged by coughing.  When the abscess
 of the liver is seated on its concave part, then,  in  conse-
 quence of adhesions,  the pus may be  discharged into the
 stomach or the intestines ; and into these last, either di-
 rectly, or by the intervention  of the biliary ducts.
  421.] The prognostics in this disease are established up-
 on the general principles relating to inflammation,  upon the
 particular circumstances of the liver,  and upon the  parti-
 cular state of its inflammation.
  The cure of this disease must proceed upon the general
 plain ; by bleeding, more  or less, according to the urgency
 of pain or pyrexia; by  the application of blisters ; by fo-
 mentations,  of the external parts in the usual manner, and
 of the internal parts by frequent emollient giysters ;  by fre-
 quently opening the belly by means of gentle laxatives, and
 by diluent and refrigerant remedies.
  422.] Although, in many cases the chronic hepatitis does
not clearly discover itself;  yet upon many occasions, it may
perhaps be discovered, or at least suspected from those causes
which might affectthe liver (316.) having been applied; from
some fulness and some tenseness of weight in the right hy-
pochondrium ; from some shooting pains at times felt in that
region ; from some uneasiness or pain  felt upon pressure in
 that part; from  some uneasiness from lying upon the left
 side ; and lastly, from some  degree of pyrexia, combined
 with  more or fewer of  these  symptoms.   When   from
 some of these circumstances a chronic inflammation is to be
suspected, it is to be treated by the same remedies as in the
last paragraph, employed more  or less, as the degree of the
 several symptoms shall more distinctly indicate.
  423.] When from  either kind  of inflammation  a sup-
 puration of the liver has  been formed,  and  the abscess
 points outwardly, the part  must be opened, the  pus evacuat-
 ed, and the ulcer  healed according to the ordinary rules for
 cleansing and healing such abscesses and ulcers.
  424.] I might  here consider the Splenitis,  or inflamma-
 tion of the spleen ; but it does not seem necessary, because
 the disease very seldom  occurs.  When it does, it may  be
 readily known by the character given in our Nosology  ;
 and its various termination, as well as the practice  which 
PRACTICE  OF PHYSIC.           153
it requires,  may be understood from what has been already
said with respect to  the inflammations of the other abdo-
minal viscera.
                  CHAPTER XI.

  OF THE NEPHRITIS, OR  THE INFLAM-
         MATION OF THE KIDNEYS.

  425.] HPHIS disease, like other internal inflammations,
         X  is alway attended with  pyrexia ; and is es-
pecially known from the region of the kidney being affected
by pain, commonly obtuse, sometimes pungent.  This pain
is not increased by the motion of the trunk of the-body, so
much  as a pain of the rheumatic kind affecting the same
region.  The  pain  of the  nephritis may be  often distin-
guished by its shooting along the course of the ureter; and
is frequently attended with a drawing up of the  testicle,
and with  a numbness of  the limb on the side affected ; al-
though, indeed, these symptoms  most commonly accom-
pany the  inflammation arising from a  calculus in the kid-
ney or in the  ureter.   The nephritis is almost constantly
attended  with frequent vomiting,  and  often with costive-
ness and  cholic  pains.  Usually the state  of the urine  is
changed;  it is  most  commonly  of  a  deep red color,  is
voided frequently, and in small  quantity at  a  time.  In
more violent cases, the urine is sometimes colorless.
  426.] The remote causes of this disease may be various;
as, external contusion ; violent or long continued  riding;
strains of the muscles of the back incumbent  on the kid.
neys;  various acrids in the course of the  circulation con-
veyed  to  the kidneys; and  perhaps some  other  internal
causes  not yet well known.   The  most frequent is that of
calculous matter obstructing the tubuli, uriniferi, or calculi
formed in the  pelvis  of  the kidneys,  and either  sticking
there, or fallen into the ureter.
  427.] The various  event of this disease may be under-
stood from  what has been delivered on  the subject of  other
inflammations.
  428.] Writers, in  treating of the cure of nephritis, have
commonly at the same time treated of  the cure of the Cal-
culus  renalis ; but,  though  this  may  often produce ne- 
PRACTICE  OF PHYSIC.
phritis, it is to be considered as a distinct and separate  dis-
ease ; and  what I have  to offer  as to the mode of  treating
it,  must  be reserved to  its  proper place.    Here  I  shall
treat only  of the cure of the Nephritis  Vera or  Idiopathica.
   429.]  The cure  of this proceeds upon the general plan,
by  bleeding,   external  fomentation,   frequent  emollient
giysters,  antiphlogistic purgatives, and the free use of mild
and demulcent liquids.*  The application of blisters is hard-
ly admissible;   or, at least,  will require great care,  to avoid
any considerable absorption of  the cantharides. f
   430.]  The Cystitis,  or inflammation  of  the bladder,  is
seldom a primary disease;  and therefore is not to be treat-
ed of here.   The  treatment of it,  so far as necessary to be
explained,  may be readily understood from what has been
already delivered.
   431.]  Of the visceral inflammations, there remains tobe
considered  the inflammation  of the Uterus; but  I omit  it
here,  because  the  consideration of it cannot  be separated
from that  of the diseases of child-bearing women.
  * These have all been enumerated in some of the preceding notes.
  + This is a very necessary caution.  Blisters  generally affect the urinary organs and vessels^
occasioning much irritation, and consequently increasing the inflammation.  As the author is
rather short in his directions for the cure of this  very troublesome inflammation, it may be pro-
per to add some particular directions for regulating our practice in these cases.
  An ulcer in the kidneys is extremely difficult to heal; we ought therefore always to attempt
the cure of nephritis by resolution.  The general remedies for answering this intention have
been  frequently enumerated, especially in the notes on art. 130—131.—The particular remedies
more peculiarly adapted to this disease are dumulcent drinks of the softest nature, and such ac
are least apt to irritate the parts ; as lintseed-tea, decoction of marsh-mallows, &c.  Nitre has
been  recommended amon; the  general antiphlogistic remedies;  but, in nephritis  its use is
doubtful, on account of its passing quickly by the kidneys, and irritating them.
  A difficulty of making water is one of the symptoms of this disease, and some practitioners
recommend heating diuretics. This practice,  however, is extremely  hurtful, and ought to be
carefully avoided, because these warm medicines, at turpentines,  balsams, ice. always increase
die irritation, especially in the urinary passages.
  As  the colon presses immediately on the kidneys, especially on the right one, we  should be
peculiarly careful to keep it empty, which is best done by giysters.   Beside the use of giysters m
evacuating the contents of the colon, they act as a fomentation to the inflamed part: we ouglit
therefore,  in these cases, to prescribe them larger than usual, and repeat them often.  They
ought to be extremely  emollient, and void of every ingredient that is any way stimulating.  A
quart of thin barley-water or lintseed-tea answers the purpose as completely as any of the more
compound emollient giysters of the Pharmacopoeias.
  With respect to diet  and regimen, we may observe that lenient nourishment is highly proper;
for every thing acrid naturally forces itself off by the urine, and consequently increases the irri-
tation.  A total abstinence from food is by  no means adviseable, because, from abstinence,
little  urine is secreted, and the smaller the quantity secreted it is generally the more acrid, and
consequently noxious.
  The patient ought to be made to sit up as much as possible. Warm soft beds, which are al-
ways  improper in all inflammatory diseases, are peculiarly hurtful in nephritis, especially if the
patient lies on his back ; for in  this posiiion the kidneys are kept  very warm, and are at the
same time pressed by the superincumbent weight of the abdominal viscera, all which will con-
tribute to increase the  inflainination.  Although lying much in bed be disapproved, the patient
ought by no means to be over fatigued with silting too long. The room  should be moderately
cool, and the bed springy, but not s»ft.
  In addition to what was said above respectingblisters in this disease,  itmav be necessary to ob-
serve, that other vesicants besides cantharides may be used, such as mustard poultices, common-
ly called sinapisms, a poultice of trie fresh leaves of the ranunculus acris, and other acrid plants. 
PRACTICE  OF PHYSIC.           I5i
                  CHAPTER.  XII.

             OF THE  RHEUMATISM.

  432.]  /~\F this disease there are  two species, the one
         \J  named  the Acute,  the other  the Chronic
rheumatism.
  433.]  It is the acute  Rheumatism which  especially be-
longs to this place, as from its causes, symptoms, and me-
thods of cure, it will appear to be a species of phlegmasia
or inflammation.
  434.]  This disease is frequent in cold, and more uncom-
mon in warm climates.   It appears most frequently  in au-
tumn and spring, less frequently in  winter  when the  cold is
considerable and constant, and very seldom during the heat
of summer.  It may occur, however, at any season,  if vi-
cissitudes of heat and cold be for the time frequent.
  435.]  The  acute rheumatism generally arises from the
application of  cold  to the body when any way  unusually
warm ;  or when one part of the body is  exposed to cold
whilst the other parts are kept  warm ; or, lastly,  when the
application of  the cold is long continued, as it is  when wet
or moist clothes are applied to any part of the body.
  436.]  These causes may affect persons of  all ages ; but
the,rheumatism  seldom appears in  either very young or in
eltfcrly persons, and most commonly occurs from the age of
puberty to that of thirty-five years.
  437.]  These  causes (435.)  may also affect persons of
any constitution; but  they  most commonly affect those of
a sanguine temperament.
  438.]  This disease  is particularly distinguished by pains
affecting the joints, for the most part the joints alone, but
sometimes affecting also the muscular parts.  Very often
the pains shoot along the  course of the  muscles,  from one
joint to another,  and are always much increased by the ac-
tion of the muscles belonging to the joint or joints affected.
  439.] The larger joints are most frequently affected ; such
as the hip-joint and knees  of  the lower, and  the  shoulders
and elbows of the  upper extremities.   The  ankles and
wrists are also  frequently  affected ;  but  the smaller joints,
such as those of the toes or fingers,  seldom suffer.
  440.] This disease although sometimes confined to one part 
 156           PRACTICE OF  PHYSIC.

 of the body only, yet very often affects many parts of it ; and
 then it comes on  with a cold  stage, which is  immediately
 succeeded by the other symptoms of pyrexia  and particu-
 larly  by a frequent,  full, and  hard  pulse.   Sometimes the
 pyrexia is formed before any pains are perceived ;  but more
 commonly pains are felt in particular parts,  before any
 symptoms of pyrexia appear.
  441.] When no pyrexia is present, the pain  is sometimes
 confined to one joint only ;  but, when any considerable py-
 rexia is present,  although the pain may  be chiefly in one
joint, yet it seldom  happens but that the  pains affect seve-
 ral joints often at the very same time, but for the most part
 shifting their place, and having abated in one joint, become
 more violent in another.  They do  not commonly remain
 long in the same joint, but frequently shift from one to ano-
 ther,  and sometimes return to joints formerly affected  ; and
 in this manner the disease often continues for a  long time.
  442.] The pyrexia attending this disease has  an exacerba-
 tion every evening, and is most  considerable during the
 night, when the pains also become more violent; and it  is
 at the same  time that the pains shift their place from one
joint to another.  The pains seem to be also increased dur-
 ing the night,  by the body being covered more closely, and
 kept warmer.
  443.] A joint, after having been for some time affected
 with pain, commonly becomes affected also with some red-
 ness and swelling, which is painful to the touch.   It seldom
 happens,  that a swelling coming on does not  alleviate jme
 pain  of the  joint ; but the swelling does not always take off
 the pain entirely, nor secure the joint against a return of it.
  444.]  This  disease is commonly  attended with  some
 sweating, which  occurs early in the course of the disease ;
 but it is seldom free or copious,  and seldom either relieves
 the pains or  proves critical.
  445.] In the course  of this  disease the  urine is high co-
 lored, and in the beginning without sediment  ; but  as the
 disease advances,  and  the pyrexia has more  considerable
 remissions, the urine deposits a lateritious sediment.   This,
 however,  does not prove entirely critical; for the disease
 often continues long after such a  sediment has appeared in
 the urine.
  446.] When blood is drawn in this disease,  it always ex-
 hibits the appearance mentioned (237.)
  447.] The  acute  rheumatism, though it has so  much 
PRACTICE  OF PHYSIC.           157
 of the nature of the other phlegmasia?, differs from all those
 hitherto mentioned, in this,  that it is  not apt to terminate
 in suppuration.  This almost never happens in rheumatism;
 hut.the disease sometimes produces effusions of a transpa-
 rent gelatinous  fluid  into the sheaths of  the tendons.  If
 we may be allowed to suppose that such effusions  are fre-
 quent, it must also happen, that the  effused fluid  is com-
 monly reabsorbed  ; for it has seldom happened, and never
 indeed to my observation, that considerable or permanent
 tumors  have  been produced, or such as required to be
 opened,  and to have the  contained fluid evacuated.  Such
 tumors, however,  have occurred to others, and the open-
 ing made  in them has produced ulcers  difficult to  heal.
 Vide Storck. Ann. Med.  II.
   448.] Wrth the  circumstances mentioned from (438. to
 447.) the  disease often continues for several weeks.   It sel-
 dom, however,  proves fatal; and it rarely happens that the
 pyrexia continues  to be considerable for more than two or
 three weeks.  While the  pyrexia abates in its violence,  if
 the pains  of the joints continue, they are less violent, more
 limited in their place, being confined  commonly to one or
 a few joints only, and are  less ready to  change their place.
   449.] When the pyrexia attending  rheumatism has en-
 tirely ceased ; when the swelling, and  particularly the red-
 ness of the joints,   are entirely gone ; but when pains still
 continue to affect certain  joints, which remain stiff, which
 feel uneasy upon motion, or upon changes of weather ; the
 disease is  named the Chronic Rheumatism, as it  very often
 continues  for a long time.   As the chronic is commonly the
 sequel of the acute  rheumatism, I think it proper to treat of
 the former also in this place.
   450.] The limits between the acute and chronic rheuma-
 tism are not always exactly marked.
   When the pains are still ready to shift their place; when
 they are especially severe in the night-time ; when, at the
 same time, they are attended with some degree of pyrexia,
 and with some sAvelling, and especially with some redness
 of the joints; the disease is to be considered as still partak-
 ing the nature of the acute rheumatism.
   But when there is no degree of pyrexia remaining; when
 the pained joints are without redness;  when they are cold
 and stiff;  when they cannot easily be made to sweat; or
when while a free and warm sweat is brought out on the rest
ot  the body, it  is  only clammy  and  cold on the pained 
153           PRACTICE  OF PHYSIC.
joints;  and when, especially the pains of these joints are
increased by cold, and relieved by heat applied to them;
the case is to be considered  as that of a purely  chronic
rheumatism.
   451.] The chronic rheumatism may affect different joints;
but is especially ready to affect those joints which are sur-
rounded with many  muscles, and those of which the mus-
cles are employed in the  most constant and vigorous exer-
tions.  Such is the case of the vertebrae of the loins, the
affection of which is named Lumbago; or that of  the hip-
joint, when the disease is named Ischias, or Sciatica.
   452.]  Violent strains and  spasms  occurring on sudden
and somewhat violent exertions, bring on rheumatic affec-
tions, which at first partake of the acute, but very  soon
change into the nature of the chronic rheumatism.
   453.]  I have thus delivered the history of rheumatism;
and suppose, that,  from what has been said, the remote
causes, the diagnosis,  and prognosis  of the disease,  may
be understood.   The distinction of the rheumatic pains
from  those resembling them,  which occur in the syphilis
and scurvy,  Avill be obvious, either from the seat of those
pains,  or from the concomitant symptoms peculiar to these
diseases.*   The distinctions of rheumatism from gout will
be more fully understood from what is to be delivered in
the following chapter.
   454.]  With respect to  the proximate cause  of  rheuma-
tism, there have been various opinions.   It has been impu-
ted to a peculiar acrimony;  of which,  however, in or-
dinary cases I can find no evidence;  and from the consi-
deration of the remote causes, the symptoms and cure of
the disease,  1 think the supposition very improbable.
   The cause of an Ischias Nervosa assinged by Cotunnius,
appears to me hypothetical, and is not supported by either
the phenomena or method of cure.  That, however, a dis-
ease of a rheumatic nature may be occasioned by  an acrid
matter applied to the nerves, is evident from the tooth-ach,
a rheumatic affection generally arisingfroma carious tooth.
   That  pains resembling those of rheumatism may  arise
from deep seated suppurations,  we known from some ca-

 * To distinguish the chronic rheumatism from venereal or scorbutic pains, is, however in
some cases, extremely difficult, and often requires the utmost sagacity of the practitioner   A
due attention to the causes of rheumatism, recited in the foregoing articles, and a strict exami-
nation whether the patient has been subjected to these causes, will sometimes determine the
disease ; but it often happens, that the same causes which produce rheumatism, also exacerbate
venereal and scorbuticpatns. No general rules can be delivered on this subject; and theDrac-
ttttoner must irust to his own sagacity for direction in this difficult diagnosis. 
PRACTICE OF PHYSIC.           159
ses depending on such a cause, and which, in their symp-
toms, resemble the lumbago or ischias.   I believe,  how-
ever, that by a proper attention, these cases depending on
suppuration, may be  commonly distinguished from the
genuine cases of lumbago and ischias; and, from what is
said in (447.) I judge it to beat least improbable, that a
genuine lumbago or ischias does ever end in suppuration.
  455.]  The proximate cause of rheumatism has been by
many supposed to be a lentor of the fluids obstructing the
vessels of the part; but the same consideration as in (241.
1, 2,  3,  4,  and 5.) will apply equally here for rejecting the
supposition of a lentor.
  456.] While  I cannot, therefore, find  either evidence
or reason for supposing that the rheumatism depends upon
any change in the state  of the fluids, I must conclude, that
the proximate cause of acute rheumatism, is commonly
the same with that  of other inflammations not depending
upon  a direct stimulus.
  457.] In the case of rheumatism, Isuppose, that the most
common  remote cause of it,  that is, cold applied, ope-
rates especially on the vessels of the joints, from these be-
ing less covered by a cellular texture than those of the in-
termediate parts of the limbs.   I suppose further, that the
application of cold produces a constriction of the extreme
vessels on the surface, and at the same time an increase of
tone or phlogistic  diathesis in the course of  them, from
which arises an  increased impetus of  the blood, and, at
the same time, a resistance to  the free passage of it, and
consequently inflammation and pain.   Further, 1 suppose,
that the resistance formed excites the  vis medicatrix to a
further increase of the impetus  of the blood; and,  to sup-
port this, a  cold stage arises,  a spasm is formed,  and a
pyrexia and phlogistic diathesis are produced in the whole
system.
  458.]  According to this explanation, the cause of acute
rheumatism appears to be exactly analogous to that of the
inflammations depending on an increased afflux of blood
to a part while it is exposed to the action of cold
  But there seems to be also, in the case of rheumatism, a
peculiar affection of the fibres of the muscles.
  These fibres seem to be under some degree of rigidity
and therefore less easily admit of motion; and are pained
upon the exertions of it.                         *
  It is also an affection of these fibres which gives an op- 
160
PRACTICE OF PHYSIC.
portunity to the propagation of pains from one joint to
another,  along the course of the muscles, and which pains
are more severely felt in the extremities of the muscles ter-
minating in the  joints, because, beyond these, the oscil-
lations are not propagated.
  This affection  of the muscular fibres attending rheuma-
tism, seems to explain why strains and spasms produce
rheumatic affections; and, upon the whole, shows, that,
with an inflammatory affection of the sanguiferous system,
there is also in rheumatism a peculiar affection of the mus-
cular fibres, which has a considerable share in producing
the phenomena of the disease.
  459.]  Having thus given  my opinion of the proximate
cause of  rheumatism,  I proceed to treat of the cure.
  460.]  Whatever difficulty may occur with respect to the
explanation given,  (457.  and 458.) this remains certain,
that  in acute rheumatism, at least in all those cases which
do not arise from direct stimuli,  there is an inflammatory
affection of the parts, and a phlogistic diathesis in the whole
system;  and upon these is founded the method of cure,
which frequent experience has approved of.
  461.] The cure therefore requires, in  the first place,  an
antiphlogistic regimen, and particularly a total abstinence
from animal food, and  from all fermented or spirituous li-
quors; substituting a vegetable or milk diet, and the plen-
tiful use of bland diluent drinks.
  462.] Upon the same principle (449.) at least with per-
haps the same exception as above, blood-letting is the chief
remedy  of acute rheumatism.   The blood ought  to  be
drawn in large quantity, and the bleeding is to be repeated
in proportion to the frequency,  fullness, and hardness of
the pulse, and to the violence of the pain.   For the  most
part, large and  repeated  bleedings, during the first days
of the disease, seem to be necessary, and accordingly have
been very much employed: but to this some bounds are
to be set; for very profuse bleedings occasion a slow re-
covery,  and, if not absolutely effectual, are ready to pro-
duce a chronic rheumatism.
   463.]  To avoid that debility of the  system,  which ge-
neral bleedings are ready to occasion, the urgent symptom
of pain may be often relieved by topical bleedings ;  and
especially when any swelling and redness have come upon
a joint, the pain of it may be very  certainly relieved  by
such bleedings ; but, as  the continuance of the disease 
               PRACTICE OF PHYSIC.             161

seems to depend more upon the phlogistic diathesis of the
whole system, than upon the affection of particular parts,
so topical bleedings will not always supply the place of the
general bleedings proposed above.*
  464.]  To take off the  phlogistic diathesis prevailing  in
this disease,  purging may be useful,  if procured  by medi-
cines which do not stimulate the whole system, such as the
neutral salts, and which have, in some measure, a refrigerant
power, f   Purging, however, is not so powerful as bleeding,
in removing  phlogistic diathesis ; and when  the disease  has
become general and violent,   frequent stools are inconveni-
ent and even hurtful, by the motion and pain which they
occasion.
   465.] In  acute rheumatism,  applications  to the pained
parts are of little service.  Fomentations, in the beginning
of the disease rather aggravate,  than relieve the pains.   The
rubefacients and camphire are more effectual in relieving the
pains ; but generally  they only shift the pain from one part
into another, and do little towards the cure of the general af-
fection.  Blistering, applied to the pained part, may also be
very effectual in removing the pain from it; but will be of
littic  use,  except where the pains are  much  confined to
one part.
   466.] The several remedies mentioned from (450. to 454.)
moderate the violence of the disease, and sometimes remove
it entirely ; but they  sometimes fail in this, and leave the
cure imperfect.  The attempting a cure by large and  re-
peated bleedings,  is  attended  with many  inconveniences,
 (see  140.) and the most effectual  and safe method of curing
 this  disease, is, after some general bleedings for taking off,

  * These topical bleedings, however, have by repeated experience been found of essential
advantage, especially when the partial inflammation lias been very violent.  They are best per-
formed by leeches, many of which ought to be applied at once all over the inflamed part.  Cup-
ping has long been the favorite practice of many physicians, but it generally irritates more than
the leeches; yet in cases that require immediate relief, it is preferable to them.
  + The Glauber, or Epsom salts, are the most convenient purges in all cases of acute rheuma-
tism.  Either of them may be given separately, or joined with the mfusum sennx, as in the fol-
 lowing formula;
              R. Infus. Sennce, |iii.
                  Sal.  Glauber. Bib-
                  Tinct. Jalap.  3i-
                  Tinct. Aromat. 3ft
                  M. f. haust.
  The more suddenly purges operate in acute  rheumatisms,  the more efficacious are  thev
 ;cneiaily tound: and as large diluting warm thin liquors considerably accelerate the operation
 <... allpuvjir?, such practice is never to be neglected in these cases. Cream of tartar whey
 m.v< (1 wuh twice its quantity of warm water, i« a very proper drink to assist the operation tr 
162            PRACTICE OF PHYSIC.

or  at  least diminishing, the phlogistic diathesis, to employ
sweating, conducted by the rules laid down (168. and 169.)*
   467.] Opiates, except where they  are  directed to pro-
cure sweat, always prove hurtful in every stage of this dis-
ease, f
  468.] The Peruvian  bark has been supposed a remedy
in some cases of this  disease ;  but we have seldom  found
it useful, and in some  cases hurtful.   It appears to me to
be fit  in those cases only,  in which the phlogistic diathesis
is already  much abated,  and where, at the  same  time, the
exacerbations of the disease are manifestly periodical, with
considerable remissions interposed.J
   469.] Calomel and  some other preparations  of mercury,
have  been recommended in the acute  rheumatism ; but I
believe they  are useful  only in cases  of the chronic kind,
or at least in cases approaching to the nature of these.
   470.] Having now  treated fully  of  the cure of  the acute
rheumatism,  I proceed  to treat of  the cure  of the chronic,
which  is so frequently a sequel of the  former.
   471.] The phenomena of the purely chronic rheumatism,
mentioned  in (438. and 439.) lead me to conclude, that its
proximate  cause is an atony, both  of  the blood-vessels  and
of the  muscular fibres  of the part  affected, together  with a
degree of rigidity and contraction in the latter,  such  as fre-
quently attends them  in a state of atony.
   472.] Upon this  view of  the proximate cause  the gene-
ral indication of  cure must be, to restore the activity  and
vigor of the vital principle in the part; and  the remedies
for this disease,  which experience has approved of, are chief-
ly such as  are manifestly suited to the indication proposed.
   473.] These remedies are either external or internal.

  * Sweating is most effectual in this disease, when produced by Dover's powder. The dose of
it is twelve or fifteen grains, repeated at intervals, of two or three hours, till a sweat be pro-
duced.  Diluent drinks are to be  used with it: and it may be necessary to observe, that they
ought to be such as are biand, and by no means stimulating; viz. barley-water, lintseed-tea,
thin water-gruel, de.
  + Notwithstanding this caution, many practitioners use opiates, especially when joined with
camphor, to procuie sweats in acute rheumatism. This compound never fails to increase the
phlogistic diathesis, and consequently  must be hurtful.  In the chronic  rheumatism, indeed,
camphor and opium together form a valuable medicine. The dose is the following bolus :
               R.  Camphor, gr. vi.
                   Sp.  Vini, gutt. x.
                   Opii, gr. i.
                   Tart. Vitriol, gr. xv.
                   Syr. q. s. M.-i. bolus.
  X Bark isalwaysan ambiguous remedy in rheumatism, and on its first introduction into prac-
tice it was thought to occasion or induce the disease. Wherever an inflammatory diathesis pre.
vails, the Peruvian bark is always  an improper medicine, and it has been found by experience
to be manifestly harttul in the beginning, or inflammatory state of rheumatism. 
PRACTICE  OF PHYSIC.               136
   The external are, the supporting  the heat of the part, by
keeping it constantly covered with flannel ;  the increasing
the heat of the part by external heat,  applied either in a dry
or in a humid  form ; the diligent use of the flesh-brush,  or
other means  of  friction ; the  application of electricity in
sparks or  shocks ; the  application  of cold*  water by affu-
sion  or immersion ;  the application of essential oils  of the
most warm  and  penetrating  kind ;  the application of salt
brine ; and,  lastly, the  employment of exercise, either of
the  part itself  so far as it  can easily bear it, or of the whole
body by  riding or other mode of gestation.
   474.]   The  internal  remedies are,  1.  Large  doses of es-
sential oil drawn from resinous substanecs,  such  as  turpen-
tine  ;f  2.  Substances containing such oils, as guaiac  ;%  3.
Volatile  alkaline  salts ;  4. These, or other medicines di-
rected to procure sweat,  (169.)  and,  lastly, Calomel,||  or
other  preparation of mercury,  in small  doses,  continued
for  some time.
   475.]  These  (462, 463.)  are  the remedies successfully
employed in the purely  chronic  rheumatism ;  and there are
still  others  recommended.   As bleeding,  general  and  to-
pical, burning,  blistering,  and   issues:  but these appear  to
me to be chiefly,  perhaps only,  useful when  the disease still
partakes  of the nature of acute rheumatism.§

  * This, when compared with article 457, and others, seems to be a typographical error, and
the author meant warm.  Practice affords many instances of chronic rheumatisms being occa-
sioned by cold bathing.
  + Turpentine is an extremely heating oil, as indeed are all the essential oils: its use there-
fore requires the greatest caution.  The dose is from eight to fifteen drops on a piece of sugar.
Venice turpentine may be more conveniently given in the form of an emulsion, by dissolving it in
watei by means of yolks of eggs.  Two scruples of turpentine is the ordinary dose ; and when
given in this liquid and diluted state,  is much preferable to the oil.
  t The officinal preparations of guaiacum, are an extract of the wood, a solution of the  rum
in reclined spirit, another in volatile alkali, and an empyreumatical oil.  The gum 11 av be
guen in the quantity of fifteen  or twenty grains for a dose, either in a bolus, or made into an
emulsion with yolk of egg and an ounce or two of water : in larger  quantities it is too purgative
a he volatile elixir of the Edinburgh  Pharmacopeia is an  excellent form, as the volatile spirit
promotes the medicinal virtue of the guaiacum. The dose of it is from a drachm to half an ounce
morning and evening, in any convenient vehicle ; a tea cupful of milk is the best as it sheaths'
in some measure the pungency of the medicine.  Guaiacum is very conveniently joined with*
rhubarb and magnesia, when we find that such a dose of it, as is necessary for procuring a suf-
clee55801'en'nS' *      tU° hea"ng* A fonr-ula of '•>« kind is described in the note on arti-
  II Calomel, perhaps, has only been serviceable in venereal cases.
-i  ■ ,,d'et'" the cur.e of chroni9 rheumatism ought to be generous and full.  In manv cases
espcualy among people in poor circumstances, good living, with two or three glasses or sherrv
  o *  mfc '!fS C"rcd,the d,sease ^"hout *"* ""-•'"""«. One material circumstance ought nw
to be omitted; viz. that the cure is much impeded by costiveness:  if, therefore the euaiacum
does not procure two motions in the day, it will be necessary to give along ^th it some warS
oun-«eAThe,|,nCl,}raTra isaPropeV medicine '" «"«e cases: itsdo"! Z fromorfe trTt™
hZTdrAL'^f el""r sacrum of the Edinburgh College Pharmacopoeia, iu do"e mafb?
worn a drachm to half  an ounce, as occasion may require.                     •*.««■} 
164
PRACTICE  OF PHYSIC.
                 CHAPTER  XIII.

   OF THE TOOTHACH,  OR ODONTALGIA.

  476.] T HAVE formerly considered this disease as aspe-
        X cies of Rheumatism, to be treated upon the same
principles as those delivered in the preceding chapter: but now
from more attentive consideration, I am led to consider the
toothach as a distinct disease.  Whilst the most of what has
been delivered in  the last chapter proceeds upon the sup-
position  that the rheumatism depends upon a certain state
of the blood vessels and of the motion of the blood in them,
without this being  produced by  the irritation of any acrid
matter applied ; I judge, that in the toothach, though there
are often the same circumstances in the  state of the blood-
vessels as in the cases  of rheumatism, these  circumstances
in toothach always arise  from  the  application t>f an acrid
matter to the nerves of  the teeth.
   477.] This disease is  often no other than a pain felt in a
particular tooth, without any inflammatory affection being
at the same time communicated  to the neighboring parts.
This, however, is rarely the case ; and for the most part to-
gether with the pain  of the tooth, there is some degree of
pain and of inflammatory  affection communicated to  the
neighboring parts, sometimes to the whole of those on the
same side of the head with the affected tooth.
   478.]  This inflammatory affection seems to_me to be al-
ways  an affection of the  muscles and of the membranous
parts  connected with these, without any tendency  to sup-
puration ; and such an affection, as is excited  by cold in
similar parts elsewhere.   It is from these circumstances that
I conclude the affection to be of the rheumatic kind.
   479.]  It is possible that the  muscles and  membranes of
the jaw may be affected by the same causes which produce
the rheumatism in other parts ; and it  is also possible, that
a  rheumatic diathesis at first produced by irritation, may
subsist in the muscles and membranes of the jaw,  so that
the inflammatory affection may be renewed by  certain
causes without any new application of acrid matter :  But
I am persuaded that  either of these occurrences are very
rare,  and I have never been able to ascertain any cases of 
PRACTICE  OF PHYSIC.           165
 toothach to be  of these kinds.  I consider it, therefore,
 as highly probable that this rheumatic affection of the jaws
 which we name toothach, is always dependent upon some
 immediate application of acrid matter to the nerves of the
 teeth.
  4S0.] It is however to be observed, that this application
 of acrid matter does not always excite a pain in the tooth
 itself,  or  an inflammatory  affection of the neighboring
 parts; but that it very often operates by producing a dia-
 thesis  only; so that cold applied to the neighboring parts
 does excite both a pain in the tooth,  and an inflammatory
 affection of the neighboring parts which did not appear
 before.
  There seems to be also certain states of the body, which
 operate upon the same diathesis so as to produce toothach.
 Such  seems to be the case of,pregnant women, who are
 more  liable to toothach than other women.   There are
 probably also  some  cases of increased irritability which
 render persons more subject to  toothach.   Thus  women
 are more liable to the disease than men, and particularly
 women liable to hysteric affections.
  481.] The acrid matter producing this disease seems to
 be generated first in the hard substances of the teeth; and
 as it often appears first upon the external surface of these,
 it might be suspected to arise from the application of exter-
 nal  matters to  the teeth:  But as the  production of this
 acrimony is often begun in the internal cavity of the teeth,
 where the operation of external matters cannot be suspect-
 ed, and as even when it begins upon the external parts of
 the teeth,  the operation of the cause is at first in a small
 portion of the teeth only, that it is difiicult to suppose that
 any matter externally applied could act in such a partial
manner; so it is presumed that the acrid matter occasion-
ing  the toothach is produced by some  vice originating  in
the substance of the tooth itself.  When it begins upon the
 external surface,  it is on the enamel; but upon the inter-
 nal surface, it must be in the bony part.  From what caus-
 es it arises  in either of these substances, I do  not at all
 know; but I suspect that it  often arises from some more
 general fault in  the fluids of the body.  The frequent use
 ot mercury, especially when thrown much upon the mouth,
 and the state of the fluids in scurvy, seem both of them to
 give a disposition  to a caries in the teeth; and it is possi-
                           Y 
166           PRACTICE OF  PHYSIC.

ble that some other acrimonious states  of the fluids may
have the same effect.
   482.] A caries in some part  of the teeth, whether aris-
ing upon their internal  surface or upon their  external,
proceeding  so far as  to reach the nerves in the cavity of
the teeth, is pretty manifestly the  cause of toothach, and
of the first attacks of it ; but when the cavity of the teeth
has been opened, so that the external air or other matters
can reach that cavity, these are often the exciting  causes
of toothach, and  serve  to prove in general, that acrid
matters applied to the nerves occasion the disease.
   483.] What is the nature of  the matter produced in  the
caries of the teeth, I do not understand, nor have I found
any proper  corrector of it; but 1  presume it to be of  the
putrid kind, as it often taints the breath with a fetid odour.
   484.] In  the cure of this disease, a long experience has
shown, that the extraction of the carious tooth proves the
most effectual,  and very often the only effectual, remedy
of the disease.  But as in some cases this extraction is not
proper, and as in many cases it  is obstinately avoided,
other means of  curing the disease, or at least of relieving
the pain have been sought for and much practised.
   485.] Among these remedies, those are likely to be the
most effectual which entirely destroy the affected nerve, or
at least so much of it as is exposed to the action of the acrid
matter in  the tooth.    When an opening is made into the
cavity of  the tooth,  the nerve of it may be destroyed most
certainly by the actual cautery; and it may also possibly
be done by the application of potential caustics, either of
the alkaline or acid kind.
   486.] When these remedies cannot be rendered effectu-
al, relief may often be obtained by diminishing the sensi-
bility of the nerve affected, by the application  of opium,
or of  the more acrid aromatic oils,* and directly to the
nerve in the tooth.  It appears also,  that the sensibility of
the affected nerve may often be for  some time diminished
by the external application of opium to the extremities of
those nerves in the skin, which are branches of  the same
 fifth  pair of nerves with those of the teeth.
   487.] When the disease consists entirely in a pain of the
nerve of the tooth, without  any considerable affection com-
municated  to the  neighboring  parts,  the remedies already
  * The Oleum Origani is the r,\ generally used for this purpose. Great care must be taken in
«Mng either these aend cjMiiitui oils, or the vitriolic or other mineral acids, that no part of tl:em
*ouch the gums.                                       ' 
PRACTICE OF  PHYSIC.
167
 mentioned are those especially to be employed  ; but when
 the disease consists very much in  an  inflammatory affec-
 tion of the muscles and membranes of the jaw,  and when
 at the same time there is little or no  access for  the above-
 mentioned remedies to the affected nerve, other measures
 are  to be employed for relieving the disease.
   488.]  If the disease be attended with any general phlo-
 gistic diathesis of the system, or with any considerable de-
 gree of pyrexia, a general bleeding may  be useful in re-
 lieving the disease : but these circumstances occur  very
 rarely, and the disease is for the most part a purely topical
 affection ;  in which, as I observed before, a general bleed-
 ing is of very little service.   As this disease, however, is a
 topical inflammation,  it might be  supposed  that topical
 bleedings would be very useful, and  sometimes they are
 so;  but it is seldom that their effects are either considera-
 ble  or permanent.  The reasons of  this I take to be that
 the  disease does not  consist in  an affection of the blood-
 vessels alone,  as in the ordinary cases of rheumatism ; but
 in a peculiar affection of the fibres both of the muscles and
 of the vessels of the part induced by irritation.   The inef-
 ficacy of topical bleedings is with me a proof of  the disease
 being of the latter kind.
  489.] The remedies therefore necessary to give relief in
 this disease, are those which take off the  spasm of  the ves-
 sels,  and especially of the muscles and membranes affect-
 ed.   Such are blistering, brought as near to the part affect-
 ed as can be conveniently done ;* and such are also increas-
 ed excretions excited  in the neighboring parts, as of the
 saliva and mucus of the mouth by  the use of acrid masti-
 catoriesf It is often sufficient to excite a strong sensation
 * Blisters are applied most  successfully behind the ears. Such applications however are al-
 ways troublesome; and their  effects are often doubtful. Other milder stimulants frequent'r
 answer all the intentions of blisters, and by many practitioners are thought to be equally effica
 dous.  The applications generally used are camphorated spirit, or volatile alkali. This last
 either alone, or mixed with an equal auantity of oil of almonds, rubbed on the jaw, the narr
 being kept warm by a piece of flannel, lias ofted been found extremely useful.
 Warmth, anyhow produced on the part, always gives relief; while, on the contrary, cold
 always exasperates the symptoms: hence the propriety of covering the jaws widi  flannel
 and avoiding a eold stream of air.                           J          "*■ *
 ♦ These are horseradish, scurvy-grass-, the greater celandine, with some others; but the ra-
 «ix pyrethn is the best.  In some pharmacopoeia, but I do not recollect which there is a for.
 mala, called Trochisci Sjalagogi, to the best of my remembrance, as follows :
           R.  Pulv. Rad. Pyrethri, 3i.
              Gum. Mastich. 3" ft.
              01. Caryopyhll. Aromat.
              01. Marjoranae, aa Ji.
              Cera Alb. q. s. ut.V. Trochisci.
wa^lngVn'd "imuUtig £ S&Ufc gindT^ PI™ * "*»» *"*"* « ■*»• * 
168
PRACTICE  OF PHYrSlC.
 in the neighboring parts; as by eau de luce, spirit of laven-
 der,  or Hungary water snuffed up the nostrils;  or by the
 vitriolic aether properly applied to the cheek.  It is upon
 the same footing that I suppose brandy or other ardent spi-
 rit held in the mouth  is often of service.
   490.] There are cases of toothach in which it does not
 appear that the disease arises from an acrid matter imme-
 diately applied  to  the nerve of a tooth; but from the ex-
 ternal application of cold, or some other causes immedi-
 ately applied to the muscles and membranes of the jaw ;
 and  Avhich therefore seem to require  some remedies differ-
 ent from those above mentioned.  But in all such cases,
 it is  to be suspected, that the effects of cold or of other
 such causes are owing to a diathesis produced by an acrid
^natter applied  to the  nerve of a tooth, and continuing
 in some measure to  act  there ; and we have according-
 ly often found, that  the  action  of  those external  causes
 were to  be obviated  only by the extraction of the tooth
 from which  the diathesis had  arisen.
                 CHAPTER XIV.

                  OF THE  GOUT.

  491.] HPHE Gout, not only as it occurs in different per-
        X.  sons, but even as  it occurs in the same person
at different times, is a disease of such various appearance,
that it is difficult to render the history of  it complete and
exact, or to give a character of it that will universally ap-
ply.  However, I shall endeavor to describe the disease as
it most commonly appears, and to  mark the varieties of  it
as well as I can.   From such a history I expect that  a ge-
neral character may be given ;  and such I think is the fol-
lowing, as given in the last edition of our Nosology :
  Gen. XXIII.  PODAGRA.   Morbus  haereditarius, ori-
ens sine causa externa evidente, sed praeeunte plerumque
ventriculi affectione insolita; pyrexia; dolor ad articulum
et plerumque pedis pollici,  certe pedum et manuum junc-
turis,  potissimum infestus ; per  intervalla revertens, et
saepe cum ventriculi et internarum partium  affectionibus
alter nans.
  4-92.J The Gout is generally a hereditary disease  : but 
PRACTICE  OF  PHYSIC.                  169
some persons,  without hereditary disposition,  seem to ac-

quire it ;  and,   in some a  hereditary  disposition may  be

counteracted  by   various   causes.     These  circumstances

may  seem to give exceptions to our  general  position ;   but

the facts  directly supporting it are very numerous.

