v > V, rmma !flWWLlJJ!__-J^S»" ARMY MEDICAL LIBRARY FOUNDED 1B36 WASHINGTON, D.C r.V #*»***'>' ' > FIRST LINES OF THE PRACTICE OF PHYSIC. BY WILLIAM CULLEN, M. D. LATE PROFESSOR OF THE PRACTICE OF PHYSIC, IN THE UNIVERSITY OF EDINBURGH, &e. &c. WITH NOTES AND OBSERVATIONS, PRACTICAL AND EXPLANATORY, AND A PRELIMINARY DISCOURSE, IN DEFENCE OF CLASSICAL MEDICINE, BY CHARLES CALDWELL, M. D. IN TWO VOLUMES. VOL. II. PHILADELPHIA: PUBLISHED BY EDWARD AND RICHARD PARKER, No. 178, MARKET-STREET. James Maxwell, Printer. 1816. WE v. 2 CONTENTS OF THE SECOND YOLUME. BOOK IV. PAGE CHAP. VI. Of the Menorrhagia, or the Immoderate Flow of the Menses, - 9 VII. Of the Leucorrhoea, Fluor Albus, or Whites, 17 VIII. Of the Amenorrhcea, or Interruption of the Menses, .....21 IX. Of Symptomatic Hemorrhagies, - 32 Sect. I. Of the Hematemesis, or Vomiting of Blood, 33 II. Of the Hematuria, or the Voiding(of Blood from the Urinary Passage, 42 BOOK V. Of Profluvia, or Fluxes, with Pyrexia, 49 Chap. I. Of the Catarrh, - ... - 50 II. Of the Dysentery, 59 PART II. Of Neuroses, or Nervous Diseases, - 73 BOOK I. Of Comata, or the Loss of Voluntary Motion, - 75 Chap. I. Of Apoplexy, - - ibid II. Of Palsy, - .... 89 BOOK II. Of Adynamic, or Diseases consisting in a Weakness or Loss of Motion in either the vital or natural Functions, - - - - 112 Chap. I. Of Syncope, or Fainting, - - ibid II. Of Dispepsia, or Indigestion, - - 122 HI. Of Hypochondriasis, or the Hypochondriac Af- fection, commonly called Vapours or Low Spirits, - - - - 140 BOOK III. Of Spasmodio Affections without fever, - 152 Sect. I. Of the Spasmodic Affections of the Animal Fane- tions, - - - 153 CONTENTS. PAGE Chap. I. Of Tetanus, - - 155 II. Of Epilepsy,......173 III. Of the Chorea, or Dance of St. Vitus, - 198 / Sect. II. Of the Spasmodic Affections of the Vital Func- tions, ... - - 201 Chap. IV. Of the Palpitation of the Heart, - - ibid V. Of Dyspnoea, or Difficult Breathing, - 205 VI. Of Asthma, - 207 VII. Of the Chincough, or Hooping Cough, - 220 Sect. III. Of the Spasmodic Affections in the Natural Functions,.....232 Chap. VIII. Of the Pyrosis, or what is named in Scotland, the Water-Brash, - - ibid IX. Of the Colic, - - - 235 X. Of the Cholera, .... 246 XI. Of Diarrhoea, or Looseness, - - 254 XII. Of the Diabetes, - - 272 XIII. Of the Hysteria, or the Hysteric Disease, 278 XIV. Of Canine Madness and Hydrophobia, - . 286 BOOK IV. Of Vesani.e, or of the Disorders of the Intellectual Func* tions, - - - «■ 290 Chap. I. Of Vesaniae in general, - ibid II. Of Mania, or Madness, - 306 III. Of Melancholy, and other forms of Insanity, 317 PART III. Of Cachexies, --._._ 326 BOOK I. Of Emaciations, ----- 327 BOOK II. Of Intumescenti.e, or General Swellings, - - 339 Chap. I. Of Adipose Swellings, • ibid II. Of Flatulent Swellings, - 343 III. Of Watery Swellings, or Dropsies, - 354 Sect. I. Of Anasarca, --.-_« 366 II. Of the Hydrothorax, or Dropsy of the Breast, 390 III. Of the Ascites, or Dropsy of the Lower Belly, 395 Chap. IV. Of General Swellings, arising from an increased bulk of the whole substance of particular parts, - - 400 Of Rachitis, or Rickets, - ibid BOOK III. Of the Impetigines, or Depraved Habit, with Affections of the Skin, - 412 Chap. I. Of Scrophula, or the King's Evil, - - 413 II. Of Siphylis, or the Venereal Disease, - 424 III. Of Scurvy, - - 438 IV. Of Jaundice, .... - 439 INDEX TWO VOLUMES, N. B. THE CYPHERS REFER TO THE NUMBER OF THE PARAGRAPHS. ABSCESS, 250 Antiphlogistic Regimen, 129 Abscesses and ulcers,the causes how conducted, 130 of their different states, 254 when employed in intermit- Acids employed in fever, 134 mittent fever, 234 refrigerant in fever, ib. Antispasmodics, employed in Action of the heart and arteries, how increased for preventing the recurrences of the parox- ysms of intermitting fever, 230 Adynamyae 1170 Amenorrhaea, 994 from retention, 995 when occurring, 997 symptoms of, 998 causes of, 999—1000 cure of, 1001—5 from suppression, 995 when occurring, 1007 symptoms of, 1009 causes of, 1007—8 cure of, 1010—11 Amentia, 1599 Anasarca, 1669 the character of, ib. phenomena of, cure of, 1669—74 1675—97 A pyrexia, distinguished from Leuco- Ascites, phlegmatia, 1670 character of, St. Anthony's Fire. See Erythema. Antimonial Emetics, employed in fevers, 181 their dilFcrent kinds, ib. the administration of them in fevers, fevers, 152—187 Aphtha, 732 Apoplexy, 1093 --------distinguished from palsy, ib. distinguished from syncope, ib. predisponent cause of, 1094 exciting causes of, 109 7-1114-15 proximate causes of, 1019—20 Serosa, proximate cause of, 1113 prognostic, 1121—22 frequently ending in hemi- phlegia, 1121 prevention of, 1123 whether sanguine or serous, stimulants hurtful in it 1135-36 from powers that destroy the mobility of the nervous power, 1137 cure of, 18:1—186 Asthma, a 1130—38 24 1710 ib. its various seat, 1711—12 the phenomena of, 1713— 14 its particular seat difficultly ascertained, 1715 the cure of, 1716—18 1374 INDEX. Asthma, phenomena of, 1376 C exciting causes of, 1382 Cachexies, character of the proximate cause of, 1385 class, 1600 distinguished from other Cachexy, the term, how ap- kinds of dyspnoea, 1386 plied by authors, 1601 sometimes occasions phthisis Calculis Renalis, 428 pulmonalis, 1387 Calx nitrata antimonii, its use frequently ends in hydrotho- in fevers, 183—185 rax, ib. Canine Madness, 1526 seldom entirely cured, 1388 the cure of, 1526—1528 Astringents, employed in in- Cardialgia, 1428 termittent fevers, 231 Carditis, 383 joined with aromatics, em- of the chronic kind, ib. ployed in intermittent Cams, 1093 fevers, ib. Cataphora, ib. joined with bitters, employ- Catarrh, 1045 ed in intermittent fevers, ib. predisposition to, 1046 Atrabilis, 1028 symptoms of, 1047 Atrophia ab alvi fluxu, 1608 remote causes of, 1046 debilium, 1607 proximate cause of, 1056 inanitorum, 1608 cure of, 1064 infantilis, 1606 produces phthisis, 1054 lactantium, ib. passes into pneumonia, 1053 lateralis, 1607—12 produces a peripneumonia a leucorrhoea, 1608 notha, 1055 nervosa, 1607 contagious, 1061 nutricum, 1608 Catarrhus, suffocativus, 376 a ptyalisma, ib. Chancre, method of treating, 1782 rachitica, 1606 Chicken Pox, 630 senilis, 1607— 12 how distinguished from small Aura Epileptica, 1307 pox, 631 Chincough, 1403 B contagious, ib. Bitters employed in intermit- frequently accompanied with tent fevers, 231 fever, 1411 joined with astringents, em- phenomena of, 1405 ployed in intermittents, ib. prognostic in, 1414 Blistering, its effects, 189—197 cure of, 1415 its mode of operation in the Chlorosis, 997 cure of fevers, 190—194 Cholera, 1454 when to be employed in symptoms of, 1454—57 fevers, 195 remote causes of, 1559—61 where tobe applied in fevers, 196 proximate cause of, I455 Bloodletting, the employment cure of, 1463__65 of it in fevers, 138—143 Chorea, 1348 the circumstances directing phenomena of, 1348__54 its use in fevers, 142 cure of, 1355 the administration of it in Chronic weakness, 1191 fevers, 143 Cceliaca, 1494 when employed in intermit- Cold, its operations, 88 tent fevers, 234 absolute, ib. INDEX. Cold, relative, 89 its general effects on the human body, 90—91 its morbid effects, 92 moderates the violence of reaction in fever, 133 its tonic power, how to be employed in fevers, 205 Cold drink, an useful tonic in fevers, 206 the limitation of its use in fevers, 207 air applied in fevers, 208 Water applied to the surface of the body in fevers, 205—209 Colic, 1436 symptoms of, 1436—39 proximate cause of, 1440 cure of, 1442 Devonshire, 1452 of Poilou, ib. cure of, 1453 Coma, 1093 Comata, 1092 Contagions, 78 their supposed variety, 79 Convulsions, 1253 Corpulency, 1622 Cynanche, 300 maligna, 311 parotidia, 332 pharyngaea, 331 tonsillaris, 301 trachealis, 318 as affecting infants, 322—329 the cure of it, 330 Cystitis, 430 D Days, critical, in fevers, 107—124 noncritical, 113 Death, the causes of, in general, 100 the direct causes of, ib. the indirect causes of, ib. the causes of in fever, 101 Debility in fevers, the symp- toms of, 104 how obviated, 202 Delirium in general, 1530—51 in fever of two kinds, 45 or insanity without fever, 1551-58 Diabetes, 1500 symptoms of, 1505—19 remote causes of, 1505 proximate cause of, 1511—13 cure of, 1514 DiaetaAquea, 157 Diarrhoea, 1466 distinguished from dysen- tery, 1467 distinguished from cholera, 1468 proximate cause of, 1469 remote causes of, 1472—94 cure of, 1495—1504 biliosa, 1481 colliquative, 1502 mucosa, 1489 Diathesis phlogistica, 62—247 how removed, 266 Diluents, their use in fevers, 154—158 Diseases, (he distinguishing of them, how attained, 2 the prevention of them, on what founded, 3 the cure of them on what founded, 4 Dropsies, 1646 in general the cause of them, 1647 of the breast. See Hydro- thorax. of the lower belly. See Ascites. Dysentery, 1066 contagious, 1074 remote causes of, 1071 proximate cause of, 1076 cure of, 1079 use of mild cathartics to be frequently repeated in it, ib. rhubarb improper in it, ib. Dysenteria alba, 1069 Dysmenorrhoea, 1013 Dyspepsia, 1190 remote causes of, 1198 proximate cause of, 1193 cure of, 1201 flatulence in it, cure of, 1221 heartburn in it, cure of, ib. pains of stomach in, cure of, ib. vomiting in it, cure of, ib. Dyspnoea, 1366 INDEX. Effluvia, human, 85 from marshes, ib. Emaciations, 1601 causes of, 1603—19 cure of, 1620 Emansio mensium, 997 Emetics, suited to the cure of fevers, 174 their effects, 176—180 a mean of removing spasm, 170 the administration of in fevers, 175 their use in intermittent fe- vers, 230—233 Emprosthotonos, 1267 Enteritis, 404 phlegmonic or erithem men- sium, a most extraordinary propensity oftentimes prevails for the eating of chalk, clay, lime-plastering, charcoal, and sometimes salt. The same preternatural appetites arise in some women dur- ing the period of gestation; thus manifesting the existence of a sympathy equalfy singular and powerful between the uterus and stomach. PRACTICE OF PHYSIC. 