   493.] This disease attacks especially  the male  sex :  but

it sometimes,  though more rarely, attacks  also the female.*

  * Hippocrates says, that women seldom have the gout, and never before the disappearance
of thecatamenia   In his time and  country, perhaps, the  ladies were more temperate than
they were  in other ages and in other places. We find the gout a familiar disease among  the
Roman ladies; which Seneca, in his ninety fifth epistle, justly ascribes  to the luxurious living
and debaucheries,  in which they indulged without control.   ..,._.,-.. .  ..  .   „  ,
  As the whole of that epistle is an excellent account of the direful effects of high living and
debauchery, it may not be unacceptable to the young practitioner, who, perhaps, might other-
wise be unacquainted with so just a description of luxurous living, and its concomitant evils.
Independent of its containing a minute relation of Roman customs, which makes it a valuable
morsel for antiquaries, it may be read with peculiar advantage by the young physician
  As an apology for giving it in the original, I shall say of Seneca what an elegant English writer
says of Cicero  : That any translation of his nervous language, is like the faint glimmerings of a
taper compared with ihe blazing light of the meridian sun.
  " Mcdicina  quondam paucarum fuit scientia herbarum, quibus sisteretur sanguis fluens, vul-
nera coiercnt paulatim.   Deinde  in  hanc pervenit tarn multiplicem varietatem. Nee  mi-
rum est; tunc illam minus neKOtii habuisse, nrmis adhunc, solidisque corporibus, et facili cibo,
nee peranem voiuptatemque corrupto.  Qui postquam ccepit, non ad lollendam, sed ad irri-
tandam fainen qua?ri, et inventat sunt mille conditurs, quibus  aviditas excitaretur :  qua? de-
siderantibusaliinentaerant, onera sunt plenis.  Inde pallor, et nervorum vino madentium tre-
mor, et miserabilior ex cruditatibus quam ex fame macies. Inde incerti labentium pedes, et
semper qualis  in ipsa ebrietate titubatio.  Inde in  totam cutem humor admissus, distentusqu*
venter, aum male assuescit plus capere, quam  poterat.  Inde suflusio lurida; bilis, et decolor,
vultus,  tabesque in se putrescentium, et retorti di^iti articulis obngescentibus, nervorum dns
sensu jacentium, torpor autpalpitatio sine intermissione  vibrantium.  duid capitis vertigines
dicamf  Quid  oculorum auriuinque tormenta, et cerebri a»stuantis verminationes, et omnia
perquxexoneramur in tern is ulceribus affect?? Innumerabilia pranerea tebrium genera, alia-
rumimpetu subeuntium, aliarum tenui peste repentium, aharum cum hoiroreet multa mem-
broruin quassatione venientium? Quid alios referam innumerabiles moibos, supplicia luxuria? •
Immunes erant ab istis malisqui nondum se deliciis soiverant, qui sibi imperabant, sibi minis-
trabant. Corpora opere ac vero labore durabant, aut cursu defatigati, aut venatu, aut tellure
versata. Exctpiebat(illos cibus qui nisi esurientibus placere non poterat.   Itaqtie nihil opus
erat tam magna medicorumsupellectile. nee tot ferramentis atque pyxidibus.  Simplex  erat ex
simplice causa valetudo. Multos morbos multa fercula fecerunt.  Vide  quantum rerum  per
unam gulam transiturarum  permisceatluxuria, terrarum marisque vastatrix.  Necesse est itaque
inter se tam diversa dissideant, et  hausta tnali digerantur, aids alio nitentibus. Nee  mirum,
quod inconstansvariusque ex discordi cibo morbus est, et ilia ex contraiiis naturae partibus in
eundem compulsa redundant.  Inde tam nullo aegrotamus genere  quam vivimus. Maximus
ille medicorum* ethujus scientia? conditor, feminis nee capillos  defluere dixit, nee pedes labo-
rare.  Atquihx jam  et capillis distituuntur, et pedibus a-grx sunt.  Non inutata feminarum
natura, sed vita est.  Nam cum virorum licentiam xquaverint, corporum quoque vinlium vitia
a?quaverunt.  Non minus  pervigilant, non minus potant, et oleo et mero viros provocanf.
-/Eque  invitis ingesta viscenbus per os reddunt, et vinum omne vomitu remetiuntur; a-que
nivem  rodunt, solatium stomachi xstuantis.  Libidinivero nee manbus quidem  cedunt, pati
rtata?.  Dii illas deaeque male perdant: adeo perversum comments: genus impudicuias virus
ineunt.  Quid ergo mirandum est, maximum medicorum ac natuix-pertissimum, in mendacia
prehendi,  cum tot femins podagric!  calvxque sint.  Beneficium sexus sui vitiis pcrdiderunt;
et quia feminam exuerunt, damnata? sunt morbis virilibus.  Antiqui  medici nesciebant dare ci-
bum saepius, et vinofulciri venas cadentes; nesciebant saniem emittcre, et  diutinam  a?grota-
tionem balneo sudoribusque laxare ;  nesciebant crurum vinculo,  brachiorumque, latemem
vim, et in medio sedentem, ad extrema revocare.  Non erat necesse circumspicere multa auxi-
liorumgenera  cum essent  periculorum paucissima.   Nunc autem quam longe prooesserunt
mala valetudinis?  Has usuras voluptatum pendimus, ulira modum lasque cnncupitatuili.  In-
numerabiles esse morbos miraris! Coquos  numera. Cessat onine studium; et libeialia  professi
sine ulla frequentia, desertis angulisprarsident.  In rhetorum ac philosophoruin scholissolitudo
est.  At quam celebres culinae sunt f Quanta nepotum focos juventus prcmit ?  Transeo pucro-
rum infehcium greges; quos post transacta convivia alia? cubiculi comumelia? expectant   Tran-
seo agmina exoletorum pernationescoloresquedescnpta, eteadem omnibus levitas sit, eadem
prima? mensura lanuginis, eadem speciescapillorum, ne quis cui rectior sit coma, crispulis miscc-
atur.  Transeo pisiorum turbam, transeo ministratorum, per quos signo dato  ad inferendam
canam riiscurntur.  Dii boni quantum hominum unus venier exercet! Quid  tu illos boletos
voluptarium venenum, nihil oculti opens judicas facere, etiamsi prafsentanS non furant' Quid
tu illam astivam  nivem  non putas cahuui jecinoribusobducere; Quid ilia osliea, inertissimaru
carnem, ccrno sa»inatain, nihil existimas limosa? gravitatis inierre f Quid illud sociorum earum.
preiiosauipisciumsaniein, non credis urere salsa tabe pra?curdia » Quid ilia purulenta, et qua!
uiituin non ab ipso  iRne in os transferuntur, judicas, sine noxa, in ipsis visceribus extincui'
Quam foedi atque pcstilentcsructus suiu, quantus* fastidmm sui, exhajautibus crapulain vote'. 
170          PRACTICE OF PHYSIC.

The females liable to it are those of  the more  robust
and full habits ; and it very often happens to such long be-
fore the menstrual evacuation has ceased.  I have found it
occurring in several females, whose menstrual evacuations
were more abundant than usual.
  494.] This disease seldom attacks eunuchs,  and when it
does,  they seem to  be those who happen to be of a  robust
habit, to lead au indolent life, and to live very full.
  495.] The  gout  attacks especially men of robust and
large bodies,  men of large heads, of full and corpulent ha-
bits, and men whose skins are covered  with a thicker rete
mucosum, which gives a coarser surface.
  496.] If with the ancients, we might ascertain, by cer-
tain terms, the temperaments of men, I would say, that
the gout attacks especially men of a cholctico-sanguine tem-
perament,  and that it very seldom attacks the purely san-
guine or melancholic.   It is however, very difficult to treat
this matter with due precision.
  497.] The gout seldom attacks persons employed in con-
stant bodily labor, or persons who  live much upon  vege-
table  aliment.  It  is also  said to be less  frequent among
those people who make no use of wine or other fermented
liquors.
  498.] The gout does not commonly attack men, till af-
ter  the age of five and thirty ;  and generally not till  a still
later period.   There are indeed instances of the  gout  oc-
curring more early ; but these are few in comparison of the
numbers which agree with what we have given as the  ge-
neral rule.  When the disease does appear early in life, it
seems to be in those in whom the hereditary disposition is
very strong, and to whom the remote causes to be hereafter
mentioned have been applied in a considerable degree.
  499.] As the gout is a hereditary disease, and affects es-
pecially men  of a  particular habit, its remote causes may
be considered as predisponent and occasional.
  500.] The predisponent cause,  so far as expressed by
external appearances or  by the general temperament, we
have already marked ; and physicians have been very con-
fident in assigning  the occasional causes :  but,  in a disease
depending  so  much upon a predisposition,  the assigning
occasional causes must be uncertain ;  as in the predisposed,
the occasional  causes may not always appear, and in per-
sons not predisposed,  they may appear without  effect.
This  uncertainty must particularly affect the case  of the 
PRACTICE  OF  PHYSIC.
171
rout; but I shall offer what appears to  me  most probable
on the subject.
   501.]  The occasional causes of  the gout seem  to be of
two kinds.   First,  those which  induce a plethoric  state of
the  body.   Secondly,  those which  in plethoric habits,  in-
duce a state of debility.
   502.]  Of the  first kind are  a sedentary indolent manner
of life,  a full diet of animal food, and the large use of wine
or of  other fermented  liquors.   These circumstances com-
monly precede  the  disease ;  and  if there  should  be  any
doubt of their  power of producing it, the fact,  however,
will  be  rendered sufficiently  probable by  what  has been
observed in (497.)
   503.]  Of the  second  kind  of occasional  causes which
induce debility  are, excess in  venery ;* intemperance in
the use of intoxicating liquors ;f  indigestion,  produced
either by the quantity or quality of aliments ;j much  ap-
plication to study or business;|| night  watching ;§  exces-
sive evacuations ;** the ceasing of usual  labor ;ff  the  sud-
den change  from  a very full to  a  very  spare diet \\\ the
large use of acids and acescents ;||||  and, lastly, cold§§ ap-
plied  to the lower extremities.
   504.]  The first (502.) seem to act by  increasing the pre-
disposition.   The  last (503.)   are commonly  the  exciting
causes, both of the first attacks,  and  of the  repetitions of
the disease.
  * Why excess of venery should be a cause of gout, has much engaged the attention of mechV
eal writers, and various reasons have been given why it should produce such an effect. There
is not the least doubt of the fact, though some authors have ventured to deny it, and have ex-i
eluded the excess of venery from being a cause of gout.
  It produces gout not primarily, but secondarily, if I may be allowed the expression, by induc-
ing a general state of debility, and by weakening the power of digestion, both of which cir-
cumstances are causes of the gout.
  4- By intemperate drinking the action of the stomach and bowels becomes extremely feeble
and languid, if it be  not wholly destroyed ; hence continual indigestions,  to which the origin
of the gout is attributed.
  X Both the quantity and quality of the aliments may produce indigestion: and hence the in-
dulging in too great a quantity of aliment, as well as in that which is of an indigestable nature,
are secondary causes of the gout; viz. causes which induce a state of debility.
  H Much application to study may doubtless induce indigestion, and thus increase the genera]
'tate of debility : it is not, however, by intense study, or deep thinking merely, that men grow
Vale amid their books, but by the sedentary life which studious men generally lead, and the un-
timely lucubrations in which they inconsiderately indulge.
  Much application to business can  only be an occasional cause of the gout, when the business
requires a sedentary and inactive life; but as most business requires activity, attention to busi-
ness is seldom the cause of gout.
  11 i'r want of sleep is always a cause of indigestion, and increases debility more perhaps, when
carried to excess, than any other of the circumstances mentioned by the author.
  ** 1 hat large evacuations induce debility is sufficiently evident.
  ++ Nothing more effectually promotes digestion than proper exercise ; the leaving off accuse
Joined labor must therefore necessarily induce indigestion and consequent debility.
  ♦t Why this induces debility is evident.  See  note on article 548.
  ■ ' That acids, by impairing the digestive powers of the stomach, may produce debility, is
what every practitioner allows.
  W 1 low cold thus applied, can produce a state of debility, is not very evident.  It is. bowevet
•ne of ine occasional (uu-.es of gout,  as experience sufficiently testifies.                 T 
172
PRACTICE OF PHYSIC.
   505.]  It is an  inflammatory  affection  of some  of  the
joints, which especially constitutes what we  call a parox-
ysm  of  the gout.   This  sometimes  comes  on suddenly
without any warning, but  is generally  preceded by seve-
ral symptoms ; such  as the ceasing of a sweating which
the feet  had  been commonly affected with before ;  an un-
usual coldness of the feet and  legs ; a frequent numbness,
alternating with a sense of prickling along the whole of the
lower  extremities  ; frequent cramps of the muscles of  the
legs ; and an unusual turgescence of the veins.
   506.]  While these symptoms take place in the lower ex-
tremities, the whole  body is affected  with some degree of
torpor and languor, and the functions  of the  stomach in
particular are more  or less disturbed.   The appetite is di-
minished, and flatulency, or other  symptoms  of indiges-
tion,  are felt.  These symptoms, and those of (505.) take
place for several days, sometimes for a week or two, be-
fore a paroxysm comes on :  but  commonly, upon the day
immediately  preceding  it,  the appetite becomes  greater
than usual.
   507.]  The circumstances of paroxysms are the follow-
ing.  They come  on most commonly in the spring, and
sooner or later according as the vernal heat succeeds sooner
or  later  to the winter's cold ; and perhaps sooner or later
also according as the body may happen to be more or less
exposed to vicissitudes of heat and cold.
   503.] The attacks are sometimes felt first in the even-
ing, but more commonly about two or three o'clock of the
morning.   The  paroxysm  begins with a pain affecting
one foot, most commonly in the ball  or first joint of the
great toe, but sometimes in other parts of the foot.  With
the coming on of this pain, there is commonly more or less
of a cold shivering,  which, as the pain increases,  gradu-
ally ceases, and is succeeded  by a hot stage of pyrexia,
which continues for  the  same time with  the pain  itself.
From the first attack, the pain becomes by degrees more
violent, and continues in this state with great restlessness
of the whole body till next midnight, after which it gradu-
ally remits; and, after it has  continued for  twenty four
hours from the commencement of the first attack, it com-
monly ceases very entirely, and, with the coming on of a
gentle sweat, allows  the patient to fall  asleep.  The pa-
tient, upon coming out of this sleep in the morning, finds
the pained  part affected  with some redaess  and swelling, 
PRACTICE  OF PHYSIC.
173
which, after having continued for some days  gradually
abate.
  509.] When a paroxysm  has  thus  come  on,  although
the violent pain after twenty four hours be considerably
abated, the patient is not entirely relieved from it.   For
some days he has every evening a return of more  consider-
able pain and pyrexia, and  which continue with more or
less violence till morning.  After continuing in this man-
ner for several days, the disease sometimes  goes entirely
off, not to return till after a long interval.
  510.] When the disease, after having  thus remained for
some  time  in  a joint; ceases  very entirely, it  generally
leaves the person in very perfect health, enjoying greater
ease and alacrity in the  functions of both body and mind,
than he had for a long time before experienced.
  511.]  At the beginning of the disease, the returns of  it
are sometimes  only once  in three or four years: but, after
some time, the intervals become shorter, and the attacks
become annual ;  afterwards  they  come  twice  each year,
and at length recur several times during the whole  course of
autumn, winter, and spring ; and as it happens that, when
the fits are frequent, the paroxysms become also longer, so,
in the advanced state of the disease, the  patient  is  hardly
ever tolerably free  from it, except perhaps for two or three
months in summer,  n
  512.] The progress  of the disease is also marked by the
parts  which it affects.  At  first,  it commonly affects  one
foot only ; afterwards every paroxysm affects both feet, the
one after the other ; and, as  the disease continues to recur,
it not only affects both  feet at  once, but  after having
ceased in  the  foot which was secondly  attacked, returns
again into the foot first affected,  and perhaps a second time
also into the other.   Its changes of place  are not only from
one foot to the other, but  also  from the feet^into  other
joints, especially those of the upper and lower extremities ;
so that there is hardly a joint of the body that is not, on
one occasion or other, affected.  It sometimes  affects two
different joints at the same time ;  but more commonly it  is
severe; in a single joint only,  and passes successively from
one joint to another ; so that  the patient's affliction is often
protracted for a long time.
  513.] When the disease has often returned, and the  pa-
roxysms have become very frequent, the pains are common-
ly less violent than they were  at first  ; but the patient is 
174            PRACTICE OF  PHYSIC.

more affected with sickness,  and the other symptoms of the
atonic gout,  which shall be hereafter mentioned.
  514.] After the first paroxysms of the disease, the joints
which have been affected are entirely restored to  their for-
mer suppleness and strength :  but after the disease has re-
curred very often, the joints affected do neither so sudden-
ly nor so entirely recover their former state, but continue
weak and stiff;  and these effects at length proceed to such
a degree, that the joints lose their motion altogether.
  515.] In  many persons, but not in all,  after the disease
has frequently  recurred,  concretions  of a  chalky  nature
are formed upon the outside of the joints,  and  for the most
part immediately under the skin.   The matter  seems to be
deposited at  first in a fluid  form, but afterwards becomes
dry and firm.  In their  dry state, these concretions are a
friable  earthy substance, very entirely  soluble in  acids.
After  they have been formed,  they contribute, with other
circumstances, to destroy the motion of the joint.
  516.] In most  persons who  have labored under the gout
for many years, a nephritic affection comes on, and disco-
vers  itself by all the symptoms which usually attend calcu-
lous concretions  in the kidneys, and which  we shall have
occasion to describe in another place.   All that is necessary
to be observed here is, that the nephritic affection alternates
with  paroxysms of the  gout;  and that the two affections,
the nephritic and the gouty, are  hardly ever present at the
same time.   This also  may be observed, that children of
gouty or  nephritic parents,  commonly inherit  one or other
of these diseases ; but whichever  may  have been the prin-
cipal disease of the parent, some of the children have the
one,  and some  the other.   In some of them, the nephritic
affection  occurs alone,  without  any  gout supervening ;
and this happens to be frequently the case of the female off-
spring of gouty parents.
  517.] In  the  whole of the history already given, I have
descrioed the most common form of the disease ; and which
therefore,  however  diversified in the  manner  I have said,
inav be still called the regular state of the gout.  Upon oc-
casion, however,  the  disease  assumes  different appear-
ances ;* but, as I suppose the disease to depend always up-

  * These different appearances which the gout assumes, are extremely unlike the regular gout
above described ; the young practitioner ought therefore to pay peculiar attention to them,
that when he observes them in patients, he may  not think them symptoms of other diseases, or
even mistake them for primary diseases. Errors of this kind are frequently committed by igno-
wnt practitioners, to their own discredit and the danger of their patient's life. 
PRACTICE  OF PHYSIC.          US
 on a certain diathesis or disposition of the system ; so every
 appearance which we can perceive to depend  upon  that
 same disposition, I shall consider as a symptom and case of
 the gout.  The  principal  circumstance in what we term
 the Regular  Gout, is the  inflammatory affection of the
joints ;  and,  whatever symptoms we can perceive to be
 connected  with, or to depend upon, the disposition which
 produces that inflammatory affection, but without its  tak-
 ing place,  or being present at the same time, we name the
 Irregular  Gout.
   518.] Of such irregular gout there are three  different
 states, which I  name the atonic,  the retrocedent, and the
 misplaced gout.
   519.] The atonic state is when the gouty diathesis  pre-
 vails in the system, but,  from certain causes,  does not pro-
 duce the inflammatory affection of the joints.  In this case,
 the morbid symptoms which appear are chiefly affections
 of the stomach ; such as, loss of appetite, indigestion, and
 its various circumstances  of sickness, nausea, vomiting,
 flatulency,  acrid eructations, and pains in the region  of
 the stomach.   These symptoms are frequently accompanied
 with pains  and cramps in several parts  of the trunk,  and
 the  upper, extremities  of  the  body, which  are relieved
 by the discharge of wind  from the  stomach.   Together
 with these  affections of  the stomach, there commonly oc-
 curs a costiveness ; but  sometimes a looseness with  cholic
 pains.  These affections of the alimentary canal are often at-
 tended with all the symptoms of hypochondriasis  ; as  de-
 jection of  mind, a constant and anxious attention to the
 slightest feelings, an imaginary aggravation of these,  and
 an apprehension of danger from them.
   In the same atonic gout,  the viscera of the thorax  also
 are sometimes affected,  and palpitations, faintings,  and
 asthma, occur.
   In  the head also occur, headachs,  giddiness,  apoplectic
 and paralytic affections.
   520.] When the several symptoms now mentioned occur
 in habits having  the marks of a gouty disposition,  this may
 be suspected  to have laid the foundation of them, and espe-
 cially when either, in such  habits, a manifest tendency to
 the inflammatory affection has formerly appeared ; or when
 the symptoms mentioned are intermixed with, and are re-
 Jicved by,  some degree of the inflammatory gout.  In such 
 176           PRACTICE OF PHYSIC.

 cases there can be no doubt of considering the whole as a
 state of the gout.
   521.] Another state of the disease I name the retrocedent
 gout.  This occurs when an inflammatory state of the joints
 has, in the  usual manner,  come  on,  but  which, without
 arising to the ordinary degree of pain  and  inflammation,
 or, at  least,  without these continuing for the usual time,
 and receding  gradually in the usual manner, they suddenly
 and entirely cease,  while some internal part becomes affect-
 ed.  The internal  part most commonly affected is the sto-
 mach,  which is  then affected with anxiety,  sickness, vo-
 miting, or violent pain ; but sometimes the internal part is
 the heart, which gives occasion to a syncope ; sometimes
it is  the lungs  which are affected with asthma ; and some-
 times it is the head,  giving occasion to apoplexy or palsy.
 In all these cases, there can  be no doubt of  the symptoms
 being all a part  of the same disease, however different the
 affection may seem to be in the parts which it  attacks.
  522.] The  third  state of irregular gout,  which we name
 the misptaced, is when the gouty diathesis, instead of pro-
ducing the inflammatory  affection of the joints, produces
an inflammatory affection of some internal  part, and which*
appears from the same symptoms that attend  the inflamma-
tion of those parts arising from other causes.
   Whether the gouty diathesis does ever produce such in-
 flammation of the internal parts without having first produc-
 ed it in the joints, or if the  inflammation of the internal
 part be always a  translation from the joints previously
 affected, I dare not  determine;  but,  even supposing the
latter to be always the case, I think the difference of the
 affection of the internal part must still distinguish the mis-
 placed from what I have named the retrocedenl gout.
   523.] What  internal parts may be  affected by the mis-
 placed gout I cannot precisely say, because I have never
 met with any cases of the misplaced gout in my practice;
 and I find no cases of it distinctly marked by  practical wri-
 ters, except that of  a pneumonic inflammation.
   524.] There are two cases of a translated gout;  the one
 of which  is an affection of the neck of the  bladder, pro-
 ducing pain, strangury, and a catarrhus vesicas: The  other
 is  an affection of the rectum, sometimes by  pain alone  in
 that part, and sometimes by  hemorrhoidal swelling there.
 In gouty persons, I  have known such affections alternate
 with inflammatory affection of the joints : But whether to 
              PRACTICE OF PHYSIC.            177

refer those affections to the retrocedent, or to the misplac-
ed o-out, I will not presume to determine.
  525.] From the history which I have now  delivered of
the gout, I think it may be discerned under all its various
appearances.  It is,  however, commonly supposed,  that
there are cases in which it may  be difficult to distinguish
gout from rheumatism, and it is possible there may be such
cases • but,  for the most part, the two diseases may be dis-
tinguished with great certainty by observing the predispo-
sition,  the antecedents, the parts affected, the recurrences
of the  disease, and its connection  with  the other parts of
the system ;  which circumstances, for the most part, ap-
pear very differently in the two diseases.
  526.] With respect to the gout, our  next business is to
investigate its proximate cause ;  which must be a difficult
task, and 1 attempt it with some diffidence.
  527.]  Upon this subject, the opinion which has general-
ly prevailed is, that the gout depends upon a certain mor-
bific matter, always present in the body ; and that this mat-
ter, by certain causes, thrown upon the joints or other parts,
produces the several phenomena of the disease.
  528.)  This doctrine, however ancient  and general, ap-
pears to me very doubtful; for,
  First, There is no direct evidence of any morbific matter
being present in persons disposed to the gout.  There are
no experiments or observations which shew that the blood,
or other humors of gouty persons, are in any respect -differ-
ent from those of other persons. Previous to attacks of the
gout, there  appear no marks of any  morbid state of the
fluids ; for the disease generally attacks those persons who
have enjoyed the most perfect health, and appear to be in
that state when the disease comes on.  At a certain period of
the disease,  a peculiar matter indeed appears in gouty per-
sons; (515.) but this, which does not appear in every instance,
and which appears only after the  disease  has subsisted for
a long time,  seems manifestly to be the effect, not the cause,
of the disease.  Further, though  there be certain  acrids
which, taken into the body, seem to excite the gout, (503.)
it is probable that these acrids operate otherwise  in exciting
the disease,  than by affording the material cause of it.  In
general, therefore, there is no proof of  any morbific mat-
ter being the cause of the gout.
  Secondly, The suppositions  concerning the particular
nature of the matter producing the gout,  have been so va- 
173
PRACTICE  OF  PHYSIC.
rious and so contradictory to each other,  as to allow us to»
conclude, that  there is truly no proof of  the existence of
any of them.  With respect to many of these suppositions.
they are so inconsistent with chemical  philosophy, and
with the laws of the animal economy, that they must be
entirely rejected.
  Thirdly, The supposition of a morbific  matter being
the cause  of the gout,  is not  consistent  with the pheno-
mena of the disease, particularly with its  frequent and
sudden translations from one part to another.
  Fourthly, The supposition is further  rendered improba-
ble by this,  that,  if a morbific matter did exist,  its ope-
ration  should be  similar in  the several parts which it at-
tacks ; whereas it seems to be very different, being  sti-
mulant, and exciting inflammation in the joints,  but se-
dative and  destroying  the tone in the stomach :  Which,
upon  the supposition of particular matter acting in both
cases, is not to be explained by any difference in the part
affected.
  Fifthly, Some facts,  alledged  in proof of a  morbific
matter,  are not  sufficiently  confirmed, such as those
which would  prove the disease to be contagious.   There
is, however, no proper evidence of this, the  facts given
being  not only few,  but exceptionable ; and the negative
observations are innumerable.
  Sixthly,  Some  arguments  brought in  favor of a mor-
bific matter, are  founded upon  a mistaken explanation.
The disease has been supposed to  depend upon a morbific
matter because it is hereditary:  But the inference is not
just;  for most hereditary diseases do not depend upon any
morbific matter,  but upon a  particular  conformation of
the structure of the  body, transmitted from the parent to
the offspring ; and this last appears to be particularly the
case in the gout.  It may be  also observed, that  heredi-
tary diseases,  depending upon a morbific matter,  always
appear much more early in life than the gout commonly
does.
  Seventhly, The supposition of a morbific matter being
the cause of the gout,  has been  hitherto  useless, as it has
not suggested any successful method of cure.  Particular
suppositions have  often corrupted the practice and have
frequently  led from those views which  might be useful,
and  from that  practice which experience had approved.
Further, though the supposition of a morbific matter has 
              PRACTICE  OF PHYSIC.           179

been generally received, it has been as generally neglected
in practice.   When the gout has affected the stomach, no-
body thinks of correcting the matter supposed  to be pre-
sent  there, but merely of restoring the tone of the moving
fibres.
  Eighthly, The supposition of a morbific matter is quite
superfluous; for it explains nothing,  without  supposing
that  matter to produce a change in the state of the moving
powers ; and a change in the state of the moving powers,
produced by other causes,  explains every  circumstance,
without the supposition of a morbific matter; and, to this
purpose, it  may be observed, that many  of the causes
{503.)  exciting the gout,  do not operate upon the state of
the fluids,  but directly and solely upon that of the  mov-
ing powers.
   Lastly, The supposition of  a morbific matter is also su-
perfluous; because, without any such supposition,  I  think
the disease  can be explained in a manner more consistent
with its phenomena, with  the laws of the animal economy,
and  with the  method of cure which experience has ap-
proved.
   I now proceed to give this explanation ; but,  before en-
tering  upon it,  I must premise some general observations.
   529.]  The first  observation is, that the gout is a disease
of the whole system, or depends  upon a certain  general
conformation  and state of the body, which manifestly ap-
pears  from  the facts mentioned from (493. to 496.)   But
the  general state of the  system  depends chiefly upon the
state  of  its primary  moving  powers ; and therefore the
gout may be supposed to  be chiefly an affection of these.
   530.]  My second observation  is, that the gout is mani-
festly  an affection of the nervous  system ;* in which the
primary moving powers   of the whole  system are  lodged.
The occasional  or exciting causes  (503.)  are  almost  all
such as act directly upon the nerves and  nervous system ;
and  the greater part  of  the symptoms  of the atonic or re-
trocedent gout are manifestly affections of the same system
 519. and 521.)  This leads us to seek for an explanation of
the whole of the disease in the laws of the nervous system,
and  particularly the changes which may  happen  in the ba~
lance of its several parts.

  » Boerhaave after describing the disease, says, Aphorism, 1262. " From all which it ap»
iicars, that the proximate cause of the gout is a vitiated state of the most minute, and conse-
quently nervous vctls of the body ; and also of that rtuid which flows through the nerves." 
180
PRACTICE  OF PHYSIC.
  531.] My third  observation is, that the stomach, which
has so universal a consent with the rest of the system, is the
internal part that is  the most frequently, and often very
considerably affected by the gout.   The paroxysms of the
disease are commonly preceded by an affection of the stom-
ach ; (506.) many of the exciting causes (503.) act first up-
on  the stomach ; and the symptoms of the atonic and retro-
cedent gout  (519. 521.) are  most commonly and chiefly
affections of the same organ.   This observation leads us to
remark, that there is a balance subsisting between the state
of the internal and that of the external parts ; and, in par-
ticular,  that the state of the stomach is connected with that
of the external parts ; (44.) so that the  state of tone in the
one may be communicated to the other.
  532.] These observations being premised, I shall  now
offer the following  pathology of the gout.
  In some persons there is a certain vigorous and pletho-
ric state of the system (495.)  which,  at a certain period of
life, is liable  to a  loss of  tone in the extremities. (498.
505.)  This is in some measure communicated to the whole
system, but appears more especially in the functions of the
stomach  (506.)  When this loss of tone occurs while the
energy of the brain still retains its vigor, the vis medicatrix
naturae is  excited to  restore the tone of the parts ; and ac-
complishes it by exciting an inflammatory affection in some
part of the extremities.  When this has  subsisted for some
days, the tone of the extremities, and of the whole system,
are restored,  and the patient returns to his ordinary state of
health.  (510.)
  533.]  This is the courgeof  things, in the ordinary  form
of the disease, which we name the regular gout;  but  there
are circumstances of the body,  in which  this course  is in-
terrupted or varied.   Thus when the  atony (505. 506.)
has taken place, if the reaction (508.) do not succeed, the
atony  continues in the stomach, or perhaps in other inter-
nal parts, and  produces that state which we have,  for rea-
sons now obvious,  named the  atonic gout.
  534.] A second  case of variation in the course of the
gout is, when, to the atony, the reaction and inflammation
have to a certain degree succeeded ; but, from causes either
internal or external,  the tone  of the extremities, and  per-
haps of the whole system, is weakened ; so that the inflam-
matory state,  before it had either proceeded to the degree,
or continued  for the  time,  requisite for restoring  the  tone 
PRACTICE  OF PHYSIC.
181
 of the system, suddenly and  entirely ceases.  Hence the
 stomach, and other internal parts, relapse into the state of
 atony ; and  perhaps have this increased by the atony com-
 municated  from  the  extremities :  All which appears  in
 what we have termed the retrocedent gout.
   535.] A third case of variation from the ordinary course
 of the gout,  is, when,  to the atony usually preceding,  an
 inflammatory reaction fully succeeds ;  but has its usual de-
 termination to the joints by some circumstances prevented ;
 and  is therefore directed to an internal part,  where it pro-
 duces  an inflammatory affection, and that  state  of things
 which we have named the misplaced gout.
   536.] We have thus offered an explanation of the circum-
 stances of the system in  the several  states of the gout; and
 this  explanation we suppose to be consistent with the phe-
 nomena of the disease,  and with the laws of the animal eco-
 nomy.  There are indeed,  with respect to the theory of the
 disease, several questions which  might be  put,  to  which
 we  have not given any answer.   But, though perhaps we
 could give  an answer to many of these questions, it does
 not here appear necessary ; as at present we  intend only to
 establish such general  facts with regard to this disease,  as
 may lay a foundation for the cure of it, so far as experience
 has enabled us to  prosecute it.   Proceeding,  therefore, up-
 on the several parts of the pathology given, as so many
 matters of  fact, I shall now  consider what may be attempt-
 ed towards the  cure of the disease.
   537.] In entering upon this,  I must observe, in the first
 place,  that a cure has been commonly thought impossible ;
 and  we acknowledge it to be very probable, that the gout,
 as a  disease of the whole habit, and very often depending
 upon original conformation, cannot be cured by medicines,
the effects of which are always very transitory, and seldom
extend to  the  producing any  considerable change of the
 whole habit.
  538.] It  would perhaps have been happy for gouty per-
 sons, if this opinion had been implicitly received by them ;
 as it would have prevented their having been so often the
 dupes of self-interested pretenders,  who have either amus-
ed them with inert medicines, or have rashly employed those
of the most pernicious tendency.  I am much disposed  to
believe the  impossibility of a cure of  the gout by medicines ;
and more certainly still incline to think, that  whatever may
be the possible power of medicines, yet no medicine for cur-
                         2 A 
182
• PRACTICE OF  PHYSIC.
ing the  gout has  hitherto been found.   Although  almost
every age has presented a new remedy, yet all hitherto of-
fered have  very soon  been either neglected as useless, or
condemned as pernicious.
   539.]  Though unwilling to admit the  power of medi-
cines,  yet I  contend that a great deal can be done towards
the  cure of the gout by a regimen : And from what has
been observed  (497.) I am firmly persuaded, that any  man
who, early in life, will enter upon the constant practice of
bodily labor, and of abstinence irom animal food, will be
preserved entirely from the disease.
   Whether  there be  any other means of radically curing
the gout  I am not ready to determine.   There are  histories
of cases  of the gout, in which it is said, that by great emo-
tions of  mind,  by wounds,  and  by  other accidents, the
symptoms have been  suddenly  relieved, and  never  again
returned ;  but  how  far these accidental  cures  might be
imitated  by  art, or would succeed  in other  cases, is at least
extremely uncertain.
   540.]   The practices proper and necessary in the  treat-
ment of the  gout,  are to be considered  under two  heads ;
first, As they are to be employed  in the intervals of parox-
ysms ; or, secondly,  As during the time of these.
   541.]   In the intervals of paroxysms, the  indications are,
to prevent the  return of paroxysms, or at least to render
them less frequent, and more moderate.  During the  time
of paroxysms,  the indications  are,  to moderate  the vio-
lence, and shorten the duration of them as much as can be
done with safety.
   5 32.]   It has  been  already observed, that the gout may
be entirely prevented  by constant  bodily exercise,  and by
a low diet;  and I am of opinion,  that this prevention may
take place  even in persons who have a hereditary  disposi-
tion to the disease.   I must add here, that, even  when the
disposition has  discovered itself by several  paroxysms of in-
flammatory  gout, I am persuaded that labor and abstinence
will absolutely  prevent any returns of it for the rest  of life.*
These,  therefore, are the means of answering the first in-
dication  to be pursued in the intervals of paroxysms ;  and

  * Several cases are" to be met w ith in practical authors, which confirm this observation. Van
 Swieten relates the case of a priest, who enjoyed a rich living, and had long been an old con-
stant sufferer in the gout; but happening at last to be taken by the pirates of Barbary, was de-
tained there in a slate of slavery tor the space of two years, and kept constantly at work in the
galleys, with only a very spare diet.  The regimen he there underwent had this good effect,
that after he was ransomed from his captivity, having lost his troublesome and monstrous fatness,
he never once had a fit of the gout, though he lived several years after the event happened. 
              PRACTICE  OF  PHYSIC.            183

I must here offer some remarks upon the proper use of these
remedies.
  543.] Exercise, in persons disposed to the  gout, is di-
rected to  two purposes : One of these is the strenghtening
of the  tone  of  the extreme vessels ; and the other,  the
guarding against a plethoric state.  For the former,  if ex-
ercise  be  employed  early in life, and before intemperance
has weakened the  body, a very moderate degree of it  will
answer the purpose ; and for the latter,  if abstinence be at
the same time observed, little exercise will be necessary.
  544.] With respect to exercise, this in general is to be
observed,  that it should never be violent; for if violent,  it
cannot be long continued, and must always endanger the
bringing  on  an  atony  in proportion to the violence of the
preceding exercise.
  545.] It is also to be observed,  that the exercise of gesta-
tion though considerable and constant, if it be entirely with-
out bodily exercise, will not answer the purpose in prevent-
ing the gout. For this end, therefore, the exercise must
be in some measure, that of the body, and  must be mode-
rate,  but  at the  same time constant and continued through
life.
  546.] In every case and circumstance of the  gout in
which the patient retains the use  of his limbs,  bodily exer-
cise,  in the intervals of paroxysms, will  always be useful ;
and,  in the  beginning of the disease, when the disposition
to it is not  yet strong, exercise may prevent a paroxysm
which otherwise might have come on.  In  more advanced
states of the disease, however, when there is some disposi-
tion to a  paroxysm, much walking will bring it on ; either
as it weakens the tone  of the lower extremities, or as it ex-
cites  an inflammatory  disposition in them  ; and it is proba-
ble, that  in the  same  manner  strains  or  contusions often
bring on a paroxysm of the  gout.
  547.J Abstinence, the other part of our  regimen (539.)
for preventing  the gout, is of more difficult application.
If an  abstinence from  animal food be entered upon early in
life, while the vigor of the system is yet entire, we have no
doubt of  its being both safe  and effectual ; but if the motive
for this diet shall not have occurred till  the  constitution
shall have been broken by intemperance,  or by the decline
of  life, a low diet may then endanger  the bringing on an
atonic state.
  548.] Further,  if a  low diet  be entered upon only in the 
184            PRACTICE OF  PHYSIC.

decline of life, and be at the same time a very great change
in the  former manner of living, the withdrawing of an ac-
customed stimulus of the system may readily throw this into
an atonic state.*
   549.] The safety of an abstemious course may be great-
er or less according  to the management of it.   It is anU
mal food which especially disposes to the plethoric and in-
flammatory state, and that food is to be therefore especially
avoided ; but, on the other hand, it is vegetable aliment of
the lowest quality that is in danger of weakening the system
too much, by not  affording sufficient nourishment; and
more particularly of weakening the tone of the stomach by
its acescency.  It is therefore a diet of  a middle nature that
is to be chosen ; and milk is precisely of this kind, as con-
taining both animal and vegetable matter.
  As approaching to the nature of milk, and as being a ve-
getable matter containing the greatest portion of nourish-
ment,  the farinaceous seeds are next to be chosen,  and are
the food most proper to  be joined with  milk.
  550.] With respect to drink, fermented  liquors are use-
ful  only when they are joined with animal food, and that
by their acescency  ; and their stimulus is  only necessary
from custom.  When, therefore, animal food is to be avoid-
ed, fermented liquors are unnecessary ; and, by increasing
the acescency of vegetables, these liquors  may be hurtful.
The stimulus of fermented or spirituous liquors,  is not ne-
cessary to  the young and  vigorous; and, when much em-
ployed, impairs the tone of the system.  These  liquors,
therefore,  are to be avoided, except so far as custom and
the declining state of the system may have rendered them
necessary.   For preventing or moderating the regular gout,
water is the only proper drink.
  551.] With respect to an abstemious course,  it has been
supposed that an abstinence from  animal food and ferment-
ed liquors,  or the living upon milk and farinacea alone for
the space of one year might be sufficient for a radical cure
of the gout ; and it is possible that,  at a certain period of
life, in certain circumstances of the  constitution, such a
measure might answer the purpose.  But this is very doubt-
ful ; and it is more probable that the abstinence must, in a
great measure, be continued, and the milk diet be persisted
in,  for the rest of life.  It is well known,  that several per-

  * A sudden change from a mil to a spare diet was justly enumerated among the occasion-'
oauses of the i-ut m article 5C0. 
PRACTICE  OF  PHYSIC.
185
 sons who  had entered on an  abstemious course,  and had
 been thereby delivered from the gout, have, however, upon
 returning  to their  former manner of full living,  had  the
 disease return  upon them with as much violence as before,
 or in a more irregular and more dangerous form.
   552.] It has been alledged, that,  for preventing the re-
 turn of the gout, blood-letting, or scarifications of  the
 feet,  frequently  repeated, and at stated times,  may be
 practised  with advantage; but of this I have  had no expe-
 rience.
   553.] Exercise and abstinence are the means of avoid-
 ing the plethoric state  which gjves the disposition to the
 gout; and are  therefore the means "proposed for prevent-
 ing paroxysms,  or at least for rendering them less frequent,
 and more moderate.  But many circumstances prevent the
 steadiness necessary in pursuing these measures; and there-
 fore, in such cases,  unless great care be taken to avoid  the
 exciting causes,  the disease may frequently return; and in
 many cases, the  preventing of paroxysms is chiefly to be
 obtained by avoiding those  exciting  causes enumerated in
 (503.)   The conduct necessary for avoiding them,  will be
 sufficiently  obvious  to persons  acquainted  with the doc-
 trines of the Hygieine,  which I suppose  to have been de-
 livered in  another place.
   554.] A due attention in avoiding those several causes
 (502. 503.)  will certainly prevent fits of the gout;  and the
 taking  care that the exciting causes be never applied in a
 great  degree,  will  certainly render  fits more moderate
 when they do come on.   But, upon the whole, it  will ap-
 pear,  that a strict attention to the whole conduct  of life,
 is in this matter necessary;* and therefore, when the pre-
 disposition has taken place, it will be  extremely  difficult
 to avoid the disease.
   555.] I am indeed firmly persuaded,  that,  by obviating
 the  predisposition,  and by  avoiding  the  exciting causes,
 the gout may be entirely prevented:  But as  the measures
 necessary  for this purpose,  will in most cases, be pursued
  * The physician has more difficulty in persuading his patients to a proper regimen in the gout
 than in any other disease ; and if he would gain reputation, he ought to pay peculiar attention
 to this part of practice, and use his utmost art in convincing his patient of the necessity of an ab-
 stemious diet, and a regular conduct.
  Gouty patients are generally the genuine offspring of jolly Bacchus, and prefer the transient
 indulgence of their jovial inclinations to the ransom of whole years of torment at the easy price
 of a life of sobriety and temperance, until the invincible Queen of tortures, as Lucian calls her,
 fully convinces them of their en or-. They are then anxious for medical advice, and after  con-
sulting the physician, they arc willing implicitly to obev his sliictest  injunctions. They seldom,
 liowever, then find much relitt; and remain living proofs of the truth of the adage :
                --------sero medicma paratur,
             Cum mala per longas. iavaluere wcra^. 
ISC
PRACTICE  OF  PHYSIC.
with difficulty,  and even  with  reluctance,  men have been

Tery desirous to find  a medicine  which might answer the

purpose  without any  restraint on  their manner of living.

TO gratify this desire, physicians have proposed, and,  to

take advantage of  it,  empirics have feigned,  many reme-

dies,  as we have already observed.   Of what nature seve-

ral of these remedies  have been, I cannot certainly say ;

but, of  those which  are  unknown,  we  conclude,  from

their having been only of temporary fame,  and from their

having soon fallen  into neglect, that they  have been either

inert  or pernicious, and therefore 1  make  no inquiry  after

them ; and shall now remark only upon one or two known

remedies for  the gout,1*which have been lately in  vogue.

   556.]  One of these is  what  has been named in England

the Portland  Powder.*   This is  not  a new medicine, but

is mentioned by Galen,  and,  with some little variation in

its composition, has been mentioned by the writers  of al-

most  every age since  that time.    It  appears  to have been

at times in fashion,  and to have again fallen into neglect  ;

und  I think that this last has been owing to its having been

found to be,  in  many instances,  pernicious.   In every in-

stance which I have known of its exhibition for the length

of time prescribed,  the persons who  had  taken it were in-



  * This medicine was so called from one .of the Dukes of Portland being cured by it of an
hereditary and inveterate gout.  It consist) of et|ual parts  of the following bitter aromatics:
■viz. Rad. aristolochiae rotunda?, Rad. gentians?, Summitat. chamedryos, Summitat. chama?pityos,
Summitat. centaur, rain.  A drachm of this powder is ordered to be taken, in  any convenient
vehicle, as a little wine, broth, tea, &c.  in a morning, fasting, the patient tasting nothing for an
hour and an half after it; it must be used in this dose for three months without the least interrup-
tion : Forty-five grains are to be taken  daily in the same manner, for the succeeding three
months: half a drachm every day, for the next six months; and half a drachm every other day,
during the second year. It is sometimes two years complete  before any change be produced,
but the patient must not therefore abandon the medicine, but continue its use.
 . These aromatic bilters have been long in use as remedies for the gout.  We find Galen pre-
scribing in this disease, the seeds and tops of wild rue, birth-wort, lesser centaury, gentian, ice.
either singly, or mixed in certain proportions.   Ti.illian describes similar antidotes, which he
says, must be continued for a great lengdi of time, viz. six or seven months, or even for a year
and upwards.  The  tetra-phaimacon of Aetius, composed of gentian, birth-wort, bay-berries,
and myrrh, is a similar reined;.', and is also directed to be used for a great length of time.  Ca;-
iius Aurelianus likewise mentions the bitters to be long used in the gout, and he gives them the
apposite epithet of annalia.  The Diatesseron, which has not been long thrown out of our shops,
and is still retained in some of the foreign pharruacopir'as, is of the same kind.
  The use of these medicines has doubtless in many cases completely cured the gout; but  in
many cases, even in those that have been cured, fatal diseases have supervened.  The ancients
were well aware of the danger of an indiscriminate use  of these medicines: " Many," says
Galen, " of a moderate and slender hab.t of body, have lost their life by the use of drinks com-
posed of these kinds of remedies, their blood being dried up.  The  numerous arthritic  cases
cured by these medicines, encouraged gouty people" to have recourse to them indiscriminately,
and without reflecting tliar tho e, wno had been cured by them, were of a humid and phleg-
matic habit, to whom .ne>lu n_', of this sort might be administered with safety." ytgineta has
a similar passage. t; lir.t, ' says he, " who endeavor to remove the disease entirely by medi-
cines, to be used through the whole year, will doubtless do service to such patients' as are in-
fested with pituitous and c\creinentitious humors in their joints, but they will hasien an un-
timely death in  persons of a dry an-l hoi habit of body, by  forcibly driving the morbific mailer
on the intestines, kidneys, lungs, or some other of the principal bowels."
  Theancien-o, then, were aware of the danger attend, ng the promiscuous use of these reme-
dies; and ihe moderns are still more convinced of that danger: hence these aromatic bitters
are entirely laid ande, a.iu iu their pi~ix the Peiuvian bark is me only tonic now u.-d, in these
case*. 
                 PRACTICE  OF  PHYSIC.               1ST


deed  afterwards free from any inflammatory affection of the

joints ; but they were affected with many symptoms  of

the atonic  gout ; and all,  soon after finishing their course

of the medicine, have  been  attacked with  apoplexy, asth-

ma, or dropsy, which proved fatal.

   551.] Another remedy which  has had the appearance of

preventing the gout, is an alkali in various forms, such as

the fixed alkali both mild and caustic,  lime water,  soap,

and absorbent earths.    Since it became common to exhi-

bit these medicines in nephritic and calculous cases,  it has

often  happened that they were given to those who were at

the same time subject to the gout; and it has  been observ-

ed, that under the  use of  these  medicines, gouty persons

have been longer free from the fits  of their disease.*   That,

however the use of these medicines has entirely prevented

the returns of gout, I do not know; because  I never  push-

ed  the use of those medicines for a long  time,  being ap-

prehensive that the long continued use of them might pro-

duce  a hurtful change in the state of  the fluids.

   558.] With respect to preventing the gout,  I  have only

one other remark to offer.    As the preventing the gout de-

pends very much on supporting the tone of the  stomach,

and avoiding  indigestion ; so  costiveness,  by occasioning

this is very hurtful to gouty  persons.   It is  therefore neces-

sary for such persons  to  prevent or  remove costiveness,

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

  * Some remarkable cases have lately  occurred in this city of the efficacy of aerated alkaline
water, in preventing the returns of the paroxysms of the gout.  It requires to be taken  for a
great length of lime, to insure success; but the patient is encouraged to persevere in its use,
in consequence of a speedy removal ot  some  of the most troublesome symptoms.
  The method of making it is described by several authors; but, for the sake of those readers
who are unacquainted with the process, I shall give an abstract of it.
  Dissolve three ounces, Troy weight, of good salt of Tartar in a gallon and a half of rain wa-
ter, or good soft spring water ; nitre the solution, and put as much of it into the middle glass
of Parker's machine  as will completely fill the vessel, reserving the remainder for a subsequent
making   The effenescingmaterials must then be put into the Tower vessel, and a gentle stream
of fixed air must be made to pass through the liquor, till it tastes evidently acidulous, which
will probably require forty-eight or sixty hours,  or in summer more.
  The meihud of managing the effervescence is of considerable consequence; for, if it is too
violent at first, much ail escapes through the  vessels  without effect.  Ascertain, by previous
experiment, how much of the vitriolic  acid,  which you have procured, for it is of very differ-
ent strengths in the shops, will saturate a drachm of the chalk.  Put tour ounces of dry powdered
chalk into the lower vessel, and shake it to one side : under that side put a wedge, so as to raise
it aoout an inch and an half frt m the table.  With a long funnel, which reaches to the bottom of
the vessel, pour in the quantity of vitriolic acid necessary for the satuiation, which  will run
down to the oiher side of the vessel, and not come into contact with the chalk : through the
same funnel, pour very slowly as much water  as will be sufficient to cover about a fourth part of
the chalk as it then lies. The vessel being gently skaken occasionally,  the effervescence will go
on very slow1}, and the alkaline liquor will  be sooner  and more effectually saturated, than if
the effervescence had been too violent. If the materials are not sufficient for giving an acidu-
lous taste to the liquor, the lower vessel must be washed, and fresh chalk and acid again put
into it.
   I'he dose of this water is half a pint about noon, and  another in the  evening.  In urgent cases
half a pint has been given morning, noon, and night, lor a considerable lime together, without
disagreeing with the stomach, or injuring the appetite  or general health of the patient.  If it
proves flatulent, a tea-spuoufui or two, but  not more, of spiriiuous  cinnamon water may be
taken in each dose.  It it inflames, or too violently  irritates  the urinary passages, live or leu,
or in urgent cases, twenty drops of laudanum, mav be  taken with each dose of  tfm water. 
183
PRACTICE  OF  PHYSIC.
same time proper, that the medicine employed  should be
such as may  keep the belly regular,  without much purg-
ing.  Aloetics, rhubarb, magnesia alba, or flowers of sul-
phur,  may be employed, as the one or the other may hap-
pen to be best suited to particular persons.*
   559.]  These are the several measures (from 541. to 558.)
to be pursued in  the intervals of the paroxysms; and we
are  next to mention the measures proper during the time
of them.
   560.]  As during the times  of paroxysms the body is in
a feverish state,  no irritation should  then be added to it;
and every part,  therefore, of the antiphlogistic regimen,
(130. to 133.) except the application  of cold, ought to be
strictly observed.
   Another  exception to the general rule may occur when
the tone of the stomach is weak, and when the patient has
been before much accustomed to the use of strong drink;
for it then may be allowable,  and  even necessary,  to give
some animal food, and a little wine.f

 * The following formula may be used in particular cases:
      R. Aloes Socotorin. 3m
         Gum. Guaiac. 3im
         Tinct. Sacrae, q. s.
         M. f. massa, in pilulas equales xv. dividenda;  quarum
            sumat iii. vel.  iv. pro re nata.
      R. Pulv. Rad. Rhei, 3iii.
         Magnes. alb. §f^.
         Gum. Guaiac. 3m
         Confect. Aromat. 3"-
         Syrup, comra. q. s.
         M. f. Elect, cujus sumat magnitudinem juglandis ma-
            ne et vespere, vel pro re nata.
 This last medicine has been extremely beneficial in removing costiveness, and in giving a
tone to the stomach.
 An ounce, or an ounce and a half, or two ounces of the tinctura sacra, is also a  good purge
for gouty persons.
 The Elixir Sennse is likewise a good medicine where we cannot use aloetic purges, as in cases
of piles: in these cases also we may use sulphur; of which the following form is very convenient.
     R. Flor. Sulphuris, §ii.
        Elect. Lenitivi, §ii.
        Pulv. Rad. Jalap. 3"«
                   Zinzib. 3m
        Syr. Simpl. q. s.
        M. f. Elect, cujus sumat quantitatem juglandis pro re
           nata.
 + The wine in these cases should be of the best kind, and such as are not apt to turn sour on the
stomach.  The dry wines, as Sherry and Madeira are most proper, while both tie rich sweet
wines and the austere thin acid wines are equally improper. 
              PRACTICE  OF PHYSIC.           J8»

  561.] That no irritation is to be added to the system dur-
ing the paroxysms of gout, except in the cases mentioned,
is entirely agreed upon  among  physicians :  But it is a more
difficult matter to determine whether, during the time of
paroxysms,  any measure may be pursued to moderate the
violence of reaction  and of inflammation.   Dr. Sydenham
has given it as his opinion, that the more violent the inflam-
mation and pain, the paroxysms will be the shorter, as well
as the interval between  the present and next paroxysm long-
er ; and,  if this opinion be  admitted as just, it will forbid
the use  of any remedies which might moderate the inflam-
mation ;  which is, to a certain degree, undoubtedly neces-
ary for the health of the body.  On the other hand,  acute
pain presses  for relief; and, although a certain degree of
inflammation may seem absolutely necessary, it is not cer-
tain but that a moderate degree of it may answer the pur-
 1>ose: And it is even  probable,  that, in many cases, the vio-
 ence of inflammation  may  weaken  the tone of the parts,
and thereby invite a  return of  paroxysms.   It seems  to me
to be in this way, that, as the  disease advances, the parox-
ysms become more frequent.
  562. From these last considerations, it  seems probable,
that, during the time of paroxysms, some measures may be
taken to moderate the violence of the inflammation and
pain ; and particularly, that in first paroxysms, and in the
young and vigorous,  blood-letting at  the arm may be prac-
tised with advantage.   But I am persuaded,  that this prac-
tice cannot  be repeated often with safety  ; because blood-
letting not only weakens the tone of the system, but may
also contribute to produce plethora.   I believe, however,
that bleeding by leeches on the foot, and upon the inflamed
part, may  be practised, and repeated with greater  safety ;
and I have  known instances of its having been practised
with safety, to moderate and shorten  paroxysms ; but bow
far  it may be carried,  we have not had experience enough
to determine.
  563.] Besides blood-letting, and the antiphlogistic re-
gimen, it has been proposed to employ remedies for mo-
derating the inflammatory  spasm of the part affected,
such as  warm bathing and  emollient poultices.   These
have sometimes been  employed with advantage and safety ;
but at other times, have been found to give occasion to a
retrocession of the gout.*
 •On this account these topical remedies ought to be used with gteat oution: the tempo.
                         2b 
190
PRACTICE  OF  PHYSIC.
   564.] Blistering is a  very effectual means of relieving
and discussing a  paroxysm of the gout; but has also fre-
quently had the effect of rendering  it retrocedent. f
   565.] The stinging with nettles I consider as analogous
to blistering ;  and I think it probable that it would be at-
tended with the same danger.
   566.] The burning with moxa,!:  or other  substances,  I
consider as a remedy of the same kind.   I have had indeed
no evidence of this  proving hurtful  ; but neither have I
had any  proper  evidence of its having proved a radical
cure.
   567.] Camphire, and  some  aromatic  oils,   have  the
power of allaying the pain,  and  of removing the inflam-
mation  from the part affected ; but  these remedies com-
monly make the  inflammation only  shift from one part to
another, and therefore with the hazard  of its falling upon
a  part where  it may be more dangerous: and they  have
sometimes rendered the gout retrocedent.
   568.] From  these reflections (563. et seq.)  it will  ap-
pear,  that some  danger must attend every external appli-
cation to  the parts affected during  a  paroxysm ; and that
therefore  the common practice of  committing the person
to patience and flannel  alone, is established  upon the best
foundation.
   569.] Opiates  give the most  certain   relief from pain ;
but, when  given in the  beginning  of gouty paroxysms,
occasion these to  return with greater  violence.  When,
however, the  paroxysms  shall  have abated in their vio-
lence, but  still continue to return,  so as to occasion pain-
ful  and  restless  nights, opiates may be  then given with
safety and advantage,  especially  in the  case  of persons

rary relief which they afford, by procuring an intermission of the pain, is agreeable to the patient,
but it is frequently the occasion of an exaceibation of all  the symptoms.
  + This is a very dangerous practice.  Blisters are however extremely useful, in bringing back
the retrocedent gout to the part originally affected ; but, the violent degree of pain that ac-
companies the gout, when brought to a part already irritated by the blisters, frequently prevents
a patient who has  once suffered it, from allowing it a second time. It is, however, so impor-
tant and necessary a practice, that it ought not to be omitted.   As soon as the gout has been
brought back to its original  place, the blisters must be immediately removed, a piece of soft
linen dipped in fresh oil, applied to the part, and the whole well wrapt up in soft flannel: a
snoderate degree of heat must be preserved in the Hannel, and the patient must be encouraged
to bear with patience the violent pain which he sutlers.
  X Moxa is a soft lanuginous suhstance prepared in Japan, from the young leaves of a species
of Artemisia, by beating thein when thoroughly dried, and rubbing them between the fingers
till nothing but the finest fibres remain.
  A little cone of this cottony substance is laid upon the skin, which is previously moistened to
prevent the cone from sliding oflf: Kire is set to the apex of the cone, and it is suffered to burn
till it extinguishes  itself. A small eschar is produced and  the ulcer either healed or kept open
as occasion requires.
  Cotton impregnated with a small quantity of a solution of nitre, and afterwards dried, answer;
the end as effectually as the Japonese moxa. 
                PRACTICE  OF PHYSIC.             191

advanced in life, and who  have been often affected with
the disease.*
   570.] When,  after paroxysms have ceased, some swel-
ling and  stiffness shall remain in  the  joints, these  symp-
toms are to be discussed by the diligent use of the flesh-
brush.
   571.] Purging, immediately after a paroxysm, will be
always employed with the hazard  of bringing it on again.
   572.]  I have now finished what has  occurred to be said
upon  the means  of preventing  and   curing the  regular
gout;  and shall now consider its management when it has
become  irregular;  of which,  as  I have observed above,
there are three different cases.
   573.] In the first case, which  I have named the Atonic
Gout,  the cure is to be accomplished by carefully  avoid-
ing  all debilitating causes ; and by employing, at the same
time, the means of strengthening  the system  in  general,
and the stomach in particular.
   574.]  For the  avoiding debilitating causes, I must re-
fer to the doctrines of  the Hygieine, as in 553.
   575.]  For strengthening  the system in general, I must
recommend frequent exercise on horseback, and moderate
walking.   Cold bathing also may answer the purpose,
and may be  safely  employed, if it appear to be powerful
in stimulating the  system,  and  be not  applied when  the
extremities  are threatened with any pain.f
   For supporting the tone of the system in general, when
threatened with atonic gout, some animal ioodj  ought to
be employed,  and  the more acescent  vegetables  ought to
be  avoided.  In  the same case, some wine§ also may be
necessary ;  but it should be in moderate quantity,  and of
the  least acescent kinds ; and, if every kind of wine shall
be found to increase  the acidity of  the stomach,  ardent
spirits and water must be employed. ||

  * The best form for exhibiting opium in these cases, is the Confectio Opiata of the London
Pharmacoparia, or the Electarium Thebaicum of the Edinburgh. The dose of the former is half
a drachm, but of the latter a drachm and an  half.
  As opiates ought never to be administered where the inflammation is violent, but only in such
cases as are attended with little or no inflammation, these warm opiates cannot be improper. If
however the practitionershould think either of the above formulae too hot, he can  have recourse
to the Tinctura Thebaica.
  + Cold bathing is a doubtful remedy, and ought to be used withcaution. If it does not prove
a tonic, it ought to be abandoned ; and we know by experience that it frequently debilitates.
  t The use of animal food is absolutely necessary, and such ought to be chosen  as is most nu-
tritive.  Beef or mutton have been with propriety preferred to ail other animal food, and some
eminent practitionershave recommended steaks to every other mode of dressing beef and mut-
 ton.  Stews, hashes, pyes, and all high seasoned dishes, ought to be avoided.
  } The wine which a gouty person uses, ought to be generous and good, as Madeira, Sherry,
 &c. the thin acescent wines, as hock, claret, &c. always do mischief.
  II In order  the more effectually to guard against acescency, the spirits and water ought, if pos-
sible, to betaken without sugar, and cold.  No drink is perhaps more prejudicial for gouty 
PRACTICE OF PHYSIC.
   5 76.]  For strengthening the stomach, bitters  and  the
Peruvian bark may be employed ;  but care must be taken
that they be not constantly employed for any great length
of time.  Compare 556.
   The most effectual medicine for strengthening the sto-
mach is  iron, which may  be employed  under  various
preparations ;  but, to me, the best appears to be  the rust
in fine powder, which may be given in very large doses.*
  For supporting the tone of the stomach,  aromatics may
be employed;  but should be used with caution, as the fre-
quent and large use of them may have an opposite effect;
and  they should  therefore be given only  in  compliance
with former habits, or for palliating present symptoms.
  When  the stomach happens to be liable to indigestion,
gentle vomits may be frequently given ; and proper laxa-
tivesf should  be  always  employed to  obviate,  or to re-
move costiveness.
  577.]  In  the atonic gout, or  in persons  liable to it, to
guard against  cold is  especially  necessary ; and the most
certain means of doing this is, by  repairing to a warm cli-
mate during the winter season.
  578.]  In  the  more violent  cases of  the atonic  gout,,
blistering the  lower extremities may be useful ;  but that
remedy  should be avoided when any pain threatens the
extremities.  In  persons liable  to the atonic gout,  issues
may be established in the extremities, as, in some measure,
a supplement to the disease.
   579.]  A second case of the irregular gout, is that which
1 have  named the Retrocedent.  When this affects  the
stomach and intestines, relief  is to be instantly attempted
by the free  use of strong wines, joined with aromatics,  and
given warm ;  or if these  shall not prove powerful enough,
ardent spirits must be employed,  and are to be given  in a
large dose.  In moderate attacks,  ardent  spirits impreg-

patients, than what is called rich punch, viz. with a large quantity of sugar and lemon, espe-
cially when taken  warm.
  * The dose must be very small at first, not exceeding four or live grains in the day ; the doses
may be daily increased  two grains, till we arrive at tenor twelve, and  after two or three days,
ten grains may be given twice a day.  Aromatics always make it sit easier on the stomach thaa
it would do if taken alone; the most convenient form therefore is the following:
             R. Rubig. Martis, gr. 10.
                Confect. Card. 3 ft.
                 Syr. Croci, q. s.
                 M. f. bolus.
  After the patient has taken two of these boluses for three or four days, he may proceed to
take three of them ; and after a few more days, if the stomach is not disordered, each bolus
may be daily increased  sill we arrive at 24, or even 30 grains, thru e a day.
  + The proper laxatives for gouty const.tutions, aie mentioned in d note on article 558. 
                PRACTICE  OF  PHYSIC.            193

nated with garlic, or with asafcetida, may be employed ;
or,  even without the ardent spirits a solution of asafcetida
with the volatile alkali  may answer the purpose.  Opiates
are  often an effectual  remedy, and may  be joined with
aromatics, as  in the  Electuarium Thebaicum ;* or thev
may be usefully joined with  volatile alkali and camphire.f
Musk  has likewise proved useful in this disease.
   When the affection of the stomach is accompanied with
vomiting, this may be encouraged, by taking draughts of
warm wine,  at first with water,  and afterwards without it;
having at length  recourse if necessary, to some of the re-
medies above mentioned,  and particularly the opiates.
   In like manner,  if the  intestines be affected with diar*
rhcea, this is to be at first  encouraged, by taking plentiful^
ly of weak broth; and when this  shall have been done sufV
ficiently, the tumult is to be quieted by opiates.
   580.]  When the retrocedent gout shall affect the lungs,
and produce asthma, this is to be cured by  opiates,  by ant-
ispasmodics, £ and, perhaps,  by  blistering  on the breast
or back.
   581.] When the  gout,  leaving  the extremities, shall af-
fect the head, and  produce  pain, vertigo,  apoplexy,  or
palsy,  our resources are very precarious.   The most pro-
bable  means of  relief is,  blistering the head: and if the
gout shall have  receded   entirely from  the extremities,
blisters may be applied to  these also.   Together with these

  ♦The following form is extremely efficacious, and at the same time pleasant to the taste; it
may be repeated three or four times, if the first does not procure relief.
            R. Elect. Thebaic. 3i.
               Aq. Cinnamom. spirituosae, 3i«fb«
               Syr. Croci, 3ii«
               M. f. haust.
  + The best way of giving these medicines is in the following form-*
            R. Opii purificati, gr. i.
               Camphor, gr. xii.
               Spt. Vini, q. s.
               Confect. Cardiac. 3»-
               M. f. bolus.
  Or the camphor may be made into a bolus with  a drachm of the Elect. Thebaic, and forty
drops of the Spintus Aromaticus, in a glass of strong wine, as Madeira or Sherry, may be drank
after it.
  X The Spiritus Ethereus Vitriolicus is a medicine used with much success in these cases. The
do-e of ii is from twenty to thirty drops in a glass of wine. The ethereal spirit is so very vola-
tile, that it will wholly evaporate, if it be suffered to stand in the wine fora few minutes; it must
therefore be drank speedily : and the dose may be repeated every two hours, in cases of emer-
gency. In most cases laudanum will answer every purpose. Ammomacum has been much
recommended, and its powers in cases of gouty asthma have freqnently been very conspicuous:
It may be given independently uf the opiates.  Two drachms of it may be made into an emul-
sion with six ounces of water: and a couple of table-spoonfulls of this emulsion may be given
c\ ery two or three hours. 
PRACTICE OF PHYSIC.
blisterings,  aromatics, and the volatile alkali,  may be
thrown into the stomach.*
   582.] The third case of the irregular gout is what I have
named  the Misplaced ; that is, when the inflammatory af-
fection  of the gout,  instead of falling upon the extremities,
falls upon some internal part.  In  this case,  the disease is
to be treated by blood-letting, and by such other remedies1
as would be  proper in an idiopathic  inflammation of  the
same parts.
   583.]  Whether the translation so frequently made from
the extremities to the kidneys,  is  to be considered as an
instance of the  misplaced gout,  seems, as we liave  said
before, uncertain ; but I am disposed to think it something
different; and therefore  am of opinion, that, in  the  Ne-
phralgia Calculosa produced upon this occasion,  the reme-
dies of inflammation are to be employed no farther than
they may be otherwise sometimes necessary in that disease,
arising from other causes than the gout.

 * Little relief has ever been obtained in these cases from internal remedies. Large doses of
the Spiritus Aromaticushave been thought serviceable, but the chief dependence is on the ef-
fect of blisters on the extremities, especially the feet, with warm fomentaiions to the legs, and
rubbing the  legs with a flesh brush, impregnated with plenty of dry flour of mustard.
              BOOK  III.
OF  EXANTHEMATA,  OR ERUPTIVE
                   FEVERS.
  584.] nr^HE diseases comprehended under this title,
         JL  which make the  third Order of  Pyrexia;  in
our Nosology,  are in general such as do not arise but up-
on occasion of a  specific contagion applied,  which  first
produces fever, and afterwards an eruption upon the sur-
face of the  body ; and which diseases,  for the mo&t part
affect persons but  once in the course of  their lives.
  585.] Whether  the character of the Order may be thus
limited, or if the Order may be allowed to  comprehend al-
so the  eruptive fevers produced by a matter generated in
the body itself, and like vise those cases  of eruption which
do not depend upon contagion, or upon a matter generat- 
PRACTICE  OF PHYSIC.
195
«d before the fever,  but upon a matter generated in the
course of  the fever, I  am not  ready to  determine.  Of
the diseases enumerated by the Nosologists as Exanthema-
ta, there are certainly three different kinds, which may be
distinguished by the  circumstances mentioned in this and
the preceding paragraph.  Of the first  kind are the Small
Pox, the Chicken Pox, the Measles, the  Scarlet Fever, and
the Plague.  Of the  second kind seems to be the Erysipe-
las;  and of the third kind I judge the  Miliaria and Pete-
chia to be.  But as I am not  sufficiently  confident in the
facts  which should support these distinctions, or which
would enable us to apply them in all cases; I go on in this
book  to treat of almost  all the exanthemata enumerated
by preceding Nosologists,  with only some difference in the
arrangement from what  it was in my former editions.
                  CHAPTER  I.

             OF THE SMALL POX.

  586.] rP,HE small pox is a disease  arising from a con-
         -L  tagion of a  specific nature,  which first pro-
duces a fever; and on the third or fourth day thereof, pro-
duces an eruption of small red pimples.   These are after-
wards formed into pustules,  containing a matter, which, in
the course of eight days from the time of the eruption, is
changed  into pus.  After this, the matter dries, and falls
off in crusts.
  587.] This is  a general idea of the disease; but there
are two particular forms or varieties of it, well known un-
der the appellations of the Distinct  and Confluent,  which
require to be specially described.
  588.] In the former, or the distinct small pox, the erup-
tive fever is  moderate, and appears to be  evidently of the
inflammatory kind, or what we name a  Synocha.  It gene-
rally comes on about mid-day,  with some symptoms of a
cold stage,  and commonly with  a  considerable langour
and drowsiness.   A hot stage is soon formed, and becomes
more considerable on the second and third days.  During
this course, children are liable  to frequent startings from
their slumbers; and adults,  if they are  kept  a-bed, are
disposed to  much sweating.   On the  third day, children 
196
PRACTICE  OF PHYSIC.
are sometimes affected with one or two epileptic fits.  To-
wards the end of the third day, the eruption commonly
appears, and gradually increases during the fourth ; ap-
pearing first upon the face, and successively on the infe-
rior parts, so as  to be completed over the whole  body on
the fifth day.
  From the third day the fever abates;  and against the
fifth it entirely ceases.  The eruption appears first in small
red spots, hardly eminent, but by degrees rising into pim-
ples.  These are generally upon the face in small  number ;
but even when more  numerous, they are separate and dis-
tinct from one another.  On the fifth or sixth day, a small
vesicle, containing an almost colorless or  whey colored
fluid, appears  upon the top  of each pimple.   For two
days, these vesicles  increase in breadth only,  and there is
a small hollow pit in their middle ; so that it is only against
the eighth day that  they are raised into spheroidical pus-
tules.
  These vesicles or pustules, from their first formation,
continue to be surrounded with an exactly circular inflam-
ed margin, which, when the pustules are numerous, diffu-
ses some  inflammation over the  neighboring skin, so  as
to give  somewhat of a damask rose-color to the spaces be-
tween  the pustules.   As the pustules increase in size, if
they be numerous on the face,  against the eighth day the
whole  of the face becomes considerably swelled;.and,  in
particular, the eye-lids are so  much swelled as entirely to
shut the eyes.
  As the disease thus proceeds, the matter in the pustules
becomes by degrees more opaque and white, and at length
of a yellowish color. On the eleventh day, the  swelling
of the face is abated,  and  the pustules seem quite full.
On the top of each a  darker spot appears ; and at this place
the pustule, on  the eleventh day, or soon  after, is spon-
taneously broken, and a portion of the matter oozes out;
in consequence  of which,  the  pustule is shrivelled, and
subsides;  while the matter oozing out dries, and forms a
crusts upon its surface.  Sometimes a little only of  the
matter oozes out; and  what remains in the pustule  be-
comes thick and  even hard.  After some days,  both  the
crust and  the hardened pustules fall off, leaving the skin
which  they covered  of a brown red color:  and it is only
after many  days  that the skin  in these places resumes its
natural color.  In some cases, where the  matter of the 
PRACTICE  OF PHYSIC.
197
 pustules has been more liquid, the crusts formed by it are
 later in falling off, and the part they covered suffers some
 desquamation, which leaves in it a small pit or hollow.
   This is the course of things on the face; and successively,
 the pustules on the rest of the body take the same.  The
 matter of the pustules, on the arms and hands, is frequent-
 ly absorbed; so that, at the height of the disease, these
 pustules appear as empty vesicles.  On the tenth and ele-
 venth days, as the swelling of the face subsides, a swelling
 arises in the hands and  feet; but which, again, subsides,
 as the pustules come to maturity.
   When the pustules on the face are numerous, some de-
 gree of pyrexia  appears on  the tenth and eleventh days,
 but disappears again after the pustules are fully ripened; or
 perhaps remains in a very slight degree till the pustules on
 the feet have finished their course.   It is seldom that in the
 distinct small-pox the fever continues longer.
   When the pustules on the face are numerous, some un-
 easiness in the throat, with a hoarseness of the voice comes
 on upon the sixth or seventh day,  and a thin liquid is pour-
 ed out from the mouth.   These symptoms increase with
 the swelling of the face ; and the liquids of the mouth and
 throat becoming thicker,  are more difficultly thrown out.
 There is,  at the same time, some difficulty of swallowing;
 so that liquids taken in to  be swallowed are frequently re-
jected or thrown out by the nose.  But all these affections
 of the fauces abate as the swelling of the face subsides.*
   589.] In the other form of small-pox, or what is called
 the Confluent, the course of the disease is, in general, the
 same with  that we have described ; but the symptoms of
 every stage are more violent, and several of the circum-
 stances are different.
   In  particular, the eruptive fever is more violent.  The
 pulse is more frequent and more contracted, approaching
 to that state of pulse which is found in  the typhus.  The
 coma is more considerable, and there is frequently a de-
 lirium.  Vomiting,  also, is a common symptom,  especi-
 ally at the coming on of the disease.  In  very  young  in-
 fants, epileptic fits are sometimes frequent on the first days

 orobIbfvdn«I1„aJ^'!(j*,iv!Js/lw8ys ulatirJ> and °ught «o be moderately encouraged.  It is
Its ^!ii ouu,!f the°bc4     m""Cr a,Uck,ne the $alivary Blands> and ,hrouSh them making
lutaidM^but'Zh0/^^5' 5?d the sa,iv»tl!on/' gradually abate as the swelling of the race
^^X^^S^^SSt1 iU<Utn,y>orare not SUCCeeded b' a swellin* of tn«
in'c^nsi^raUX^ ™M °f "P^ence, *"<* ** explanation of it see™ to be i.volred
                          2c 
198
PRACTICE  OF PHYSIC.
of the disease, and sometimes  prove fatal  before  any
eruption appears ;  or they usher in a very confluent and
putrid small-pox.
  590.]  The eruption appears more early on the third day,
and it is frequently preceded or accompanied with an  ery-
sipelatous efflorescence.  Sometimes the  eruptibn appears
in clusters, like that of the measles.   When the eruption is
completed, the pimples are  always more numerous upon
the face, and at this same time smaller and less eminent. After
the eruption,  the fever suffers some remission,  but never
goes  off entirely ;  and, after the  fifth  or sixth  day, it
again increases, and continues considerable through  the re-
maining course of the disease.
  The vesicles formed on the  tops  of the pimples  appear
sooner;  and  while  they increase in breadth, do not retain
a circular, but are every way of an  irregular figure.  Many
of them run  into one another,  insomuch that  very often
the face is covered rather with one vesicle than with a num-
ber of pustules.   The vesicles, so far as  they are any-wise
separated, do not arise to a spheroidical  form,  but  remain
flat, and sometimes the whole of the face is of an even sur-
face.  When  the pustules are in any  measure  separated,
their circumference  is not bounded  by an  inflamed  mar-
gin, and  the part of the skin that  is free from pustules is
commonly pale and flaccid.
  The liquor that is in the pustules changes from a clear to
an opaque appearance, and becomes whitish or brownish,
but never acquires the yellow color and thick consistence
that appear in the distinct small-pox.
  591.]  The swelling of the face which attends the distinct
small-pox, when they are numerous, and almost then only,
always  attends the confluent, comes  on more  early, and
arises to a greater degree ; but abates on the tenth day, and
on the eleventh still more.  At this time the pustules or ve-
sicles break,  and shrivelling pour out a liquor that is form-
ed into brown or black crusts,  which do not fall off for ma-
ny  days after.  Those of the face,  in falling off, leave trie
parts they cover  subject to a desquamation, which pretty
certainly  produces pittings.
   On the other parts of the body, the pustules of the con-
fluent small-pox are more distinct  than upon the face, but
never acquire the same maturity and consistence of pus as
in the properly distinct kind.
   The salivation which only sometimes attends the  distinct 
PRACTICE  OF PHYSIC.
199
small-pox, very constantly attends the confluent :  and both
the salivation and the affection of the fauces above-mention-
ed are, especially in adults, in a higher degree.  In infants,
a diarrhoea comes frequently in place of the salivation.
  In the confluent small-pox, there is often a considerable
putrescency of the fluids, as appears from petechiae, from
serous vesicles, under which the skin shows a disposition to
gangrene, and from bloody urine  or other hxmiorrhargy,
all which symptoms frequently accompany this disease.
  In the confluent small-pox, the fever, which had only suf-
fered a remission from the time of eruption to that of matu-
ration, is often, at or immediately after this period,  renew-
ed with considerable violence.  This is what has been called
the Secondary Fever ; and is, in different cases,  of various
duration and event.
   592.] We have thus endeavored  to describe the  various
circumstances of the small-pox ; and from the difference of
these circumstances, the event of  the disease may  be deter-
mined.  The  whole of the prognosis may  be nearly com-
prised in the following propositions.
  The more exactly the disease retains the form of the  dis-
tinct kind, it is the safer ; and the more completely the dis-
ease takes the form of the  confluent kind, it is  the more
dangerous.
  It is only when the distinct kind shows a great number of
pustules on the face, or otherwise, by fever or putrescency,
approaches to the circumstances of  the confluent,  that it is
attended with any danger.
   In the confluent small-pox there is always danger ;  and
this is always more considerable  and certain, according as
the  fever  is more violent and permanent, and especially as
the marks and symptoms of putrescency are more evident.
   When the putrid  disposition is very great,  the disease
sometimes proves fatal before  the eighth day ; but in most
cases it is on the  eleventh that  death happens, and some-
times it is  put off till the fourteenth or seventeenth day.
  Though the small-pox should not be immediately fatal,
the more violent kinds are often followed  by a morbid state
of the body,  of  various kind  and event.   These conse-
quences,  as I judge,  may be imputed sometimes to an acrid
matter produced  by the preceding disease,  and deposited
in different parts ;  and  sometimes to an inflammatory dia-
thesis produced, and determined  to particular parts of the
body. 
200           PRACTICE  OF PHYSIC.

   593.]  It is, I think, agreed among  practitioners, that,
in  the  different cases of small-pox, the difference chiefly
depends upon the appearance of distinct or confluent; and,
from the above description of these  kinds,  it will appear,
that they chiefly differ in the period of the eruption, in the
number  of pustules produced, in the form  of the pustules,
in the state of the matter contained in them, in  the conti-
nuance of  the fever, and lastly, in the danger of the disease.
   594.]  Upon inquiring into the causes of these differences,
we might  readily  suspect, that they depended upon a dif-
ference  of the contagion  producing the  disease.   This,
however, is not probable ;  for there are innumerable in-
stances of the contagion, arising  from  a person laboring
under the small-pox of  the distinct kind,  producing  the
confluent ;  and on the contrary.   Since the practice of in-
oculation became frequent, we have  known  the same vario-
lous matter produce in one person  the distinct, and in ano-
ther, the confluent small-pox.  It is therefore highly pro-
bable, that the difference of the small-pox does not depend
upon any  difference of the contagion,  but  upon some dif-
ference in  the state of the person to whom it is applied, or
in the state of certain circumstances concurring with the
application of the contagion.
   595.]  To find out  wherein the difference in the state of
the persons to  whom the contagion of the small-pox is  ap-
plied consists, I  observe, that the difference between the
distinct and  confluent small-pox  consists especially in the
number of pustules produced ; which, in the distinct, are
generally few, in  the confluent, always many.   If, there-
fore, we shall be able to discover what,  in the state of dif-
ferent persons,  can give occasion to more or fewer pustules,
we shall probably be able to account for all the other dif-
ferences of the distinct and confluent small-pox.
   596.]  It is evident, that the contagion of the small-pox
is  a ferment with respect to the human  fluids, and  assimi-
lates a great part of them to its own nature ;* and it is pro-
bable, that the quantity thus assimilated, is, in proportion
to the bulk of their several bodies, nearly the same in dif-
ferent persons.  This quantity passes again out of the body,

 * This opinion is most probably true, but it is by no means, as the author says, evident. His
reasoning, however, is ingenious and deserves attention. The expulsion, or rather evacuation
ot ihe morbific matter is admitted as the cure of the disease, and the difierence of the disease iw
the different manner in which this evacuation is made : But, the author las not proved either
of the premises he has advanced, viz. that the quantity of human fluids which the ferment as.
similates, is nearly the same in different persons, nor that any part of the morbihe matter,  or
the morbid assimilated fluids pass off by perspiration. 
PRACTICE  OF PHYSIC.            201
partly by insensible perspiration,  and partly by being depo-
sited in pustules ; but if the quantities generated be nearly
equal,  the  quantities passing out of the body by the  two
ways mentioned, are very unequal in different persons ; and,
therefore, if  we can explain the causes which determine
more  to pass by the one way than by the other, we may
thereby discover the causes which give occasion to more pus-
tules in  one person than in another.
  597.] The causes which determine more of the variolous
matter  to  pass by  perspiration, or  to form  pustules,  are
probably certain circumstances of the skin, that determine
more or Jess of the variolous matter to stick in it,  or to pass
freely through it.
  598.] The circumstance of the skin, which seems to de-
termine the variolous matter to stick in it,  is  a certain state
of inflammation depending,  much  upon  the heat of it.
Thus we have  many instances of parts of the  body, from
being more heated, having a greater number of pustules
than other parts.   In the present practice of  inoculation,
in which few pustules are produced, much seems to be ow-
ing to the  care that is taken to keep the skin cool.  Parts
covered with plaisters, especially with those of a stimulant
kind,  have more pustules than other parts.  Further,  cer-
tain circumstances, such as adult age, and full living, deter
mining  to a phlogistic diathesis,  seem to produce a greater
number of  pustules ;  while the contrary circumstances have
contrary effects.
  599.] It is therefore probable, that an inflammatory state
of the  whole system, and more particularly of the skin,
gives  occasion  to  a greater number of pustules : and the
causes of this may likewise produce most of the other cir-
cumstances of the confluent small-pox  ; such as the period
of eruption ; the continuance of the fever ; the effusion of
a more putrescent matter, and less fit to be converted into
pus;  and,  what arises from thence, the  form and other
circumstances of the pustules.
  600.] Having thus attempted to account for the chief
difference which occurs in the state of the small-pox, we
shall now try the truth of our doctrine, by its application
to practice.
  601.] In considering the  practice, we  view it first, in
general, as suited to render the disease more  generally be-
nign and safe, and this by the practice of inoculation.
  602.] It is not necessary here to describe the operation^ 
202
PRACTICE  OF PHYSIC.
of inoculating ;  and what we name the practice of inocu-
lation, comprehends all the several measures which precede
or follow that operation, and are supposed to produce its
salutary effects.
  These measures are chiefly the following.
  1. The choosing for the subject  of inoculation persons
otherwise free from disease,  and not liable,  from their age
or other circumstances,  to any incidental disease.
  2. The choosing a person at the time of life most favor-
able to a mild disease.
  3. The choosing for the practice  a season the most con-
ducive to the mildness of the disease.
  4. The preparing the person to be inoculated, by absti-
nence from animal  food  for some time before inoculation.
  5. The preparing the person by  courses  of  mercurial
and antimonial medicines.*
  6. Tiie taking care,  at the time of inoculation,  to avoid
cold, intemperance, fear, or other  circumstances  Avhich
might aggravate ihe future disease.
  7. After these  preparations and precautions, the choos-
ing a fit  matter to be employed  in inoculation, by taking
it from a person of a sound constitution, and free  from any
disease  or suspicion of  it ; by taking it from a person who
has had the small-pox of the most benign kind ; and, lastly,
by taking the matter from such persons, as soon as it has
appeared in the pustules, either in  the part inoculated, or
on other parts of the body.
  8. The introducing, by inoculation,  but a small portion
of the contagious matter.
  9. After inoculation,  the continuing  the vegetable diet,
as well as the employment  of  mercurial and antimonial
medicines ;  and, at the same time, frequently employing
purgatives.
  10. Both  before and  after inoculation, taking care to
avoid external heat, either from the sun,  artificial  fires,
warm chambers, much  clothing, or  being much in bed ;
and, on  the contrary,  exposing the person to a free and
cool air.
  i I. Upon the  appearance of  the eruptive  fever, the ren-
dering that moderate by the employment of purgatives ; bv
tbe use of cooling and antiseptic acids ;  and  especially by
exposing the person frequently to a cool and even a cold air,
at the same time giving freely of cold drink.
* f <mpaie this par.tgraphwitb. what follow; in article W8. 
PRACTICE  OF PHYSIC.
203
   12. After the eruption, the continuing the application
 of cold air, and' the  use of purgatives, during the course
 of the disease, till the pustules are fully ripened.
  603.] These are the measures proposed and practised in
the latest and most improved state of inoculation ; and the
advantages obtained by the whole of the practice, or at least
by most of the measures above mentioned,  are now ascer-
tained by a long experience to amount to this, That, in
ninety-nine cases of the hundred, inoculation gives a dis-
tinct  small-pox  only,  and  that also very generally of the
mildest form; but it will still  be useful, for the proper
conduct of  inoculation,  to  consider the importance and
utility of the several measures above mentioned, that we
may thereby more exactly determine upon what the advan-
tages of inoculation more certainly depend.
  604.] As the common infection may often  seize persons
laboring under  another  disease, which  may render the
small-pox more  violent, it is obvious that inoculation must
have a great advantage,  by avoiding such  concurrence.
But  as the avoiding such concurrence may  often, in the
mean while, leave persons exposed to the common infec-
tion,  it merits inquiry,  whether every diseased state should
restrain from the practice of inoculation, or what are the
particular diseases that should do so.  This is not yet suf-
ficiently ascertained by  observation;  and we have fre-
quently remarked that the small-pox have often occurred
with a diseased  state of the body, without being thereby
rendered  more violent.  In particular, we have observed,
that a scrophulous habit, or even the presence  of scrophula,
did  not render the small-pox more  violent; and  we have
observed also, that several diseases of the skin are equally
innocent.  1 am of opinion, that they are the diseases of the
febrile kind, or ailments ready to induce or aggravate a
febrile state, that especially give the concurrence which is
most dangerous with the small-pox.  I dare not attempt
any general rules; but I am disposed to  maintain,  that
 though a person be in  a diseased state, if that state  be of
 uncertain nature and effect, and at the same time the small-
 pox be exceedingly rife,  so as to render it extremely diffi-
 cult to guard against the common infection, it will always
 be safer to give the small-pox by inoculation,  than to leave
 the person to take them by the common infection.
   605.] Though inoculation has been practised with safety
 upon persons of all ages; yet from what has actually oc- 
 204           PRACTICE  OF PHYSIC.

 curred in the cases of common infection, and from sever-
 al other considerations,  there  is reason  to conclude, that
 adults are more liable to a violent disease than persons of
 younger years.  At the same  time,  it  is  observed,  that
 children, in the time  of their  first dentition,  are  liable,
 from this irritation, to have the small-pox rendered more
 violent; and that  infants,  before the time  of dentition,
 upon receiving the contagion of the small-pox, are liable
 to be affected with epileptic fits, which frequently prove
 fatal.   It  is, therefore,  upon  the  whole, evident, that,
 though circumstances may admit, and even render inocu-
 lation at any age proper; yet, for the most part, it will be
 still  more advisable to choose persons at an age, after the
 first dentition is over and before the time of puberty.
   606.]  Though  inoculation has been practised with safe-
 ty at every season of the year ;  yet, as it is certain that the
 cold  of winter may increase the inflammatory, and  the
 heats of summer increase the  putrescent state  of the small-
 pox, it is highly probable that  inoculation may have some
 advantage,  from avoiding the extremes,  either of heat or
 cold.
   607.]  Although the original  temperament and constitu-
 tions of men are not to be readily changed ; it is sufficient-
 ly certain, that the  conditions of the human body may, by
 various causes, in many respects be occasionally very much
 changed; and therefore, as  the  use of animal food may
 increase both the inflammatory  and putrescent state of  the
 human  body, so it must render persons,  on receiving
 the contagion of the small-pox, less secure against  a  vio-
 lent disease; and, therefore,  inoculation  may derive some
 advantage  from abstinence from animal food,  for some
 time before  the inoculation is  performed:  but  I am of opi-
nion  that a longer time than that usually prescribed may be
often necessary; and I  am  persuaded,  that  the Scottish
mothers who avoid giving their children animal food  till
they are past the small-pox, render this disease in them
of a  milder kind.
   60S.] I cannot deny  that mercurial and antimonial me-
dicines may have some effect in  determining to a more free
perspiration, and therefore may be. of  some use in prepar-
ing a person for the  small-pox;  but there are many obser-
vations which render me  doubtful as to their effect.   The
quantity of both these medicines, particularly of the an-
timony, commonly employed, is too inconsiderable to pro- 
PRACTICE  OF PHYSIC.           205
 duce any effect.   It is time, that the mercurials have often
 been employed more freely ;  but even their salutary effects
 have not been evident, and their mischievous effects, have
 sometimes appeared.   I doubt, therefore, upon the whole,
 if inoculation derives any advantage from these pretended
 preparatory courses of medicines.
   609.]  As it has been often observed, in the case of al-
 most all contagions, that cold, intemperance, fear,  and
 some other circumstances, concurring with the application
 of the contagion, have greatly aggravated the future disease,
 so it must be the same in the case of the small-pox ; and it
 is undoubted, that inoculation must derive a  great, and
 perhaps its principal, advantage, from avoiding  the con-
 currences above mentioned.
   610.]  It has been commonly supposed,  that  inoculation
 has derived some advantage from the choice of the matter
 employed in it;  but,  from what has been observed in 594,.
 it must appear very doubtful if any choice be necessary,
 or can be of any benefit in determining  the state of the
 disease.*
   611.]  It has been supposed by some,  that inoculation has
 an advantage, by introducing a small portion only of  the
 contagious matter: but this rests upon an uncertain foun-
 dation. It is not known what quantity is introduced by  the
 common infection, and it may be a small quantity  only.
 Although it were larger than  that thrown in by inoculation,
 it is  not ascertained that the circumstance  of quantity
 would have auy effect.  A certain quantity of ferment may
 be necessary to excite fermentation in a given mass:  but
 that quantity given,  the fermentation and assimilation  are
 extended to the  whole mass;  and Ave do not find that a
 greater quantity than is just necessary, either increases  the
 activity of the fermentation, or more certainly  secures  the
 assimilation of the whole.  In the case of the small-pox, a
 considerable difference in the quantity of contagious mat-
 ter introduced, has not discovered any effect in modifying
 the disease.
   612.] Purging has the effect of diminishing the activity
 of the sanguiferous system, and of obviating its inflamma-
 tory state.   It is therefore probable,  that the frequent use
 of cooling pm-gativcs is a practice attending inoculation
 which may be of considerable advantage;  and, probably,

• miW°^rjfeth" Se"' h°WCVer' Uis doubtle" bctter *° tawuiaie with matter taken from
a.D 
206             PRACTICE  OF  PHYSIC.


it  is also useful  by diminishing the determination to  the

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

as  they  are commonly  managed,  are useful only as they

make a part of the purging course.*

   613.]  It is probable,  that the state of the small-pox de-

pends very much upon the  state of the eruptive fever,  and

particularly  upon  moderating the inflammatory  state  of

the skin; and, therefore,  it is probable, that the measures

taken for moderating  the eruptive fever and inflammatory

state of  the skin, afford the  greatest improvement which

has been made in the  practice  of inoculation.   The  ten-

dency of purging,  and the  use of acids for this purpose, is

sufficiently obvious ; and upon the same ground, we should

suppose, that blood-letting might be useful; but probably

this has been  omitted, for the same reason that might  per-

haps have led to  the omission of other remedies also; which

is, that we have  found a  more powerful and affectual one

in the application of cold  air, and the use  of cold drink.