25 vessels of the uterus; which therefore do not impel the blood into their extremities with a force sufficient to open these, and pour out blood by them.* 1000. How it happens that at a certain period of life a fiaccidity of the system arises in young women not originally affected with any such weakness or laxity, and of which but a little time before, they had given no indication, may be difficult t» explain; but I would attempt it in this way. As a certain state of the ovaria in females, prepares and disposes them to the exercise of venery, about the very period at which the menses first appear, it is to be presumed, that the state of the ovaria and that of the uterine vessels are in some measure connected together; and as generally symptoms of a change in the state of the former appear before those of the latter, it may be inferred that the state of the ovaria has a great share in exciting the action of the uterine vessels and producing the menstrual flux. But analogous to what happens in the male sex, it may be presumed, that in females a certain state of the genitals is necessary to give tone and tension to the whole system; and therefore that, if the stimulus arising from the genitals be wanting, the whole system may fall into a torpid and flaccid state, and from thence the chlorosis and retention of the menses may arise.f * In this article our author pursues his erroneous doctrine touch* ing the proximate cause of menstruation. f Without making ourselves the advocates of any part of our author's reasoning on this subject, or even pretending fully to comprehend it we believe it to be true, that there exists between a sound state of the ovaria and the process of menstruation, an VOL. II. ft 26 PRACTICE OF PHYSIC. 1001. It appears to me, therefore, that the retention of the menses is to be referred to a certain state or af- fection of the ovaria: but what is precisely the nature of this affection, or what are the causes of it, I will not pretend to explain; nor can I explain in what manner that primary cause of retention is to be removed. In this, therefore, as in many other cases; where we cannot assign the proximate cause of diseases, our indications of cure must be formtd for obviating and removing the morbid effects or symptoms which appear. 1002. The effects, as has been said in 999, consist in a general flaccidity of the system, and consequently in a weaker action of the vessels of the uterus; so that this debility may be considered as the more im- mediate cause of the retention. This, therefore, is to be cured by restoring the tone of the system in general, and by exciting the action of the uterine vessels in particular. 1003. The tone of the system in general is to be re- stored by exercise, and in the beginning of the disease, by cold bathing. At the same time, tonic medicines may be employed; and of these the chalybeates have been chiefly recommended.* intimate connection. But whether this connection be the relation-- ship of cause and effect, or that of concomitant effects, arising from a common cause, we pretend not to decide. We shall only state what is reported to be the fact, that on an examination of the ge- nital system in females who have never menstruated, the ovaria have been always found in a defective state. * Pure bitters, Peruvian bark, chalybeates, and all the other tonics recommen ed in menorrhagia and leucorrhoea, except the astringents, may be advantageously employed in the present dis- ease. They may be administered also under the same formula. PRACTICE OF PHYSIC. 27 1004. The action of the vessels of the uterus may be excited: 1st, By determining the blood into them more copi- ously; which is to be done by determining the blood into the descending aorta, by purging, by the exercise of walking, by friction, and by warm bathing of the lower extremities-. It is also probable that the blood may be determined more copiously into the hypogastric arteries which go to the uterus^ by. a compression of the iliacs; but the trials of this kind hitherto made have seldom succeeded.* 1005. 2dly, The.action of the uterine vessels may be excited by stimulants applied to them. Thus those purgatives which particularly stimulate the intestinum rectum, may also prove stimulant to the uterine vessels connected with those of the rectum. The exercise of venery certainly proves a stimulus to the vessels of the uterus; and therefore may be useful when, with pro- priety, it can be employed. The various medicines recommended as stimulants of the uterine vessels, un- der the title of Emenagogues, have never appeared to me to be effectual; and I cannot perceive that any of them are possessed of a specific power in this respect. Mercury, as an universal stimulant, may act upon the uterus, but cannot be very safely employed in chloro- tic persons. One of the most powerful means of ex- citing the action of the vessels in every part of the If preceded by an emetic they will act with more certainty and higher effect. ,, ■ * With a view to the promotion of the object herein contem- plated, dancing, jumping the rope, and riding on horseback, are important exercises. 28 PRACTICE OF PHYSIC. system is, the electrical shock; and it has often been employed with success for exciting the vessels of the Uterus.* 1006. The remedies (1002—1005.) now mention- ed, are those adapted to the retention of the menses; and I am next to consider the case of suppression. In en- tering upon this, I must observe, that every interruption of the flux, after it has once taken place, is not to be * The purgatives usualfy employed for such purposes, are aloes, scammony, and gamboge, given in suitable doses, and at such times as the practitioner may deem necessary. A strong in- fusion of senna, stimulating the rectum very considerably, con- stitutes a useful remedy in this complaint. For awakening the action of the uterine vessels, other remedies, not of purgative qualities, are highly recommended, and have, we feel persuaded, been usefully employed. These may be divided into external and internal. The external are, blisters on the os sacrum, or on the inside of the thighs, as near to the groins as practicable, and warmth ap- plied to the pudenda in the form of steam, or cloths wet with water, as hot as can be borne without pain. To this head belongs electricity frequently passed through the region of the uterus, and the lumbar region generally. The internal are the savin, in powder or tincture, tincture of myrrh, the radix senekae in powder or decoction, and the clavus or ergot of rye, which, in proper doses, is reported to be a safe and very powerful remedy. For information as to the effects and mode of exhibition of this latter medicine, the reader is referred to a paper by Dr. Bigelow, in No. II. Vol. V. of the " New England Journal of Medicine and Surgery." Other interesting papers on the medicinal qualities of the same article, have appeared of late in the northern section of our country. Amenorrhea being sometimes accompanied with hepatic af- fections, renders the employment of mercury essential. In other cases of the complaint, that remedy is of more doubtful pro- mise. PRACTICE OF PHYSIC. 29 considered as a case of suppression. For the flux, up- on its first appearance, is not always immediately esta- blished in its regular course; and therefore, if an inter- ruption happen soon after the first appearance, or even in the course of the first, or perhaps second year after, it may often be considered as a case of retention, espe- cially when the disease appears with the symptoms pe- culiar to that state. 1007. Those which may bo, properly considered as cases of suppression, are such as occur after the flux has been for some time established in its regular course, and in which the interruption cannot be referred to the causes of retention (1001, 1002.) but must be imputed to some resistance in the extremities of the vessels of the uterus. Accordingly, we often find the suppression induced by cold, fear, and other causes which may pro- duce a constriction of these extreme vessels. Some physicians have supposed an obstructing lentor of the fluids to occasion the resistance now mentioned: but this is purely hypothetical, without any proper evidence of the fact; and it is besides, from other considerations, improbable. 1008. There are indeed some cases of suppression that seem to depend upon a general debility of the sys- tem, and consequently of the vessels of the uterus. But in such cases, the suppression always appears as symp- tomatic of other affections, and is therefore not to be considered here. 1009. The idiopathic cases of suppression (1007.) seldom continue long without being attended with va* rious Symptoms or disorders in different parts of the body; very commonly arising from the blood which 30 PRACTICE OF PHYSIC. should have passed by the uterus, being determined more copiously into other parts, and very often with such force as to produce hemorrhagies in these. Hence hemorrhagies from the nose, lungs, stomach, and other parts, have appeared in consequence of suppressed menses. Besides these, there are commonly hysteric and dyspeptic symptoms produced by the same cause; and frequently colic pains, with a bound belly.