Whatever doubts or  difficulties our theory might present

to  us  on this  subject, they may be entirely neglected,  as

the practice of Indostan had long ago,  and the practice of

this country has lately, by a large and repeated experience,

ascertained  the safety and efficacy of this remedy:  and as

it may and can be more certainly employed with the prac-

tice of inoculation, than it can be in cases of common in-

fection,  it must  give a singular advantage to the former.f

   614.]  After the  eruption, when a few pimples only have

appeared on the face, the continuing the application of  cold


  * All purges are extremely nauseous to children; and as it is of little consequence what purga-
tives wc use, if we only avoid the hot drastic stimulants, we ought to pay attention to the agree-
ableness of the form. Children may in general be deceived by the following device : Put half
an ounce of senna leaves (after the stalks are all picked out) into a tea-pot, with a quarter of
an ounce of green tea ; pour on it a quart of boiling water.  Let the child see it poured out
into a tea-cup, sweetened  with plenty of moist sugar, and cream put to it.  The child will drink
it with avidity.  A tea-cupful may be given  every hour till it begin to operate.
  If tiiii divice should faiia second time, another maybe used in its stead. Two drachms of
senna leaves, powdered, may be added to half a pound of ginger-bread paste; the mass  mar
*e divided into fifteen small cakes to be baked : give the child one of these cakes everjr half
hour till it begins to operate, or till he has taken a sufficient dose for his age.  A drachm of jalap
may be used instead of the senna.
  If neither of these artifices succeed, a dose of powdered senna, with or without a little gin-
ger, may be given in orange marmalade.
  Children will sometimes eat as many tamai inds as will sufficiently answer all the intentions of
a formal purge.  A little Cassia-pulp,' added to the tamarinds, will inciease their activity, and
will not be easily perceived by the dnld.
  The empirics have committed many strange chemical blunders in compounding their purges
for inoculation.  Dimsdale's powder, may serve as an example: it consists of tartar emetic, and
crabs claws.  The calcareousearth deprives the tartar emetic of itsarid; in consequence of which,
the antimony will be inert, except  it accidentally meets with an acid in the stomach; and  evesi
then the acid must be in such a quantity as to saturate the crabs claws, before it can acton the
antimonial calx.
  + Notwithstanding the justness of this remark, bleeding ought not to be employed, except
in cases where the phlogistic diathesis and symptoms aie violent: the fright which children suf-
fer in consequence of the operation, may  oe productive of much mischief; and purgatives,
when properly administered, supersede the necessity of bleeding, especially when the coW re-
gimen is employed at the same time-. 
PRACTICE  OF PHYSIC.            207
air, and the  employment of purgatives,  has indeed been
 the practice  of many inoculators :  but I think,  these prac-
 tices cannot be said to give any peculiar advantages to ino-
culation ;  for when the state of the eruption is determined,
when  the number of pustules is very  small,  and the fever
has  entirely  ceased, I  hold the safety  of the  disease  to
J^e absolutely ascertained, and the further use of remedies
entirely superfluous.   In such cases, I judge the use of pur-
gatives to be not only  unnecessary,  but that they may be
often hurtful.
   615.] I  have thus considered the several circumstances
and practices accompanying inoculation, and have endea-
vored to ascertain the utility and importance of each.   Up-
on the whole, I hope I have sufficiently ascertained the ge-
neral utility  and great  advantage  of this practice, especi-
ally consisting in  this,  that if  certain precautions,  prepa-
rations, and  remedies,  are of  importance, all of them can
be employed with more certainty  in the practice of  inocu-
lation, than in the case of common infection.*
   It remains  now that I should offer some  remarks  on the
conduct of the small-pox, as received by infection, or even
when,  after inoculation, the symptoms shall prove violent.
 The latter sometimes happens, although  every  precaution
and remedy  have been employed.   The cause of this is
not well known; but it appears to me to  be  commonly
 owing  to a disposition  of the  fluids to putrescency.   But,
.however this may be, it will appear, that,  not only in the
 case of common infection, but even in that of inoculation,
 there  may be occasion for studying  the conduct  of this
 disease, in all its possible varying circumstances.
   616.] When, from the prevailing of small-pox as an epi-
 demic, and more especially when it  is known that a  person
 not formerly affected with the disease has been  exposed to
 the infection, if such person should  be seized with the symp-
toms of fever,  there can be little doubt of its being  an at-
 tack of the smah\pox ;  and therefore he is to be treated in
 every respect as if the disease  had  been received by  inocu-

  • The author seems to,have forgotten a frequent consequence of inoculation, that demands
 ?P^e *"em,on' v";aJ». inflammation of the axillary glands, that often terminates in suppura-
 tion. Many cases of this kind occurred to me in  practice, and I attempted several methods of
 preventing the suppuration ; of which I found the following tile most efficacious : If onlv one
 rj!™ punctured, the gland of that arm, when such an accident happened, and not of
 Sunk imnrmi.V"Pf'^j In"temP("»g the resolution, which perhaps some practitioners may
 foThVimn-aZrt^i.nPJ etlCOldcomi>res?es' lmP«SM'ed with a solution of Saccharum Saturru,
 •••■ntaS^Jffiar^^rtf pou,,loe '° lIie uicerof the Puncture-  riie consequence
  No hi ™nt2mr«r« ?»l ?Tthe P,unctur-» and » diminution of the axillary swelled gland.
 .»...- I «)lue<luences attended any of  those cases where the tumor was thus resolved; but what
 these tumors suppurate, they are apt to produce siaous ulcers, very difficult to l££ 
203
PRACTICE  OF  PHYSIC.
lation.   He is  to  be  freely  exposed to a cool air,  to be
purged, and to have cooling acids given liberally.*
   617.]  If these measures  moderate  the  fever, nothing
more is necessary :  but if the nature of the fever attacking
a  person be uncertain ;  or if, with suspicions of the small-
pox, the symptoms of  the  fever be violent:  or even if,
knowing the disease to be  small-pox,  the measures men-
tioned (596.) shall  not moderate the fever sufficiently ;• it
will be  proper to  let some blood :  and this  will be  more
especially proper,   if the person be an adult, of a plethoric
habit, and accustomed to full living.f
   618.]  In the same circumstances, we judge it will be
always proper to give a vomit,  as useful in  the commence-
ment  of all fevers, and more especially in this, where a
determination to the stomach appears from  pain and  spon-
taneous vomiting.
   619.]  It frequently happens,  especially in  infants,  that
during the eruptive  fever of  the  small-pox,  convulsions
occur.   Of these,  if only one or  two fits appear on the
evening preceding the eruption,  they give a favorable prog-
nostic of a mild disease, and require no remedy ; but  if
they occur  more  early, and  be violent and frequently re-
peated,  they are very dangerous, and require a speedy re-
medy.   Far this purpose, bleeding is hardly ever of service;
blistering  always  comes too  late ;  and the only remedy I
have found effectual, is  an opiate given in a large dose.J
   620.]  These are  the remedies necessary during the erup-
tive fever;  and if, upon  the eruption, the  pimples upon
the  face be very few and distinct,  the  disease is  no further
of any danger, requires  no remedies,  and the purgatives,
which, as has  been said  before, are by some practitioners
continued, prove often hurtful.
   But when, upon  the eruption, the pimples on the face are
very numerous ; when they are not distinct;  and especially
when, upon the fifth day, the fever does not suffer a consi-
derable remission,!]  the disease will still require a great deal
of attention.

 * The cooling acids have been described in former note:, {Art. 131. and 134 ) Whey made
with cream of tartar is very useful in the small-pox, as it is a cooling drink, and at the same
time laxative. It is made by throwing into a quart of boiling milk half an ounce or six drachms
of  powdered cream of tai tar.
 + This practice is most judicious, and ought to be strictly followed.
 X The doses for children in these cases are as lollows: A child of half a year, five drops of
laudanum: From half a year to a year, six drops: From one to two years, seven or eight: from
two to three, nine or ten : Five year.-, twelve, or at most fifteen.  These are large doses, and
are such as are only to be given to robust children.
 if The practitioner ou^htto  be particularly attentive to the symptoms which appear on the
f.ftb day. The subsequent paragraphs render any farther remarks needless. 
PRACTICE OF PHYSIC.             209
   621.] If,  after the eruption, the fever shall continue;  the
 avoiding heat, and continuing  to  expose  the' body  to a
cool air, will still be proper.  If the fever be considerable,
with a full  and hard pulse, in an adult person,  a bleeding
will be necessary; and, more certainly, a cooling purgative.
It is,  however,  seldom that a repetition of the bleeding will
be proper,  as a loss of strength does usually come on very
soon ;  but the repetition of a purgative, or the frequent use
of laxative  giysters, is commonly useful.*
   622.]  When a  loss of strength, with  other  marks  of a
 putrescent tendency of the fluids, appears, it will  be  ne-
cessary to exhibit  the  Peruvian bark in substance,  and  in
large  quantity, f   In  the same case,  the free use of acids,
and of nitre,^ is useful; and it is commonly proper also to
give wine very freely.\J
   623.]  From the fifth day of the disease,  onward through
the whole course of it, it is proper to give an opiate once or
twice a day ; taking care,  at the same time, to obviate cos-
tiveness, by purgatives, or laxative giysters.
   624.]  In  a violent disease, from the eighth to  the ele-
venth day,  it is proper to lay on blisters successively on dif-
 ferent  parts of the body ; and that without regard to the
parts being  covered with pustules.
   625.]  If,  in this disease, the tumor of the fauces be con-
siderable ; the deglutition  difficult ; the  saliva  and mucus
viscid, and with difficulty  thrown out ; it will be proper to
apply  blisters to the  external fauces, and to employ dili-
gently detergent gargles.§
   626.]  During the whole course of the disease, when any

  * Laxative giysters are preferable to repeated purgatives, on account of their not debilitating
the patient so much as purgatives. The following form has been found very effectual:
               R. Fol. Senns, Sft.
                 Sal. cathartic, amar. %i.
                 Aq. bullient. lb.  i.
                 Colatura frigidae adde.
                 Syr. e  Spin. Cervin. §i.
                 Ol.Olivar.  §£>.
                 M.
  Or even a simple solution of Epsom salt in warm water.
  + The method of giving the bark in the small-pox, is the same with that mentioned  in the
■ote on article 317. For children, the glyster there mentioned, is extremely convenient, and
proves wonderfully efficacious.
  X The Spiritus Nitri dulcis is the best form in which nitre can be given to children. See the-
notes on article 131.
  II 'Ilie wine best  suited to these cases is Port wine : but as children sometimes loath it, good
claret may be substituted in its place.
  t The best detergent gargles in this case are the tincture of roses with honey; or the earele of
?mgargir°d«cM?uVSnote.d ^^ mentioned in ** uote on atticle 317 '> or D&oW 
 i3lO             PRACTICE  OF  PHYSIC.

 considerable fever is present,  the frequent exhibition of an*
 -timonial medicines,  in nauseating  doses,  has been found
 useful ;* and these, for the most part,  sufficiently answer
 the purpose of purgatives.
    627.]  The remedies mentioned  from 621.  to  625. are
 those frequently necessary,  from the fifth day,  till the sup-
 puration is finished.  But as,  after that period, the fever  is
 sometimes  continued  and  increased;  or,  as  sometimes,
 when  after there  has been little or no fever before, a fever
 -now arises, and continues with considerable,danger ; this is
 what is called the Secondary Fever, and requires particular
 treatment.
   628.]   When thesecondary fever follows the distinct small-
 pox,  and the pulse is full and hard,  the case is to be treat-
 ed as an inflammatory affection,  by bleeding and  purging.
 But,  if  the secondary fever follow the confluent small-pox,
 and  be  a continuance or exacerbation  of the fever which
 had subsisted before,  it is to be considered  as of the putrid
 kind ; and in that case, bleeding is improper.   Some purg-
 ing may be necessary ; but the remedies to be chiefly de-
 pended on, are the Peruvian bark and acids.f
   When the secondary fever first appears, whether it is af-
 ter a distinct, or confluent  small-pox, it will be useful to ex-
 hibit an antimonial emetic in nauseating doses,  but in  such
 a manner as to produce some vomiting.
   629.]  For avoiding  the pits which frequently follow the
*mall-pox,  many  different  measures have been proposed $
 but none of them appear to be sufficiently certain4

  * A solution of two grains of emetic tartar in eight ounces of water answers this intention
 very effectually. The dose is to be determined by the nauseating effect produced: a table-
 spoonful of the solution may be given occasionally every two or three hours.  Care, however,
 must be taken, that  vomiting is not produced : and, at  the tame time, a sufficient quantity
 must be given to produce a nausea.  Both these circumstances depend on the age, strength, and,
 constitution of the patient and on the violence of the disease.
  + The secondary fever is always the worst, and most dangerous stage of the disease. In the
 distinct small pox it seldom occurs; but it is a constant attendant on the confluent kind.  It
 seems to be owing to the absorption of the matter: for it never appears, evidently at least, till
 after the suppuration : and. ceteris paribus, it is always more violent in proportion to the quan-
 tity of pustules. Some authors recommend opening the pustules, in order to  evacuate the
 matter, as a preventative against the secondary fever ;  and when the eruption is large, this
 practice is advisable.
  The Peruvian bark must be given in these cases in the-largest quantities that the stomach can
 bear, and also in giysters as formerly mentioned. Some practitioners, beside the internal use of
 bark, and giving it in giysters, have advised it tobe applied externally  by throwing the dry
 powder on those parts of the body that are the most exulcerated.
 , X The most effectual means of preventing  pits, are to avoid, much exposure to the cold air,
lo anoint the face with cii, fcc. 
PRACTICE  OF PHYSIC.           211
                   CHAPTER  II.

             OF THE  CHICKEN-POX.

  630.] rP*HIS disease seems to depend upon aspecifie
         JL   contagion,  and  to affect persons but once in>
their lives.   It is hardly ever attended with any danger; but
as it seems frequently to  have given occasion to the suppo-
sition of a  person's having the small-pox twice,  it is proper
to study this  disease,  and to distinguish it from the genu-
ine small-pox.*
  631.] This may be  generally done  by attending to the
following circumstances.
  The eruption of the chicken-pox comes on with very
little  fever preceding it, or with  fever  of no  determined
duration.
  The pimples  of  the chicken-pox,  more  quickly than
those of the  small-pox,  are formed into  little  vesicles or
pustules.
  The matter in these pustules remains fluid,  and never ac-
quires the color  or consistence of the pus which appears in
the pustules of the small-pox.
  The pustules  of  the chicken-pox are always in three or
four days from their first appearance, formed into crusts.
  See Dr. Heberden in Med. Transact. Vol. I. art. xviL
                   CHAPTER  III.

                OF THE  MEASLES.

  632.] HT^HIS disease also depends upon a specific con«
         X.  tagion, and affects persons but once in their
lives.
  633*] It occurs most frequently in children ; but no a?e
is exempted from it, if  the persons  have not  been sub*
jected to it before.
  634.] It commonly appears as an epidemic, first in the
month of January, and ceases soon after the summer sol-

 * As this disease is generally mild, and scarcely ever requires the assistance of art in the cure.
me author very properly passes it over in a cursory manner. It sometimes; however, very
much resembles the mild small pox ; and in such cases may requir« the treatment which hat been
recommended as serviceable in that disease. 
212           PRACTICE  OF PHYSIC.

stice ; but various accidents, introducing the  contagion,
may produce the disease at other times of the year.
  635.]  The disease always  begins with a cold  stage,
which is soon followed by a hot, with  the ordinary symp-
toms of  thirst, heat, anorexia, anxiety, sickness,  and vo-
miting ;  and  these are more or less considerable in diffe-
rent cases.   Sometimes from the beginning, the  fever is
sharp and violent ; often,  for the  first two days, it is ob-
scure and inconsiderable,  but always becomes  violent be-
fore the eruption, which usually happens upon the fourth
day.
  636.]  This eruptive fever from its  commencement, is
always attended with hoarseness, with a frequent hoarse dry
cough, and  frequently with some difficulty of breathing.
At the same time, the eye-lids are somewhat swelled, the
eyes are  a  little inflamed, and pour  out tears ; and,  to-
gether,  with these symptoms, there is a coryza, and fre-
quent sneezing.  For  the most  part, a constant drowsi-
ness attends the beginning of this disease.
  63 7.] The eruption, as we have said, commonly ap-
pears upon the fourth day, first on the face, and succes-
sively on the lower parts of the body.   It discovers itself
first in small red points ; but, soon after a number of these
appear in clusters, which do not arise into visible pimples,
but by the touch are found to be a little  prominent.  This
is the case on the face ; but on other parts of the body,
the prominence, or roughness, is hardly to be perceived.
On the face the eruption retains its redness, or has that in-
creased  for two days :  but, on the third, the vivid redness
is changed to a brownish red ; and,  in a day or two more,
the eruption  entirely disappears,  while a meally  desqua-
mation takes place.  During the whole time of the erup-
tion, the face is  somewhat turgid, but seldom considera-
bly swelled.
  638.]  Sometimes, after  the eruption has appeared,  the
fever ceases  entirely : but this is seldom the  case ; and
more commonly the fever continues, or is increased after
the eruption, and  does not cease till  after the  desquama-
tion.  Even  then the fever  does  not always cease,  but
continues with various duration and effect.
  639.]  Though the fever happen to cease upon the erup-
tion's taking place,  it is common for the cough to continue
till after the desquamation, and  sometimes much longer.
  In all cases, while the fever continues, the  cough also 
PRACTICE  OF PHYSIC.          213
 continues, generally with an increase of the difficulty of
 breathing; and both of these symptoms sometimes arise to
 a degree that  denotes a pneumonic affection.   This may
 arise at any period of the disease; but very often it does
 not come on till after the desquamation of the eruption.
  After  the same period,  also, a  diarrhcea  frequently
 comes on, and continues for some time.
  640.]  It is  common for the measles,  even when they
 have not been of a violent kind, to be succeeded by in-
 flammatory  affections, particularly opthalmia and phthisis.
  641.]  If the blood be drawn from a vein during the
 measles, with the circumstances necessary to favor the se-
 paration of  the gluten, this always appears separated, and
 lying  on the  surface of the crassamentum, as in inflam-
 matory diseases.
  642.]  For the most  part, the measles, even  when vio-
 lent, are without any putrid tendency ; but in some cases,
 such a tendency appears, both  in the course  of the dis-
 ease, and especially after the ordinary course of it is fi-
 nished.  See Dr. Watson, in London Med. Observations,
 Vol. IV. art.  xi.
  643.]  From what is delivered, from 636, to 641, it will
 appear, that the measles are  distinguished by a catarrhal
 affection, and  by an  inflammatory diathesis to a considera-
ble degree, and therefore the danger attending them arises
chiefly from the coming on of a pneumonic inflammation.
  644.]  From this consideration it  will be  obvious, that
 the remedies  especially  necessary, are those which may
 obviate and diminish  the inflammatory diathesis ;  and
 therefore, in a particular manner, blood-letting.  This re-
 medy  may  be employed at any time in the course of the
disease,  or after its ordinary course is finished.  It is to be
employed more or less according to the urgency of the
symptoms of fever,  cough, and dyspnoea; and generally
maybe employed  very freely.*  But, as the  symptoms
ot pneumonic  inflammation seldom  come on during the
eruptive fever; and,  as this fever is sometimes violent im-
 mediately before the eruption, though a sufficiently  mild
 disease be to follow ; so bleeding is seldom very necessa-
ry during the  eruptive fever,  and may often be reserved
for  the periods of  greater danger which perhaps  are to
ensue.
beena^en^erw^Va^o^^coli^ueH6 " \ absoluteIr7 neceisi^ « but' t0° free* "* * jt <™
 5  »ucnucu wiui a long continued weakness, and a very slow recovery.
                         2 E 
214
PRACTICE  OF PHYSIC.
  645.]  In all cases of measles, where there are no marks
of putrescency,  and  where  there is no reason, from the
known nature of the epidemic, to apprehend putrescency,
bleeding is the remedy to be depended upon ;  but assist-
ance may also be obtained  from  cooling purgatives; and
particularly  from  blistering on the sides, or between the
shoulders.
  646.]  The dry cough may be alleviated by the large use
of demulcent pectorals,  mucilaginous, oily, or  sweet.*
It may,  however, be observed, with respect to these de-
mulcents,  that  they are not so powerful in involving and
correcting the acrimony of the mass of blood as  has been
imagined ; and that their chief operation is by besmearing
the fauces, and thereby defending them from the irritation
of acrids, either arising from  the lungs, or distilling from
the head.
  647.]  For moderating and  quieting the cough  in this
disease, opiates certainly prove the most effectual means,
whenever they can be safely employed.   In the  measles,
in which an  inflammatory state prevails in a considerable
degree, opiates may be supposed to be inadmissible ; and,
in those cases in which a  high  degree of pyrexia and dysp-
noea show either the presence, or  at least the danger,  of
pneumonic  inflammation, I  think that opiates might be
very hurtful.   In cases,  however,  in which  the  dyspnoea
is not considerable, and where bleeding, to obviate or abate

  * Two ounces of pearl barley, and four ounces of dried figs, cut, boiled in a gallon of water
to three quarts is a good drink in these cases. If the patient loaths this drink, lintseed tea, or
a slight infusion of Orrice root in boiling water, may be substituted in its place, or a solution
uf an ounce of gum arable in a point of water.
  Oily emulsions are also recommended; the most useful is the following:
           R. 01. Amygdal. S".
               Aq.  Font.  §vi.
               Alkali Caustic, q. s. ut fiat Emuls. cui adde
               Syrup. Althsese, §ii.
  The patient may take half a tea-cupful of this emulsion occasionally, when the cough is most
troublesome. The cough may also be relieved,  by taken now and then a tea-spoonful ot the
following Linctus:
           R. 01. Amygdal.
               Syrup. Althaeae.
               Conserv. Cynosbat. aa. §i.
               M. f. Liner.
         Or the following:
            R. Mel. anglic.
               01. Amygdal. aa. 511.
               Succ. Limon. Bi.
               M. f. Linct. 
PRACTICE  OF  PHYSIC.
215
ihe  inflammatory  state,  has  been  duly employed,  and
where the  cough  and watchfulness  are the urgent symp-
toms, I think that opiates may be safely  exhibited  and
with great advantage.*   I  think, further  that,  in all the
exanthemata, there is an acrimony diffused over the  sys-
tem, which gives a considerable irritation; and,  lor  oO vi-
ating the  effects  of this, opiates are  useful,  and alwaxs
proper, when no particular contra-iudication  prevails
   648 ]  When the desquamation of the measles is finished,
though there should  then be no disorder remaining,  phy-
sician's have thought  it necessary to  purge  the patient sev-
eral times, with a view  to draw off the dregs ot tins dis-
ease, that is,  a portion of the morbific matter which is sup-
posed to  remain long in the body.   I  cannot reject this
supposition;  but,  at the same time, cannot  believe, that
 the remains of the morbific matter, diffused over the whole
mass of  blood,  can be entirely drawn off by purging; and
it appears to  me, that  to avoid the consequences of the
measles,  it is not the drawing off the morbific matter which
we  need to study,  so much as the obviating and removing
the  inflammatory state of the  system which had been in-
 duced by the disease.   With this last view, indeed,  purg-
 ing may  still be a proper remedy ;  but bleeding, in pro-
 portion to the  symptoms of inflammatory  disposition,  is
 yet more  so.f
   649.]  From our late  experience  of the benefit of cold
 air  in the eruptive fever of the small-pox,  some  physicians
 have been of opinion, that the practice might be transfer-

   • Opiates, in all inflammatory cases, ought to be cautiously used.  The danger arising from
 tbem is considerably obviated, by using only the gummy part of the opium, and therefore the
 watery solution of opium, is in these cases preferable to any other form.
   The Syrupus papaveris albi, is an opiate peculiarly adapted to this disease; the dose of it is
 immaterial; provided we do not exceed four ounces in  the four and twenty hours; a table-
 spoonful may be taken when the cough is troublesome, and may be repeated every two or three
 hours according to the urgency of the symptoms.                        ...
   + The complaints which the measles leave  are chiefly pneumonic.  The cough is the most
 troublesome symptom, and to relieve the patient from it, not only bleeding and purging must
 be used, but expectorants ought also tobe administered. The Lac Ammoniacum, formerly
 mentioned, has often proved beneficial.                    . .
   On the supposition, that the cough and pneumonic affection remaining after the measles are
 owing to a peculiar acrimony, some practitioners have recommended alteratives and demul-
 cents : Experience, however, has found little advantage from their use. I once saw a body
 opened, tliat had died thirty-two days after the eruption: the internal surface of the bronchi*
 was  covered with small fursuraceous scales, somewhat like those that appear on the skin when
 the eruption goes off.  Hence 1 have been induced to suppose, that expectorants are the best
 remedies in these cases, and indeed, experience confirms the practice.  Bleeding and purging
 are only to be occasionally used,  in order to prevent the inflammation.
   The best meilwd of avoiding the ill consequences that follow the  disease, is a free use of de-
 mulcent drinks, during the eruption, and of expectorants immediately after it. The Decoctum
 liordei cotnpositum, of the  London Pharmacopoeia, is peculiarly adapted to these cases, but it •
 is much unproved by adding half an ounce of Orrice root, when it is nearly boiled enough : If
 the orrice be added too soon, the efficacious part of it evaporates.  The Lac Ammoniacum
 above mentioned, is a very proper expectorant, but if it should prove too nauseous, or through
 use, be loathed by the patient, recourse may be had to the weak solution of the tartar emetic, so
 iiften mentioned in these notes. 
216           PRACTICE OF PHYSIC.

red to the measles; but we have not yet had trials sufficient
to ascertain this.
  There is no doubt that external heat may be very hurtful
in the measles,  as in  most other  inflammatory diseases;
and therefore the body ought to be kept in a moderate tem-
perature during  the whole course of the measles ; but how
far, at any period of the disease, cold air may be applied
with safety, we are yet uncertain.  Analogy, though so
often the resource of physicians, is, in general, fallacious;
and further, though the analogy with the small-pox might
lead to the application of cold air during the eruptive fever of
the measles, the analogy with catarrh seems to be against the
practice.  After the eruption had appeared upon the skin,
we have had many instances of cold air making  it disap-
pear, and thereby producing much disorder in  the system;
and have also had frequent examples of such  disorder be-
ing removed by restoring the heat of the body, and there-
by again bringing forth the eruption.*



                   CHAPTER  IV.

           OF  THE  SCARLET FEVER.

   650.]  TT may be doubted if the scarlet fever be a dis-
         X ease specifically different from the Cynanche
Maligna above  described.  The latter is almost always at-
tended with a scarlet eruption;  and,  in all the instances I
have seen of  what may be called the scarlet fever, the dis-
ease, in almost every person affected, has  been attended
with an ulcerous sore throat.
   651.]  This view of  the matter may create some doubt;
but I am still of  opinion, that there is a scarlet fever which
is a disease  specifically different from the Cynanche Ma-
ligna.
   Dr. Sydenham has  described a scarlet fever, which he
had seen prevailing as an epidemic, with all the  circum-
stances of the fever and eruption, without its being accom-
panied with  any affection  of the throat; at least he does
not take notice of any such affection, which such an accu-
rate observer could not  fail to have done,  if any such
symptom, as we have commonly seen making a principal
  * Though the application of cold air be dangerous, yet ventilation is of considerable use in
the measles t as is also a frequent change pf linen, and cleanliness. 
PRACTICE  OF  PHYSIC.
part of the disease, had attended those cases which he had
observed.  Several other writers have described the scar-
let fever  in the same manner, and  I know physicians who
have seen the disease in that form;  so  that there can be no
doubt  of there being a scarlet fever not necessarily  con-
nected with an ulcerous sore throat,  and therefore a dis-
ease different from the Cynanche Maligna.
  652.]  But, further, although in all the instances of scar-
let  fever which I have seen, (and in the course  of forty
years I have seen it six or seven times prevailing as an epi-
demic  in Scotland) the disease,  in almost all the persons
affected,  was attended with an ulcerous sore throat, or was
what Sauvages  names the Scarlatina Anginosa;  and al-
though, in some instances the ulcers of the throat were of a
putrid  and gangrenous kind, and at the same time the dis-
ease in all its symptoms resembled very exactly the Cy-
nanche Maligna; yet I am still  persuaded, that not only
the Scarlatina of Sydenham, but that even the  Scarlatina
Anginosa of Sauvages, is a different disease from the Cy-
nanche Maligna; and I have formed this opinion from the
following considerations.
  653.]  1st,  There is a scarlet fever entirely free from any
affection  of the throat,  which sometimes prevails as an epi-
demic ; and therefore there is a specific contagion produc-
ing a scarlet eruption without any determination to  the
throat.
  2dly, The Scarlatina, which, from  its matter being ge-
nerally determined to the throat, may be properly termed
Anginosa, has, in many cases of the same epidemic, been
without any affection of the throat;  and therefore the con-
tagion  may be supposed to be more especially determined
to produce the eruption only.
  3dly, Though in all the epidemics that I could alledge
to be those  of the Scarlatina Anginosa,  there have been
some cases,  which, in the  nature of the ulcers, and  in
other circumstances,  exactly  resembled the cases of the
Cynanche Maligna; yet I have  as  constantly remarked,
that these cases have not been above one  or two in a hun-
dred, while the rest have all of them been with ulcers of a
benign kind, and with circumstances hereafter to be des-
cribed, somewhat different from those of  the  Cynanche
Maligna.
  4thly,  On the other hand, as  I have two or three times
seen the Cynanche Maligna epidemically prevailing ; so, 
213
PRACTICE  OF  PHYSIC.
 among the persons affected, I have seen instances of cases
 as mild as those of the Scarlatina Anginosa usually are :
 but'here  the proportion was  reversed;  these mild cases
 were not one fifth of the whole,  while the rest were of the
 putrid and malignant kind.
  Lastly, It applies to the same purpose to observe, that,
 of  the Cynanche Maligna, most of the instances terminate
 fatally ; while, on the other hand, that is the event of very
 few of the cases of the Scarlatina Anginosa.
  654.] From these considerations, though it may appear
 that there is some affinity between the Cynanche Maligna
 and Scarlatina Anginosa, it will still remain probable that
 the two diseases are specifically different.  I have been at
 some pains to establish this opinion : for, from all my  ex-
 perience, I find, that those two  diseases require a differ-
 ent treatment;  and  I  therefore  now  proceed to mention
 more particularly the  circumstances of the Scarlatina An-
 ginosa.
  655.] This disease commonly appears  about the begin-
 ning of winter,  and continues throughout that season.  It
 comes on with some  cold shivering, and other  symptoms
 of the fever which usually introduces the other exanthe-
 mata.   But here there is no cough, nor the other catarrhal
 symptoms which attend the measles; nor  is there that anx-
 iety and vomiting which commonly introduce the conflu-
 ent small-pox, and which more  certainly introduce  the
 Cynanche Maligna.
  Early in the disease, some uneasiness is felt in the throat; '
 and frequently  the deglutition is difficult, generally more
 so than  in the Cynanche Maligna.   Upon looking into the
 fauces,  a redness and swelling appear in color and bulk ap-
proaching to the state of these symptoms in the Cynanche
 Tonsillaris ;  but in the  Scarlatina, there is always more  or
 less of sloughs,  which seldom appear in the Cynanche Ton-
 sillaris ; and the sloughs are commonly whiter than those in
 the  Cynanche Maligna.
  While these  appearances are discovered in the fauces,
 upon the third or fourth day a scarlet eruption appears on
 the  skin in the  same form as described  in 314.   This erup-
 tion is commonly more considerable and universal than in
 the  Cynanche; but it  seldom produces a remission of the
 fever.  The eruption for the most part  remains till the third
 or fourth day after its first appearance ; but then goes  off,
 ending  in a meally desquamation.  At this time the fever 
PRACTICE  OF PHYSIC.            219
usually subsides ; and generally, at the same  time,  some
degree of sweat comes on.
   The sloughs  on the fauces,  which appeared early in  the
disease,  continue for some days ; but then falling off, dis-
cover the swelling abated, and an  ulcer formed on one  or
both tonsils showing a laudable pus; and soon after the fever
has subsided, these ulcers heal up entirely.  For the most
part  this  disease has much less of  coryza  attending it
than the  Cynanche Maligna ; and, when there is a coryza
attending the Scarlatina,  the  matter discharged  is less acrid,
and has not the fetid smell which it  has in the other disease.
  In the Scarlatina, when the eruption  has  entirely disap-
peared, it frequently  happens, that  in a few days after,
the whole body is  affected  with an anasarcous swelling ;
which, however, in a few days more, gradually subsides.
   We have thus described the most common circumstances
of  the Scarlatina Anginosa ; and have only to add, that
during the time of its being epidemic,  and especially upon
its first setting in, there are always a few cases in which  the
circumstances of the disease  approach very  nearly to those
of the Cynanche Maligna ; and it is only in  these instances
that the disease is attended with any  danger.*
   656.]  With respect to the cure of this disease, when the
symptoms of it are  nearly the same with those of the Cy-
nanche  Maligna,  it requires  exactly the same  treatment as
directed in 317.
   657.]  When  the scarlet fever appears without any  af-
fection of the throat, the treatment of it is very simple, and
is delivered by Dr. Sydenham.   An  antiphlogistic regimenf
is commonly all that is  requisite ;  avoiding, on one hand,
the application of cold air ; and, on the  other,  any increase
of  external heat.
   658.]  In the ordinary  state of the  Scarlatina Anginosa,
the same treatment  is, in most cases, sufficient; but  as
here, the fever is commonly more  considerable, and  there
is likewise an affection of the throat, some remedies may be
often necessary.
   659.]  When there is a pretty high degree of fever, with
a full pulse, and a  considerable  swelling   of the  tonsils,

  * These cases in which the disease is attended with danger, are, however, very few, and ar«
only the effect of art.  Teazing the patient by doing too much; tormenting him with a closo
confinement to his bed, well furnished with blankets; and adding fuel to the flame, by forcing
him to swallow large quantities of cordials and alcxipharmics, are the sure methods of increasing
the disease: and the patient, distressed by the excessive officiousness of his sage doctor, w
obliged to take refuge in the arms of Death.
  + The antiphlogistic ie»imen must not however be carried too far, lest we imduce a stale of
debility thai may prove hurtful-. 
PRACTICE OF  PHYSIC.
bleeding  is very proper, especially in adults ; and  it ha»
been frequently practised with advantage :  but as, even in
the Cynanche Tonsillaris,  much bleeding is seldom neces-
sary ; (305.) so, in  the Scarlatina, when the state of the
fever and  the appearances  of the fauces render the nature
of the disease ambiguous,  bleeding may be omitted ; and,
if not  altogether avoided,  it should at least not be  large,
and ought not to be repeated.
   660.] Vomiting, and especially nauseating doses of eme-
tics,* notwithstanding the inflamed state of the fauces, have
been found  very useful  in this disease.  An open belly  is
proper  in every form  of this disease ; and when the nau-
seating  doses of emetics operate a little  downwards, they
are more serviceable.
   661.] In every form of the Scarlatina Anginosa, through
the whole course of it,  detergent garglesf should  be em-
ployed, and more or less as the quantity of sloughs and the
viscid mucus in the fauces may seem to  require.
   662.] Even in the milder  states of the Scarlatina  Angi-
nosa,  it has been common  with practitioners to exhibit the
Peruvian  bark through the whole course  of the disease ;
but we  are assured, by much experience,  that in such ca«
ses it may be safely omitted,  though in  cases any ways am-
biguous it may not be prudent to neglect this remedy.
   663.] The anasarcous swelling, which frequently follows
the Scarlatina Anginosa, seldom requires any remedy ; and,
at least, the purgatives  so much  inculcated, and so com-
monly exhibited, soon take off the anasarca.
                    CHAPTER V.

                 OF THE PLAGUE.

                     SECTION I.

         Of the Phenomena of the Plague.

  664.] fT,HE Plague is a disease which  always arises
         JL  from contagion ; which affects many persons
about the same  time ; proves fatal to great numbers, gene-
rally produces fever ; and in most persons, is attended with
buboes or carbuncles.
 * These have been mentioned in former notes.
 + The detergent gargles were described in ihe note on article 317. Tincture of roses is gene-
rally used, and in most cases answer every intention. If, however, the ulceration is considera-
ble, and the sloughs do not easily cast off, recourse must be bad to Dr. Fothergill's gargle, des-
cribed in article 317. 
PRACTICE OF PHYSIC.
221
  665.] These are the circumstances which, taken together,
give the character of the disease ; but it is accompanied
with many symptoms almost peculiar  to itself, that,  in dif-
ferent persons, are greatly diversified in number and degree,
and  should be particularly studied.  I would wish  to lay
a foundation for this ;  but think it unfit  for a person who
has never seen the disease to attempt  its particular history.
For  this,  therefore,  I must  refer to the  authors who have
written on the subject ; but allowing those only to be con-
sulted,  who have themselves seen and treated the disease in
all its different forms.
   666.] From the accounts  of such authors, it appears  to
me, that  the  circumstances  which particularly distinguish
this disease, and especially the more violent and dangerous
states of it, are
   1st,  The great loss  of strength in the animal functions,
which often appears early in  the disease.
   2dly, The stupor, giddiness, and consequent staggering,
which resembles drunkenness, or the head-ach and various
delirium ;  which are all of them symptoms denoting  a great
disorder in the functions of the brain.
   Zdly, The anxiety,  palpitation,  syncope, and especially
the weakness  and irregularity of the pulse,  which denotes
a considerable disturbance in the  action of the heart.
   4thly, The nausea and vomiting, particularly the vomit-
ing  of  bile, which shows an  accumulation of vitiated bile
in the gall-bladder  and biliary ducts, and from thence de-
rived into the intestines and stomach ; all of which symp-
toms I suppose  to denote a considerable spasm, and loss of
tone,  in the extreme vessels on the surface of the  body.
   Sthly,  The  buboes or carbuncles,  which denote an acri-
mony prevailing in the fluids.  And,
   Lastly, The  Petechia;, hemorrhagies, and colliquative
diarrhoea, which denote a putrescent tendency prevailing to
a great degree in the mass of blood.
   667.] From the consideration of all these symptoms, it
appears, that the plague is especially  distinguished by a spe-
 cific contagion,  often suddenly producing the most conside-
rable  symptoms of  debility in the nervous system or mov-
ing powers, as well as of a general putrescency in the fluids :
 and it is from the consideration  of these circumstances as
 the proximate  cause, that I think both  the prevention and
 cure of the plague must be directed.
   668.] If this  disease should revisit the northern  parts of
                           2f 
222
PRACTICE  OF PHYSIC.
Europe,  it is probable, that, at the time, there will be no>
physician then alive, who, at  the first appearance of the
disease, can be guided by his former experience, but must
be instructed by his study of the writers on this  subject,
and by analogy.  It is, therefore, I hope, allowable for me,
upon  the  same grounds, to offer  here my opinion  with re-
spect  to both the prevention and cure of this disease.
  This paragraph  was  written before I had any notice of
the plague of Moscow, anno 1771 ;  but I think it will still
apply  to the case of Great Britain and of  many other
northern  states.
                     SECTION II.

          Of the Prevention of the Plague.