* 1010. In the idiopathic cases of suppression, (1007.) the indication of cure is to remove the constriction af- fecting the extreme vessels of the uterus; and for this purpose the chief remedy is warm bathing applied to the region of the uterus. This, however, is not always effectual, and I do not know of any other remedy adapt- ed to the indication. Besides this, we have perhaps no other means of removing the constriction in fault, but that of increasing the action and force of the vessels of the uterus, so as thereby to overcome the resistance or constriction of the extremities. This, therefore, is to be attempted by the same remedies in the case of suppression, as those prescribed in the cases of reten- tion (1003, 1005). The tonics, however, and cold- bathing (1003.) seem tobe less properly adapted to the cases of suppression, and have appeared to me of am- biguous effect, f * In cases of suppressed menses, vicarious hemorrhagies have appeared not only from the parts herein stated, but from the kid- neys, the hemorrhoidal vessels, the fingers, the eye, and from warts and the surfaces of ulcers. t In the treatment of this disease, vomiting and blood-letting, when skilfully directed, are important remedies. So is the warm bath, both local and general. PRACTICE OF PHYSIC. 31 1011. It commonly happens in the case of suppres- • sion, that though the menses do not flow at their usual periods, there are often at those periods some marks of an effort having a tendency to produce the discharge. It is, therefore, at those times especially when the efforts of the system are concurring, that we ought to employ the remedies for curing a suppression; and it is com- monly fruitless to employ them at other times, unless they be such as require some continuance in their use to produce their effects. . 1012. Nearly similar to the cases of suppression, are those cases in which the menses flow after long inter- vals, and in lesser quantity than usual; and when these cases are attended with the disorders in the system (1009.) they are to be cured by the same remedies as the cases of entire suppression. 1013. It may be proper in this place to take notice of the desmenorrhea, or cases of menstruation in which the menses seem to flow with difficulty, and are accom- panied with much pain in the back, loins, and lower belly. We impute this disorder partly to some weaker action of the vessels of the uterus, and partly, perhaps more especially, to a spasm of its extreme vessels. We have commonly found the disease relieved by employ- ing some of the remedies of suppression immediately before the approach of the period, and at the same time employing opiates. In other respects the practice here does not differ materially from that recommended in a suppression of the menses. In difficult and painful menstruation, the warm bath, well timed blood-letting, and opiates, constitute the usual, and most impor* ant remedies. 32 PRACTICE OF PHYSIC. CHAPTER IX. OF SYMPTOMATIC HEMORRHAGIES. 1014. 1 HAVE thought it very improper, in this work, to treat of those morbid affections that are almost always symptomatic of other more primary diseases; and this for several reasons, particularly because it introduces a great deal of confusion in directing practice, and leads physicians to employ palliative measures only. I shall here, however, 'deviate a little from my general plan, to make some reflections upon symptomatic hemorrha- gies. 1015. The hemorrhagies of this kind that especially deserve our notice, are the Hematcmesis, or Vomiting of Blood; and the Hematuria, or the Voiding of Blood from the urinary passage. Upon these I am here to make some remarks; because, though they are very generally symptomatic, it is possible they may be some- times primary and idiopathic affections; and because they have been treated of as primary diseases in almost every system of the practice of physic. PRACTICE OF PHYSIC. 33 SECTION 1. OF THE HEMATEMESIS, OR VOMITING OF BLOOD, 1016. Ihave said above in 994, in what manner blood thrown out from the mouth may be known to proceed from the stomach, and not from the lungs; but it may be proper here to say more particularly, that this may be certainly known, when the blood is brought up manifestly by vomiting without any coughing; when this vomiting has been preceded by some sense of weight, anxiety, and pain, in the region of the stomach; when the blood brought up is of a black and grumous ap- pearance, and when it is manifestly mixed with other contents of the stomach; we can seldom have any doubt of the source from whence the blood proceeds, and therefore of the existence of the disease we treat of. 1017. We must allow it to be possible that a ple- thoric state of the body from general causes may be accompanied with causes of a peculiar determination and afflux of blood to the stomach, so as to occasion an hemorrhagy there, and thence a vomiting of blood; and in such a case this appearance might be considered as a primary disease. But the history of diseases in the re- cords of physic, afford little foundation for such a sup- position; and on the contrary, the whole of the in- stances of a vomiting of blood which have been record- ed, are pretty manifestly symptomatic of a more primary affection. vol. 11. £ 34 PRACTICE OF PHYSIC Of such symptomatic vomitings of blood, the chief instances are the following: 1018. One of the most frequent is that which appears in consequence of a suppression of an evacuation of blood, which had been for some time before established in another part of the body, particularly that of the menstrual flux in women. 1019. There are instances of a vomiting of blood happening from the retention of the menses: but such instances are very uncommon; as retention of the menses rarely happens in consequence of, or even with a ple- thoric state of the body; and as rarely does it produce that, or the hemorrhagy in question. There are instances of a vomiting of blood happen- ing to pregnant women; that might therefore also be imputed to the suppression of the menses, which hap- pens to women in that state. There have indeed been more instances of this than of the former case; but the latter are still very rare: for although the blood which used to flow monthly before impregnation, is, upon this taking place, retained, it is commonly so entirely employed in dilating the uterine vessels, and in the growth of the foetus that it is seldom found to produce a plethoric state of the body, requiring a vicarious out- let. The vomiting of blood, therefore, that is vicarious of the menstrual flux, is that which commonly and almost only happens upon a suppression of that flux, after it had been for some time established. 1020. When such a suppression happens, it may be supposed to operate by inducing ;i plethoric state of the whole body, and thereby occasioning hemorrhagy from PRACTICE OF PHYSIC. 35 other parts of it; and hemorrhagies from many differ- ent parts of the body have been observed by physicians as occurring in consequence of the suppression we speak of. It is, however, the great variety of such hemor- rhagies, that leads me to think, that with the plethoric state of the whole body there must be always some pe- culiar circumstances in the part from which the blood flows, that determines its afflux to that particular, often singularly odd, part; and therefore, that such hemor- rhagies may from these circumstances occur without any considerable plethora at the same time prevailing in the whole system. 1021. It is to be observed, that if we are to expect an hemorrhagy in consequence of the suppression of the menses inducing a plethoric state of the system, we should expect especially an hemoptysis, or hemorrhagy from the lungs, as a plethora might be expected to show its effects especially there; and accordingly, upon occa- sion of suppressed menses, that hemorrhagy occurs more frequently than any other: but even this, when it does happen, neither in its circumstances nor its consequences, leads us to suppose, that at the same time any considerable or dangerous plethora prevails in the body. 1022. These considerations (in 1020, 1021.) will, I apprehend, apply to our present subject; and I would therefore alledge, that a hematemesis may perhaps de- pend upon particular circumstances of the stomach de- termining an afflux of blood to that organ; and may therefore occur without any considerable or dangerous plethora prevailing in the system. What are the cir- cumstances of the stomach, which upon the occasion 36 PRACTICE OF PHYSIC. mentioned, may determine an afflux of blood to it, I cannot certainly or clearly explain; but presume that it depends upon the connection and consent which we know to subsist between the uterus and the whole of the alimentary canal, and especially that principal part of it, the stomach.* 1023. From these reflections, we may, I think, draw the following conclusions: I. That the hematemesis we speak of is hardly ever a dangerous disease. II. That it will hardly ever require the remedies suit- ed to the cure of active hemorrhagy; and at least that it will require these only in those unusual cases in which there appear strong marks of a general plethora, and in which the vomiting of blood appears to be considerably active, very profuse, and frequently recurring. III. That a vomiting of blood from suppressed menses, ought seldom to prevent the use of these re- medies of amenorrhoea, which might be improper in the case of an active idiopathic hemorrhagy. 1024. Another case of symptomatic hematemesis quite analagous to that already mentioned, is the hema- temesis following, and seemingly depending upon, the suppression of an hemorrhoidal flux, which had been established and frequent for some time before. * Besides the powerful sympathy known to subsist between the uterus and stomach, a preternatural determination of blood to the latter organ appears to be oftentimes produced by an immoderate use of wine, ardent spirits, vinegar, or some other strongly stimu- lating beverage. Most of the serious cases of hematemesis we have had occasion to witness, have occurred in the persons of ha- bitual drunkards—at least, of individuals addicted to intempe- rance. PRACTICE OF PHYSIC. 37 This may perhaps be explained by a general plethoric state induced by such a suppression; and indeed some degree of a plethoric state must in such a case be sup- posed to take place; but that supposition alone will not explain the whole of the case; for a general plethora would lead us to expect an hemoptysis (1021.) rather than an hematemesis; and there is therefore something still wanting, as in the former case, to explain the par- ticular determination to the stomach. Whether such an explanation can be got from the connexion between the different parts of the sanguife- rous vessels of the alimentary canal, or from the con- nexion of the whole of these vessels with the vena por- tarum,. I shall riot venture to determine. But in the mean time I imagine, that the explanation required is rather to be obtained from that connexion of the sto- mach with the hemorrhoidal affection that I have taken notice of in 945.* * Hematemesis arising from a suppression of the hemorrhoidal flux is by no means a rare occurrence. As we know of no remedies or modes of practice that belong in a particular manner to this disease, we have but little to say on the subject of its treatment. As a general rule, what is appli- cable in other cases of hemorrhagy, will be found equally appli- cable;and useful here. Perfect quietude of both body and mind should be strictly enjoined. If the habit be plethoric and the symptoms inflammatory, blood-letting will be requisite. Owing, however, to the powerful influence of affections of the stomach, in moderating the action of the heart and arteries, this remedy can rarely be carried to any considerable extent. We have occasion- ally repeated it two or three times: but such cases seldom occur. Here, however, as in all other instances of disease, the pulse and' the state of the system must direct. 38 PRACTICE OF PHYSIC. 1025. How we may explain the hematemesis occa- sioned by a suppression of the hemorrhois, the consi- In hematemesis, as in haemoptysis, it is particularly necessary that the drinks be cool. Perhaps even iced water swallowed in small quantities, and frequently repeated, might be found useful, by acting as an astringent on the ruptured vessel. Drinks of a mucilaginous quality, as flax-seed tea, barley water, or a solution of gum arabic in water, are also productive of salutary effects. In the treatment of hemoptysis, culinary salt is a useful re- medy: what would be its effect in that of hematemesis? In addition to the use of astringents, as symptoms may indicate, the application of cups and blisters to the abdomen will prove ad- vantageous. So will the frequent emptying of the bowels by means of injections. Should purgatives be found necessary, as they sometimes are, the mild saline ones will be most suitable. Castor oil is also, at times, exhibited with advantage. Cases of hematemesis that had obstinately resisted other means, have yielded, at length, to copious purging. When this disease is to be regarded as a translation of hemor- rhois to the stomach, the application of leeches to the hemorrhoi- dal vessels is a promising remedy. As a styptic in it, the tinctura ferri muriatis, in doses of from twenty to thirty drops, exhibited every two hours, in cold water, is recommended as useful. Should pain or irritation render opium necessary, its exhibition by injection will be entitled to a preference. Although spermaceti is favourably spoken of by European practitioners, we acknowledge ourselves at a loss as to the grounds of the prescription. We do not consider it a very promising re- medy. If hematemesis arise from an obstruction or enlargement of the liver or spleen, its cure will depend on a removal of these affec- by mercury and other suitable remedies. In obstinate cases of it, arising from common causes, repeated injections of cold water have been found efficacious. PRACTICE OF PHYSIC. 39 derations in 1020, 1021, will apply here as in the ana- logous case of hematemesis from suppressed menses; and will therefore allow us also to conclude here, that the disease we now treat of will seldom be dangerous, and will seldom require the same remedies that idiopa- thic and active hemorrhagy does. 1026. The cases of hematemesis already mentioned, may be properly supposed to be hemorrhagies of the ar- terial kind; but it is probable that the stomach is also liable to hemorrhagies of the venous kind (767.) In the records of physic there are many instances of vomiting blood, which were accompanied with a tume- fied spleen, which had compressed the vas breve, and thereby prevented the free return of venous blood from the stomach. How such an interruption of the venous blood may occasion an hemorrhagy from either the ex- tremities of the veins themselves, or from the extremi- ties of their correspondent arteries, we have explained above in 768; and the histories of tumefied spleens compressing the vasa brevia, afford an excellent illus- tration and confirmation of our doctrine on that subject, and render it sufficiently probable that vomitings of blood often arise from such a cause. 1027. It is also possible, that an obstruction of the liver resisting the free motion of the blood in the vena portarum, may sometimes interrupt the free return of the venous blood from the vessels of the stomach, and thereby occasion a vomiting of blood; but the instances of this are neither so frequent nor so clearly explained as those of the former case. 1028. Besides these cases depending on the state *f the liver or spleen, it is very probable that other he- 40 PRACTICE OF PHYSIC. morrhagies of the stomach are frequently of the venous kind. The disease named by Sauvages, Melasna, and by other writers commonly termed the Morbus Niger (771.) consisting in an evacuation either by vomiting or by stool, and sometimes in both ways, of a black and gru- mous blood, can hardly be otherwise occasioned, than by a venous hemorrhagy from some part of the internal surface of the alimentary canal. It is, indeed, possible, that the bile may sometimes put on a black and viscid appearance, and give a real foundation for the appellation of an Atra Bilis: but it is certain, that instances of this are very rare; and it is highly probable that what gave occasion to the notion of an atra bilis among the ancients, was truly the ap- pearance of blood poured into the alimentary canal in the manner 1 have mentioned; and which appearance, we know, the blood always puts on when it has stagna- ted there for any length of time. I suppose it is now generally thought, that Boerhaave's notion of such a matter existing in the mass of blood, is without any foundation; whilst, by dissections in modern times, it appears very clearly, that the morbus niger presenting such an appearance of blood, always depends upon the effusion and stagnation I have mentioned. 1029. From this account of the melaena it will appear that vomiting of blood may arise in consequence of blood being poured out in the manner I have mention- ed, either into the cavity of the stomach itself, or into the superior portions of the intestines, from whence matters often pass into the stomach. PRACTICE OF PHYSIC. 41 1030. Both in the case of the melaena, and in the analogous cases from affections of the spleen or liver, it will appear, that the vomitings of blood occurring must be considered as symptomatic affections, not at all to be treated as a primary active hemorrhagy, but by reme- dies, if any such be known, that may resolve the pri- mary obstructions. 1031. I believe I have now mentioned almost the whole of the causes producing an hematemesis; and cer- tainly the causes mentioned, are those which most com- monly give occasion to that symptom. Possibly, how- ever, there may be some other causes of it, such as that singular one mentioned by Sauvage of an aneurism of the aorta bursting into the stomach; and it is possible, that some diseases of other contiguous parts, which have become closely adhering to the stomach, may some- times, by a rupture into the cavity of the stomach, pour blood into it, which is afterwards rejected by vomiting. It is possible also, that abscesses and ulcerations of the stomach itself, may sometimes pour blood into its ca- vity to be thrown up by vomiting. I did not think it necessary, among the symptomatic vomitings of blood, to enumerate those from external violence, nor, what is analogous to it, that which arises from violent straining to vomit; which last, however is much more rare than might be expected. In either of these cases the nature of the disease cannot be doubtful; and the management of it will be readily understood from what has been delivered above with respect to mo- derating and restraining hemorrhagy in general. vol. ir. f 42 PRACTICE OF PHYSIC SECTION II.» OF THE HEMATURIA, OR THE VOIDING OF BLOOD FROM THE URINARY PASSAGE. 1032. IT is alleged, that an hematuria has occurred without any other symptom of an affection of the kid- neys or urinary passages being present at the same time; and as this happened to plethoric persons, and recurred at fixed periods, such a case has been suppos- ed to be an instance of idiopathic hematuria, and of the nature of those active hemorrhagies I have treated of before. * Practitioners of medicine are frequently at a loss as to the cause of the vitiated condition of urine. The following circum- stances may serve, at times, as discriminating marks of hema- turia. The blood, which may have become black and grumous, being specifically heavier than the urine, falls to the lower part of the bladder. It is consequently discharged in larger quantities, in the beginning, than towards the end of making water. Hence the urine first evacuated is deep coloured and muddy; but, as it continues to flow, becomes lighter coloured by degrees, until it assumes, at length, its natural appearance. Besides the antihemorrhagic remedies, already recommended in hematemesis and elsewhere, ura ursi is said to be peculiarly useful in hematuria. Digitalis is also very highly recommended. Cold applications to the scrotum in men and the pudenda in wo- men, are found to be productive of beneficial effects. So also is the employment of emetics. By means of injections the bowels should be kept free from irritating contents. If the disease continue obstinate, let cups be applied to the re- gion of the kidneys. Nor would we withhold blisters from th PRACTICE OF PHYSIC. 