  669.] WITH respect to the prevention :  As we are firm-
ly persuaded that the disease  never arises in the northern
parts  of Europe,  but  in consequence of its being imported
from some other country ; so the first measure necessary, is
the magistrate's  taking care to prevent the importation :
and this may generally be done by a due attention to bills
of health, and to the proper performance of quarantines.
  670.] With respect to the latter, we are persuaded, that
the quarantine of persons may safely  be much  less than
forty  days ; and, if this were allowed, the execution of the
quarantine would be more exact and certain, as the tempta-
tion to break it would be in a great measure removed.
  671.] With  respect to  the quarantine of goods,  it can-
not be perfect,  unless the suspected goods be unpacked and
duly  ventilated,  as well as the other means employed  for
correcting the  infection  they may carry ;  and,  if all  this
were properly done,  it is probable that the  time commonly
prescribed for the quarantine of goods might also be short-
ened.
   672.] A second measure, in the way of prevention, be-
comes requisite, when an infection has reached and prevail-
ed in any  place, to prevent that infection  from spreading
into other  places.  This can be done  only  by preventing
the inhabitants, or the goods  of  any infected place, from
going out of it, till they have undergone a proper quarantine.
   673.]  The third measure for prevention, to be employed
 w ith great care, is to hinder the infection  from spreading 
PRACTICE OF PHYSIC.
823
among  the inhabitants of the place in which it has arisen.
The measures necessary for this, are to be directed by the
doctrine laid  down  in  82 ;  and from that doctrine we in-
fer, that all persons who can avoid any near communica-
tion  with infected persons, or goods, may  escape the in-
fection.
  674.] For avoiding such  communication, a  great  deal
may be done by the magistrate :  1. By allowing as many
of the inhabitants as are free from  the infection, and not
necessary to the service of the place, to go out of it.  2. By
prohibiting  all  assemblies, or unnecessary  intercourse of
the people.   3.  By taking care  that necessary communica-
tions be performed without contact.   4. By making such ar-
rangements  and provisions  as may render it easy for  the
families remaining,  to shut themselves  up in their  own
houses.  5.  By  allowing persons to quit  houses in  which
an infection appears, upon  condition  that they go into la-
zarettoes.   6. By ventilating and purifying, or destroying
at the public expence, all  infected goods.   Lastly,  by
avoiding hospitals, and providing separate apartments  for
infected persons.
  The execution of these measures will require great au-
thority, and much vigilance  and attention, on  the part of
the magistrate ;  but it is not our province to enter into any
detail on this subject of the public police.
  675.] The fourth and  last part of the  business of  pre-
vention, respects the conduct of persons necessarily remain-
ing in infected places,  especially of those obliged to have
some communication with persons infected.
  676.]  Of those obliged to remain irt infected places, but
not obliged  to have any near communication with  the sick,
they may be preserved from the contagion by avoiding all
near communication  with other persons, or their goods;
and it  is probable,  that a small distance  will  answer the
purpose, if, at the same time, there be no stream of air to
carry the effluvia of persons, or goods,  to some distance.
  677.] For those who are necessarily obliged  ito have a
near communication with the sick, it is proper to let them
know, that  some of  the most powerful contagions do not
operate, but when the bodies of men exposed to the conta-
gion are in certain circumstances which render them more
liable to be  affected by it; and therefore,  by avoiding these
circumstances and causes, they  may often escape infection.
   678.]  The  bodies of men  are especially liable to be af- 
'22i
PRACTICE  OF PHYSIC.
fected by contagions, when they are any ways considerably
weakened by want  of  food, and even by a scanty diet, or
one of little  nourishment; by intemperance  in drinking,
which when the  stupor of intoxication  is over, leaves the
body  in  a weakened state ; by excess in venery ; by great
fatigue ;  or by any  considerable evacuation.
  679. The causes which, concurring with contagion, ren-
der it more certainly active, are cold, fear, and full living.
  The several means, therefore, of avoiding or guarding
against the action of cold  (94,  to 96.)  are  to be carefully
studied.
  680.] Against fear the mind is to be fortified as well as
possible,  by inspiring a favorable idea of the power of pre-
servative means ; by destroying the opinion of the incura-
ble nature of the  disease ; by occupying mens minds with
business  or labor; and  by avoiding all  objects of fear, as
funerals,  passing bells, and any notice of the death of parti-
cular friends.
  681.] A full diet of  animal food increases the Irritability
of the  body, and favors the operation of contagion ;  and
indigestion, whether from the quantity or quality of food,
has the same effect.
  682. Besides giving  attention to  obviate the several cir-
cumstances (609, 678, to 681.) which favor the operation
of contagion, it  is probable that some means may be em-
ployed for strengthening the bodies of men,  and thereby
enabling them to  resist contagion.
  For  this purpose, it is probable, that the moderate use
of wine, or of spirituous liquors, may have a good effect.
  It is probable also, that exercise, when it can be employ-
ed, if so moderate as to be neither heating nor fatiguing to
the body, may be employed with advantage.
  Persons who have tried cold bathing,  and commonly feel
invigorating effects from it, if they are any ways secure
against having already  received infection, may possibly be
enabled to resist it by the use of the cold bath.
  It is probable,  that some medicines also may be useful in
enabling men to resist infection ; but amongst these I can
hardly admit the numerous alexipharmics formerly propos-
ed ; or, at least,  very few of them, and those only of tonic
power.   Amongst these last we reckon the Peruvian bark ;
and it is  perhaps the most effectual.  If any thing is to be
expected from antiseptics, I think camphire, whether  in- 
PRACTICE  OF PHYSIC.
225
ternally or externally employed,  is one of the most promis-
ing.
  Every person is to be indulged in the use of any means
of preservation of which he has conceived a good opinion,
whether it be a charm or a medicine, if the latter be notdi.
rectly hurtful.
  Whether issues be useful in preserving from, or in mode-
rating the effects of contagion, I cannot determine from the
observations I have yet read.
  683.] As neither the atmosphere in general,  nor any con-
siderable portion of it, is tainted or impregnated with the
matter of contagions ;  so the lighting of fires over a  great
part  of the infected city,  or  other general fumigations in
the open air, are of no use for preventing the disease, and
may perhaps be hurtful.
  684.] It would probably contribute much  to check the
progress of  infection, if  the poor were enjoined to make a
frequent change of clothing, and  were suitably provided
for that purpose ; and if they were, at the  same time, in-
duced  to  make  a frequent ventilation of their houses and
furniture.
                    SECTION III.

             Of the Cure of the Plague.

  685.] IN the cure of the plague,  the indications are
the same as those of fever in general,  (126.) but here they
are not all equally necessary and important.
  686.] The measures  for moderating the violence of re-
action,  which  operate  by  diminishing the action  of the
heart and arteries (128.) have seldom any place here, ex-
cepting so far as the antiphlogistic regimen is generally
proper.   Some  physicians, indeed, have recommended
bleeding; and there may occur cases in which bleeding may
be  useful; but, for the most part,  it is unnecessary,  and
in many  cases it might be very hurtful.
  Purging has also been recommended ; and, in some de-
gree, it may be useful in drawing off the bile, or other pu-
trescent matters frequently present in the intestines; but a
large evacuation this way may certainly be hurtful.
  687.] The moderating the violence  of reaction,  so far
as it can  be done by taking  off the spasm of the extreme 
PRACTICE OF PHYSIC.
vessels (151.) is a measure  of the utmost necessity in the
cure of the plague; and the whole of the means  (152, to
200.) suited to  this indication are extremely proper.
  688.]  The giving an emetic at the very first approach of
the disease,  would probably be of great service; and it  is
likely, that  at some other periods of the  disease, emetics
might be useful, both by evacuating bile abundant in the
alimentary canal, and  by taking off the spasm of  the ex-
treme vessels.
  689.]  From some principles with respect to fever in ge-
neral, and with respect to the plague in particular,  1 am
of opinion, that, after the exhibition of the first vomit, the
body should be  disposed to sweat; which ought to  be rais-
ed to a moderate degree only,  but continued for at  least
twenty-four  hours, or  longer if the patient bear it easily.
  690.]  This sweating should be excited  and conducted
agreeably to the rules laid down in 168.   It is to  be pro-
moted by tfce  plentiful use  of diluents,  rendered more
grateful  by  vegetable acids, or more powerful by being
impregnated with some portion of neutral salts.
  691.]  To  support the  patient under the continuance of
the  sweat, a little weak broth,  acidulated with juice of
lemons,  may be given frequently; and sometimes a  little
wine, if the heat of the body be not considerable.
  692.]  If sudorific medicines are judged to be necessary,
opiates are the  most effectual and safe: but they  should
not  be combined  with aromatics; and  probably may be
more effectual,  if joined with a portion of emetics, and of
neutral salts.
  693.]  If,  notwithstanding the use of emetics and sudo-
rifies, the disease should still continue, the cure must de-
pend upon  the employment of means for  obviating debi-
lity and  putrescency ; and for this purpose, the various re-
medies proposed above (from 201,  to  227.) may all be ad-
ministered, but especially the tonics;  and of these the chief
are cold drink and the Peruvian bark.
  694.]  In the  cure of the plague, some attention is due
to the management of buboes and carbuncles: but we do
not touch this,  as it belongs to the province of surgery.*

  * The reader might possibly expect a detail of the medicines used in the plague, with their
doses, ami the manner of administering them ; but 1 thought it better to refer to the authors
who have eilher seen the disease, or who have expressly written on it.
  On consulting different authors, it appears, that every particular epidemic requires a different
treatment, in some parts of the cure at least.  Should any young practitioner he  unfortunate
enough to have occa>ion to exercise his art in the cure of the plague, he must chiefly be directed
by this general indications of the cure of fevers. 
PRACTICE  OF PHYSIC.          227
                   CHAPTER VI.

OF  ERYSIPELAS,  OR ST. ANTHONY'S FIRE.

  695.] TN 274, I mentioned the distinction which I pro-
        JL posed to make between the diseases to be named
the Erythema and the Erysipelas ;  and from thence it will
appear, that Erysipelas, as an Erythema  following fever,
may have its place here.
  696.] I suppose the erysipelas to depend on a matter ge-
nerated within the body, and which, analogous to the other
cases of exanthemata, is, in consequence of fever, thrown
out upon the surface of the body.   I  own it may be  diffii-
cult to apply this to every particular case of erysipelas:
but I take the case in  which it is generally supposed to ap-
ply, that of the erysipelas of the face ;  which I shall there-
fore consider here.
  697.] The Erysipelas of  the face comes on with a cold
shivering, and other symptoms of pyrexia.   The hot stage
of this is frequently attended with a confusion of head, and
some degree of delirium ; and almost always with drowsi-
ness, or  perhaps coma.  The pulse is always  frequent,
and  commonly full and hard.
  698.] When these  symptoms  have  continued for one,
two, or at most three days, there  appears, on  some  part
of the face, a redness, such as that  described in (275.) as
the appearance of Erythema.  This redness, at first, is of
no  great  extent ; but gradually  spreads from the part it
first occupied to the other parts of the face, commonly till
it has  affected the whole; and frequently from the face it
spreads over the  hairy scalp, or descends on some part of
the neck.   As the redness spreads, it commonly disappears,
or at least decreases, in the parts it had before occupied.
All the parts upon which the  redness appears are, at the
same time, affected with some swelling, which continues
for some  time after the redness has abated.  The  whole
face becomes considerably turgid ;  and the eye-lids are
often so much swelled as entirely to shut up the eyes.
   699.]  When the redness and swelling have proceeded for
some  time, there commonly arise,  sooner or later, blisters
of a larger or  smaller size, on  several parts of the face.
These contain a thin yellowish or  almost colorless liquor^ 
PRACTICE  OF PHYSIC.
which sooner or later runs out.  The surface of the skin,
in the blistered places, sometimes becomes livid and black-
ish ; but this livor seldom goes deeper than the surface,  or
discovers any degree of gangrene affecting the skin.  On
the parts of the face not affected with blisters, the cuticle
suffers, towards the end  of the disease, a considerable des-
quamation.  Sometimes the tumor of the eye-lids ends in a
suppuration.
  700.] The inflammation  coming upon the face does not
produce  any remission of the fever  which had before pre-
vailed ;  and sometimes the fever increases with the increas-
ing and spreading inflammation.
  701.] The inflammation  usually continues for eight  or
ten days ; and  for the same  time,* the fever and  symptoms
attending it also continue.
  702.] In the  progress of  the inflammation  the delirium
and  coma attending it sometimes go  on increasing, and
the patient dies apoplectic on the seventh, ninth, or ele-
venth day of  the disease.   In such  cases,  it has  been
commonly supposed that the disease is translated from  the
external to the internal parts.  But I have not seen any  in-
stance in which it did not appear to me, that the affection
of the brain was merely a communication of the external
affection,  as this continued increasing at the  same time
with the internal.
   703.] When the fatal event does not take place, the in-
flammation, after having  affected a part, commonly  the
whole of the face, and  perhaps the  other external parts of
the head,  ceases.   With the inflammation, the fever also
ceases; and without any evident crisis,  the patient returns
to his ordinary state of  health.
   704.]  This  disease  is not commonly  contagious;  but
as it  may arise from an acrid matter externally applied,
so it is possible that the disease may sometimes be commu-
nicated from  one person to  another.
   Persons who have once labored  under this disease  are
liable to returns of it.
   705.]  The event of this disease  may be foreseen from
the state of the s}^mptoms which denote more or less affec-
tion of the brain.   If neither delirium nor coma come on,
the disease is seldom attended with  any danger  ; but when
these symptoms appear early in the disease, and are  in a
considerable degree, the utmost danger  is  to  be  appre-
hended. 
                PRACTICE  OF PHYSIC.           229

   706.] As this disease often arises in the part, at the same
 time with the coming on of the pyrexia; as I have known
 it with all its  symptoms, arise from an acrimony applied to
 the part;  as  it is commonly  attended Avith a full  and fre-
 quently a hard pulse; as the blood drawn in this disease
 shows the same crust upon its surface, that appears in the
 phlegmasia? ; and, lastly as the swelling of the eye-lids, in
 this disease,  frequently ends in a  suppuration; so, from
 these  considerations, it seems doubtful if this  disease be
 properly, in  Nosology, separated  from the  Phlegmasia?.
 At any rate,  I take the disease I have described to be M'hat
 physicians have named the Erysipelas Phlegmonodes,  and
 that it partakes a great deal of the nature of the Phleg-
 masiae.
   707.] Upon  this conclusion,  the Erysipelas of the face
 is to be cured very much in the same manner as phlegmo-
 nic inflammations, by  blood-letting,  cooling purgatives,
 and by employing every part  of the  antiphlogistic regi-
 men ;* and our experience has confirmed the fitness of this
 method of cure.
   708.] The evacuations  of blood-letting and  purging,
 are to be employed more or less according to the urgency
 of symptoms,  particularly those of the pyrexia,  and of
 those which mark an affection of the brain.  As the pyrexia
 continues and often increases with the inflammation of the
 face ;  so the evacuations  mentioned may be employed at
 any time in the course of the disease.
   709.] In this, as in other diseases of the  head, it is pro-
 per to put the patient, as often as he can easily bear it, into
 somewhat of an erect posture.
   710.] As in this disease there is always an external af-
 fection, and  as in many instances there is no other;  so va-
rious external applications to the part affected have been
 proposed ; but  almost all of them  are  of doubtful effect.
 The narcotic,f refrigerant,  and astringent^  applications,
 are suspected of disposing to gangrene ; spirituous|| appli-
 cations seem  to increase the inflammation ; and  all oily or
 watery§ applications seem to occasion its spreading.  The
 application that seems most  safe, and  which is  now most

  * The antiphlogistic regimen, ice. have been described in former notes. See article 129, et serf.
  + The leaves of solanum, of hemlock, of henbane, and other similar plants applied as fo-
 mentations.
  X Solutions of Saccharum Saturni, or Vitriolum album, applied cold.
  II Especially if they are such as are compounded with aromatics or volatile salts, as campho-
 rated spintof wine, Hungary water, volatile liniment, &c.
  ; The reason is evident, because they confine the acrimonious liquor discharged from the part
 affected.                                         *
                           2c 
230
PRACTICE OF  PHYSIC.
commonly employed,  is that of a dry mealy powder fre-
quently sprinkled upon the inflamed parts.*
  711.] An Erysipelas  Phlegmonodes frequently appears
on  other parts of the  body, beside the face ; and such
other  erysipelatous inflammations frequently end in sup-
puration.   These cases are  seldom dangerous.   At com-
ing on, they are sometimes attended with drowsiness, and
even  with some delirium ; but this rarely happens ; and
these symptoms do  not continue after the inflammation is
formed.   I have never seen an instance of the translation
of this inflammation from the limbs to an  internal part;
and though these inflammations  of  the limbs be  attended
with  pyrexia,  they seldom require  the same evacuations
as the erysipelas of the face.  At first they are to be treat-
ed by dry mealy applications only ;  and  all humid  appli-
cations, as  fomentations,  or poultices, are  not  to  be  ap-
plied, till, bv  the continuance of the disease, by the in-
crease of swelling, or  by a throbbing felt  in the part,  it
appears that the disease is proceeding to suppuration.
  712.] Wc have hitherto considered eiysipelas as in  a
great measure  of a phlegmonic nature ;  and agreeably to
that opinion, we have  proposed our method of cure. But
it is  probable, that an erysipelas is sometimes attended
with, or  is a  symptom of, a putrid fever ; and, in such
cases, the'evacuations proposed above may be improper,
and the use of  the Peruvian bark may be necessary ; but  I
cannot be explicit upon this subject, as  such putrid cases
have  not come under my observation.
                   CHAPTER VII.

            OF THE  MILIARY FEVER.

   713.] r | ''HIS disease is said to have been unknown to
          JL  the ancients, and that it appeared, for the
 first time, in Saxony,  about the  middle of the  last cen-
 tury, f  It is said to have spread from thence into all the

  * Wheat flour is apt to run into hard lumps by the thin acrimonious liquor which always ex-
 hales from parts affected with erysipelas. Oatmeal not  being so liable to this inconvenience, is
 therefore preferable : it ought to be wiped off, and a fresh quantity applied twite or thrice a
 day.
  Many practitioners recommend the application of cabbage leaves to erysipelatous swellings,
 and their efficacy has been frequently approved. They ought toberemuveciassoon as they grow
 waun or uneasy, and fiesh told ones applied.
  + Hoffman, Wel«.h, and ev.-ral other writers, fix the first appearance of this disease at Leip»
'Sic in the years 1651 and  167>J. i'nis opinion, however, is false; for descriptions of miliary trup- 
PRACTICE  OF PHYSIC.
231
©ther parts of Europe ;*  and,  since the period mentioned,
to have appeared in many countries in which  it had never
appeared before.
  714.]  From the time of its having been first particularly
observed, it has  been described and treated of  by  many
different writers ;  and by all of them,  till very lately, has
been considered as a peculiar  idiopathic disease.
  It is said to have been constantly attended with peculiar
symptoms.   It comes on  with a cold stage,  which is often
considerable.   The hot stage  which succeeds,  is attended
"with great  anxiety,  and  frequent  sighing.   The  heat  of
the body becomes great, and soon  produces profuse sweat-
ing ; preceded, however, by  a sense  of pricking, as  of
pin-points in  the skin; and the sweat is  of a peculiarly
rank and disagreeable odor. The eruption appears sooner or
later in different persons, but at no determined  period  of
the  disease.   It seldom or never appears on the  face ; but
discovers itself first upon the neck and breast,  and from
thence often spreads over the whole body.
  715.]  The eruption named Miliary is said to  be of two
kinds,  the one  named the Red, the other the White  Milia-
ry.   The former which in  English  is  strictly named the
Rash, is commonly allowed to be a symptomatic  affection ;
and as the latter is the only one that has any pretensions to
be considered,  as an idiopathic disease,  it is this  alone that
I shall more particularly describe  and treat of in  the  pre-
sent chapter.
  716.]  What then is called the  White Miliary eruption ap-
pears at first like the red,  in  very small red pimples, for the
most part distinct, but sometimes clustered together.  Their
slight prominence is distinguished better by  the finger  than
by  the eye.   Soon after  the appearance  of this  eruption,
and at least on the second day,  a small vesicle appears upon

tions are to be found in.the writings of the ancients, and among the moderns we  find Riveri'iis
describing it in France, just after the appearance of the comet of the year IdlS; to which phe-
nomenon that author ascribes the fatal epidemic, as well as the bloody wars that were at that
time making horrid devastations in Europe!
  * Wc meet with several accounts of the appearahce qf the miliary eruption in different parts
of Europe soon after the middle of the last century, not only by medical writers,  but by gene-
ral historians; araoiig the latter of whom we may mention Robert Sibbald, who takes notice of
■tin his Scotia itlustrata, puoiished at Edinburgh in the year 1684.  (Sibbald, however, was a
physician.)  To enumerate the medical writers who have described the disease iu the different
parts of Europe, would take more room than the short compass ot these notes admits, the chief
of them are Welsch, Hoffman, Laugius, Reyger, Bonetus, Gnnwald, Sydenham,  Ramizina, FucU-
sius, &c. &c
  1 le au.iiurs above mentioned, and several  others about the end of the last and beginning of
this centu.s, entertained various opinions concerning the nature of the miliary eruption, some ot
thein supposing it to be a critical termination cf a peculiar fever, and others on  the contrary
strenuously inMsting that it was only accidental or symptomatic, and never critical or salutary.
The controversy, which was carried on with some warmth, is now terminated, a' « ill appear by
what luliuw* j but the inquisitive young physician u>ul find both entertainment and instruction
in perusing it. A very good abstract ot it occurs in De Haen's treatise on the division of  Fevers. 
232          PRACTICE OF PHYSIC.

the top of each  pimple.   At first  the  vesicle  is whey co-
lored ; but  soon becomes white,  and  stands  out  like  a
globule on the top of the pimple.  In two or three days,
these globules break, or are rubbed off; and are succeeded
by small  crusts, which soon after fall off in small scales.
While one set of pimples takes this course, another set suc-
ceeds ; so that the disease often continues upon the skin for
many days  together.  Sometimes when one crop of this
eruption  has disappeared, another,  after some interval,  is
produced.   And it has been further observed, that in some
persons there is  such a tendency to this disease,  that they
have  been affected with it several  times in the course of
their lives.
   717.] This disease is said to affect both sexes,  and per-
sons of all ages and constitutions ;  but it has been observed,
at all times,  to affect especially, and most frequently, ly-
ing-in women.
   718.] This disease is  often  accompanied with  violent
symptoms, and  has  frequently proved fatal.  The symp-
toms attending it are, however, very various.   They  are,
in one or other instances,  all the several symptoms attend-
ing febrile diseases ; but I cannot find that any symptom or
course of symptoms  are  steadily the same in different per-
sons, so as to furnish any specific character to the disease.
When the disease  is violent, the most common symptoms
are phrenitic, comatose, and convulsive affections which are
also symptoms of all fevers treated by a very warm regimen.
   719.]  While there is such a variety of symptoms appear-
ing in this disease, it is not to be expected that any one
particular method of cure can  be proposed :  and  accord-
ingly we find, in different  writers, different methods and
remedies  prescribed ; frequent disputes  about  the most
proper ;  and those received and practised by some, oppos-
ed and rejected by others.
   720.]  I have thus given an account of what I have found*
delivered by authors who  have considered  the white miliary
fever as an  odiopathic  disease :  but, now,  after having
often observed the disease, I must say that I doubt much if
it ever be such an idiopathic, as has been supposed,  and I
suspect that  there is much fallacy in what has been written
on the subject.
   721.]  It seems to  me very  improbable, that this should
have been really a new disease  when it was first considered
as such.   There appear to me very clear traces of it in au- 
PRACTICE  OF  PHYSIC.
233
thors who wrote long before that period ;  and,  though
there were not, we know that the descriptions of the an-
cients were inaccurate and imperfect,  particularly with res-
pect to cutaneous  affections ; whilst  we know also very
well,  that those affections which usually appeared as symp-
tomatic only, were commonly  neglected, or  confounded
together under a general appellation.
  722.]  The antecedent symptoms of  anxiety,  sighing,
and pricking of th,e skin, which have been spoken of as pe-
culiar to  this disease, are,  however,  common to many
others ; and, perhaps to all those in  which sweatings are
forced out by a warm regimen.
  Of the symptoms said to be concomitant of this eruption,
there are none which can be said to be constant and peculiar
but that of sweating.  This, indeed, always precedes and ac-
companies the eruption ;  and,  while the mliary eruption at-
tends many  different diseases, it never,  however, appears in
any of these, but after sweating; and, in persons laboring un-
der these diseases, it does not appear,  if sweating be avoid-
ed.   It is  therefore  probable, that the eruption  is the effect
of sweating ; and that it is the  produce of a matter, not
before prevailing in the mass of blood, but generated, un-
der particular circumstances, in the skin itself.   That it de-
pends upon particular circumstances of the skin,  appears
Further from hence, that the eruption  seldom or never ap-
pears upon the face, although  it affects the whole of the bo-
dy  besides ;  that it comes upon those places especialIv
which are more closely covered ; and that it can be brought
out upon particular  parts by external applications.
  723.] It is to be  observed, that this eruptive disease dif-
fers from the other exanthemata in many circumstances ; in
its not being contagious, and  therefore never   epidemic ;
that the eruption appears at no determined  period of the
disease ;  that the eruption has no determined duration ;
that successive eruptions frequently appear in the course of
the same  fever ; and  that such eruptions frequently recur
in the course of the same person's life.
  All  these circumstances render it .extremely probable,
that, in the miliary fever, the morbific matter is not a sub-
sisting contagion communicated to the blood, and  thence,
in consequence of fever and assimilation, thrown out upon
the surface of the body ;  but a matter occasionally produc-
ed in the skin itself, by sweating.
  724.]  This conclusion is further rendered probable, from 
04
PRACTICE  OF PHYSIC.
hence,  that, while the miliary eruption has  no peculiar
symptoms, or  concourse of  symptoms, belonging to  it;
yet  upon occasion, it accompanies  almost all febrile  dis-
eases, whether  inflammatory or putrid, if these happen to-
"be  attended with  sweating ;  and  from  thence it may be
presumed,  that the miliary eruption is a symptomatic affec-
tion only, produced in the manner we  have said.
  725.] But, as this symptomatic affection does not always-
accompany every instance  of sweating,  it may be proper
to inquire what arc t'.ie circumstances  which especially de-
termine this eruption to appear ?   To this,  however, I can
.give no full and proper answer.   I cannot say that there is
any one circumstance which in all cases  gives occasion to this
eruption  ; nor can I say  what different causes may, in dif-
ferent cases, give occasion to  it.   There  is only one obser-
vation I can offer to the purpose of this inquiry ;  and it is,
that, of the persons,  sweating under febrile diseases,  those
are especially liable to the miliary eruption,  who have been
previously weakened  by large evacuations, particularly of
blood.   This will explain why  it happens to  lying-in wo-
men  more frequently than  to any other persons ; and  to
confirm this explanation,  I  have remarked,  that  the erup-
tion happened to women not in child-bed, but  who had been
much subjected to a  frequent and  copious menstruation ;
and to an  almost  constant fluor albus.  I have  also had
occasion to observe it happen  to men in fevers, after wounds
from which they had suffered a great loss of blood.
   Further, that this  eruption  is  produced by  a  certain
state of debility,  will appear probable,  from its often oc-
curring in fevers of the putrid kind, which are always at-
tended with great debility.   It is true,  that  it also  some-
times attends inflammatory diseases, when it cannot be ac-
counted  for in the same  manner ;  but I believe it will be
found to attend  especially those inflammatory diseases in
which  the sweats  have been  long protrr.cted  or frequently
repeated, and  which have thereby produced a  debility,
and perhaps a debilitating putrid  diathesis.
   726.] It appears so clearly  to me, that this eruption is
always a symptomatic* and  factitious affection, that I am
  * As this disease is always symptomatic and never idiopathic,  the method of curing must ne-
cessarily vary in diffeient cases; the chief attention of the physician must therefore be turned
to the primary disease, and to the means of preventing this symptom from appearing in those
diseases which it accompanies.
  The author judiciously begins his method of cure bv giving directions for preventing the erup-
tion, which he properly supposes tobe entirely factitious, and to depend on the application ot
too much heat. With a proper attention to the directions given  in the text, we may in rjeneral
prevent the eruption.  If, however, the eruption is present before the phvsician is called, those
remedies must be used for its removal that  are eumetated in the subsequent article*. 
                PRACTICE  OF PHYSIC.            233

persuaded it may be in  most  cases prevented merely by
avoiding  sweats.  Spontaneous sweatings,  in the begin-
ning of diseases, are  very rarely critical; all sweatings, not
evidently critical,  should be prevented ; and  the promot-
ing them,  by increasing external heat, is  commonly very
pernicious.  Even critical sweats should hardly be encou-
raged by such  means.   If therefore,  spontaneous sweats
arise,  they are to be checked by the coolness of the cham-
ber ; by the lightness and  coolness  of  the bed-clothes; by
the person's laying out theirhands and arms,  and by their
taking cold drink:  and, by these  precautions, I  think I
have frequently  prevented miliary  eruptions,  which  were
otherwise likely to have appeared,  particularly in lying-in
women.
   727.]  But it  may happen, when these precautions have
been neglected, or  from other circumstances,  that a mi-
liary eruption does actually appear ; and the question will
then be put, how the case  is to be treated ? It is a question
of consequence, because 1 believe that the matter here ge-
nerated is often of a virulent kind ; it is frequently the off-
spring of putrescency; and,  when treated by  increasing
the external heat of the body, it seems to acquire  a viru-
lence  which produces  those symptoms mentioned in 718,
and proves certainly fatal.
   It has been an unhappy  opinion with most physicians,
that eruptive diseases were ready to be hurt by cold;  and
that it was therefore necessary to cover up the body very
closely,  so as thereby to increase the  external heat.   We
now know that this is a  mistaken  opinion ; that increasing
the external heat of the body is very generally mischiev-
ous  ;  and that several eruptions not  only admit, but require
the application of cold air.  We are now* persuaded,  that
the practice which formerly prevailed, in the case of milia-
ry eruptions,  of covering  up the body close,  and both by
external  means,  and internal remedies,  encouraging the
sweatings which accompany this eruption, was highly per-

 * The present rational practice has  entirely, altered the regimen in fevers; and instead at
macerating the patient in a hot bed, and obliging him to breathe the corrupt air of a confined
chamber,  we now cover him with light bed-clothes, and ventilate his room.
 It may,  however, be necessary to guard the young physician against the excess of this practice.
The precept, Omne nimium nocet, should always be attended to. If the patient feels any dis-
agreeable effects, or if he should suffer rigors, or trembles from the admission of told air, it is
certainly prejudicial, and its admission ought to be regulated.
 It may not be improper to mention another caution, viz. That the young practitioner must
not, by the means here recommended, check sweats that are really critical. To determine
what sweats are, and what are not, critical, is perhaps, in some cases, atiended with considera-
ble difficulty.   In general, however, critical sweats may be known by their happening on the-
critical days before mentioned in article 107. et seq. and by their always being immediately fol-
lowed by an abatement of all, or at least the greatest part, of the symptoms. 
PRACTICE OF  PHYSIC.
nicious, and commonly fatal.  I am therefore of  opinion,
even when a miliary eruption has appeared, that in all ca-
ses where the sweating is not manifestly critical, we should
employ all the several means of stopping it that are men-
tioned above; and I have sometimes had occasion to observe,
that even the admission of cool air was safe and useful.
  72S.] This is, in general, the treatment of miliary erup-
tions ; but, at the same time,  the  remedies suited to the
primary disease, are to be employed ; and therefore, when
the eruption happens to accompany inflammatory affec-
tions, and when the fulness and  hardness of the pulse or
other symptoms show  an inflammatory state present, the
case is to be treated by blood-letting, purging, and other
antiphlogistic remedies.
  Upon the other hand,  when the miliary eruption attends
diseases in which debility and putrescency prevail, it will
be proper to avoid  all evacuations,  and employ tonic and
antiseptic remedies, particularly the Peruvian  bark,  cold
drink, and cold air.
  I shall conclude this  subject with mentioning, that the
venerable octogenarian practitioner, de Fischer, when
treating of this subject, in laying down the indications of
cure, has given this as one of them :  " Excretionis peri-
phericae non primariam habere  rationem."



                 CHAPTER  VIII.

   OF THE REMAINING EXANTHEMATA.

       URTICARIA, PEMPHIGUS, AND APHTHA.

  729.] ""T^HE Nettle Rash is a name applied to two dif-
         X  ferent diseases.   The one is the chronic erup-
tion  described by Dr. Heberden in the Medical Transac-
tions, Vol. I. art.  xvii. which, as  not being a febrile dis-
order, does not belong to this place.  The other is the
Urticaria  of  our  Synopsis,  which as taken  into every
system of Nosology as  one of the  Exanthemata Febrilia,
is properly to be treated of here.
  730.] I have never observed this disease as  contagious
and epidemic;  and the few sporadic cases of it which have
occured to me,  have seldom  taken the regular course  des-
cribed by authors.   At the same  time, as the accounts of 
PRACTICE OF PHYSIC.
237
different authors are not very  uniform, and hardly consist-

ent, I cannot enter further into the  consideration  of this

subject:  and I hope it is not very necessary, as on all hands

it is agreed to be a mild  disease, and  such  as seldom re-

quires the use of remedies.  It is generally sufficient to ob-

serve an antiphlogistic regimen,  and to keep  the patient in

a temperature that is neither hot nor cold.

   731.] The Pemphigus,  or Visicular fever,  is a rare  and

uncommon disease, and very few instances of it are record-

ed in the writings of physicians.   As I have  never  had oc-

casion to see it,  it would be improper for me to treat of it ;*

and I do not choose to repeat after others,  while the disease

has yet been little observed, and its character does not seem

to be  exactly ascertained.  Vid. Acta Helvetica,  vol.  ii.

p. 260. Synops. Nosolog. vol. ii. p.  149.

   732.] The Aptha,  or Thrush, is a disease better  known;

and, as it commonly appears in infants, it is  so well under-

stood, as not to  need our treating of it here.   As an idiopa-

thic disease,  affecting adults, I  have  not seen it in this coun-

try: but it  seems tobe more frequent  in Holland ; and,

therefore,  for  the  study  of it,  I refer  to  Dr. Boerhaave,

and  his commentator Van Swieten,  whose  works  are in

every body's hands, f

   733.] The Petechia has been,  by all  our Nosologists,

enumerated  amongst  the  exanthemata ; but  as, according

to the  opinion  of most physicians, it  is very justly held to

be always  a  symptomatic  affection only,  I cannot give it a

place here.


  »It appears from  the following passage in the  author's  Synopsis, that he had afterwards seen.
it: " Collega nosier eximus Franciscus Home,  mihi hominem leviter febricitantem ostendit,
" cui, primum in brachiis, et successivedemum in totocorpore, visiculae magmtudine avellanac
" obortx  sunt, et post duos tresve dies  effuso humoris  serosi pauxillo, collapsae sunt.  Haec
" febris autem nullam indolem vel typum peculiarem monstrabat, et cito disparuit nequaquam
" contagiosa."
  + Boerhaave only  saw aphthae twice without, and preceding, fever, and Van Swieten only
once; but Ketelaer says he has frequently seen them.  They sometimes accompany intlamm a-
tions of the viscera, and other inflammatory fevers,  and are often difficult to remove. They
are to be treated in the same manner as the ulcerations in  the Cynanche maligna, by gargles of
the detersive kind, until the aphthous crust separates and  falls off; but when that crust has fal-
len off, the painfullness of the nakedly exposed sensible parts requires emollient applications;
of which kind a decoction of Rad.  Alth. or an infusion of  lintseed, are proper gargles alone : if
honey be added, the patient complains of its making the parts smart. The patient's diet ought
to be of the mildest kind,  that it may be swallowed  without causing much pain.
  The aphthous crust frequently appears at the anus, which symptom generally leads us to con-
clude, as Is really the case, that aphthae covers the whole intesdnal canal. Hence  considerable
danger arises.  The absorbents are  covered, and refuse admittance to all nourishment; hence
an increased debility, with all its evil consequences. In  these cases, a nutritive, (liquid, and
detersive diet, must be used.  For this purpose a decoction of bread, with wine and honey, is
the properest drink. Such a decoction is extremely  nutritive, and also a verse to putrefaction,
and therefore well adapted tu the exigency of the case.
2h 
PRACTICE  OF PHYSIC.
       BOOK  IV.
OF  HEMORRHAGIES.
                   CHAPTER I.

       OF HEMORRHAGY IN GENERAL.

  734.] TN establishing a class or order of diseases under
        A the title of  Hemorrhagies, Nosologists have
employed the single  circumstance of an effusion  of red
blood,  as  the character  of such a class or order.  By this
means they have associated diseases which  in their  nature
are very different; but, in every methodical distribution,
such arbitrary  and unnatural  associations should be avoid-
ed  as  much as  possible.  Further, by that management
Nosologists have suppressed or lost sight of an  established
and  well-founded  distinction of hemorrbagies into Active
and Passive.
  735.] It is my design to restore this distinction ; and I
shall therefore here, under the title of Hemorrhagies, com-
prehend those only which have been commonly  called Ac-
tive, that is, those attended with  some degree  of pyrexia ;
which seem always to depend upon an increased impetus
of the blood in the vessels pouring it out, and which chiefly
arise from an internal cause.   In this I follow Dr. Hoffman,
Avho joins the active hemorrhagies with the febrile diseases ;
and have accordingly established these hemorrhagies as  an
order in the class of pyrexia.   From  this order  I exclude
all  those effusions of  red blood that are owing entirely to
external violence; and all  those which,  though arising
from internal causes, are, however, not attended with py-
rexia,  and which seem to be  owing to a putrid  fluidity of
the blood, to the weakness or to  the erosion of  the vessels,
rather than to any increased impetus  of the blood in them.
   736.]  Before proceeding  to treat  of those proper  he-
morrhagies  which form an order  in our Nosology, I shall
treat of active hemorrhagy in general ; and indeed the se-
v.r;;l genera and  specie-,, to  be treated of particularly af- 
PRACTICE  OF  PHYSIC.
232
terwards,  have so many circumstances in common with one
another, that the general consideration to  be now  offered
will prove both proper and useful.
                     SECTION I.

        Of the Phenomena of Hemorrhagy.

  737.] The phenomena of hemorrhagy are generally the
following.
  Hemorrhagies happen especially in plethoric habits, and
to persons of a sanguine temperament.   They appear most
commonly in the spring, or in the beginning of summer.
  For some time,  longer or shorter in different cases, be-
fore the blood flows,  there are some  symptoms of fulness
and tension about the parts from  whence the blood  is to
issue.  In such parts as fall under our view,»there are some
redness, swelling,  and sense of heat or of itching ; and in
the internal parts  from  which blood is to flow, there is a
sense  of weight  and heat ;  and,  in  both cases, various
pains are often felt  in the neighboring parts.
  738.] When these  symptoms have  subsisted  for  some
time,  some degree of a  cold stage of pyrexia comes on,
and a hot stage is formed ; during which, the blood flows
of a florid color, in a  greater or lesser  quantity, and conti-
nues to flow for a  longer or shorter time ; but commonly,
after some time, the effusion spontaneously ceases,  and to-
gether with it the pyrexia also.
  739.] During the hot stage which  precedes an hemor-
rhagy, the pulse is frequent, quick,* full, and  often hard  ;
but as the blood flows, the pulse  becomes softer and less
frequent.
  740.] In hemorrhagies,  blood drawn from a vein,  does,
upon its concreting, commonly show the gluten separated,
or a crust formed,  as in the cases of Phlegmasiae.
  741.] Hemorrhagies from  internal  causes, having  once
happened,  are  apt, after a certain interval,  to return ; in
some cases very often, and frequently at stated periods.
  742.] These are, in general, the phenomena kof hemor-
rhagy ; and if in somecases,  all of them be not exquisitely
marked,  or if  perhaps some  of them do not at all appear,
  * The difference between a frequent and quick pulse, wa; mentioned in a note on article 33$. 
240           PRACTICE OF PHYSIC.

it imports only, that,  in different cases the system is more
or less generally affected ;  and that, in some cases, there
are purely topical hemorrhagies,  as there are purely topi-
cal inflammations.
                   SECTION II.

    Of the Proximate Cause of Hemorrhagy.