43 1033. I cannot positively deny the existence of such a case; but must observe, that there are very few in- stances of such upon the records of physic; that none have ever occurred to my observation, or to that of my friends; and that the observations adduced may be fal- lacious, as I have frequently observed an hematuria without symptoms of other affection of the kidney or urinary passages being, for the time, present; whilst, however, fits of a nephralgia calculosa having, before, or soon after, happened, rendered it to me sufficiently probable, that the hematuria was owing to a wound made by a stone present in some part of the urinary passages. 1034. The existence of an idiopathic hematuria is further improbable, as a general plethora is more likely to produce an hemoptysis (1021.) and as we do not well know of any circumstance which might determine more particularly to the kidneys. An idiopathic hematuria, same part, from any apprehension of the production of strangury. Should that affection occur, it may even prove useful on the prin- ciple of revulsion; which is but another term for that of sym- pathy. The carbonate of soda is recommended here as an efficacious remedy. In a paper, contained in the 8th volume of Medical Tracts and Observations, a case of hematuria, of great obstinacy, is reported to have been cured by a decoction of peach leaves. The decoc- tion was prepared by boiling an ounce of the dried leaves in a quart of water, until it was reduced to a pint and a half. Of this the patient drank a pint in the course of the day. In this complaint, nauseating doses of tartarized antimony con- stitute a remedy of fair promise. So does vitriolated zink, ex- hibited in such quantities, and at such intervals, as to produce on the stomach a similar effect. 44 PRACTICE OF PHYSIC. therefore, must certainly be a rare concurrence; and in- stances of symptomatic affections of the same kind are very frequent. 1035. One of the most frequent is, that hematuria which attends the nephralgia calculosa, and seems ma- nifestly to be owing to a stone wounding the internal surfaee of the pelvis of the kidney or of the ureter. In such cases, the blood discharged with the urine is sometimes of a pretty florid colour, but for the most part is of a dark hue: the whole of it is sometimes dif- fused or dissolved, and therefore entirely suspended in the urine; but if it is in any large quantity, a portion of t it is deposited to the bottom of the vessel containing the voided blood and urine. On different occasions, the blood voided puts on different appearances. If the blood poured out in the kidney has happened to stagnate for some time in the ureters or bladder, it is sometimes co- agulated, and the coagulated part is afterwards broken down into a grumous mass of a black or dark colour, and therefor® gives the same colour to the urine voided; or if the quantity of broken down blood isri small, it gives only a brownish urine resembling coffee. It some- times also happens, that the blood stagnating and coa- gulating in the ureters, takes the form of these vessels, and is therefore voided under the appearance of a worm; and if the coagulated blood happens to have, as it may sometimes, have, the gluten separated from the red globules, these worm-like appearances have their ex- ternal surface whitish, and the whole seemingly forming a tube containing a red liquor. I have sometimes ob- served the blood which had seemingly been coagulated in the ureter, come away in an almost dry state, resem- bling the half-burnt wick of a candle. PRACTICE OF PHYSIC. 45 1036. These are the several appearances of the blood voided in the hematuria calculosa, when it proceeds especially from the kidneys or ureter; and many of the same appearances are observed when the blood pro- ceeds only from the bladder when a stone is lodged there; but the attending symptoms will commonly point out the different seat of the disease. In one case, when a quantity of blood from the kid- ney or ureter is coagulated in the bladder, and is, there- fore, difficultly thrown out from this, the pain and un- easiness on such an occasion may appear chiefly to be in the bladder, though it contains no stone; but the an- tecedent symptoms will commonly discover the nature of the disease. 1037. In any of the cases of the hematuria calculosa, it will hardly be necessary to employ the remedies suit- ed to an active hemorrhagy. It will be proper only to employ the regimen fit for moderating hemorrhagy in general, and particularly here to avoid every thing or circumstance that might irritate the kidneys or ure- ters. Of such cases of irritation there is none more frequent or more considerable than the presence of hardened fasces in the colon; and these, therefore, are to be frequently removed by the frequent use of gentle laxatives. 1038. The hematuria calculosa may be properly con- sidered as a case of the hematuria violenta: and, there- fore, I subjoin to that the other instances of hematuria from external violence; such as that from external con- tusion on the region of the kidney, and that from the violence or long continued exercise of the muscles in- cumbent on the kidneys. An instance of the latter cause occurs especially in riding. 46 PRACTICE OF PHYSIC. 1039. It may also be considered as a case of the he- matura violenta, when the disease occurs in conse- quence of the taking in of certain acrid substances, which pass again especially by the urinary passages; and by inflaming and swelling the neck of the bladder, bring on a rupture of the over-distended blood-vessels, and give occasion to a bloody urine. The most noted in- stance of this is in the effect of cantharides in a certain quantity, any way introduced into the body. And pos- sibly some other acrids may have the same effect. 1040. Beside these most frequent instances of hema- turia, which cannot be considered as idiopathic hemor- rhagies, there are some other instances of hematuria mentioned by authors, that are still, however, manifest- ly symptomatic; such as a discharge of blood from the urinary passages, in consequence of a suppression of either the menstrual or hemorrhoidal flux. These may be considered as analogous to the hematemesis produ- ced by the like causes; and the several reflections made above on that subject, will, I think, apply here, and par- ticularly the conclusions formed in 1023. Instances, however, of either of these cases, and especially ©f the first, have been extremely rare. 1041. Of such symptomatic hematuria there is, how- ever, one instance deserving notice; and that is, when a suppression of the hemorrhoidal flux, either by a communication of vessels, or merely by the vicinity of parts, occasions a determination of blood into the vessels of the neck of the bladder, which in conse- quence of a rixis or anastomosis, pour out blood to be voided either with or without urine. This case is what ' has been named the Hemorrhoides Vesicas; and with some propriety, when it is manifestly an evacuation vi- PRACTICE OF PHYSIC. 47 carious of what had before been usually made from the rectum. With respect to the management of the he- morrhoides vesicae, I would apply the whole of the doctrines that I have delivered above, with respect to the cure of the proper hemorrhoidal affection. 1042. There remains still to be mentioned one other instance of symptomatic hematuria, which is that which happens in the case of confluent and putrid small-pox, as well as in several other instances of putrid diseases. The blood, in such cases, may be presumed to come from the kidneys; and I apprehend that it comes from thence in consequence of that fluidity which is always produced in the blood approaching to a putrid state. Such hematuria, therefore, is not to be considered as a symptom of any affection of the kidneys, but merely as a mark of the putrescent state of the blood. 1043. In certain diseases the urine is discharged of such a deep red colour, as to give a suspicion of its be- ing tinged by blood present in it; and this has given occasion to Sauvages, amongst the other species of he- maturia, to mark the hematuria spuria, and the hema- turia latertia; both of which, however, he supposes to be without any blood present in the urine. In many cases it is of importance, in ascertaining the nature of the disease, to determine whether the red colour of urine be from blood present in it, or from a certain state of the salts and oils which are always in greater or lesser proportion constituent parts of the urine; and the ques- tion may be commonly determined by the following considerations. It has been observed above, that when any consider- able quantity of blood is voided with the urine, there is 48 PRACTICE OF PHYSIC. always a portion of it deposited at the bottom of the vessel containing the voided blood and urine: and in such a case there will be no doubt in attributing the colour of the urine floating above to some part of the blood diffused in it. The question, therefore, with re- spect to the presence of blood in the urine can only oc- cur when no such deposition as I have mentioned ap- pears; and when.the blood that may be supposed to be present is dissolved or diffused, and therefore entirely suspended in the urine. In this case the presence of the blood may be commonly known, 1st, By the colour, which blood gives, different, from any urine without blood that I have ever seen; and I think a little expe- rience will enable most persons to make this distinction. 