  743.] THE pathology of hemorrhagy seems to be suffi-
ciently obvious.   Some inequality in the distribution of
the blood occasions a congestion in particular parts of the
sanguiferous system; that is, a greater quantity of blood
is poured into  certain vessels than their natural capacity is
suited to receive.  These vessels become thereby preterna-
turally distended ; and  this distention, proving a stimulus
to them,  excites their  action to a  greater degree  than
usual,  which,  pushing  the blood with unusual  force into
the extremities of these vessels opens them by anastomosis,
or rupture; and, if these extremities be loosely situated on
external surfaces, or on the internal surfaces  of certain ca-
vities that open outwardly, a quantity of blood flows out
of the body.
  744.] This reasoning will, in some measure,  explain the
production ot  hemorrhagy. But it appears to me, that, in
most cases, there are some  other circumstances that concur
to produce it; for it is probable, that, in consequence of con-
gestion, a sense of resistance arises, and excites the action
of the Vis Medicatrix Naturae, the exertions of which are
usually made by the formations of a cold stage of pyrexia,
inducing a more vigorous action of the vessels ; and the
concurrence of this exertion more  effectually  opens the
extremities, and occasions the flowing out of the blood.
   745.] What has been delivered in the two  preceding
paragraphs, seems to explain the whole phenomena of he-
morrhagy, except the circumstance of its frequent recur-
rence, which I apprehend may be explained  in the follow-
ing manner.   The  congestion  and  consequent irritation
being taken off by the flowing of the blood; this therefore,
soon  after, spontaneously ceases;  but,  at the same time,
the internal causes which had before produced the unequal
distribution of the  blood, commonly remain,  and  must
now operate the more  readily,  as the over-stretched  and 
PRACTICE  OF PHYSIC.
241
relaxed vessels of the part will more easily admit of a con-
gestion of blood in them, and,  consequently,  produce the
same series of phenomena as before.
  746.] This may sufficiently explain the ordinary return
of hemorrhagy; but there  is still another circumstance,
which, as commonly concurring, is to be taken notice of;
and  that  is, the general  plethoric state  of  the  system,
which renders every cause of unequal distribution of more
considerable effect.   Though hemorrhagy may often de-
pend upon the state of the vessels of a particular part be-
ing favorable to a congestion's being formed in them; yet,
in order to that state's producing its effect, it is necessary
that the whole system should be at least in its natural ple-
thoric  condition; and, if this should be in any degree in-
creased beyond what is natural, it will still more certainly
determine the effects of topical conformation to take place.
The return  of hemorrhagy, therefore, will be more cer-
tainly  occasioned,  if the system becomes preternaturally
plethoric; but hemorrhagy has always a tendency to in-
crease  the plethoric state of the system, and,  consequent-
ly,  to  occasion its own return.
  747.] To show that hemorrhagy does contribute to pro-
duce or increase the plethoric state of the system,  it is on-
ly necessary  to observe, that the  quantity  of serous fluids
being  given, the state of the excretions depends  upon  a
certain balance between the force of the larger arteries pro-
pelling the  blood, and  the resistance  of  the excretories:
but the force of the arteries depends upon  their fulness and
distension, chiefly given to them by the  quantity of red
globules and gluten,  which are for the greatest part con-
fined to the red arteries; and therefore, the spoliation made
by an hemorrhagy, being chiefly of red globules and  glu-
ten,  the  effusion  of blood  must leave  the red  arteries
more empty and weak.  In  consequence of the weaker ac-
tion of the red arteries, the excretions are in proportion di-
minished ; and,  therefore,  the  ingesta continuing the
same,  more fluids  will be accumulated in  the  larger ves-
sels.   It is by this means that the loss of blood by  hemor-
rhagies, whether artificial or spontaneous, if within certain
bounds, is commonly so soon recovered : but as the dimi-
nution of  the excretions, from a less quantity of fluid be-
ing impelled into the excretories, gives occasion to these
vessels to fall into a contracted state ; so, if this shall con-
tinue long, these vessels will become more rigid, and will 
242           PRACTICE OF PHYSIC.

not yield to the same impelling force as before.  Although
the arteries, therefore,  by new blood collected in them,
shall have  recovered  their former fulness, tension,  and
force ; yet this force will not be in balance with the resist-
ance of the more rigid excretories,  so as to restore the for-
mer state  of excretion; and, consequently, a further ac-
cumulation will take place in the arteries, and an increase
of their plethoric state be thereby induced.   In this man-
ner, we perceive more clearly, that hemorrhagy, as pro-
ducing a more plethoric state of the system,  has a tenden-
cy to occasion  its own recurrence with greater violence ;
and, as the renewal and further accumulation of blood re-
quire a determinate time, so, in the several repetitions of
hemorrhagy, that time will be nearly the same ; and there-
fore the returns of hemorrhagy will be  commonly at stated
periods, as has been observed frequently to happen.
  748.] I have thus explained the nature of hemorrhagy
in general, as depending upon some inequality in the dis-
tribution of the blood, occasioning a congestion of it in par-
ticular parts of the sanguiferous system.   It is indeed pro-
bable, that, in most persons,  the  several parts of the san-
guiferous  system, are in  balance  with one  another; and
that the density, and consequently the resistance, in the
several  vessels, is in  proportion to the quantity of blood
which each should receive;  from whence it  frequently
happens, that no inequality in the distribution of the blood
takes place in the course of a long life. If, however, we con-
sider that the sanguiferous system is constantly in a pletho-
ric state, that is, that the vessels  are constantly distended
beyond that size which they would be of,  if free from any
distending force, we shall be satisfied that this state may be
readily changed. For as, on the one hand, the vessels are
elastic, so as to be under a constant tendency  to  contract
upon the withdrawing of any part of the distending force  ;
and, on the  other hand, are not so rigid but that, by an in-
crease of  the impetus of the blood in them, they may be
more than ordinarily distended;  so we can easily under-
stand how, in most persons, causes of an increased contrac-
tion or distension may arise in one part or other of the
system, or that an unequal distribution may take place;
and how,  in an exquisitely distended or plethoric system,
a small inequality  in the distribution  of  the blood  may
form those congestions which give occasion to hemorrhagy.
   749.] In this manner  I endeavor to explain how hemor- 
PRACTICE  OF PHYSIC.
243
rhagy may be occasioned atany period of life,  or in any
part of the body: but hemorrhagies happen in certain parts
more frequently  that in others, and at certain  perioas  of
life more readily than at others ;  and therefore in deliver-
ing the general doctrine of hemorrhagy, it may be required
that I should explain those circumstances which  produce
the specialities mentioned; and I shall now attempt it.
   750.]  The human body,  from being of a small bulk at
its first formation, grows afterwards to a  considerable size.
This increase of bulk consists,  in a  great measure, in the
increase  of the quantity of fluids and a proportional en-
largement of the containing vessels.   But at the same time,
the quantity of solid  matter is also  gradually increased ;
and,  in whatever manner we may suppose this to  be done,
it is probable that the progress, in  the whole growth  of
animal bodies,  depends upon the extension of the arterial
system ;  and such is the constitution of the sanguiferous
system, that the motion of the blood in the arteries has a
constant tendency to extend them in every dimension.
   751.]  As the state of the animal solid is, at the first for-
mation of the body, very lax and yielding ; so the extension
of the system proceeds, at first, very fast:  but, as the ex-
tension gives occasion to the apposition of  more matter to
the solid parts, these are, in proportion to their extension,
constantly acquiring a greater density, and therefore giving
more resistance to their further extension and growth.  Ac-
cordingly, we observe, that as the growth of the body ad-
vances, its increase, in any given time,  becomes propor-
tionally less and less, till at length it ceases altogether.
   752.]  This is the general idea of the growth of the hu-
man body, till it attain the utmost bulk which it is capable
of acquiring : but it is to be remarked, that this growth
does not  proceed equally in every part of the body, it be-
ing requisite for the economy of the  system, that certain
parts should be first evolved, and should also acquire their
full bulk  sooner than others.   This appears particularly
with respect to the head, the parts of which appear to be
first evolved, and soonest to acquire their full size.
   753.] To favor this unequal growth, it is presumed, that
the dimensions or the  laxity of the vessels of the  head,  or
that the direction of the force of the blood,  are adapted to
the purpose ; and from  what has been said in 751, it  will
also certainly follow, that as the vessels of the head grow
fastest, and soonest  acquire  their  full size, so they  will 
PRACTICE OF PHYSIC.
 soonest  also acquire  that density which  will prevent their
 further extension.   While, however, the  force of the heart
 and the  quantity of the fluids, with respect to the whole
 system,  remain  the same, the distending  and extending
 powers will be directed to such parts as  have not  yet ac-
 quired the same density and dimensions as those  first evolv-
 ed ; and thus the distending and extending powers will pro-
 ceed to operate till every part of the system, in respect of
 density and resistance, shall have been brought to be in ba-
 lance with every other, and till the whole  be  in  balance
 with the force of the  heart,  so that there  can be no further
 growth in any particular part, unless some  preternatural cir-
 cumstance shall happen to arise.
  754.]  In this process of the growth  of the body, as it
 seems in general to depend upon a certain balance between
 the force of the heart or distending power,  and the resist-
ance of the solids ; so it will appear, that, while the solids
remain very lax and yielding,  some occasional increase of
the distending power may arise without producing any very
perceptible disorder in the system.   But, it will also  appear,
that, in  proportion as the distending power and resistance
of the  solids come to be more nearly in  exact balance with
one another,  so any increase of the distending  power will
more  readily produce a rupture of vessels, which  do not
easily yield to extension.
  755.]  From all this, it must  follow,  that  the effects of
any unusually plethoric state of the system,  will be differ-
ent according as this shall occur at different periods of the
growth of the body.  Accordingly, it is evident that if the
plethoric state arises  while the head is yet  growing,  and
while the determination of the blood is still more to the head
 than to the other parts, the increased quantity of the blood
will be especially determined  to the head ;  and as there also,
at the same time,  the balance  between the distending and
extending poweis is most nearly adjusted, so  the determi-
nation  of the blood will most readily produce in that part
 a rupture of the vessels, or an  hemorrhagy.  Hence it is,
 that hemorrhagies  of the  nose  so frequently happen  to
young persons ; and in these more readily, as they approach
 nearer to their acme, or full growth ; or, it may be said,
 perhaps  more properly, as they  approach  nearer to the
 age of puberty, when,  perhaps, in both  sexes, but espe-
 cially in the female, a new determination arises in the system.
  756.]  The determination of a greater quantity of blood 
               PRACTICE OF PHYSIC.            245

 to the vessels of the head, might be supposed to occasion a
 rupture of vessels in other parts of the head, as well as in
 the nose : but such a rupture does not commonly happen  ;
 because in the nose there is, for the purpose  of sense, a
 considerable net-work of blood-vessels expanded on the in-
 ternal surface of the nostrils, and covered only with thin and
 weak teguments.  From this circumstance it is, that upon
 any increased impetus of the blood in the vessels of the head,
 those of the nose are most easily broken ;  and  the effusion
 from the nose taking place,  it not only relieves the other
 extremities of the external carotid, to which the arteries of
 the nose chiefly belong, but relieves  also, in a great mea-
 sure, the system of the internal carotid.  For, from the in-
 ternal carotid, certain  branches are sent  to  the  nose, are
 spread out on its internal surface,  and probably inosculated
 with the extremities of the external carotid : so that, which-
 soever of the extremities are broken, the  vis derivationis of
 Haller  will take place  ; the effusion will relieve the whole
 sanguiferous system of  the head, and the same effusion will
 also commonly prevent an  hemorrhagy  happening at the
 same time in any other part of the body.
   757.]  From these principles, it will appear why hemor-
 rhagies of the nose,  so frequent before the period of puber-
 ty, or of the acme, seldom  happen  after these  periods :
 and I must observe further, that although they should occur,
 they would not afford any objection to  my doctrine, as such
 hemorrhagies might be imputed to a peculiar laxity of the
 vessels of the nose, and  perhaps to a habit acquired with
 respect to  these vessels, while the balance of the system
 might be otherwise duly adjusted.
   758.] When the process of the growth of the body goes
 on regularly,  and the balance of the system is properly ad-
justed to the gradual growth of the  whole, as well as to
 the successive growth of the several parts, even a  plethoric
 state does not produce any hemorrhagy, or at.least any af-
 ter that of the nose : but if, while the plethoric state con-
 tinues, any inequality shall also subsist in any of  the parts
 of the system, congestions, hemorrhagic or inflammatory,
 may be still readily formed.
   759.] In general, it may be observed, that, when the se-
 veral parts  of the  system of the aorta have attained their
 full growth, and are duly balanced with one another, if then
 any considerable degree of plethora remain  or arise, the
 nicety of the balance will be between the symptoms of the
                          2i 
246
PRACTICE  OF PHYSIC.
aorta and pulmonary artery, or  between the vessels of the
lungs and those of all the rest of the body.  And although
the lesser capacity of the vessels of the lungs is commonly
compensated by the greater velocity of the blood in them ;
yet, if this velocity be not always adjusted to the necessary
compensation, it is probable that a plethoric state of the
whole body will always be especially felt in the lungs ; and
therefore, that an hemorrhagy, as the effect of a general
plethora, may be frequently occasioned in the lungs,  even
though there be no fault in their conformation.
  760.] In some cases, perhaps, an hemorrhagy from the
lungs,  or aii hemoptysis, does  arise from the general ple-
thoric state of the body ; but an  hemoptysis more frequent-
ly does,  and may be expected  to happen, from a fault}'
proportion  hetween  the capacity of the lungs  and that of
the rest of the body.
  161.] When such a disproportion takes place, it will be
evident,  that an  hemoptysis will especially happen  about
the time that the body is approaching to its acme ; that is,
when the system  of  die aorta has arrived  at its utmost ex-
tension and  resistance, and when,  therefore, the plethoric
state of the whole must especially affect the lungs.
  762.] Accordingly, it has been constantly observed, that
the hemoptysis  especially occurs about the time of the bo-
dy's arriving at  its acme* ; but I must remark also, that the
hemorrhagy may occur sooner or later, according as the ba-
lance between  the vessels of the lungs,  and those of the
system of the aorta, happens to be more or less exactly ad-
justed to one another ; and it may therefore often  occur
much later than the  period mentioned, when that balance,
though not quite even,  is however not so  ill  adjusted, but
that some other concurring causes are necessary to give it
effect.
  763.] It  was anciently remarked by  Hippocrates,  and
has been confirmed by modern observation, that the hemop-
tysis generally occurs in persons between  the age of fifteen
and that of five and  thirty ;  that it may happen at any time
between these two periods ;  but that it seldom happens be-
fore the former,  or after the latter ; and  it may be proper
here to inquire into the reason of these two limitations.
  764.] With respect to the first, the reason of it has been
already explained in 761, and 762.
  With respect to the second limitation,  I expect that the 
               PRACTICE OF PHYSIC.            247

reason of it will be understood from the following  consi-
derations.
  It has  been  already  observed,  that the extension  and
orowth of the  body require the plethoric state of the ar-
terial system;  and nature has provided for this, partly by
the constitution of the blood being  such that a great por-
tion of it is unfit to pass into the exhalents and excretories;
partly by giving a certain density and resistance to the seve-
ral exhalents and excretories through which the fluids might
pass  out of the red arteries ; and partly, but especially,
by a resistance in the veins to the free passage of the blood
into them from the arteries.
   765.]  With  respect to this  last  and chief circumstance,
it appears from the experiments  of Sir Clifton Wintring-
ham, in  his Experimental Inquiry, that the proportional
density of the coats of  the veins to that of the coats of the
arteries,  is  greater in young  than  in old animals:  Irom
which it may be presumed, that the resistance to the  pas-
sage of the blood from  the arteries into the veins,  is great-
er°in young animals than in old; and, while this resistance
continues, the plethoric state  of the arteries must be con-
stantly continued  and supported.   As however the density
of  the coats of the vessels consisting chiefly of a cellular
texture,  is increased by pressure;  so, in proportion as the
coats of the arteries are more exposed to pressure by dis-
tension than those of the veins,  the former, in the progress
of  the growth of the body, must increase much more in
density than the latter;  and, therefore, the coats of  the ar-
teries, in respect of density and resistance, must come,  in
time, not only to be in balance with those  of the veins,
but to prevail over them:  a fact which i.s sufficiently'prov-
ed by the experiments of  the above mentioned ingenious
author.
   By these means, the proportional quantities of blood in
the arteries and veins must change in the course of life.   In
youno-er animals the quantity of blood in the arteries must
be proportionally greater than in  old ones; but by the in-
creasing  density  of the arteries,  the quantity of blood in
them must be continually diminishing, and that in the veins
be proportionally increasing,  so as at length to be in a pro-
portionally  greater  quantity than  that in  the  arteries.
 When this change happens in the proportional quantities
of the blood in the arteries and veins,  it must be evident
that  the  plethoric state of the arteries  will be in a great 
 248          PRACTICE OF PHYSIC.

measure taken off; and therefore that the arterial hemor-
rhagy is no longer likely to happen; but that if a general
plethoric state afterwards take place in the system it must
especially appear in the veins.
  766.] The change I have mentioned to happen in  the
state of the arterial and venous systems, is properly sup-
posed to take place in the human body about the age of
thirty-five, when it is manifest that the vigor of the body,
which depends so much upon the fulness and tension of the
arterial  system, no longer  increases;  and therefore it is
that the same age is the period,  after which the arterial he-
morrhagy, hemoptysis, hardly  ever appears.  It is true,
there are instances of  the hemoptysis happening at a later
period; but it is  for the reasons given (757.) which show
that an hemorrhagy may happen at any period of life, from
accidental causes  forming congestions, independent of the
state of the balance of the system at that particular period.
  767.] I have said (765.)  that if after the age of thirty-
five, a general and preternatural plethoric state  occur, it
must especially appear in the venous system ; and I must
now observe, that this venous plethora may also give oc-
casion to hemorrhagy.
  768.] If a plethoric state of the venous system take place,
it is to be presumed, that it will especially and in the first
place affect the system of the vena portarum,  in which the
motion of the venous  blood is more slow than elsewhere ;
in which the motion of the  blood is little assisted by exter-
nal compression ;  and  in which, from  the want  of valves
in the veins that form the vena portarum, the motion of the
blood is little assisted  by the compression that is applied;
while,  from  the same want of valves in those veins, the
blood is more ready to regurgitate in them.   Whether any
regurgitation of the blood can produce an action in the
veins, and which inverted, or directed towards  their  ex-
tremities, can force these, and occasion hemorrhagy, may
perhaps be disputed:  but it appears to me that an hemor-
rhagy,  produced  by a plethoric state of the veins, may be
explained in  another  and more probable manner.   If the
blood be accumulated in the veins, from an  interruption of
its proper course,  that accumulation must resist the free pas-
sage of the  blood from the  arteries into the veins.   This
again must produce some congestion in the extremities of
the red arteries,  and  therefore  some increased  action in
them,  which must be determined  with  more than usual 
PRACTICE  OF PHYSIC.            249
force, both upon the extremities of the arteries, and upon
the exhalants proceeding from them;  and this force may
occasion an  effusion of blood, either  by  anastomosis  or
rupture.
  769.] In this manner I apprehend the hemorrhoidal flux
is to be explained, so far as it depends upon the state of the
whole system.  It appears most commonly to proceed from
the extremities of the hemorrhoidal vessels, which,  being
the most dependent and distant branches of those veins that
form the vena portarum, are therefore the most readily af-
fected by every  accumulation  of  blood in that system  of
veins, and consequently by  any general  plethora in the ve-
nous system.
  770.] It is  here to be observed, that I have spoken of this
hemorrhagy  as proceeding from the hemorrhoidal vessels
only, as indeed it most commonly does ; but it will be rea-
dily understood, that the same accumulation and  resistance
to the venous blood may, from various causes, affect  many
of the extremities of the vena portarum, which lie very su-
perficially upon the internal surface of the alimentary canal,
and give occasion to what has been called the Morbus Niger
or Meloena.
  771.] Another part in which an unusually plethoric state
of the veins may have particular effects, and occasion hemor-
rhagy, is the  head.   In this, the venous system is of a  pecu-
liar conformation, and such as seems intended by nature  to
give there a slower motion to the venous blood.  If,  there-
fore,  the plethoric  state of the venous system  in general,
which seems to increase as  life advances, should  at length
increase to a  great degree,  it  may very readily affect the
venous vessels of the head,  and produce there such a resist-
ance to the arterial blood, as to determine this to be poured
out from the nose, or into the cavity of the cranium.   The
special effect  of the latter effusion will be,  to produce the
disease termed Apoplexy ; and which, therefore, is pro-
perly named  by Doctor Hoff man, Ha-morrhagia Cerebri:
and the explanation of its cause,  which I have  now given,
explains well why it  happens especially to men of  large
heads and short necks, and to men in the decline of life,  when
the powers promoting the  motion of the blood are  much
weakened.
  772.] I have thus  attempted to give  the history of the
plethoric and hemorrhagic states of  the human "body,  as
they occur at the different periods of life ; and hope I have 
250
PRACTICE OF  PHYSIC.
thereby explained,  not only the  nature of hemorrhagy in
general, but also of the particular hemorrhagies which most
commonly appear, and as they occur successively at the dif-
ferent periods of  life.
                     SECTION III.

      Of the Remote Causes of Hemorrhagy.

   773.]  IN the explanation hitherto given, I have especially
considered the predisposition to hemorrhagy ;  but it is pro-
per also, and even necessary,  to take  notice  of the  occa-
sional causes, which not only concur with the predisponent,
in exciting hemorrhagy, but may also sometimes be the sole
causes of it.
   774.]  These occasional causes are,
   1.  External heat, which, by rarefying the blood, produ-
ces or increases the plethoric  state of the body ; and the
same heat, as giving a stimulus  to the whole system, must
urge  any particular determinations before established, still
further,  or may urge to excess  any inequality, otherwise
innocent; so that,  in either way, external heat may  imme-
diately excite hemorrhagies, to which there was a predispo-
sition, or may form congestions  where  there were none be-
fore,  and thereby occasion hemorrhagy.
   2.  A considerable and sudden diminution of the weight of
the atmosphere,  which  seems  to occasion the same  effects
as heat,  by producing also an expansion of the blood.
   3.  Whatever increases the force  of  the circulation, and
thereby the velocity of  the blood, may operate in the same
manner as heat, in urging not only previous  determinations
with  violence, but also in urging  to  excess inequalities,
otherwise innocent.  All violent exercise, therefore, and es-
pecially all violent efforts,  which, not  only by a larger and
longer inspiration,  but  also by the simultaneous action  of
many muscles interrupting the free motion of the  blood,
impel it  with unusual force into the extreme vessels more ge-
nerally, and,  according to the different postures of the body,
and mode of the effort, into certain vessels more particularly.
   Among the causes increasing the force of the circulation,
anger* and other violent active passions are to be reckoned.
 * Passionate children frequently brin:; on a bleeding of the nose ; and when such an accident
happens, ihe child's race, before the blood breaUs oui, becomes red, and all the vessels of toe
head and neck seem distended and full. 
PRACTICE  OF PHYSIC.
251
  4. The violent exercise of particular parts of the body.
If these are already affected with congestions,  or liable to
them, such exercise may be considered  as  a stimulus ap-
plied to the vessels of that particular part.  Thus, any vio-
lent exercise of respiration* may excite hemoptysis, or oc-
casion its return.
  5. The postures of the body increasing determinations,
or ligatures occasioning accumulations of the blood in par-
ticular parts of the body.
  6. A determination into certain vessels rendered habitual
by the frequent repetition of hemorrhagy from them.
  7. Cold, externally applied, as changing the distribution
of the blood,  and determining it in greater quantity into
the internal parts.
                     SECTION IV.

            Of the Cure of Hemorrhagy.

  775.]  HAVING thus considered the proximate  and re-
mote causes of hemorrhagy in general, our next business is,
to treat of the cure of the disease in the same manner.
  In entering upon this subject, the  first question which
presents itself, is, Whether the cure of hemorrhagies ought
to be attempted  by art, or if they should be left to the con-
duct of nature ?
  176.]  The latter opinion was the favorite doctrine of the
celebrated Dr. Stahl, and his followers.  They maintained,
that the human body is much disposed  to a plethoric state ;
and, consequently, to many  disorders  which nature endea-
vors to obviate  and relieve by exciting hemorrhagy :  that
this, therefore, is often necessary to the balance and health of
the system : that it is accordingly to be  generally encou-
raged, sometimes solicited, and is not to be suppressed,  un-
less when it goes to great excess, or happens in parts in which
it may be dangerous.
  177.]  Much of  this doctrine may be admitted.   The hu-
man body, upon many occasions, becomes  preternaturally
plethoric ;  and  the dangerous consequences which might
from thence be apprehended, seem to be obviated by an he-
morrhagy taking place : and, further,  the necessity of  he-

  * As playing on the German flute, or any eiher wind instrument that requires a great force
to blow it. 
252           PRACTICE OF PHYSIC.
 morrhagy often appears from hence, that the suppression
 of it seems to occasion many disorders.
   All this seems to be just; but,  in the conclusion drawn
 from it, there is a fallacy.
   778.] It appears to me certain,  that hemorrhagy, either
 upon its first attack, or upon its after recurrence,  is never
 necessary to the health of the body, excepting upon the sup-
 position, that the plethoric state which seems to require the
 evacuation, cannot be otherwise prevented or removed ; and
 as I imagine  it possible by other means to prevent or remove
 a plethoric state, so I do not think that hemorrhagy is, in all
 cases, necessary.   In general, I am of opinion, that hemor-
 rhagy is to be avoided.
   1.  Because it does not always happen in parts where it
 is safe.
   2.  Because often, while it does relieve a plethoric state,
 it may, at the same time, induce a very dangerous disease.
   3.  Because it may often go to excess,  and either endan-
 ger life, or induce a dangerous  infirmity.
   And,  lastly, Because  it has  a tendency to increase the
 plethoric state it was meant to relieve ;  to occasion its own
 recurrence (720.) and thereby to induce a habit, which,  if
 left to the precarious and unequal operation of nature, may
 from the frequent errors  of this, be attended  with much
 danger.
   779.]  It is further to be considered,  that hemorrhagies
 do not always arise from the necessities of the system, but
 often proceed from incidental causes.  It  appears to me that
 all  hemorrhagies of the latter  kind may be  immediately
suppressed, and the repetition of them,  as it induces a ple-
thora, and a habit not otherwise necessary, may  be pre-
vented with great advantage.
  780.]  Upon  the whole  of this subject, I conclude, that
every preternatural hemorrhagy, or, in other words, every
one except that of the menses in females, is to  be avoided,
and especially the returns  of it prevented  ; and I therefore
now proceed  to mention,  how hemorrhagy, and its recur-
rences, may, and should be prevented.
  781.] From the principles delivered above, it will imme-
diately appear, that the prevention, either of the first at-
tacks,  or of the returns of hemorrhagy, will chiefly, and
in the  first place, depend upon  the preventing or removing
any considerable degree of a plethoric state which may hap-
pen to prevail in the body.  It is true,  that, where the he- 
PRACTICE OF PHYSIC.
253
morrhagy depends upon the particular conformation of cer-
tain parts, rather than  upon  the general plethoric state of
the whole ;  the measures  for  removing or  preventing the
latter, may not always be sufficient for preventing hemor-
rhagy ; but at the same time it must be evident, that de-
terminations,  in consequence  of the conformation of parti-
cular parts, will always be urged more or less, in propor-
tion to the greater or lesser degree of the plethoric state of
the  whole system ;  and therefore, that,  even in the cases
depending upon particular conformation,  the preventing
or  removing  an unusual  plethoric  state, will always be a
chief means of preventing hemorrhagy.  It  is further to
be attended to, that there may be several inequalities in the
balance of the system,  which may  have little or no effect
unless when the system becomes preternaturally plethoric ;
and therefore,  that,  in all cases, the preventing or remov-
ing  of the  plethoric state of the system, will be a chief
means of preventing the first attacks, or the returns of he-
morrhagy.  It now, therefore, remains to explain, how the
plethoric state of the system is to be prevented or removed.
  782.]  The  fluids  of the human body are in continual
waste by the excretions, but are commonly replaced by the
aliments taken in ; and if the quantity of aliments in any
measure exceed that of the excretions, an increase of the
quantity  of the fluids  of the body, or,  in other words,  a
plethoric state, must necessarily arise.  This, to a certain
degree, is requisite for the growth of the body,  but,  even
then, if the proportion of the aliments to the excretions, be
greater than is suited to the growth of the body, and more
certainly  still, if, after the growth is completed, when an
equality between the ingesta  and  the exweta  should be es-
tablished, the disproportion still continue, a preternaturally
plethoric  state must arise.  In both cases, it is evident,
that the plethora must be prevented or corrected by adjust-
ing the ingesta and excreta to each other; which generally
may be  done,  either by diminishing the ingesta, or by in-
creasing the excreta.*  The former may be effected by the
management of diet, the latter by the management of exer-
cise.
  783.] The ingesta may be  diminished, either  by giving
aliment in less quantity than  usual, or by giving aliments
of a less nutritious quality  ; that is, aliments of a substance
which under  the same  bulk and weight, contain less of  a

 * This effect mav surtly be more speedily produced by using both these means at once.
                          2k 
254            PRACTICE OF PHYSIC.

matter capable  of being converted into animal fluids,  and
more of a matter ready to pass off by the excretions,  and
consequently less of a matter to be retained and accumu-
lated in the vessels.
  The choice of aliments suited to  these purposes must be
left to be directed by the doctrines of the Materia Medica.
  784.]  The increasing of the excreta,  and  thereby dimi-
nishing the plethoric state of the system,  is to be obtained
by  increasing the exercise  of the body ; and generally for
adjusting the balance between the ingesta and excreta,  and
thereby  obviating the plethoric state,  it is necessary  that
exercise, in a due measure, be very constantly employed.*
  785.]  The observing abstinence,  and the employment of
exercise, for obviating or removing the plethoric state of
the body,  were  formerly considered pretty fully, when
treating of the gout,  (547, to 551.)  so that the less is ne-
cessary  to be said here : and it is now only  requisite to ob-
serve, that the same doubts, as in cases of the gout do  not
occur here with regard to the safety of  those  measures,
which,  in a plethoric state of the body disposing to  hemor-
rhagy,  are always admissible and proper.   Here, however,
it is to be observed, thut some choice in the mode of exer-
cise is  necessary, and that  it should be different  according
to the particular determinations which may happen to pre-
vail in the system.  In general, in the case of plethora dis-
posing  to hemorrhagy, bodily exercise will always be ha-
zardous, and gestation more commonly safe.
  786.]  Artificial evacuations may be employed to dimi-
nish the plethoric  state of the body :  and  when,  at any
time, it has become considerable, and immediately threat-
ens a disease, these  evacuations should be made to the quan-
tity that the symptoms seem to require.   But it is constant-
ly to be attended to,  that blood-lettings are improperly em-
ployed  to prevent a plethora, as  they have a tendency to in-
crease it (120.) and as they require to be often repeated,
and are thereby apt to induce a habit which may be attend-
ed with  much danger, f
 * The exercise best adapted to these cases is such as does not heat the body or increase the
force of the blood. Hence riding moderately, travelling in a carriage, or sailing, are preferable
to walking.  Young people may use such gentle exercise as may amuse the mind, and at t'.c-
same time conduce to bodily health, as gardening, several agricultural labile, cr mechanical
operations;  or some of the sports that require a gentle bodily exertion, as bowling, ar< her}. fcc.
 + Brisk purges are perhaps preferable to every other mode of evacuating the ingesta: and in
these ca»s we may have recourse to drastics without any apprehension of dan^r.  I tie f'>'-
luwing formula? may serve as specimens of the purges useful in these cases.
          R. Pulv. Rad. Jalap. g£>.
                  Aromat. 3i. 
PRACTICE  OF  PHYSIC.
23a
   787.] While  a plethora, and thereby the predisposition
to  hemorrhagy,  is avoided,  or  removed, the  other mea-
sures necessary  for preventing the occurrence  of this, are
those for  avoiding  the remote  causes.   These have been
enumerated in 774,  and the means of avoiding them, so far
as within our  power, are sufficiently obvious.
  788.] Having thus mentioned the means of preventing
either the first attacks,  or the  recurrence  of hemorrhagy ;
I must next say how it is to  be managed when  it has actu-
ally come on.
   789.] When an  hemorrhagy has come  on which appears
to have arisen from a preternaturally plethoric state, or from
some change in  the balance of  the sanguiferous  system, no
measures are to  be immediately taken for  suppressing it ; as
we may expect, that, when the quantity of blood necessary
for the relief  of the system is poured out, the effusion will
spontaneously cease.*
  790.] In many cases however,  it may be suspected, that
the quantity of blood poured out,  is not exactly in propor-
tion to the necessities of the system, either for relieving a
general plethora  or a particular congestion,  but  that  it is
often to a greater quantity  than these require.   This we
suppose to happen in consequence of an inflammatory dia-
thesis prevailing, and of a febrile spasm being formed ; and
therefore it is  in many cases proper,  as well as for the most

             Sal. Tart. 3ft.
             Syr. Simp. q. s.
             M. f. Elect.
  This electuary may  be divided into four doses, one of which may be taken early in the morn-
ing, at occasion may require.
         R. Pilul. Rusi, 5 ft.
             Calomel, gr. vi.
             Syr. Simpl. q. s.
             M. f. Massa in pilulas equales sex dividend.
  Two of these pills may be taken in the evening, and the remaining four the following morn-
ing.
         R. Resin. Jalap. 9i.
             Tere in mortar, cum Sacch. alb. 3 ft.
             Amygdal. dulc. decorticat. No.  ii.
             Adde gradatim Aq. Cinnamom.  simpl. %'u
             M. f. haust. mane sumend.
  This is a very elegant purge, and has the peculiar advantage of operating powerfully without
griping or occasioning much inconvenience.
  • The doctrine here delivered, and the practice founded on it, is pure Stahlianism; and is,
doubtless, in these cases the best practice. A patient, however, is not always satisfied when
the physician is inactive, which often obliges him to prescribe some of the medicamenta in-
rrtiora, and the choice of them must be left to the practitioner's ovni sagacity. 
256            PRACTICE OF  PHYSIC.

part safe, to moderate the evacuation,  and, when it threat-
ens to go to excess, to suppress it altogether.
  791.]  An hemorrhagy may be moderated by avoiding
any irritation that might concur to increase it; so that every
part of the antiphlogistic regimen  is to be observed ; in par-
ticular, external heat, both as it rarefies the fluids, and sti-
mulates  the solids, is to be carefully  avoided  : and, it is
probable, that in  all cases an  hemorrhagy may be safely
moderated by cool air applied, and cold drink exhibited.
  792.]  A second means for the same  purpose,  is, the use
of refrigerant medicines, and particularly of acids and nitre.*
  793.]  A third means which has been frequently  employ-
ed, is that of blood-letting.   The propriety of this prac-
tice may be doubtful, as the quantity  of  blood poured out
by the hemorrhagy, may be supposed to answer  the purpose
of an evacuation in any other way ; and I am ready to al-
low,  that the practice has been often superfluous, and some-
times hurtful,  by making a greater evacuation than was ne-
cessary or safe.  At the same time, 1 apprehend it  is not for
the mere purpose of  evacuating,  that  blood-letting is to be
practised in the  cure  of hemorrhagy ;  but that  it is further
necessary for taking  off the  inflammatory diathesis which
prevails, and the febrile spasm that has been formed.   Ac-
cordingly, in the case of hemorrhagy,  when the pulse is not
only frequent, but quick and full, and does not become softer
or slower upon  the flowing of the blood,  and that the effu-
sion is profuse,  and threatens to continue so,  it appears to
me, that blood-letting may be necessary, and I have often
found it useful.  It seems  probable also,  that the particular
circumstances of venesection may render  it more  powerful
for taking off the tension and inflammatory irritation of the
system,  than any gradual flow from an artery.
  794.]  That a spasm of  the extreme vessels has a share in
supporting hemorrhagy, appears to me probable from hence,
that blistering has been often found useful in moderating and
suppressing the disease.
   795.]  Do emetics  and vomiting contribute to the cure of

  * The refrigerant medicines have been enumerated in former notes, articles 134. and 135.
The Tinctura rosarum is a very proper acid refrigerant in most hemorrhagies. The dose of it
must be proportioned to the exigency of the case; it ought never to exceed four ounces in the
space of an hour; an ounce every half hour is generally sufficient, and a greater quantity at a
time frequently occasions gripes, and by its irritation increases the disease : especially if it does
not produce a diarrhoea which is seldom the case.  With respect to nitre, the precautions, men-
tioned in the note on article 135, must be observed.  The dulcified spirit of vitriol or of nitre,
are not always safe medicines in these cases, as they heat and irritate. The acid of tartar, in the
form described in the note on article 134. answers very well in most cases. 
PRACTICE  OF PHYSIC.
257
hemorrhagy ?  see Dr. Bryan Robinson on the virtues and
power of medicines.
   796.]  When an  hemorrhagy is very  profuse,  and seems
to endanger life, or even threatens to induce a dangerous
infirmity, it is agreed on all hands,  that it is to be  immedi-
ately suppressed by every means in our power,  and particu-
larly that,  besides the means above-mentioned for moderat-
ing the disease, astringents, internal or external, where the
latter can be applied, are  tobe employed for suppressing it.
   797.]  The  internal  astringents are either vegetable  or
fossil.
   The vegetable astringents, are  seldom very powerful in
the cure of any hemorrhagies, except those of the alimen-
tary  canal.
   The fossil  astringents are  more powerful;  but  some
choice amongst the different kinds may be proper.
   The chalybeats, so frequently employed,  do not appear
to me to be very powerful.
   The preparations of lead are certainly more so, but are
otherwise of so pernicious a quality,  that they  should not
be employed except in cases of the utmost  danger.  The
Tinctura Saturnina, or Antiphthisica, as it has been called,
appears to be of little efficacy;*  but whether from  the
small portion  of  lead which it  contains,  or from the state
in which the lead is in it,  I am uncertain.
   The fossil astringent that appears to me the most power-
ful,  and at the same time the most safe,  is alum.f
   798.]  External astringents,  when they can  be applied,
are more effectual than the internal.   The choice  of  these
is left to the surgeons.
   799.]  The most powerful of all astringents appears to
me to be cold, which  may be employed, either by ap-
plying cold water to the surface of the body, or by throw-
ing it into the internal parts4
   800.]  For suppressing hemorrhagies, many superstitious
remedies and  charms||  have  been recommended, and pre-
 * It is a very dangerous medicine, and ought to be used with the utmost caution. But since
its efficacy is doubtful, we had better abandon it altogether, except when every other remedy
 + Alum frequently irritates if given in too large doses at first, proving sometimes a purgative
and sometimes an emetic.  In cases of great danger, however, it must be given in lar?e quan-
tities by frequently repeating small doses. Five grains is a sufficient dose to begin with: but it
may be repeated every hour, or ever/ half hour. Some authors have given it in doses of a scru-
ple several times  a day ; but that is certainly too great a quantity at once.
 {Van Swieten relates a case of a bleeding at the nose being stopped by the application of
pledgets, dipped in cold wine and water, to the scrotum ; a shivering was produced, and the
bleeding stopped.                                         '
 II It is astonishing that these charms should continue in use in this enlightened age.  They are
practised among  the country people frequently. Some of them, however, act mechanically, ae
riie application o f the great key of the church door to the nape of the neck, in bleedings at the 
 253           PRACTICE OF  PHYSIC.

 tended to liave been employed with success.  The seeming
 success of these, however, has been generally owing to the
 by-standers' mistaking a spontaneous ceasing of the hemor-
 rhagy for the effect of the remedy.  At the same time,  I
 believe,  that those remedies may have been sometimes use-
 ful, by impressing the mind with horror, awe, or dread.
   801.]  Upon occasion of the profuse hemorrhagies, opi-
 ates have been employed  with advantage; and, when the
 fulness and inflammatory diathesis of the system have been
 previously taken off by the hemorrhagy itself, or by blood-
 letting, I think opiates may be employed with safety.*
   802.]  For restraining hemorrhagy, ligatures have been
 applied upon the limbs, in the view of retarding the return
 of the venous  blood  from the extremities ;  but they ap-
 pear to me to be of uncertain and ambiguous use.
   803.]  In the case of profuse hemorrhagies, no pains are
to be taken to prevent a Deliquium  Animi, or  fainting, as
the happenning of this is often the most certain means of
 stopping the hemorrhagy. f
   804. Having thus delivered the general doctrine of he-
morrhagy, I proceed to consider the particular  cases  of it.
 It may perhaps be remarked, that 1  have marked  fewer of
these than are commonly enumerated by the nosologists ;
but my  reasons for differing from these authors,  must be
left to a nosological discussion, to be entered into elsewhere
 more properly than here.
                   CHAPTER  II.

OF  THE EPISTAXIS,  OR HEMORRHAGY  OF
                     THE NOSE.

  805.] rT",HE state of the vessels upon the internal sur-
         X  face of the nose being such as  already men-
tioned (757.) renders an hemorrhagy from that more  fre-
quent than from any other  part of the body.
  806.] The blood commonly flows from one nostril only ;

nose ; drinking large draughts of cold water out of a human skull, &c. The cold iron and the
cold water were in fact proper remedies.
 * Opium, however, ought to be cautiously avoided in active hemorrhagies, which are fre-
quently accompanied with a phlogistic diathesis; and it is well known, that in such a diathesis,
opium is generally, if not universally, hurtful.  But, as the author observes, when the hemor-
rhagy has reduced the inflammatory diathesis, we may then give  opium freely; and for this
purpose large doses aie preferable to smaller ones.
 * Attention, however, is necessary in this case, as fainting is frequently the forerunner of death. 
               PRACTICE OF  PHYSIC.          259

 and probably, because an hemorrhagy from one vessel re-
 lieves the congestion in all the neighboring vessels.
   The blood flowing  from  both nostrils at the same time,
 shows commonly a more considerable disease.
   807.]  This  hemorrhagy  happens to persons  of every
 constitution and temperament, but most frequently to those
 of a plethoric habit and sanguine temperament.  It hap-
 pens to both sexes, but most frequently to the male.
   808.]  This hemorrhagy may occur at any time of life;
 but most commonly happens to young persons,  owing to
 the state of the balance of the system peculiar to that age,
 as mentioned in 755.
   809.]  Although generally it happens to persons before
 they have  arrived at  their  full growth,  and more rarely
 afterwards; yet sometimes it happens to persons after their
 acme, and during the state of manhood :  And it must then
 be imputed to an unusually plethoric state of the system ;
'to an habitual determination of the blood to the vessels of
 the nose; or to the particular weakness of these.
   810.]  In all these cases the disease may  be  considered as
 an hemorrhagy purely arterial, and depending upon an ar-
 terial plethora ;  but it sometimes occurs in  the decline of
 life, when probably it depends upon, and may be  consi-
 dered as a  mark of a venous plethora of the  vessels of the
 head.  See 771.
   811.]  This hemorrhagy happens also at any  period of
 life, in certain febrile diseases,  which are  altogether or
 partly of an inflammatory nature, and which show a par-
 ticular determination of the blood to the vessels of the
 head.   These diseases often admit of a  solution by  this
 hemorrhagy,  when it may be properly  termed critical.
   812.]  The disease sometimes comes on  without any pre-
 vious  symptoms ; particularly, when some  external vio-
 lence has a share in producing it.  But,  when it proceeds
 entirely  from  an internal cause, it is commonly  preceded
 by headachs,  redness of the eyes, a florid color of the
 face, an unusual pulsation  in the  temples, a sense of  ful-
 ness about the nose,  and an  itching of  the nostrils.   A
 bound belly, pale urine, coldness  of the feet, and cold  shi-
 vering over the whole body, are also sometimes among the
 symptoms that precede the disease.
   813.]  From the weakness of the vessels of the nose,  the
 blood often flows from them without any considerable ef-
 fort of the whole system,  and therefore  without anv  ob- 
 260          PRACTICE OF PHYSIC.

 servable febrile disorder ;  which, however, in many cases;
 is, in all its circumstances, very discernible.
  814.] An hemorrhagy of the nose happening to young
 persons, is, and may generally be considered, as a slight
 disease  of little consequence, and hardly requiring any re-
 medy.   But, even in young persons, when it recurs very
 frequently, and is very copious, it will require particular
 attention, as it is to  be considered as a mark of arterial
 plethora ;  and, as frequently returning, it may increase the
 plethoric state ; which, in a more advanced stage  of life,
may give the blood a determination to parts from which
the hemorrhagy would be  more dangerous.   All  this will
 more particularly require  attention,  according as  the
 marks of plethora, and of particular congestion,  preced-
 ing the  hemorrhagy,  are  more considerable ;  and as the
 flowing of the blood is attended with a more considerable
 degree of febrile disorder.
  815.] When the epistaxis happens to persons after  their
 acm6,  returning frequently, and flowing copiously,  it is
 always  to be  considered as a  dangerous disease, and  as
 more certainly threatening the consequences mentioned in
 the last paragraph.
  816.] When this  hemorrhagy happens in the decline of
 life, it may be considered  as in itself very salutary : but at
 the same time, it is  to be considered as a mark of a  very
 dangerous state of the system; that is, as a mark of a very
 strong tendency to a venous plethora in the vessels of the
 head :  and I  have accordingly  observed it often  followed
 by apoplexy, palsy,  or such like diseases.
  811.] When an hemorrhagy from the nose happens in
 febrile diseases, as mentioned in 811, and is in pretty large
 quantity, it may be considered as critical and salutary; but
 it is very apt to be profuse, and even in this way dangerous.
  It upon some occasions occurs during the eruptive fever
 of some exanthemata, and  in  such cases sometimes sa-
 lutary ; but, if these exanthemata be accompanied  with
 any putrid tendency, this hemorrhagy, like artificial blood-
 lettings, may have very bad effects.
  818.] Having thus explained the several  circumstances
 of epistaxis,  I proceed to consider the management and
 cure of it.   I  use the expression of management,  because
 it has been usually  thought to require no cure,  but that
 nature should be  allowed to throw out blood in  this way
 very frequently,  and  as often as it appears to ayise from 
PRACTICE OF PHYSIC.            261
 internal causes, that is, from a state of the  system sup-
 posed to require such evacuation.
   819.]  I am however,  of opinion, for the reasons given
 in 778. that this  disease  is very seldom  to be  left to the
 conduct of nature ; and that in all cases it should  be mo-
 derated by keeping the  patient in cool air; by giving cold
 drink ; by keeping the  body and head erect; by avoiding
 any  blowing of the nose, speaking,  or  other  irritation :
 And, when the blood has flowed  for some time, without
 showing any tendency to cease, a profuse bleeding is to be
 prevented by measures  employed  to stop it,  such as pres-
 sing  the nostril from which the blood flows,  washing the
 face with cold water,  or applying this to other parts of the
 body.
   820.]  Even in the case of young persons, where the dis-
 ease is least hazardous, and even in the first attacks, I judge
 such measures to be proper; but they will be  still more
 proper if the disease frequently recurs without any external
 violence ;  if the returns shall happen to persons  of a habit
 disposed to be plethoric; and more particularly, if the marks
 of a plethoric  state appear in the precedent symptoms (812.)
   821.]  Even in young persons,  if the bleeding be very
 profuse  and  long  continued, and more  especially if the
 pulse become weak and the face pale,  I  apprehend it will
 be  proper to  suppress the hemorrhagy by every means in
 our power.  See 796, and following paragraphs.*
   822.]  Further, in the  same case  of young persons,  when
 the returns of this hemorrhagy become frequent,  and es-
 pecially with the marks of a plethoric habit,  I think it ne-
 cessary to employ such a regimen as may prevent a pletho-
 ric state, (782. 786.)   At the same time, care  should  be
 taken to avoid all circumstances which may determine the
 blood more fully to the  vessels of  the head, or prevent  its
 free  return from them; and,  by keeping an  open  belly to
 make some derivation from them.f
  823.]  In adult persons  liable to frequent returns of the
 epistaxis, the  whole of the measures proposed  (822.) are
 more certainly and freely to be employed.   When, with
 the circumstances mentioned in 812, the'tendency to a pro-

 * Beside the general directions referred  to above, plugs of lint or cotton, impregnated with
 vinegar and a solution of alum, are recommended. Thick cotton threads, impregnated wiih
 these styptic solutions, have been passed through the nostril, and brought out by the mouth by
 means of a bent probe, with great success.
 + For this purpose Glauber's salt seems'peculiarly adapted. It operates speedilv, and wiihout
 °;'. m;UC . ,1 « .'ril5 «vf1cua,lnS « <he same times, not only the contents of the intestinal canal.
but the superfluities of the sanguiferous system.
2l 
262           PRACTICE OF PHYSIC.

fuse hemorrhagy appears, a bleeding at the arm  may be
proper, even in young persons ; but in the case of adults,
it will be still more allowable,  and even necessary.
  824.] In persons of  any age liable to frequent returns
of this hemorrhagy, when the measures proposed in 816.
et. seq. shall have been neglected, or from peculiar circum-
stances in the balance of the system, shall have proved in-
effectual, and the symptoms threatening hemorrhagy (817.)
shall appear, it will then be proper, by blood-letting, cool-
ing purgatives,  and every part  of the antiphlogistic regi-
men, to prevent the hemorrhagy,  or at least to prevent its
being profuse when it does happen.
  825.] In the  circumstances just now mentioned (824.)
the  measures proposed are proper, and even necessary;
hut  it should at the same time be observed, that these are
practised with much less advantage than those pointed out
in 823 ;  because,  though those suggested here may pre-
vent the coming  on of the hemorrhagy for  the present,
they certainly however dispose to the return of that ple-
thoric state which required their being  used ;  and there
can  be no proper security against  returns of the disease,
but  by pursuing the means proposed in 822.
   826.]  When the hemorrhagy  of the  nose happens to
persons approaching their full growth, and when its returns
have been preceded by the symptoms (812.) it may be sup-
posed, that, if  the returns can be prevented  by the mea-
sures proposed in 824,  these may be safely employed;  as
• the  plethoric state induced will be rendered  safe,  by  the
change which is soon to take place in the balance of  the
system.   This, however, cannot be admitted ; as the eva-
cuations  practised upon this plan will have all  the conse-
quences which, I have already  observed, may  follow  the
recurrence of the hemorrhagy itself.
   827.]  When the hemorrhagy of the nose shall be found
to make its returns at nearly stated periods, the measures
for preventing it (824.) may be practised with  great cer-
tainty ; and, upon every repetition of blood-letting, by di-
minishing the quantity taken away, its tendency to induce
 a plethora may be in some measure avoided.    When in-
 deed, the repetition of evacuations is truly  unavoidable,
 the diminishing them upon every repetition is properly
 practised ; but it  is a practice of nice and precarious ma-
 nagement, and should by no means be trusted to,  so far 
PRACTICE OF PHYSIC.
263
as to supersede the measures proposed in 824,  wherever.
these can be admitted.
  828.] When the  hemorrhagy of the nose happens in
consequence of a venous plethora in the vessels of the head,
as in 771. the  flowing of the blood pretty largely  may
be allowed, especially when it happens after the suppres-
sion or ceasing  of  the  menstrual  or hemorrhoidal  flux.
But though the flowing of the blood is,  on  its first occur-
ring, to be allowed,  there is  nothing more proper  than
guarding against its returns.  This is  to be done not only
by  the measures proposed in 782. et seq. but,  as the ef-
fects of a plethoric state of the vessels of the  head are very
uncertain  ; so, upon any appearance of it, and  especially
upon any  threatening of hemorrhagy, the plethora is to be
removed,  and  the hemorrhagy to be obviated immediately
by proper evacuations, as blood-letting, purging, and issues;
or by restoring suppressed evacuations, where this can be
done.
                  CHAPTER  III.

OF THE  HEMOPTYSIS,  OR  HEMORRHAGY
                FROM THE LUNGS.

                    SECTION  I.

   Of the Phenomena and Causes of Hemoptysis.

  829.] XT THEN, after  some  affection of  the  breast,
         V V  blood is  thrown out from the mouth, and is
brought out with more or less of coughing, there can be no
doubt that it comes from the lungs ; and this generally as-
certains the disease of which I am now to treat.  But there
are cases in which the source of the blood spit out is uncer-
tain ;  and therefore, some other considerations to be men-
tioned hereafter, are tiften necessary to ascertain the exist-
ence of an hemoptysis.
  830.] The blood-vessels of the lungs  are more numerous
than those of any other part of the body of the same bulk.
These  vessels, of the largest  size, as they arise from  the
heart, are more immediately than in any other  part subdi-
vided into vessels of the  smallest size ; and these small ves-
sels spread out near to the internal  surfaces of the bronchial 
264
PRACTICE OF PHYSIC.
cavities, are situated in a loose cellular texture, and cover-
ed by a tender membrane only :  so that, considering how
readily and frequently these vessels are gorged with blood,
we may understand why an hemorrhagy from them is, next
to that of the nose, the most frequent of  any; and particu-
larly, why any  violent shock given to the  whole body so
readily occasions an hemoptysis.
  831.] An hemoptysis may be occasioned by external vio-
lence, at  any  period of life ;  and I have explained above
(759.) why, in  adult  persons, while the arterial plethora
still prevails in the system, that is,  from the age of sixteen
to that of five-and-thirty, an hemoptysis may at  any time
be produced,  merely by a plethoric state of the lungs.
  832.] But it  has been also  observed above,  (760.) that
an hemoptysis more frequently arises from a faulty propor-
tion  between the capacity of the vessels of the lungs and
that  of the rest of the body.   Accordingly it is often a he-
reditary disease, which implies a peculiar and faulty con-
formation.  And the disease also happens especially to per-
sons who discover the smaller capacity of their lungs, by the
narrowness  of their chest, and by the prominency of their
shoulders  ; which  last is a mark of their haying been long
liable to a difficult respiration.
  833.] With these circumstances also the disease happens
especially to persons of a sanguine temperament;  in whom,
particularly, the  arterial plethora  prevails.   It  happens
likewise to persons of a slender delicate make, of which a
long neck is a mark;  to persons of much sensibility and ir-
ritability,  and  therefore of quick parts, whose bodies are
generally  of  a  delicate structure ;  to persons who have
been formerly liable to frequent hemorrhagies of  the nose ;
to persons who have suffered a suppression of any hemorrha-
gy they had formerly been liable to, the most  frequent in-
stance of which is in females who have suffered a suppression
of their menstrual flux; and,  lastly, to persons who have
suffered the amputation of any considerable limb.
  834.] In  most of these cases (833V) the  disease happens
especially to persons about the time of their coming to their
full growth, or soon  after it,  and this for the reasons fully
set foith above.
  835.]  From all that has been  said from 830, to 834,
the predisponent  cause of hemoptysis will be sufficiently
understood, and the disease may happen  from the mere cir-
cumstance of the predisponent cause arising  to  a considera- 
PRACTICE OF PHYSIC.
265
ble degree.  In the predisposed, however, it is often brought
on by the concurrence of various occasional and exciting
causes.   One of these, and perhaps a frequent one, is ex-
ternal heat; which, even when in no great degree, will bring
on  the disease  in  spring,  and the beginning of summer,
while the heat  rarefies the  blood  more than it relaxes the
solids which had been before contracted  by the cold of
winter.   Another exciting cause is a sudden diminution of
the weight of the atmosphere, especially when concurring
with any effort in bodily exercise.  This effort, too, alone,
may often, in the predisposed, be the exciting cause ; and,
more particularly, any violent exercise of respiration.  In
short, in the predisposed,  any degree of external violence
also may bring on the disease.
  836.] Occasioned  by one or other of these causes (835.)
the disease comes on with a sense of weight and anxiety in
the chest, some uneasiness in breathing, some pain of the
breast or other parts of the thorax, and some sense of heat
under the sternum ; and very often, before the disease ap-
pears,  a saltish taste is perceived in the mouth.
  837.] Immediately before the  appearance of blood,  a
degree of irritation is felt at the top of the larynx.   To re-
lieve this, a hawking is made, which brings up a little blood,
of a florid color, and somewhat frothy.  The irritation re-
turns ; and, in  the same manner, more blood of a like
kind is brought up, with some noise in the windpipe, as
of air passing through a fluid.
  838.] This is commonly the manner in which the he-
moptysis begins ;  but sometimes at the very first the blood
comes up by coughing, or at least somewhat of coughing
accompanies the hawking just now mentioned.
  839.] The blood  issuing is  sometimes, at first in very
small quantity, and  soon  disappears  altogether : but, in
other cases, especially when it repeatedly occurs, it is in
greater quantity,  and frequently continues to  appear at
times for several days  together.  It is sometimes profuse  ;
but rarely in such quantity as either by its excess, or by
its  sudden  suffocation, to  prove immediately mortal.  It
commonly either ceases spontaneously, or is stopped by
the remedies employed.
   840.]  When blood is thrown out from the mouth, it is
not  always easy to  determine from what internal part it
proceeds ;  whether from the internal surface of the mouth
itself,  from the fauces, or adjoining cavities of the nose, 
266
PRACTICE OF  PHYSIC.
from the stomach, or from the lungs.  It is, however, verv
necessary to distinguish the different cases ; and, in most
instances, it  may be done by attending to the  following
considerations.
   841.] When  the blood spit out, proceeds from some
part of the internal  surface of the mouth itself, it comes
out without any hawking or coughing ; and generally, up-
on inspection, the particular source  of it becomes evident.
   842.] When blood proceeds from the fauces,  or adjoin-
ing cavities of the nose, it may be brought out by hawk-
ing, and sometimes by coughing,  in the manner we have
described in 836, and 838 ; so  that, in this way, a doubt
may arise concerning its real source.  A patient often lays
hold of these circumstances  to please  himself with the
opinion of its coming from the fauces, and he may be al-
lowed to do so : but a physician cannot readily be deceiv-
ed, if he consider, that a bleeding from the fauces is more
rare than one from the lungs ;  that the  former seldom hap-
pens but to persons who have been  before liable either to an
hemorrhagy of the nose, or to some evident cause of ero-
sion ; and, in most cases, by  looking into the  fauces, the
distillation of the blood, if it comes from thence,  will be
perceived.
   846.] When blood proceeds from the lungs,  the manner
in which it is brought up will commonly show from whence
it comes: but,  independent of that, there are many cir-
cumstances which may occur to point it out, such as the
period of life, the habit of body, and  other marks of a
predisposition (832.—834.) and together  with these, the
occasional causes  (835.)  having been immediately  before
applied.
   844.] When vomiting  accompanies  the throwing out of
blood from the  mputh, as vomiting and coughing often
mutually  excite each other;  so they  may be frequently
joined, and render it doubtful whether the blood thrown
out proceeds from the lungs  or from  the stomach.  We
may however generally decide, by considering, that blood
does not so frequently  proceed from the stomach as from
the lungs  : that blood proceeding from the stomach com-
monly appears in greater quantity,  than when it proceeds
from the lungs :  that the blood proceeding from the lungs
is usually of a florid color, and mixed with a little frothy
mucus only ;  whereas the blood from the stomach is com-
monly of  a darker color, more  grumous, and mixed with 
              PRACTICE OF  PHYSIC.           267

the other contents of the stomach :  That  the coughing or
vomiting,  according as the one or the other first arises in
the cases in which they are afterwards joined, may some-
times point out the source of the blood ; and, lastly, that
much may be learned from the circumstances and  symp-
toms which have preceded the hemorrhagy.
  Those which precede  the  hemoptysis, enumerated in
836, are  most of them evident marks of an affection of
the lungs.  And, on the other hand, the  hematemesis, or
issuing of blood from the stomach, has also its peculiar
symptoms and circumstances preceding it; as, for instance,
some morbid affection of this organ, or at least some pain,
anxiety, and  sense of weight, referred distinctly to  the re-
gion of  the stomach.   To all this may be added, that the
vomiting  of  blood happens  more frequently  to  females
than to males ; and to the former, in consequence of a sup-
pression of their menstrual flux : and, by attending to all
these considerations  (841.—844.) the  presence  of the he-
moptysis may commonly be sufficiently ascertained.
                    SECTION II.

            Of the Cure of Hemoptysis.

  845.] THIS  disease is sometimes attended with little
danger ;  as when it happens to females in consequence of
a suppression of the menses ;* when, without any marks of
a predisposition, it arises from external violence ; or when,
from whatever cause arising, it leaves behind it no cough,
dyspnoea, or other  affection of the lungs.   Even in such
cases, however, a danger may arise from too large a wound
being made in the vessels of the lungs ; from a quantity of
red blood being left to stagnate in the cavity of the bron-
chiae ;  and  particularly, from  any determination of the
blood being  made into the vessels of the lungs, which, by
renewing the hemorrhagy,  may have dangerous conse-
quences.  In every instance therefore of hemoptysis,  the
effusion is to be moderated by the several means mention-
ed  (791, to 794.)
   846.]  These measures are especially necessary when the
hemoptysis  arises in consequence  of  predisposition ; and

  • The author might have added, " And when no symptoms of phthisis have preceded or ac-
" companies the hemorrhage." 
 268             PRACTICE OF PHYSIC.

 in all cases where  there is the appearance of a large effu-
 sion, or where the hemorrhagy frequently returns,  the ef-
 fusion is not only to be moderated,  but to be entirely stop-
 ped, and  the returns of it prevented  by every means in
 our power.   See 796, and following.*
   847.] To stop an hemoptysis,  or prevent the returns of
 it,  two medicines  have been frequently employed ; neither
 of  which  I can  approve of.   These are, chalybeates, and
 the Peruvian bark.   As both of them contribute to increase
 the phlogistic diathesis of  the system,  they  can hardly  be
 safe in  any  case of active  hemorrhagy,  and  I have fre-
 quently found them hurtful.
   848.] As the hemoptysis which happens in consequence
 of  predisposition,  is always attended with a  phlogistic dia-
thesis :  and, as  the bad consequences of the  disease are es-
 pecially to be apprehended from  the continuance  of that
diathesis ; so this is  to be industriously taken off by blood-
 letting, in greater or smaller quantity, and more  or less
 frequently repeated, according  as  the  symptoms shall di-
 rect.   At  the  same time, cooling purgatives are to  be em-
 ployed, and every part  of the antiphlogistic regimen is to
 be  strictly enjoined.   The refrigerants may also be adminis-
 tered ;  taking care,  however,  that the acids, and more es-
 pecially the nitre,f do not excite coughing.
  * The tincture of roses has been frequently employed with success in these cases :  alum, how-
 ever, is the principal astringent-  It may be given, either by itself m small and often repeated
 doses, or combined with  terra Japonica. The following formula is very convenient:
         R. Alumin.
             Terr. Japonic,  aa. 5'.
             Conserv. Rosar.  §i.
             M.  f. Elect, cum. syr. commun. q. s.
  The dose ought to be proportioned to the exigency of the case : in general, the  above pre-
 scribed mass may be divided into ten equal parts; one of which may be  given every two hours,
or in uVgent cases, every hour.  In using this medicine, it will be necessary to keep  the belly
open : but  for this purpose, purgatives are ill adapted, as they carry off with them the medi-
cine that is  employed: giysters are therefore preferable ;  and in order that they be the more
effectual, they ought to be somewhat of a stimulating nature : as,
         R. Infus. Sennae, Svi.
             Sal. Cathartic. Amar. §i.
             Decoct. Hordei,  Bviii.
             M.
        Or,
         R. Pulp. Tamarind.  I'u.
             Crem.  Tart. 5 ft.
             Coque  in Aq. font. q. s. ad colaturae §xii.
             Adde,  Mann. I'u.
             M.
  + Nitre ou»ht to be cautiously used in all complaints of the lungs, on account of the irritation
which it produces, and ihe subsequent cough which it excites. 
                 PRACTICE OF PHYSIC.             269


   849.]  From  what was observed  in  794, it  will appear

that blistering upon the breast or back may be a remedy of

hemoptysis, when  it is present; and that issues in the same

places may be useful in preventing the recurrence of it when
it has ceased.

   850.]  The avoiding of motion is generally a proper part

of the antiphlogistic  regimen ;  and in the hemoptysis,  no-

thing is  more necessary than avoiding bodily exercise : But

some  kinds of gestation,  assailing,* and travelling in  an

easy carriage on smooth roads, have often proved a remedy.

   851.]  Such is the treatment I can propose for the hero<*p-

tysis, considered merely  as  an  hemorrhagy :  But  wheu,

in spite of  all  our precautions,  it continues  to recur, it is

often followed  by an  ulceration  of the lungs, and  a phthi-

sis  pulmonalis.  This, therefore, I  must  now proceed to

consider ;  but, as it arises also from other causes besides the

hemoptysis, it must be treated of with a more general view.f
                       CHAPTER IV.



OF  THE PHTHISIS  PULMONALIS,  OR  CON-

            SUMPTION  OF THE  LUNGS.


                         SECTION  I.



   Of the Phenomena and  Causes of  the Phthisis

                         Pulmonalis.


   852.]  HHHE Phthisis  Pulmonalis I would define to be,

           JL   an expectoration of pus, or  purulent  matter

from the lungs,  attended with a hectic fever.

  • A sea-voyage has often been prescribed for hemoptysis: it is nevertheless, a very dangerous
practice, on  account of the violent agitation produced by the sea-sickness in the action of vo-
miting. The violence of the retchings in sea-sickness, especially after the contents of the stom-
ach are thoroughly evacuated, has been known to cause hemoptysis,  by a rupture of some consi-
derable vessel.  The hemorrhagy, indeed, hence proceeding, is not  an active hemorrhagy; but,
nevertheless, in a phlogistic diathesis, which predisposes to an active hemorrhagy, we ought al-
ways to be cautious how we employ remedies, which, although they do not immediately increase
the predisposing diathesis, produce the least irritation, or give any violent shock in their action.
 Speaking loud, singing, playing on wind instruments, and whatever requires any exertion of
the lungs, ought to be carefully avoided.
  + In the cure of the hemoptysis, the patient's drink ought to be of the acidulous kind, or of
the acidulous and astringent Kinds conjoined.  The vitriolic acid is therefore the most eligible,
but it ought to be well diluted. A pleasant drink may be composed of one part of the tincture
of roses, and four of cold water: or  the tincture of roses may be prescribed with five times the
quantity of water that ii ordered in the Pharmaccepia. The acid of tartar dissolved in  twenty
times its weight of water, and sweetened with a little syrup of roses, is also a suitable drink.
A decoction either of the fresh fruit of quinces, sweetened with sugar, or an infusion of quince
marmalade, is another excellent acid astringent.
 In addition to what has been said, it may be proper to obsei ve, that opium is admissible only
in very few cases of hemoptysis, viz. when the hemoptysis is the consequence of coughing. These
eases are very di mcultly distinguished. If the blood De thrown out into the lunga, a cough is

                               2 M 
270            PRACTICE OF PHYSIC.

   As this  is the principal species of phthisis, I shall fre.
quently in this chapter employ the general term of phthisis,
though strictly meaning the phthisis pulmonalis.
   853.]  I have met with some instances  of an expectora-
tion of purulent matter, continuing for many years, accom-
panied with very few symptoms of hectic, and  at least with-
out any  hectic exquisitely formed : But, in none  of these
instances, were the persons so entirely free from symptoms
of hectic, as to form any exception to the general definition.
   854.]  In every  instance  of an expectoration of pus,  I
presume there is an ulceration of the lungs.  The  late Mr.
de Haen is the only author that I know of, who has advanced
another opinion, and has supposed,  that  pus may be form-
ed in the blood-vessels, and  be from thence poured  into the
bronchiae.  Admitting his fact,  I have attempted an expla-
nation of the appearance of pus  without ulceration in 349 ;
but, after all,  I cannot help suspecting the accuracy of his
observations ; must entirely reject his explanation of them ;
must however allow, that we still want facts to support the
explanation I have offered ;  and doubt much if it will apply
to any case  of phthisis.   For these reasons I still conclude,
agreeably to the faith of all other dissections,  and the opi-
nions  of all physicians, that the symptoms mentioned in
our definition depend always upon an ulceration formed in
the lungs.
   855.]  It has sometimes happened, that a catarrh was at-
tended with  an expectoration  of a  matter so much  resem-
bling  pus, that physicians  have been often uncertain whe-
ther it was mucus  or pus,  and therefore whether  the dis-
ease was a catarrh or a phthisis.   It is often of  consequence
to determine  these questions ; and it appears to me that  it
may  be  generally done,  with sufficient  certainty, from
the following considerations, of which each particular is not
always singly decisive, but when they are taken together,
can hardly deceive us.
   1. From the color of the matter ;  as mucus is naturally
transparent, and  pus  always  opaque.  When  mucus  be-
comes opaque, as it sometimes does,  it  becomes  white,
yellow, or greenish ; but the  last mentioned color is hardly
ever so remarkable in mucus as in pus.
 excited for its discharge, and then the hemoptysis is the primary disease: in this case opium
 does more harm than good.  But if a cough arising from any other irritating cause, than extra
 vased blood in tie lungs, should by its violence and long continuance, produce an hemoptysis,
 then opium, joined with such lemedies as aie suitable to remove  the peculiar irritation, is the
 only medicine on which we can have any reliance ; and in these cas;s we must use it in hi%e
 doses, such as forty or fiity drops of laudanum. 
PRACTICE  OF PHYSIC.
271
   2.  From the consistence ;  as mucus is more viscid and co-
herent, and pus less so, and may be said to be more friable.
When mucus is thrown into water, it is not readily diffused,
but remains united in uniform and circular masses: but pus,
in the same circumstances, though not readily diffused, does
not remain  so uniformly  united, and by a little Agitation
is broken into ragged fragments.
   3.  From the odor ; which is  seldom perceived in mucus,
but frequently in pus.  It has been proposed to try the odor
of the matter expectorated, by throwing it upon live  coals ;
but in such a trial both mucus and pus give out a disagreea-
ble smell, and it is not easy to distinguish between them.
  4.  From the specific gravity compared with water ;  and
indeed, it is usual for the mucus of the  lungs to swim on
the surface of water,  and for pus to sink in it.  But  in this
we may sometimes be deceived ; as pus which has entangled
a great deal of air may swim, and  mucus that is free from
air may sink.
  5. From the mixture which  is discernible in the matter
brought up : for if a yellow or greenish matter appears sur-
rounded with a  quantity of  transparent or less opaque  and
less colored matter,  the more strongly colored matter may
be generally considered as pus ;  as  it is not easy to under-
stand  how one portion of the mucus of the lungs can  be ve-
ry considerably changed, while the rest of it is very little so,
or remains in its ordinary state.
  6. From the  admixture of certain substances with  the
matter thrown out from the lungs.   To this purpose we are
informed by  the experiments of the late Mr. Charles Dar-
win:  a.  That the vitriolic acid  dissolves  both mucus  and
pus, but most readily the former : That, if water be added
to such a solution of mucus, this is  separated,  and  either
swims on the surface, or,  divided into flocculi,  is suspend-
ed in the liquor ; whereas, when water is added to a like so-
lution  of pus, this  falls to the bottom, or by agitation  is
diffused so as to exhibit an uniformly turpid liquor,   b. That
a solution of the caustic  fixed alkali, after some time,  dis-
solves mucus,  and generally pus ;  and,  if water be  added
to such solutions, the pus is precipitated, but the mucus  is
not.   From such experiments it is  supposed, that pus  and
mucus may be certainly distinguished from each  other.
  7. From the expectoration's being attended with a hectic
fever.   A catarrh, or expectoration of mucus,  is often at-
tended with fever ; but never, so  far as I have observed, 
272           PRACTICE OF PHYSIC.

with such a fever as I am presently to describe as a hectic.
This, in my opinion, is the most certain mark of a puru-
lent state in some part of the  body ;  and if others have
thought differently,  I am persuaded that it has been owing
to thisjjyiat, presuming upon the mortal nature Of a con-
firmed'w purulent  phthisis, they  have considered every
case in which a recovery happened, as a catarrh only : but,
that they  may have been mistaken in this,  shall be shewn
hereafter.
  856.] Having thus considered  the first part of the charac-
ter  of the phthisis  pulmonalis as  a mark of an ulceration of
the lungs ; and having just now  said, that the other part of
the character, that is, the hectic  fever, is a mark or indica-
cation of the same thing ;  it is proper now to consider this
here,  as I had with that view omitted it before (74.)
  857.] A hectic  fever has the  form of a remittent, which
has exacerbations twice every day.   The first of these oc-
curs about noon,  sometimes a little sooner or later ; and a
slight remission of it happens about five, afternoon.  This
last is  soon succeeded by another exacerbation,  gradually
increasing till after midnight:  But after two o'clock of the
morning,  a remission takes  place, which becomes more and
more considerable  as the morning advances.  The exacer-
bations are  frequently attended  with some degree of cold
shivering  ; or at least, the patient is exceedingly sensible
to any coolness of the  air, seeks external heat,  and often
complains of a sense  of cold, when,  to the thermometer, his
skin is preternaturally warm.  Of these exacerbations, that
of the evening is always the most considerable.
  858.] It has commonly been given as a part of the cha-
racter of a hectic  fever, that an exacerbation  of it com-
monly appears after the taking  food; and it is  true that
dinner, which is taken at noon or after it,  does seem to oc-
casion some exacerbation.  But this must not make us judge
the mid-day exacerbation to be the effect of eating only ; for
I have often observed it  to come on an hour before noon,
and often some hours before dinner; which, in this country
at present, is not taken till some time afternoon.  It is indeed
to be observed, that in almost every person, the taking food
occasions some degree of fever :  but  I am persuaded  this
would not appear so considerable in a hectic, were it not that
an exacerbation of fever is  present from another cause; and
accordingly, the taking food in the morning has hardly any
sensible effect. 
PRACTICE OF  PHYSIC.
273
  859.] I have thus described the general form of  hectic-
fever ;  but many circumstances attending it, are further to
be taken notice of.
  The fever I have described does not commonly subsist
long,  till  the  evening exacerbations become attended with
sweatings  ; which continue to recur, and to prove more and
more profuse,  through the whole course of the disease.
  Almost  from the first appearance of the hectic, the urine
is high-colored, and deposits a copious branny red sediment,
which  hardly ever falls close to the bottom of the vessel.
  In the hectic, the appetite for food is generally  less im-
paired  than in  any other kind  of fever.
  The thirst is seldom considerable; the mouth is commonly
moist ; and  as  the disease advances, the tongue  becomes
free from all fur, appears very clean ; and in the advanced
stages  of  the disease, the tongue and fauces appear to be_
sowewhat inflamed, and become more or  less covered with
aphthae.
  As the disease advances, the red vessels of the adnata of
the eye disappear,  and the whole of the adnata becomes of
a pearly white.
  The face  is  commonly pale;  but,  during the exacerba-
tions, a florid red, and an almost circumscribed spot, appear
on each cheek.
  For  some  time,  in the course of a hectic, the belly is
bound ; but, in the advanced stages of it, a diarrhoea almost
always comes  on, and continues to recur frequently during
the rest of the disease, alternating in some measure with the
sweatings mentioned above.
  The disease is  always attended with a debility,  which
gradually increases during the course of it.
  During the  same course, an emaciation takes place, and
goes to a greater degree than  in almost any other case.
  The falling  off of the hairs, and the adunque form of the
nails, are also symptoms of the want of nourishment.
  Towards the end of the disease, the feet are often affected
with cedematous swellings.
   The exacerbations of the fever are seldom attended with
any headach,  and scarcely ever with delirium.
  The senses and judgment commonly remain entire to the
very end  of the disease ;  and  the  mind, for the most part,
is confident  and full of hope.
  Some days before death, a  delirium comes on, and com-
monly continues to the end. 
274
PRACTICE  OF PHYSIC.
   860.]  The hectic fever now described (857,858.)  as ac-
 companying a purulent state of the  lungs, is perhaps the
 case in which it most frequently appears : but I have never
 seen it in any case, Avhen there  was not evidently, or when
 I had not ground to suppose, there was a permanent puru-
 lency or ulceration  in  some external or internal  part.    It
 was for this reason that in 74,1  concluded it to be a sympto-
 matic fever only.   Indeed, it appears to me to be always the
 effect of an acrimony absorbed  from abscesses or ulcers, al-
 though it is not equally  the effect of every sort of acrimony;
 for the scorbutic and cancerous kinds often subsist long in
 the body without producing a hectic.  What is the precise
 state of the acrimony producing this, I cannot determine,
 but it seems to be chiefly that of a vitiated purulency.
  861.] However this may be,  it appears, that the hectic's
 depending in general upon an acrimony, explains its pecu-
 liar circumstances.  The febrile state seems to be chiefly an
 exacerbation of that frequency  of  the pulse, which occurs
 twice every day to persons in health,  and may be  produced
 by acrimony alone.  These  exacerbations, indeed, do  not
 happen without the proper circumstances of pyrexia ;  but
 the spasm of the extreme vessels in a hectic does not seem
 to be so considerable as in other  fevers ;  and  hence the state
 of sweat and urine which appears so early and so constantly
in hectics.   Upon the same supposition of an acrimony cor-
 rupting the fluids,  and debilitating the moving powers, I
 think that most of the other symptoms may also be explained.
  862.] Having thus considered the characteristical symp-
 toms and chief part of  the proximate cause of the phthisis
pulmonalis, I proceed to observe, than an ulcer of the lungs,
and its concomitant circumstances of hectic fever,  may arise
 from different previous affections of the lungs ; all of which
 however may, in my opinion, be referred to five heads ; that
is,  1. To an hemoptysis ; 2.  To a suppuration of  the lungs
 in consequence of pneumonia ;  3. To catarrh ; 4. To asth-
 ma ; or, 5.  To a tubercle.  These several affections, as cau-
 ses of ulcers, shall now be  considered in the order men-
 tioned.
  863.] It has been commonly supposed, that an hemop-
 tysis was naturally, and almost  necessarily,  followed by an
 ulcer of the lungs:  but I will presume to say, that,  in ge-
 neral,  this is a mistake; for there have been  many instances
 of hemoptysis occasioned by external violence,  without
 being followed by any  ulcer of the lungs:  and there have
^ 
PRACTICE OF PHYSIC.           275
 also been many instances of hemoptysis from  an internal
 cause, without any consequent ulceration.  And this too
 has been the case, not only when the hemoptysis happen-
 ed to young persons,  and recurred for several times,  but
 when it has often recurred during the course of a long life.
It is indeed easy to conceive,  that a rupture of the vessels
of the lungs like that  of the vessels of the nose, may be
often healed, as the surgeons speak, by the first intention.
It is probable therefore, that it is an hemoptysis in parti-
cular circumstances only, which is necessarily followed by
an ulcer;  but what these circumstances are, it is difficult to
determine.   It is possible, that merely the degree of rup-
ture,  or frequently repeated rupture preventing the wound
from healing by the first intention,  may occasion an ulcer;
or it is possible that red blood effused, and not  brought up
entirely by coughing, may, by stagnating in the bronchije,
become acrid,  and erode the  parts.  These however  are
but suppositions, not  supported by any clear evidence.
And, if we consider that those cases of hemoptysis which
follow the predisposition (831.—834.) are those especially
which end in phthisis, we shall be led to suspect that there
are some other circumstances which concur here to deter-
mine  the consequence  of hemoptysis, as  1 shall hereafter
endeavor to show.
  864.] Any supposition,  however, which we can  make
with respect to the innocence of an hemoptysis, must not
supersede the measures proposed above for its cure; both
because we cannot certainly foresee what may be the conse-
quence of  such an accident,  and  because the measures
above suggested are safe ; for, upon every supposition, it
is a diathesis phlogistica that may urge on every bad con-
sequence to be apprehended.
  865.] The second cause of an ulceration of the lungs, to
be considered, is  a suppuration formed in consequence of
pneumonia.
  866.] From  the  symptoms mentioned  in  857, 858,
it may with reason be concluded, that an abscess, or, as it
is  called, a vomica, is formed in some part of  the pleura,
and most frequently in that portion of it investing the lungs.
Here  purulent matter  frequently remains for some time,
as if enclosed in a cyst: but commonly it is  not long  be-
fore  it comes to  be either absorbed, and transferred to
some other part of the  body; or that it breaks through in-
to the cavity of the limes, or into that of the thorax.  In 
2576            PRACTICE OF PHYSIC.

the latter case, it produces the disease called empyema;
but it is only when the matter is poured into the cavity of
the bronchiae,  that it properly constitutes the phthisis pul-
monalis. In the case of empyema, the chief circumstances
of a phthisis are indeed also present; but I shall here consi-
der that case only in which the abscess  of the lungs gives
occasion to a purulent expectoration.
  867.] An abscess of the lungs, in consequence of pneu-
monia,  is not always followed by a phthisis : for sometimes
a hectic fever is not formed ; the matter  poured into the
bronchia? is a proper and benign pus, which is frequently
coughed up very readily, and spit out; and, though this
purulent expectoration should continue for some time, yet
if a hectic does not come on, the ulcer  soon heals,  and
every  morbid symptom disappears.   This has happened
so frequently, that we may conclude, that neither the ac-
cess of  the air, nor the constant  motion of the lungs,  will
prevent an ulcer of these parts from healing, if the mat-
ter of it be well-conditioned.  An abscess of the  lungs,
therefore, does  not necessarily produce the phthisis pul-
monalis ;  and if it be followed by such a  disease,  it must
be in  consequence of  particular circumstances which cor-
rupt the purulent matter produced, render it unsuitable to
the healing of the ulcer, and at the same time make it af-
ford an acrimony, which, being absorbed,  produces a
hectic and its consequences. ,
  868.] The corruption of the  matter  of such abscesses
may be owing to several causes, as, 1. That the matter ef-
fused  during the inflammation, had not been a pure serum
fit to be converted into a laudable pus, but had been united
with other matters which prevented that, and gave a consi-
derable acrimony to the whole : Or, 2. That the matter ef-
fused, and converted into pus,  either merely by a long
stagnation  in a  vomica, or by its  connection  with an em-
pyema, had been  so  corrupted,  as to become unfit for the
purpose of pus in the healing of the ulcer.   These seem to
he possible causes of  the corruption of matter in abscesses,
so as  to make  it the occasion of  phthisis in persons other-
wise sound ; but it is  probable, that a pneumonic abscess
does especially produce phthisis when it happens to persons
previously  disposed to that disease, and therefore only as it
concurs writh some other causes of it.
   869.] The third cause supposed  to produce phthisis, is a
catarrh; which in many cases seems, in length of time,  to 
PRACTICE  OF PHYSIC.            277
 have the expectoration of mucus proper to it, gradually
 changed into an expectoration of pus; and at the same time,
 by the addition of a hectic fever,  the disease, which was at
 first a pure catarrh, is converted into a phthisis.  This sup-
 position,  however is not easily to be admitted.  The catarrh
 is properly an affection of the mucous glands of the treachea
 and bronchia?,  analogous to  the coryza, and  less violent
 kinds of cynanche tonsillaris,  which very seldom terminate
 in suppuration.  And although a catarrh should be disposed
 to such termination,  yet the ulcer produced might readily
 heal up, as it does in the case of a cynanche tonsillaris; and
 therefore should not produce a phthisis.
   870.]  Further,  the catarrh, as purely the effect of cold,
 is generally a mild disease, as well as of short duration;
 and of the numerous instances of it, there are at most but
 very few cases which can be said  to have  ended in phthisis.
 In all those cases in which this seems to have happened, it
 is to me probable, that the persons affected were peculi-
 arly predisposed to phthisis.  And the beginning of phthisis
 so often  resembles a catarrh, that the former may have
 been mistaken for the latter.   Besides, to increase the fal-
 lacy, it often happens that the application of cold, which
 is the most  frequent  cause  of catarrh, is  also frequently
 the exciting cause of the cough which proves the begin-
 ning of phthisis.
  871.] It is to me,  therefore probable,  that a  catarrh
 is very seldom the foundation of phthisis; but 1 would not
 positively assert that  it never  is so;  for it is possible that
 the cases of a more violent  catarrh may  have joined with
them a pneumonic affection, which may end in a suppura-
 tion ; or it may happen that a long continued catarrh,  by
the violent agitation of the lungs in coughing, will produce
 some of those tubercles which are presently to be mention-
 ed as the most frequent cause of  phthisis.
  872.] It must be  particularly  observed  here, that no-
thing said in 871 should allow us  to neglect any appear-
 ance of catarrh, as is too frequently done; for it may be
 either the beginning of a phthisis, which is mistaken for a
 genuine catarrh, or that even as a catarrh continuing long,
it may produce a phthisis, as in 871.
   873.] Many physicians have supposed an acrimony  of
 the fluids eroding some of the vessels of the lungs,  to be a
 frequent cause of  ulceration and phthisis.  But this ap-
 pears to me to be a mere supposition; for in any of the in-
                          2 s 
278           PRACTICE  OF PHYSIC.

stances of the production of phthisis which I have seen,
there was no evidence of any acrimony of the blood capa-
ble of eroding the vessels.  It is true, indeed, that in ma-
ny  cases an acrimony subsisting in some part of  the fluids,
is thcecause of the disease ; but it is at the same time pro-
bable, that this acrimony operates by producing tubercles,
rather than bysany direct erosion.
  874.]  It has been  mentioned  in 862, that an  asthma
may be considered as one of the causes of phthisis; and
by asthma I mean,  that species of it which has been com-
monly named the Spasmodic.  This disease frequently
subsists very  long without producing any other, and may
have its own peculiar fatal termination, as shall be explain-
ed hereafter.   But I have seen it frequently end in phthisis ;
and in such cases I suppose it to operate in the  manner
above ailed ged  of catarrh,  that  is, by producing tuber-
cles, and their  consequences, which shall  be presently
mentioned.
  875.]  I come now to consider the fifth head of the cause
of phthisis, and which I apprehend to be the most frequent
of any.  This I have said, in general, to be tubercles; by
which terms are meant,  certain small tumours, which have
the appearance of indurated glands.   Dissections have fre-
quently shown such tubercles formed in the lungs ; and al-
though at first indolent, yet at length they become inflam-
ed, and are thereby changed into little abscesses, or vomi-
cae, which breaking,  and pouring their  matter into the
bronchiae, give a purulent expectoration, and thus lay the
foundation of phthisis.
  876.] Though the matter expectorated upon these occa-
sions has the appearance of pus, it is seldom  that of a lau-
dable kind; and, as the ulcers do  not readily heal, but arc
attended with a hectic fever, for the most part  ending fa-
tally, I presume  that the matter  of  the ulcers  is  imbued
with  a peculiarly noxious acrimony; which  prevents
their healing,  and produces a phthisis in all its  circum-
stances, as mentioned above.
  877.] It is  very probable that the acrimony which thus
discovers itself in the ulcers,  existed before, and produced
the tubercles themselves: and it  is to this acrimony that
we must  trace up the cause of the phthisis following these
tubercles.  This acrimony is probably, in different cases,
of different kinds ; and it will not  be easy to  determine its
varieties: but to a certain length I shall attempt it. 
PRACTICE  OF PHYSIC.
279
   878.] In one case, and that, too, a very frequent one,
of phthisis, it appears,  that the noxious acrimony is of the
same kind with that which prevails in the scrophula.  This
may be concluded from observing, that a phthisis, at its
usual  periods, frequently attacks persons born of scrophu-
lous parents; that is, of parents who had been affected with
scrophula in their younger years: that very often, when the
phthisis appears, there occurs at the same  time  some lym-
phatic tumors in  the internal parts; and very often I have
found the tabes mesenterica, which is a scrophulous affec-
tion,  joined with the phthisis pulmonalis.   To all this I
would add, that, even when no  scrophulous affection has
either manifestly preceded or accompanied a phthisis, this
last however most commonly affects persons of  a habit re-
sembling the scrophulous ;  that is, persons of a sanguine,
or of a sanguineo-melancholic temperament,  who have ve-
ry fine skins, rosy complexions, large veins, soft flesh, and
thick  upper lip: and further, that in such persons the phthi-
sis comes  on in  the same  manner that it  does in persons
having tubercles, as shall be  immediately explained.
   879.] Another species of acrimony producing tubercles
of the lungs, and thereby phthisis, may be said to be the
exanthematic.  It is well kflown, that the smalLpox some-
times, and more frequently the measles, lay the foundation
of phthisis. It is probable also, that other exanthemata have
the same  effect;  and from the phenomena of the disease,
and the dissections of persons who have died of it,  it is
probable, that all the exanthemata may occasion  a phthi-
sis, by affording a matter .which in the first place produces
tubercles.
   880.] Another acrimony,  which  seems sometimes  to
produce phthisis, is the siphylitic; but whether  such  an
acrimony produces phthisis in any other persons  than  the
previously disposed, does not appear to me certain.
   881.] What  other species of  acrimony, such   as from
scurvy, from pus absorbed from other parts of the body,
from  suppressed eruptions, or from other  sources, may al-
so produce tubercles and phthisis, I cannot now decide,
but must  leave to be determined by those who have had
experience in such eases.
   882.] There is one peculiar case of phthisis,  which from
my own experience I can take notice of.  This is the case
of phthisis from  a calcarious matter formed in the lungs,
and coughed up, frequently with a little blood, sometimes 
230
PRACTICE  OF PHYSIC.
 with mucus only, and sometimes with pus.  How this mat-
 ter is generated,  or in what precise part of the  lungs it  is
 seated, I acknowledge myself ignorant.   In three cases of
 this kind which have occurred to me, there was at the same
 time no appearance of stony  or earthy  concretions in any
 other  part of the body.  In one of these cases, an exqui-
 sitely formed phthisis  came on,  and proved mortal: while
 in the other two, the symptoms of phthisis were never fully
 formed; and after some  time, merely by a milk diet and
 avoiding  irritation, the patients entirely recovered.
   883.]  Another foundation for phthisis, analogous, as I
judge, to that of tubercles,  is that which occurs to certain
 artificers  whose employments keeps them almost constantly
 exposed to dust; such as stone-cutters, millers, flax-dressers,
 and  some others.   I  have not observed in this country ma-
 ny instances of phthisis which  could  be referred  to this
 cause; but, from Ram azzini, Morgagni,  and some other
 writers,  we must conclude such  cases to  be  more frequent
 in the  southern parts of Europe.
   884.]  Besides these  now mentioned, there are probably
 some other causes producing tubercles, which have not yet
been ascertained  by observation  ;  and it is  likely, that in
the state of tubercles there is a variety not yet accounted for ;
but all this must be left to future  observation  and inquiry.
   885.] It has been frequently  supposed  by physicians^
that the phthisis is a contagious disease ;  and I dare not as-
sert that it never is such: but in  many hundred instances of
the disease which  I  have seen,  there has been hardly one
which  to me could appear to have arisen from contagion.
It is possible, that in warmer climates the effects of conta-
gion may be more discernible.
   After having said, that a phthisis arises from  tubercles
more frequently than from any other cause,  and after hav-
ing attempted to assign the variety of these,  I now proceed
to mention the peculiar circumstances and symptoms which
usually accompany the coming  on of the disease from tu-
bercles.
   886.] A tuberculous and purulent state of the  lungs has
been observed in very  young children, and in some others
at several different periods before the age of  puberty and
full  growth ; but  instances  of this kind  are rare : and the
attack of phthisis, which we have  reason to impute to tu-
bercles, usually  happens at the  same period which  I have
assigned for the coming on of the hemoptysis, 
                PRACTICE  OF  PHYSIC.         281