2dly, By this, that the presence of blood always dimi- nishes the transparency of the urine with which it is mixed; and it is very seldom that urine, though very high coloured, loses its transparency; at least this hard- ly ever appears, if the urine is examined when recently voided. 3dly, When urine has blood mixed with it, it tinges a piece of linen dipped into it with a red colour, which the highest coloured urine without blood, never does. 4thly, High coloured urine without blood, up- on cooling, and remaining at rest in a vessel, almost al- ways deposits a lateritious sediment; and if upon any occasion bloody urine should deposit a sediment that may be of a portion of the blood formerly diffused in it, the difference, however, may be discerned by this, that the sediment deposited by urine without blood, upon the urine's being again heated, will be entirely redissolved, which will not happen to any sediment from blood. Lastly, we know no state of urine with- PRACTICE OF PHYSIC. 49 out blood, which shows any portion of it, coagulable by a heat equal to that of boiling water; but blood diffused in urine is still coagulable by such a heat; and by this test, therefore, the presence of blood in urine may be commonly ascertained. BOOK V. OF PROFLUVIA,* OR FLUXES, WITH PYREXIA. 1044. FORMER nosologists have established a class of diseases under the title of Fluxes, or Profiuvia; but as in this class they have brought together a great num- ber of diseases, which have nothing in common ex- cepting the single circumstance of an increased dis- charge of fluids, and which also are, in other respects, very different from one another; I have avoided so im- proper an arrangement, and have distributed most of the diseases comprehended in such a class by the no- sologists, into places more natural and proper for them. I have, indeed, still employed here the general title; but I confine it to such fluxes only as are constantly attended with pyrexia, and which therefore necessarily belong to the class of diseases of which I am now treat-1 . * We have already observed, and, therefore, need not repeat, that both the diseases included by our author under the order profluvia, belong of right to that of phlegmasia^. They are fe- brile complaints marked by an inflammatory topical affection. VOL. II. C --—nrTT^.T M ♦t, **fel 50 PRACTICE OF PHYSIC. Of the fluxes which may be considered as being very constantly febrile diseases, there are only two, the catarrh and dysentery; and of these, therefore, I now proceed to treat. CHAPTER I. OF THE CATARRH. 1045.THE catarrh is an increased excretion of mu- cus from the mucous membrane of the nose, fauces, and bronchiae, attended with pyrexia. Practical writers and nosologists have distinguished the disease by different appellations, according as it happens to affect those different parts of the mucous membrane, the one part more or less than the other: But I am of opinion, that the disease, although affect- ing different parts, is always of the same nature, and proceeds from the same cause. Very commonly, in- deed, those different parts are affected, at the same time; and therefore there can be little room for the distinction mentioned. The disease has been frequently treated of under the title of Tussis, or Cough; and a cough, indeed, always attends the chief form of catarrh, that is» the increased excretion from the bronchiae; but a cough is so often a symptom of many other affections, which are very dif- ferent from one another, that it is improperly employed as a generic title. v 1046. The remote cause of catarrh is most common- ly cold applied to the body. This application of cold producing catarrh, can in many cases be distinctly ob- f PRACTICE OF PHYSIC. 51 served; and I believe it would always be so, were men acquainted with, and attentive to, the circum- stances which determine cold to act upon the body. (See 94—96.) From the same paragraphs we may learn what in some persons gives a predisposition to catarrh.* 1047. The disease, of which I am now to treat, ge- nerally begins with sohie difficulty of breathing through the nose, and with a sense of some fulness stopping up that passage. This is also often attended with some dull pain and a sense of weight in the forehead, as well as some stiffness in the motion of the eyes. These feelings, sometimes at their very first beginning, and always soon after, are attended with the distillation from the nose; and sometimes from the eyes, of a thin fluid, which is often found to be somewhat acrid, both by its taste, and by its fretting the parts over which it passes. 1048. These symptoms constitute the coryza and gravedo of medical authors, and are commonly attend- ed with a sense of lassitude over the whole body. Sometimes cold shiverings are felt, at least the body is more sensible than usual to the coldness of the air; and with all this the pulse becomes, especially in the even- ings, more frequent than ordinary. 1049. These symptoms seldom continue long before they are accompanied with some hoarseness, and a sense of roughness and soreness in the trachea, and with * Tke opinion here asserted we believe to be erroneous. So strong 1fc, at times, the predisposition to catarrh, in consequence of certain corbific conditions of the atmosphere, that exposure and other causes too slight to be noticed, will produce the dis- ease. $2 PRACTICE OF PHYSIC. some difficulty of breathing, attributed to a sense of straitness of the chest, and attended with a cough, which seems to arise from some irritation felt at the glottis. The cough is generally at first dry, occasion- ing pains about the chest, and- more especially in the breast. Sometimes, together with these symptoms, pains resembling those of the rheumatism are felt in se- veral parts of the body, particularly about the neck and head. While these symptoms take place, the appetite is impaired, some thirst arises, and a general lassitude is felt over all the body. 1050. These symptoms (1047—1049.) mark the violence and height of the disease; which, however, does not commonly continue long. By degrees the cough becomes attended with a copious excretion of mucus; which is at first thin, but gradually becoming thicker, is brought up with less frequent and less labo- rious coughing. The hoarseness and soreness of the trachea likewise going off, the febrile symptoms abat- ing, the cough becoming less frequent, and with less expectoration, the disease soon after ceases altoge- ther.* 1051. Such is generally the course of this disease, which is commonly neither tedious nor dangerous; but, upon some occasions, it is in both respects otherwise. A person affected with catarrh seems to be more than usually liable to be affected by cold air; and in that con- dition, if exposed to cold, the disease, which seemed to * 1047—48—49—50. The description of catarrh herein given is accurate and excellent. It may be truly denominated, a pic- ture of the disease. The sensation in the chest, however, excited by coughing, is, for the most part, a soreness or an uneasiness, ra* ther than a pain. PRACTICE OF PHYSIC. 53 be yielding, is often brought back with greater violence than before; and is rendered not only more tedious than otherwise it would have been, but also more dangerous by the supervening of other diseases. 1052. Some degree of the cynanche tonsillaris, often accompanies the catarrh; and, when the latter is aggra- vated by a fresh application of cold, the cynanche also becomes more violent and dangerous, in consequence of the cough which is present at the same time. 1053. When a catarrh has been occasioned by a violent cause; when it has been aggravated by impro- per management; and especially when it has been ren- dered more violent by fresh and repeated applications of cold, it often passes into a pneumonic inflammation attended with the utmost danger. 1054. Unless, however, such accidents as those of 1051—1053, happen, a catarrh, in sound persons not far advanced in life, is, 1 think, always a slight disease, and attended with little danger. But, in persons of a phthisical disposition, a catarrh may readily produce an hemoptysis, or perhaps form tubercles in the lungs; and more certainly, in persons who have tubercles already formed in the lungs, an accidental catarrh may occasion the inflammation of these tubercles, and in consequence produce a phthisis pulmonalis. 1055. In elderly persons, a catarrh sometimes proves a dangerous disease. Many persons, as they advance in life, and especially after they have arrived at old age, have the natural mucus of the lungs poured out in greater quantity, and consequently requiring a frequent expectoration. If therefore a catarrh happen to such persons, and increase the influx of fluids to the lungs, with some degree of inflammation, it may produce the 54 PRACTICE OF PHYSIC. peripneumonia notha, which in such cases is very often fatal. (See 376. 382).