   887.]  The phthisis from tubercles does also generally af-
 fect the same  habits as the hemoptysis, that is,  persons of
 a slender make, long necks, narrow  chests,  and  prominent
 shoulders ; but very frequently the persons liable to tuber-
 cles have less  of a florid countenance, and of  the other
 marks of an exquisitely sanguine  temperament, than the
 persons liable to hemoptysis.
  888.]  This  disease,  arising from tubercles, usually com-
 mences  with  a slight and short cough,  which becomes
 habitual, is often  little remarked  by  those  affected, and
 sometimes so little as to be absolutely denied by them.  At
 the  same time their breathing becomes easily hurried by
 any bodily motion, their body grows leaner, and they be-
 come languid and indolent.  This state sometimes continues
 for a year, or even for two  years, without the  persons
 making any complaint of it, excepting only that they are
 affected by cold more readily than usual, which  frequently
 increases their  cough,  and produces some catarrh.   This,
 again, however, is sometimes relieved ; is supposed to have
 arisen from cold alone  : and therefore gives no alarm either
 to the patient or to his friends,  nor leads them to take any
 precautions.
  889.]  Upon one  or other of these  occasions of catching
 cold, as we commonly speak,  the cough becomes  more con-
 siderable ;  is particularly troublesome  upon the patient's
 lying down at  night; and in this state continues longer than
 is usual in the case of  a simple catarrh.  This is more es-
 pecially to call for attention, if the increase and continuance
 of cough come on during the summer season.
  890.]  The cough which comes on as  in 888, is  very often
 for a long time without any expectoration ; but when, from
 repeatedly catching cold, it becomes more  constant, it is
•then  at  the same time  attended with some expectoration,'
 which is most  considerable in  the mornings.  The  matter
 of this  expectoration becomes by  degrees  more copious,
 more viscid, and more opaque ; at  length  of a yellow or
 greenish color,  and of  a purulent appearance.  The whole
 of the matter,  however,  is not  always at  once entirely
 changed in this manner ; but, while one part of it  retains
 the usu^l form of  mucus, another suffers the changes now
 described.
  891.]  When the cough increases,  and continues very fre-
 quent through the night, and when the  matter expectorated
 undergoes the changes I have  mentioned,  the breathing  at 
282
PRACTICE OF PHYSIC.
the same time becomes more difficult, and the emaciation
and weakness go on also increasing.  In the female sex, as
the disease advances,  and sometimes early in its progress,
the menses ceases  to flow ; and this circumstance  is to be
considered as commonly the effect, although the sex them-
selves are ready to believe it the sole cause of the disease.
  892.] When the cough comes on as in 888, the pulse is
often  natural, and for sometime  after continues to be so;
but the symptoms have seldom subsisted  long  before the
pulse  becomes frequent,  and sometimes to a considerable
degree, without much  of  the other symptoms of fever.
At length, however, evening exacerbations become remark-
able ; and by degrees the fever assumes the exquisite form
of hectic, as described in 857, 859.
  893.] It is seldom that the cough, expectoration, and fe-
ver, go on increasing, in the manner now described, without
some pain being felt in some part of the thorax.   It is usu-
ally and most frequently felt at first under the sternum,  and
that especially,  or almost only, upon occasion of coughing ;
but very often,  and that too, early in  the course of the dis-
ease, a pain is felt on one side, sometimes very constantly,
and so as to prevent the person from lying  easily upon  that
side ;  but at other times  the pain is felt only upon a full in-
spiration, or upon coughing.  Even when no pain is felt,  it
generally happens that phthisical persons cannot lie easily
on some one of their sides, without having their difficulty
of breathing increased, and their  cough excited.
  894.] The phthisis  begins,  and sometimes proceeds to
its fatal issue, in the manner described from 888, to 894,
without any appearance of hemoptysis.   Such cases are
indeed rare;  but it is  very common for the disease  to ad-
vance far, and even to an evident purulency and hectic state,
without any appearance of blood in the spitting  : so that it
may be affirmed, the disease is frequently not founded in he*
moptysis.  At the same time, we  must allow, not only  that
it sometimes begins  with an hemoptysis, as is said in 863,
but further, that it seldom happens that in the progress of
the disease mure or  less of an hemoptysis does not appear.
Some degree of blood-spitting does,  indeed, appear some-
times in the state mentioned (888, 892.)  but more com-
monly in the more advanced stages of the disease only,  and
particularly upon the first appearance of purulency.  How-
ever this may be, it is seldom, in  the  phthisis from  tuber-
cles, that the hemoptysis is considerable, or requires any re- 
               PRACTICE  OF PHYSIC.           283

medies different from those which are otherwise necessary
for the state of the tubercles.
  895.] I have  now described a succession of symptoms
which,  in different cases, occupy more  or less time.   In
this climate they very often take up some years, the symp-
toms>appearing  especially in the winter  and spring, com-
monly becoming easier,  and  sometimes  almost disappear-
ing, during the summer rbut returning again in winter, they
at length after two or three years, prove  fatal, towards the
end of spring or the beginning of summer.
 .  896.] In  this disease, the prognosis is for the most part
unfavorable.  Of  those affected  with it, the greater number
die ;  but tiiere are also many of them who recover entirely,
after having been in very unpromising circumstances.  What
are, however, the circumstances more certainly determin-
ing to a happy or  to a fatal event, I have not yet been able
to ascertain.
   897.] The following aphorisms are the  result of my ob-
servations.
  A phthisis pulmonalis  from  hemoptysis, is more  fre-.
quently recovered  than one from tubercles.
  An hemoptysis not only is not always followed by a phthi-
sis, as we have said above  (863.) but even when  followed
by  an ulceration,  the ulceration is  sometimes  attended
with  little of hectic,  and frequently admits of being soon
healed.   Even  when  hemoptysis and ulceration have hap-
pened to be repeated, there are instances  of persons reco-
vering entirely after several such repetitions.
   A phthisis from  a  suppuration in consequence  of pneu-
monic inflammation, is  that which most  rarely  occurs in
this climate ; and a phthisis does not always  follow such
suppuration, when the abscess formed soon breaks and  dis-
charges a laudable pus;  but, if the abscess continues long
shut up, and till after a  considerable degree of hectic has
been formed, a  phthisis is then  produced,  equally danger-
ous, as that from other causes.
  A phthisis from tubercles has, I think, been  recovered  :
but it is of  all others the most dangerous ;  and, when aris-
ing from a hereditary taint is almost certainly fatal.
  The danger of a phthisis,  from whatever cause it may
have arisen, is  most certainly to be judged of  by the de-
gree to which the hectic and  its consequences have arrived.
From a certain degree  of emaciation,  debility, profuse
sweating, and diarrhua,  no person  recovers. 
284
PRACTICE OF PHYSIC.
   A mania  coming on, has been found to remove all the
symptoms, and sometimes has entirely cured  the disease ;
but, in other cases, upon the going off of the  mania,  the
phthisis has recurred, and proved fatal.
   The pregnancy of women has often retarded the progress
of a phthisis; but commonly it is only till after delivery,
when the  symptoms of phthisis return with  violence, and
soon prove fatal.
                     SECTION II.

               Of the Cure of Phthisis.

  898.] FROM what has been just now said, it will readily
appear, that the cure of  the  phthisis  pulmonalis must  be
exceedingly difficult; and that  even the utmost care and
attention in the employment of remedies,  have seldom suc-
ceeded.  It may be doubtful whether  this failure is  to  be
imputed to the imperfection of our art, or to the  absolutely
incurable nature of the disease.   I am  extremely averse  in
any case to admit of the latter supposition,  and can always
readily allow of the former ;  but, in the mean time, must
mention here, what has been attempted towards either cur-
ing or moderating the violence of this disease.
  899.] It must  be  obvious  that according to the differ-
ent circumstances  of this  disease, the method of  cure must
be different.   Our first attention should  be employed  in
watching the  approach of the disease, and preventing  its
proceeding to an incurable state.
  In all persons of a phthisical habit, and especially in those
born of phthisical parents, the  slightest  symptoms' of the
approach of phthisis,  at the phthisical period of life,  ought
to be attended to.*
  900.] When an hemoptysis occurs, though it be not al-
ways  followed with ulceration and phthisis, these however
are always to be  apprehended ; and every precaution is to
be taken against them.   This is especially to be done by
employing every means of moderating the hemorrhagy, and
of preventing its return, directed in 891,  et seq.  and these
precautions ought to be continued for several years after the
occurrence of the hemoptysis.
 * This early attention to the first symptoms of the disease is of the utmost consequence, for It
is onW in the early stage thatany remedies can be employed with success* as experience has
sufficiently taught, he'e article 90&. et seq. 
PRACTICE OF PHYSIC.
285
   HOI.] Th.e phthisis which  follows a suppuration from
 pneumonic inflammation, can only be prevented with cer-
 tainty, by  obtaining a  resolution  of such inflammation.
 What may be attempted towards the cure of an abscess and
 ulcer which have taken place, I shall speak of hereafter.
   902.] I have said, it is doubtful if a genuine catarrh ever
 produces a  phthisis ; but have allowed that it possibly may:
 and  both upon this  account, and  upon  account of  the
 ambiguity which may arise, whether the appearing catarrh
 be a primary disease, or the effect of a tubercle, I consider
 it as of consequence to cure a catarrh as soon as possible
 after its first appearance.  More especially  when  it shall
 linger, and continue for some time, or shall, after  some
 intermission, frequently return, the cure of it should be
 diligently attempted.   The  measures requisite  for this
 purpose shall be mentioned afterwards, when we come to
 treat of catarrh as a primary  disease ; but, in the  mean
 time,  the means necessary for preventing its producing a
 phthisis shall be mentioned immediately, as  they  are  the
 same  with those I shall point out as necessary for prevent-
 ing a phthisis from tubercles.
   903.] The  preventing of a phthisis from asthma must
 be by curing, if possible, the asthma, or at least by mode-
 rating it as much as may be done: and as it is probable that
 asthma occasions phthisis, by producing tubercles, the mea-
 sures necessary for preventing phthisis from  asthma, will
 be the same with those necessary in the case of tubercles,
 which I am now about to mention.
   904.]  I consider tubercles as by much the most frequent
 cause of phthisis ; and even in many cases where this seems
 to depend upon hemoptysis,  catarrh, or asthma, it does
 however truly arise from tubercles.   It is upon this sub-
ject,  therefore,  that I shall have occasion to treat of  the
 measures most commonly requisite for curing phthisis.
   905.]  When,  in a person born  of phthisical parents, of
a phthisical  habit, at the phthisical period of life, the symp-
toms  (888.) in the spring, or the beginning of summer,
shall appear in the slightest degree,  we may presume that
a tubercle,  or tubercles, either have been formed, or  are
forming in the lungs ; and therefore, that every means we
can devise for preventing their formation, or for procuring
their  resolution, should be employed  immediately, even
although the patient himself should overlook or neglect  the,
symptoms, as imputin g them to accidental cold.
                         2o 
286           PRACTICE OF PHYSIC.

  906.] This is certainly the  general indication ;  but how
it may be executed, I cannot readily say.   I  do not  know
that,  at any time, physicians have proposed any remedy
capable of  preventing the formation  of  tubercles,  or  of
resolving them when formed.  The analogy  of scrophula,
gives  no assistance in this matter.  In scrophula the  reme-
dies that are seemingly of most  power, are,  sea-water, pr
certain mineral waters ;  but  these  have generally proved
hurtful in the case of tubercles of the lungs.  I have known
several instances of mercury very fully  employed for cer-
tain diseases, in persons who  were supposed at the time to
have  tubercles formed,  or forming,  in their lungs;  but
though the mercury proved a cure for those other diseases,
it was of no service in  preventing phthisis,  and in some
cases  seemed to hurry it on.
  907.] Such appears to me to be the  present state of our
art, with respect to the cure of tubercles ; but I do not des-
pair of a remedy for the purpose being found hereafter.  In
the mean time, all that at present seems to be within the
reach  of our art,  is to  take the measures proper for avoid-
ing the inflammation of tubercles.   It is probable that tu-
bercles may subsist long without producing any  disorder ;
and lam disposed to think,  that  nature  sometimes resolves
and discusses tubercles  which  have been formed ;  but that
nature does  this only when  the tubercles remain in an  un-
inflamed state; and therefore, that the  measures  necessary
to be  taken, are chiefly those for avoiding the inflammation
of the tubercles.
  908.] The inflammation of a tubercle of the  lungs is to
be avoided upon the general plan of avoiding inflammation,
by blood-letting, and  by an antiphlogistic regimen ; the
chief  part of which, in this case, is the use of a  low diet.
This supposes a total abstinence from animal food, and the
using  of vegetable food almost alone : but it has been found,
that it is not necessary for the patient to be confined  to ve-
getables of the weakest nourishment, it being sufficient that
the farinacea be employed,  and together with  these, milk.
  909.] Milk has  been generally considered  as the chief
remedy in  phthisis, and in the case  of every tendency to
it  ; but whether from  its  peculiar  qualities, or from  its
being of a lower quality, with respect to nourishment, than
any food entirely animal, is not certainly determined.  The
choice and administration of milk will be properly directed,
by considering the nature  of the milk of the several ani- 
               PRACTICE  OF PHYSIC.            287

mals from  which  it  may be  taken, and the particular state
of the patient with respect to the period and circumstances
of the disease, and to the habits of his stomach with respect
to milk.
  910.]  A second means of preventing  the inflammation
of the tubercles of the lungs, is, by avoiding any particu-
lar irritation of the affected part, which may arise from any
violent exercise of respiration ;  from  any  considerable  de-
gree of bodily exercise ; from  any  position  of the body,
which straitens the capacity of the thorax ; and lastly, from
cold applied to the surface of the body,  which determines
the blood in  greater quantity  to the internal parts,  and par-
ticularly to the lungs.
   911.]  From the  last-mentioned  consideration,   the  ap-
plication of  cold  in  general,  and therefore the  winter-sea-
son, in cold  climates, as diminishing the cutaneous perspi-
ration, is to be avoided;  but more particularly,  that appli-
cation of cold is to be shunned that may suppress perspira-
tion,  to the degree of occasioning a catarrh, which consists
in an inflammatory  determination  to the  lungs, and  may
therefore most certainly produce an  inflammation of the
tubercles there.
   By considering, that the avoiding  heat is  a part of the
antiphlogistic regimen above recommended,  and by com-
paring this  with what  has been just now said respecting
the avoiding cold, the proper choice of climates and sea-
sons for phthisical patients will be readily understood.
   912.] A third means  of  avoiding the inflammation of
the tubercles of  the  lungs consists,  in diminishing the  de-
termination  of the blood to  the lungs, by supporting  and
increasing the determination to the surface of the body ;
which is to be chiefly and most safely done by warm cloth-
ing,*  and the frequent use of the exercises of gestation.
   913.] Every mode  of gestation  has  been  found of use
in  phthisical  cases  ;  but riding on horseback,  as  being
accompanied with  a great deal of bodily exercise, is less
safe  in  persons  liable to an hemoptysis.   Travelling  in a
carriage unless  upon  very smooth roads mav also  be of
doubtful  effect; and  aJl  the  modes of gestation that are
employed on land,  may fall short of the  effects  expected

  * This is a most essential part in the cure  of phthisis, and raanv other diseases prevalent in
 cold climates.
  The warm clothing that is most effectual is  flannel shirts next to the skin  It feels a little dis-
 agreeable at first to a person unaccustomed to it; but thegre.it lelief ii affords, and the com-
 lortable serration it produces, are so strong inducements for continuing its use. that few peo-
 ple who have once experienced its bcneuVul  effects liave anv desire tu lvlinquish it. 
 288           PRACTICE OF PHYSIC.

 from them, because they cannot be rendered sufficiently
 constant; and therefore it is that sailing, of all other modes
 of gestation, is the most effectual in pneumonic cases, as
 being both the smoothest and most constant.
   It has been imagined, that some benefit is derived from
 the state of the atmosphere upon  the  sea; but I cannot
 find  that any impregnation  of this which  can be supposed
 to take place, can be of service to phthisical persons.  Iti*
 however probable, that frequently some  benefit may be
 derived from the more moderate temperature and greater
 purity of the air upon the sea.
   914.] In order to take off any inflammatory  determina-
 tion of  the blood into the vessels of the lungs, blisters  ap-
 plied to some part of the thorax may often be of service ;
 and for the same  purpose,  as well as  for moderating the
  eneral inflammatory state of the  body, issues of various
  inds may be employed with advantage.
  915.] The several measures to be pursued in the case of
 what  is properly  called an Incipient Phthisis, have now
 been mentioned ;  but they have seldom been employed in
 such cases  in due time,  and have therefore, perhaps, sel-
 dom proved effectual.  It has more commonly happened,
 that after some time, an inflammation has come upon  the
 tubercles, and an abscess has been formed, which opening
 into the cavity  of  the bronchia?, has produced  an  ulcer,
 and a confirmed phthisis.
  916.] In this state of matters, some new indications dif-
 ferent from the former may be supposed to arise, and indi-
 cations for preventing absorption, for preventing the effects
 of the absorbed matter upon  the blood, and for healing  the
 ulcer, have been actually proposed.  I cannot find,  how-
 ever,  that any of the means  proposed for executing  these
 indications, are either probable or  have proved effectual.
If, upon some occasions, they have appeared to be useful,
it has been probably by answering some other intention.
  While no antidote against the poison which especially
 operates here, seems to have been as yet found out, it ap-
pears to me, that too great a degree of inflammation  has a
great  share in preventing the healing of the ulcer which
occurs ; and such  inflammation is certainly what has a
great  share  in urging on its fatal consequences.   The only
practice, therefore, which I  can venture to propose, is the
same  in the ulcerated as in the crude state of a tubercle ; 
PRACTICE OF PHYSIC.           289
  that is,  the employment of means for moderating inflam-
  mation, which have been already mentioned (908. et seq.J
    911.) The balsamics whether natural or artificial, which
  have been so commonly advised in cases of phthisis, ap-
  pear to me to  have been  proposed  upon no  sufficient
  grounds, and to have proved commonly hurtful.   The re-
  sinous and acrid substance of myrrh, lately recommended,
  has  not appeared to me to be of any service, and in some
  cases to hive proved hurtful.*
    918.]  Mercury, so  often useful in healing  ulcers, has
  been speciously enough proposed in this disease; but whe-
  ther that it be not adapted to the particular nature  of the
  ulcers of the lungs occurring in phthisis,  or that it proved
  hurtful because it cannot have effect without exciting such
  an inflammatory state  of the whole system, as,  in a hec^
  tic  state, must  prove  very hurtful, I cannot  determine.
  Upon many trials which I have seen made, it has proved of
  no service, and commonly  has appeared to be manifestly
  pernicious.
    919.]  The Peruvian bark has been recommended for se-
 veral purposes in phthisical cases; and it is said, upon some
 occasions to have been  useful;  but I have seldom found  it
 to be so; and as by its  tonic power it increases the phlo-
  fistic diathesis of the system,  I have frequently  found  it
  urtful.  In some cases, where the morning remissions of
 the fever were considerable, and the noon  exacerbations
 well marked, I have observed the Peruvian bark given in
 large quantities, have the effect of stopping these exacer-
 bations,  and at the same time of relieving the whole of the
 phthisical symptoms: but in the cases in which I observed
 this, the fever  showed  a constant tendency  to recur; and
 at length the phthisical  symptoms also returned, and prov-
 ed quickly fatal,
   920.]  Acids  of all kinds, as antiseptic  and refrigerant,
 are useful in cases of phthisis; but the native acid of  ve°-e-
 tablesf is more useful than the fossil acids, as it can be*gi-
 ven in much larger quantities, and may also be given more
 safely than vinegar,  being less liable to excite coughing.
   921.]  Though our art can do so little towards the  cure
 of this disease, we must,  however,  palliate the uneasy
 symptoms of  it  as well as we can.  The symptoms especial-
  • From the preceding account of the disease, it is sufficiently evident that all acrid and hot
 substances must be huitful in ph'.hisis.  The balsamics have been long recommended in these
 cases, even by the best authorities, but on what piinciple is not easy to determine.
  + The acid fruits, acid of tartar, acid o( sorrel, and other plants yielding an acid, but not aa
acrid, juice. The caung of oranges is therefore serviceable.              ' 
590
PRACTICE OF PHYSIC.
ly urgent are the cough and diarrhoea.   The cough may be
in some measure relieved by  demulcents, (872.) but the
relief obtained by  these is imperfect and transitory, and
very often the stomach is disturbed  by the quantity  of
oily, mucilaginous, and sweet substances, which are on
these occasions taken into it.
   922.] The only certain means of relieving the cough, is
by employing opiates.  These, indeed, certainly increase
the phlogistic diathesis of the system; but commonly they
do not so much harm in this way, as they do  service by
quieting the  cough, and giving sleep.   They are supposed
to be hurtful by checking expectoration: but  they  do it
for a short time only; and, after a sound sleep,  the expec-
toration in the morning  is  more easy than usual.  In the
advanced state of the disease, opiates seem to increase the
sweatings  that occur; but  they compensate this, by the
ease they afford in a  disease wbich cannot be  cured.
   923.] The diarrhoea which happens in the advanced state
of this disease,  is to  be palliated by moderate astringents,
mucilages, and opiates.
   Rhubarb,  so  commonly prescribed in every diarrhoea,
and all other purgatives, are  extremely  dangerous in the
colliquative  diarrhoea of hectics.
   Fresh subacid fruits,  supposed  to be  always laxative,
are often  in the diarrhoea of hectics,  by their  antiseptic
quality, very useful.


                  CHAPTER  V.

OF THE HEMORRHOIS; OR OF  THE HEMOR-
      RHOIDAL SWELLING AND FLUX.

                    SECTION I.

 Of the Phenomena and Causes of the Hemorrhois.

   924.]   A  DISCHARGE  of blood from  small tumors
        il on the  verge of the  anus,  is  the symptom
which generally constitutes  the Hemorrhois ; or,  as it is
vulgarly called, the Hemorrhoidal Flux.  But a discharge
of blood from within the anus, when the blood is of a flo-
rid color,  showing it to have come from  no great distance,
is also considered as the same disease;  and physicians have 
PRACTICE  OF PHYSIC.
291
 agreed in making two cases or varieties  of it, under the
 names of External and Internal Hemorrhois.
   923.] In both cases it is supposed that the flow of blood
 is from  tumors previously formed,  which are  named He-
 morrhoids, or piles; and  it frequently happens,  that the
 tumors  exist without any  discharge .of blood; in  which
 case, however, they are supposed to be a part  of the same
 disease, and  are  named  Hemorrhoides Csecse,  or Blind
 Piles.
   926.] These tumors, as  they appear without the anus,
 are  sometimes  separate,  round,  and prominent,  on  the
 verge of the  anus; but frequently the tumor  is only one
 tumid ring, forming, as it were, the anus pushed without
 the body.
   927.]  These tumors, and the discharge of blood from
 them, sometimes come on as an affection purely topical, and
 without any previous  disorder in other parts of the body :
 but it frequently happens, even before the tumors are form-
 ed, and more especially before the  blood  flows, that vari-
 ous disorders are felt in different parts of the body, as head-
 ach, vertigo, stupor, difficulty of breathing, sickness, colic-
 pains, pain of the  back and Joins ;  and  often, together with
 more or fewer of these symptoms, there occurs a consider-
 able degree of pyrexia.
  The  coming on of  the disease with  these symptoms, is
 usually  attended with  a sense of fullness, heat, itching, and
 pain in and about the anus.
  Sometimes the disease is preceded by a discharge of se-
 rous matter from the anus: and sometimes  this  serous dis-
 charge, accompanied with some swelling,  seems to  be  in
 place of the discharge of blood, and to relieve those disor-
 ders of  the system  which we have mentioned.  This serous
 discharge, therefore, has been named the Hemorrhois Alba.
  928.] In the hemorrhois, the quantity of  blood discharg-
 ed is different upon different occasions.    Sometimes the
 blood flows only upon the persons going to stool; and com-
 monly, in larger or lesser quantity,  follows the discharge  of
the faeces.  In  other cases,  the blood flows without any dis-
 charge of faeces ; and then, generally, it is after having been
 preceded by the disorders above mentioned, when it is also
 commonly in larger quantity.   This discharge of blood  is
often very considerable ; and, by the repetition, it is often
so great, as we could hardly suppose the body to bear but
with the hazard of  life. Indeed,  though rarely,  it has been 
292           PRACTICE OF PHYSIC.
so great as to prove suddenly fatal.   These considerable dis-
charges occur especially to persons who have been frequent-
ly liable to the disease.   They often induce great debility ;
and frequently a leucophlegmatia, or dropsy, which proves
fatal.
  The tumors and discharges of blood in this disease, often
recur at exactly stated periods.
  929.] It often happens, in the decline of life, that the
hemorrhoidal flux, formerly frequent, ceases to flow ;  and,
upon that event, it generally happens that the persons are
affected with apoplexy or palsy.
  930.] Sometimes hemorrhoidal tumors are affected  with
considerable inflammation ; which, ending in suppuration,
gives occasion to the formation of fistulous ulcers in  those
parts.
  931.] The hemorrhoidal tumors  have been  often consi-
dered as varicous tumors,  or dilatations of veins ; and it is
true,  that in some cases varicous dilatations  have appeared
upon dissection.   These, however,  do not always appear;
and I presume it is not the ordinary case, but that the tu-
mors are formed by an effusion of blood into  the  cellular
texture of the intestine near to its  extremity.   These tu-
mors, especially when recently formed,  frequently contain
fluid blood ; but, after they have remained for some time,
they are commonly of a firmer substance.
  932.] From a consideration of their causes, to be here-
after mentioned, it is sufficiently probable, that hemorrhoi-
dal tumors are produced  by some interruption of the free
return of blood from the veins of the lower extremity of
the rectum ; and it is possible, that a considerable accumu-
lation of blood in these veins, may  occasion a rupture of
their extremities,  and thus produce the hemorrhagy or tu-
mors I have mentioned.   But, considering that the hemor-
rhagy occurring here is often preceded  by pain,  inflamma-
tion, and a febrile state, as well as by many other symptoms
which show a connection between the topical affection and
the state of the whole system, it seems probable that the
interruption of the venous blood, which  we  have supposed
to take place, operates in the manner explained in 768, and
therefore, that the discharge of blood here is commonly from
arteries.
  933.] Some physicians have been of opinion,  that a dif-
ference in  the nature of the hemorrhois, and of its effects
upon the  system,  might  arise from the difference of the he- 
               PRACTICE  OF PHYSIC.           293

morrhoidal vessels from which the blood issued.   But it ap-
pears to me,  that hardly in any case we can distinguish the
ve.ssefs from which the  blood flows ; and that the frequent
inosculations, of both the arteries and  veins which belong
to the lower extremity of the rectum will render the effects
of the hemorrhagy nearly the same, from whichsoever of
these vessels the blood proceed.
   934.]  In 768, I have endeavored  to explain the  mannet
in which a certain state of the  sanguiferous  system might
give occasion to an hemorrhoidal flux ; and I have no doubt,
that this flux may be produced in that  manner.   I cannot,
however, by any means admit  that the disease is so often
produced in that manner, or that, on  its first appearance,
it  is so  frequently a systematic  affection,  as the Stahlians
have imagined, and would have us to believe.   It occurs in
many persons before the period of life at which the venous
plethora takes place ;  it  happens to females-j^n whom a ve-
nous plethora,  determined to the hemorrhoidal vessels, can-
not be supposed; and it happens to both sexes,  and to per-
sons of all ages, from causes which do not affect the sytem,
and are manifestly suited to produce a topical affection only.
   935.]   These causes of a topical affection are,  in  the first
place, the frequent voiding of hard and bulky faeces, which,
not only  by  their long stagnation in the rectum,  but espe-
cially when voided, must press upon the veins of the anus,
and interrupt the course of the blood in them.  It is for this
reason that the disease happens so often to persons of a slow
and bound belly.
   936.]   From.the causes just now mentioned, the disease
happens especially to persons liable to some degree of a pro-
lapsus ani.  Almost every person in voiding  fseces has the
internal  coat of the rectum more or less protruded  with-
out the body ; and this will be to a greater or lesser degree,
according as the hardness and bulk  of the faeces occasion a
greater or lesser effort or pressure  upon the anus.   While
the gut is thus pushed out, it often happens that the sphinct-
er ani is contracted  before the gut is replaced; and,  in con-
sequence thereof, a strong constriction is made, which pre-
venting the fallen-out gut from being replaced ; and at the
same time preventing the return of blood from it, occasions
its being considerably swelled, and its forming a tumid ring
round the anus.
   937.]  Upon the sphincter's being a little relaxed, as it is
immediately after its strong contraction,  the fallen-out por-
                          2 v 
294            PRACTICE OF  PHYSIC.

tion of the gut is commonly again taken within the body ;
but by the frequent repetition of such an accident, the size
and  fullness  of the ring formed by  the fallen-out gut, is
much increased.  It is therefore more slowly and difficultly
replaced;  and in this consists the thief uneasiness of hemor-
rhoidal persons.
  938.] As the internal edge of the ring mentioned, is ne-
cessarily divided by clefts, the  whole often assumes the ap-
pearance of a number of distinct swellings ; and it  also fre-
quently happens, that some portions of it, more considera-
bly swelled than others, become more protuberant, and
form those small tumors more strictly called Hemorrhoids,
or Piles.
  939.] From considering that the pressure of faeces, and
other causes  interrupting the return of venous blood from
the lower extremity of the rectum, may  operate a  good
deal higher lifHn the gut than that  extremity, it  may be
easily understood that tumors  may  be formed within the
anus; and probably it also happens, that  some of the tu-
mors  formed without the anus, as  in  938, may  continue
when taken within the body,  and even be increased by the
causes just now mentioned.  It is thus that  I would explain
the production of internal piles, which,  on account of their
situation and bulk,  are not protruded on the person's going
to stool, and  are often, therefore,  more painful.  The same
internal piles are more especially painful, when affected  by
the hemorrhagic effort described in 744, and 768.
  940.] The production  of piles is particularly illustrated
by this, that pregnant  women are frequently affected with
them.   This  is to be accounted for, partly from the pressure
of the uterus upon the rectum,  and partly from the costive
habit to which pregnant women are usually liable.   I have
known many instances of piles occurring for the first time
during the state of pregnancy  ; and there are few women
that have borne children who  are afterwards entirely free
from  piles.   The Stahlians have commonly asserted, that
the male  sex is more frequently  affected  with this disease
than the female ; but in this country I have constantly found
it otherwise.
  941.] It is commonly supposed, that the frequent use of
purgatives, especially of those of  the more acrid kind, and
more particularly of aloetics, is apt to produce the hemor-
rhoidal affection ; and as these purgatives  stimulate chiefly 
PRACTICE  OF PHYSIC.          295
 the great guts, it seems sufficiently probable that they may
 excite mis disease.
   94£.]  I  have now mentioned several causes which may
 produce the hemorrhoidal tumors and flux as a topical af-
 fection only; but must observe  farther, that although the
 disease appears first as a purely topical affection, it may, by
 frequent repetition,  become  habitual ; and therefore  may
 become  connected with the  whole system, in the  manner
 already explained, with respect  to hemorrhagy in general,
 in 747.
   943.]  The doctrine now referred to will, it is apprehend-
 ed, apply very fully to the case of the hemorrhoidal flux ;
 and will  the more readily apply, from the person who has
 been once affected being much exposed to a renewal of the
 causes which first occasioned the disease ;  and from many
 persons being much exposed to a congestion in the hemor-
 rhoidal vessels, in consequence  of their being often  in an
 erect position of the  body, and in an exercise which pushes
 the blood  into the depending vessels,  while  at the  same
 time, the effects of these circumstances are much  favored
 by the abundance and laxity of the  cellular texture about
 the rectum.
   944.]  It is thus that the hemorrhoidal flux is so often ar-
 tificially  rendered an  habitual and systematic affection ; and
 I am persuaded, that it is this which has given occasion to
 the Stahlians toconsider the disease as almost universally such.
   945.]  It is to be particularly  observed  here, that when
the hemorrhoidal disease has either been originally, or has
become in the manner just  now explained,  a systematic
 affection, it then acquires a particular connection  with the
stomach, so that certain  affections there excite the hemor-
 rhoidal disease, and  certain states of the hemorrhoidal af-
fection excite disorders of the stomach.
   It is perhaps owing to this  connection, that the gout
 sometimes affects the rectum.  See 524.
                    ... _          ™=,

                    SECTION II.

      Of the Cure of Hemorrhoidal Affections.

   946.]  ALMOST at all times it  has been  an opinion
 amongst physicians,  and from them spread amongst the
 people, that the hemorrhoidal flux is  a salutary evacuation,
 which prevents many diseases that  would otherwise have 
296            PRACTICE OF PHYSIC.

happened; and that it even contributes to  give  long life.
This opinion, in later times,  has been especially  maintain-
ed by Dr. Stahl,  and his followers; and has had  a great
deal of influence upon the practice of physic in Germany.
  947.]  The question arises with respect to hemorrhagy in
 feneral,  and indeed it has been extended so far by  the
 tahlians.  I have accordingly considered it as  a  general
question  (766—779.) but it has been more especially agi-
tated with regard to  the disease  now under  considera-
tion :  And as to this, although 1 am clearly of opinion that
the hemorrhois may take place in  consequence of the ge-
neral state of the system (768.) or,  what is still  more fre-
quent, that by repetition it may become  connected  with
that general state (942.) and in either case  cannot  be  sup-
pressed without great caution;  I must beg leave, notwith-
standing this, to maintain, that the first is a rare  case; that
generally the disease first appears as an affection  purely to-
pical, (934—941.) and that the allowing it to become habi-
tual  is never proper.   It is a  nasty disagreeable  disease,
ready to go to excess,  and to  be thereby very hurtful, as
well as sometimes fatal.  At best it is liable to  accidents,
and thereby to unhappy consequences.  I am therefore of
opinion,  that not  only the first approaches of the disease
are to be guarded against, but even that, when it has taken
place for some time, from whatever cause it may have pro-
ceeded,  the flux is always to  be moderated, and the ne-
cessity of it, if possible, superseded.
  948.]  Having  delivered these general rules, I proceed
to mention more  particularly, how the disease is to be
treated,  according to  the different circumstances under
which it may appear.
  When we can manifestly discern the first appearance of
the disease to arise from causes acting upon the  part only,
the  strictest attention should be  employed in guarding
against the renewal of  these causes.
  949.]  One of the most frequent of the remote causes of
the hemorrhoidal affection, is a slow and bound belly (935.)
and this is to be constantly obviated by  a proper diet,*
which each individual's own experience must direct; or,
if the management of diet be not effectual, the belly  must
be kept  regular by such  medicines as may prove gently
laxative, without irritating the rectum, f   In most cases  it
  * Broths of all kind are proper in the^e cases: barley broth is preferable to that which is made
with rice'. Barley gruel, with pruens, is an excellent laxaii\e broth.
  ■)■ The lenitive electuary alone may in many cases be sufficient, when given in the quantity of 
PRACTICE OF PHYSIC.
297
will be of advantage to acquire a habit with respect to time,
and to observe it exactly.
   950.]  Another cause of hemorrhois to be especially at-
tended to, is the prolapsus or protrusion of the anus, which
is apt to happen on a person's having a stool,  (936.)   If  it
shall  occur  to any considerable  degree, and at the same
time be not easily and immediately replaced, it most cer-
tainly produces piles, or increases them when otherwise pro-
duced.  Persons therefore liable to this prolapsus, should,
upon their having  been  at stool, take great pains to have
the gut immediately replaced, by lying  down in a hori-
zontal posture,  and pressing gently upon the anus, till the
reduction shall be completely obtained.
   951.]  When  the prolapsus of which I speak, is  occa-
sioned only by voiding hard and bulky faeces, it should be
obviated  by  the means mentioned  in  949,  and may be
thereby avoided.   But in some persons it is owing to a lax-
ity of  the rectum; in which case it is often most consider-
able upon occasion of a loose stool;  and then the disease
is  to be treated by astringents,* as well as by proper arti-
fices for preventing the falling down of the gut.
   952.]  These are the means to be employed  upon the first
approaches of the hemorrhoidal  affection ; and when  from
neglect it shall have frequently recurred, and has become
in some measure established, they are no less proper.  In
the latter case,  however, some other means are also neces-
sary.   It is particularly proper to guard  against a plethoric
state of the body ; consequently, to avoid a sedentary life,
a full diet, and particularly intemperance in the use of strong
liquor ; which, as I should have observed  before, is,  in au
cases of hemorrhagy,  of the greatest influence in increasing
the disposition to the disease.
   953.]  I need hardly repeat here, that exercise of all kinds
must be a chief means of obviating and removing a pletho-
ric state of the body ; but upon occasion of the hemorrhoi-
dal flux immediately approaching, both walking and riding,
as increasing the determination of the blood into the hemor-
half an ounce or six drachms. The following formula may be used where greater costiveness
prevails:
       R. Sal. Nitri, 3ii.
          Pulv. Jalap. 3i.
          Elect. Lenitivi, %\.
          M. f. Elect, cujus sumat q. n. m. pro  re nata.
  * Astringents may be used both internally and externally. The internal astringents are Alum,
 Kino, Terra Janonica, ice.  But in cases of hemorrhoids from laxity, nothing produces a better
 effect that the frequent application of pledgets dipped in a strong infusion of galls, or oak bark; 
29B           PRACTICE  OF PHYSIC.

rhoidal vessels, are to be avoided.   At other times, when no
such determination has been  already formed, those modes
of exercise may be very properly employed.*
   954.] Cold bathing is another remedy that may be em-
ployed to obviate  plethora, and prevent hemorrhagy ;  but
it is to be used with caution.   When the hemorrhoidal flux
is approaching, it may be dangerous to turn  it suddenly
aside by cold bathing : but during the intervals of  the dis-
ease, this remedy may be employed with advantage; and
in persons liable to a prolapsus ani, the frequent washing of
the anus with cold water may be very useful.
  955.] These are the means for preventing the recurrence
of the  hemorrhoidal flux ; and  in all cases,  when it is  not
immediately approaching, they are to be  employed.   When
it has actually come on,  means are to be employed  for mo-
derating it at much as possible, by the person's lying in a
horizontal position upon a hard bed  ; by avoiding exercise
in an erect posture;  by using a cool diet; by  avoiding  ex-
ternal  heat;   and  by obviating the irritation  of hardened
faeces by the use of  proper laxatives (9+9.)   From what
has been said above,  as to the being careful not to increase
the determination  of the blood into the  hemorrhoidal ves-
sels, the propriety,of these measures must sufficiently ap-
pear ;  and if they were not so  generally neglected, many
persons would escape the great  trouble, and the various bad
consequences, which so frequently result  from this disease.
  956.]  With respect to the further cure of this  disease,
it is almost in two cases only  that hemorrhoidal  persons
call for the assistance of the  physician.   The one is when
the affection is accompanied with much  pain ; and of this
there are two cases,  according as the pain  happens to at-
tend the external or  the internal piles.
  957.]  The  pain of the external   piles arises especially
when a considerable protrusion of the rectum has happened;
and when, continuing unreduced,  it  is  strangled  by  the
constriction of the sphincter ; while, at the same time,  no
bleeding happens,  to take off the swelling of the protruded
portion of the intestine.   Sometimes an inflammation super-
venes,  and greatly aggravates the pain.  To relieve the pain
in this  case, emollient fomentations  and poultices are some-
times of service ; but a more effectual relief is to be obtain-
ed by applying leeches to the tumid  parts.
 * It is doubtful whether riding is ever adviseable in any period of the disease.  Riding fir
%uently produces Piles, in persons not in tlie least predisposed to them. 
PRACTICE OF PHYSIC.           299
  958.] The other case in which hemorrhoidal persons seek
assistance,  is that of excessive bleeding.  Upon the opinion
so generally received of this discharge being salutary* and
from the observation that upon the discharge occurring per-
sons have sometimes found  relief  from various disorders,
the most part of persons liable to it are ready to let it go too
far  ; and indeed the  Stahlians will not allow it to be a dis-
ease,  unless when it has actually gone to excess.   I am,
however, well persuaded, that this flux ought always to be
cured as soon as possible.
  959.J When the disease occurs as a purely topical affec-
tion,  there can be no doubt of the  propriety of this rule ;
and, even when it has occurred as a  critical discharge in
the case of a  particular disease, yet when  this disease shall
have been entirely cured and removed,  the preventing any
return of the hemorrhois, seems to be both safe and proper.
  960.] It is only when the disease arises  from  a plethoric
state of the body, and from a stagnation of blood in the hy-
pochondriac  region, or when, though originally  topical,
the disease, by  frequent repetition, has become habitual,
and has thereby  acquired a connection  with the  whole sys-
tem, that any doubt can arise as to the safety of curing it
entirely.  Even  in these cases, however, I apprehend it
will be always proper to moderate the bleeding ; lest by  its
continuance or repetition, the plethoric state of the body,
and the particular determination of the blood into the he-
morrhoidal vessels, be increased,  and the recurrence of the
disease, with all its inconveniences and danger, be too much
favored.
  961.] Further,  even in the cases stated (960.) in so far as
the plethoric state of the body,  and the  tendency to that
state, can be obviated  and removed, this  is  always to  be
diligently attempted ; and  if it can be executed with suc-
cess,  the flux may be entirely suppressed.
  962.] The Stahlian opinion, that the hemorrhoidal flux
is only in excess when  it occasions great debility, or a leu-  •
cophleguiatia,  is by no means just ; and it appears to me,
that the smallest approach towards producing either of these,
should be considered as an excess,  which  ought to be pre-
vented from going farther.
   963.]  In  all cases therefore of excess, or of any approach
towards it, and  particularly when the disease depends upon
a prolapsus ani, (950.) I am  of opinion that astringents, both
internal and external, may be safely and properly  employ- 
300           PRACTICE OF PHYSIC.

ed ; not indeed to induce an immediate and total suppres-
sion, but to moderate the hemorrhagy, and by degrees to
suppress it altogether, while at the same time measures are
taken for removing the necessity of its recurrence.
  964.] When the  circumstances (945.) marking a con-
nection between the hemorrhoidal affection and the state of
the stomach occur, the measures necessary are the same as
in the case of atonic gout.
liND  OF THE FIRST VOLUME.