* 1056. The proximate cause of catarrh seems to be an increased afflux of fluids to the mucous membrane of the nose, fauces and bronchiae, along with some de- gree of inflammation effecting these parts. The latter cir- cumstance is confirmed by this, that in the case of ca- tarrh, the blood drawn from a vein commonly exhibits the same inflammatory crust which appears in the case of phlegmasiae.f 1057. The application of cold which occasions a ca- tarrh, probably operates by diminishing the perspira- tion usually made by the skin, and which is therefore determined to the mucus membrane of the parts above mentioned. As a part of the weight which the body daily loses by insensible evacuation, is owing to an ex- halation from the lungs, there is probably a connexion between this exhalation and the cutaneous perspiration so that the one may be increased in proportion as the other is diminished: And therefore we may understand how the diminution of cutaneous perspiration, in con- sequence of the application of cold, may increase the afflux of fluids to the lungs, and thereby produce a ca- tarrh.! * 1054—5. The sentiments expressed in these articles are equally important and true. They, therefore, merit the utmost attention, and should be made the foundation of great precaution on the part of physicians as well as of patients. t Catarrh consists in an inflammatory affection of this mem- brane, accompanied with fever. Of such affection an increased secretion is the natural consequence. \ The explanation herein attempted is too mechanical to apply to living matter. Like all other febrile complaints, catarrh is a PRACTICE OF PHYSIC. 55 1058. There are some observations made by Dr. James Keil which may seem to render this matter doubtful; but there is a fallacy in his observations. The evident effects of cold in producing coryza, leave the matter in general without doubt; and there are several other circumstances which show a connexion between the lungs and the surface of the body. 1059. Whether from the suppression of perspira- tion, a catarrh be produced merely by an increased af- flux of fluids, or whether the matter of perspiration be at the same time determined to the mucous glands, and there excite a particular irritation, may be uncer- tain; but the latter supposition is sufficiently probable.* 1060. Although, in the case of a common catarrh, which is in many instances sporadic, it may be doubtful whether any morbific matter be applied to the mucous glands; it is, however, certain, that the symptoms of catarrh do frequently depend upon such a matter being applied to these glands; as appears from the case of measles, chin-cough, and especially from the frequent occurrence of contagious and epidemical catarrh. 1061. The mention of this last leads me to observe, that there are two species of catarrh, as I have marked in my Synopsis of Nosology. One of these, as I suppose disease of association. It begins at a point, and becomes general on principles of sympathy. Without the influence of such prin- ciples, iiow could a mere check or diminution of cutaneous per- spiration determine an immoderate afflux of fluids to the schnei- derian membrane? Such determination can arise only from the sympathy which exists between that membrane and the skin. * The supposition herein stated, we think extremely imfirobable. There exists in physiology no principle on which it can be main- tained. 56 PRACTICE OF PHYSIC. is produced by cold alone, as has been explained above, and the other seems manifestly to be produced by a specific contagion. Of such contagious catarrhs, I have pointed out in the Synopsis many instances occurring from the 14th century down to the present day. In all these instances the phenomena have been much the same; and the dis- ease has always been particularly remarkable in this, that it has been the most widely and generally spread- ing epidemic known. It has seldom appeared in any one country of Europe, without appearing successively in every other part of it; and in some instances, it has been even transferred to America, and has been spread over that continent, so far as we have had opportunities of being informed. 1062. The catarrh from contagion appears with nearly the same symptoms as those mentioned (1047— 1049.) It seems often to come on in consequence of the application of cold. It comes on with more cold shi- vering than the catarrh arising from cold alone, and sooner shows febrile sympttfcns, and these likewise in a more considerable degree. Accordingly, it more speedily runs its course, which is commonly finished in a few days. It sometimes terminates by a spontaneous sweat; and this in some persons, produces a miliary eruption. It is, however, the ferbile state of this dis- ease especially, that is finished in a few days; for the cough, and other catarrhal symptoms, do frequently continue longer; and often, when they appear to be go- ing off, they are renewed by any fresh application of cold.* * 1060—1—2. By his observations contained in these three articles, it is our author's intention to designate influenza. That disease, although always epidemic, is never contagious. It arises, PRACTICE OF PHYSIC. 57 1063. Considering the number of persons who are affected with catarrh, of either the one species or the other, and escape from it quickly without any hurt, it may be allowed to be a disease very free from danger; but it is not always to be considered as such; for in some persons it is accompanied with pneumonic in- flammation. In the phthisically disposed, it often ac- celerates the coming on of phthisis; and in elderly per- sons, it frequently proves fatal in the manner explained above. (1053 and 1055.)* 1064. The cure of catarrh is nearly the same, whe- ther it proceed from cold or contagion; with this differ- ence, that in the latter case, remedies are commonly more necessary than in the former. In the cases of a moderate disease, it is commonly sufficient to avoid cold, and to abstain from animal food for some days; or perhaps to lie a-bed, and, by taking frequently of some mild and diluent drink a lit- tle warmed, to promote a very gentle sweat; and after these to take care to return very gradually only, to the use of the free air.f we apprehend, from a morbific matter diffused throughout the atmosphere; but that matter is utterly incapable of specific pro- pagation. The view of it herein given, although brief, is accurate, and communicates a faithful picture of the complaint; although somewhat, it must be acknowledged, of a miniature size. * The statement given in this article is not only true, but of great moment. No disease is so powerful as influenza in ripen- ing the seeds of pulmonary consumption. Nor does any one prove ' so fatal*—certainly none more fatal—to persons who are far ad- vanced in years L-Jt such persons, therefore, as well as those predisposed to consumption,, most vigilantly guard against the disease. t Instead of a mere avoidance of animal food, the patient should avoid solid food of every description. His only aliment ought to VOL. II. II 58 PRACTICE OF PHYSIC. 1065. When the disease is more violent, not only the antiphlogistic regimen must be exactly observed, but various remedies also become necessary. To take off the phlogistic diathesis which always at- tends this disease, blood-letting, in a larger or smaller quantity, and repeated according as the symptoms shall require, is the proper remedy. For restoring the determination of the fluids to the surface of the body, and at the same time for expeding the secretion of mucus in the lungs, which may take off the inflammation of its membrane, vomiting is the most effectual means. For the latter purpose, it has been supposed, that squills, gum ammoniac, the volatile alkali, and some other medicines, might be useful: but their efficacy has never appeared to me to be considerable; and, if squills have ever been very useful, it seems to have been ra- ther by their emetic, than by their expectorant powers. When the inflammatory affections of the lungs seem to be considerable, it is proper, besides blood-letting, to apply blisters on some part of the thorax. As a cough is often the most troublesome circum- stance of this disease, so demulcents may be employed to alleviate it. See 373. But after the inflammatory symptoms have much abated, if the cough should still continue^piates afford the most effectual means of relieving it; and in the cir- cumstances just now mentioned, they may be very safely employed. See 375. After the inflammatory and febrile states of this dis- ease are almost entirely gone, the most effectual means be, barley water, bran tea, flax-seed tea, gum arabic dissolved in water, and other farinaceous and mucilaginous drinks. PRACTICE OF PHYSIC. 59 of discussing all remains of the catarrhal affection, is by some exercise of gestation diligently employed.* CHAPTER II. OF THE DYSENTERY. 1066. I HE dysentery is a disease in which the patient has frequent stools accompanied with much griping, and followed by a tenesmus. The stools, though fre- quent, are generally in small quantity; and the matter voided is chiefly mucus, sometimes mixed with blood. At the same time the natural faeces seldom appear, and, when they do, it is generally in a compact and hardened form. 1067. This disease occurs especially in summer and autum.i, at the same time with autumnal intermittent and remittent fevers; and with these it is sometimes com- bined or complicated, f * For determining to the surface and promoting expectoration, nauseating doses of tartarized antimony, combined with nitre is a useful remedy. So is a combination of ipecacuanha and opium, when there exists an irritating, troublesome cough. To the excellent plan of treatment herein proposed and suffici- ently detailed by our author, we shall only further add, that we have seen many cases of influenza, in which a determination to the abdominal viscera was so strong, as to render copious purging a necessary remedy: and that, in other instances, the disease having apredominant determination to the skin, yielded most readily to plentiful sweating—so diversified is its character on different oc- casions. ' t Dysentery is a disease very incidental to armies, when, after or during warm weather, they are long exposed to heavy rains, or lie in low swampy grounds. 60 PRACTICE OF PHYSIC. 1068. The disease comes on sometime with cold shiverings, and other symptoms of pyrexia; but more commonly the symptoms of the topical affection appear first. The belly is costive, with an unusual flatulence in the bowels. Sometimes, though more rarely, some de- gree of diarrhceaas the first appearance. In most cases the disease begins with griping, and a frequent inclination to go to stook In indulging this, little is voided; but some tenesmus attends it. By degrees, the stools become more frequent, the griping more severe, and the tenes- mus more considerable. Along with these symptoms there is a loss of appetite; and frequently sickness, nausea, and vomiting, also affecting the patient. At the same time there is always more or less of pyrexia present, which is' sometimes of the remittent kind, and observes a tertian period. Sometimes the fever i^. ma- nifestly inflammatory, and very often of a putrid kind. These ferbile states continue to accompany the disease during its whole course, especially when it terminates soon in a fatal manner. In other cases, the ferbile state almost entirely disappears, while the proper dysen- teric symptoms remain for a long time after.* 1069. In the course of the disease, whether of a shorter or longer duration, the matter voided by stool is very various. Sometimes it is merely a mucous matter, without any blood, exhibiting that disease which * Dr. Roderer has named the morbus mucosus, and others the dysenteria alba.- For the most part, however, the mucus discharged is more or less mixed with blood. * In consequence of the offensiveness of the alvine discharges, we are less surprised at the application of the term « putrid" to dysentry, than to most other diseases. Still, however, the epithet is incorrect in relation even to this complaint. PRACTICE OF PHYSIC. 61 This sometimes appears only in streaks amongst the mucus; but at other time* is more copious, tinging the whole of the matter discharged; and upon some occa- sions a pure and unmixed blood is voided in consid- erable quantity. In other respects, the matter voided is variously changed in colour and consistence, and is commonly of a strong and unusually fetid odour. It is probable that sometimes a genuine pus is vpided; and frequently a putrid sanies, proceeding from gangrenous parts. There are very often mixed with the liquid mat- ter some films of a membranous appearance*, and fre- quently some small masses of a seemingly sebacious matter. 1070. While the stools consisting of these various matters are in many instances, exceedingly frequent, it is seldom that natural faeces appear in them; and when they do appear, it is, as I have mentioned, in the form of scybala, that is, in somewhat hardened, separate balls. When these are voided, whether by the efforts of nature, or solicited by art, they procure a remission of all the symptoms, and more especially of the fre- quent stools, griping, and tenesmus. 1071. Accompanied with these circumstances, the disease proceeds for a longer or a shorter time. When the pyrexia attending it is of a violent inflammatory kind, and more especially when it is of a very putrid nature, often terminates fatally in a very few days, with all the marks of a supervening gangrene. When the febrile state is more moderate, or disappears alto- gether, the disease is often protracted for weeks, and even for months; but even then, after a various duration, it often terminates fatally, and generally in consequence of a return and considerable aggravation of the inflamma- 62 PRACTICE OF PHYS'C tory and putrid states. In some cases the disease ceases spontaneously; the frequency of stools, the griping, and tenesmus, gradually diminishing, while natural stools return. In other cases, the disease with moderate symptoms, continues long, and ends in a diarrhoea, sometimes accompanied with lienteric symptoms. 1072. * .The remote causes of this disease have been variously judged of. It generally arises in summer or autumn after considerable heats have prevailed for some time, and especially after very warm, and at the same time very dry states of the weather; and the disease is more frequent in warm, than in cooler climates.—It happens, therefore, in the same circumstances and sea- sons which considerably affect the state of the biie in the human body; but as the cholera is often without any dysenteric symptoms, and copious discharges of bile have been found to relieve the symptoms of dysen- tery, it is difficult to determine what connexion this disease has with the state of the bile. 1073. It has been observed, that the effluvia from very putrid animal substances, readily affect the ali- mentary canal; and upon some occasions they certainly produce a diarrhoea; but, whether they ever produce a genuine dysentery, I have not been able to learn with certainty. 1074. The dysentery does often manifestly arise from the application of cold, but the disease is always contagious: and, by the propagation of such contagion, independent of cold, or other exciting causes, it be- comes epidemic in camps and other places. It is, therefore, to be doubted, if the application of cold does ever produce the disease, unless where the specific con- tagion has been previously received into the body: and, PRACTICE OF PHYSIC. 63 upon the whole, it is probable, that a specific contagion is to be considered as always the remote cause of this disease.* 1075. Whether this contagion, like many others, be of a permanent nature, and only shows its effects in certain circumstances which render it active, or if it be occasionally produced, I cannot determine. Neither, if the latter supposition be received, can I say by what means it may be generated. As little do we know any thing of its nature considered in itself; or at most, this only, that, in common with many other contagions, it appears to be commonly of* a putrid nature, and capable of inducing a putrescent tendency in the human body. This, however, does not at all explain its peculiar power in inducing those symptoms which properly and essen- tially constitute the disease of dysentery. (1066.)| * From what we have already repeatedly said, it is well known that we do not believe in the contagious nature of dysentery. That disease prevails often as an epidemic, spreading rapidly from a common origin. But it is never, we think, propagated from the sick to the well. In this respect it stands on a footing with the other- phlegmasia, with which, of right, it ought to be associ- ated. t We do not understand the strange doctrine, which maintains, that a contagion may be in its nature <£ permanent," and yet " show its effects" only " in certain circumstances." Contagion is afioison. If, therefore, its nature be permanent, its effects or action will be equally permanent—at least as often as it meets with a subject on which it may act. As well might we'maintain that fire will burn or water drown only occasionally, as become the advocates of the hypothesis herein set forth. A poison is, in its nature, something potential. It will act as long as it exists. The idea of a poison with its powers suspended or annihilated, amounts to an absurdity. In his exposition of the nature of this disease, we think our- au- 64 PRACTICE OF PHYSIC. 1076. Of these symptoms the proximate cause is still obscure. The, common opinion has been, that the disease depends upon an acrid matter received into, or thor exceedingly visionary: in that of its treatment, he is no less defective. Without, therefore, considering ourselves bound to follow in]the track which he has marked out, or to assume as our text what he has written, we shall, somewhat briefly, but as com- prehensively as we can, deliver our sentiments on these two sub- jects.— * Although ultimately an intestinal, dysentery is, at its commence- ment, a gastric disease. Like other complaints arising from an aeriform poison, it originates in the stomach, but is soon thrown on the bowels, which then become its permanent seat; whence it extends itself throughout the system. Dysentery, then, we consider as an inflammatory affection of the lower intestines—more especially of their interior coats—ac- companied with fever. It might be denominated, perhaps, not incorrectly, a catarrhal or rheumatic affection of these parts. That in consequence of its inflammatory condition, there is a pe- culiar and very obstinate spasm of the colon, impeding its peri- staltic motion, and preventing the expulsion of its foecal contents, is also true. This spasm, however, is an effect, not the original cause, of the disease. Remove entirely the inflammatory state of the part, and the morbid irritability attending it, with the spasm of the colon, will cease to exist. The pathology of dysentery we believe to be the same with that of peripneumony, hepatitis, gastritis or nephritis. The dif- ference of the disease arises from the difference of the part in- flamed, added to that of the morbific cause. Like most other febrile affections, this complaint is also accompanied with a stric- ture, or want of healthy action on the surface of the body. The cutaneous secretion is, therefore, in a defective state—in more common language, perspiration is suppressed.—From this general morbid state of things arise the nature and severity of the pain that is felt. If this view of the pathology of dysentery be correct, the indi- cations of cure are sufficiently obvious. They are, to remove in- PRACTICE OF PHYSIC. 65 generated in the intestines themselves, exciting their peristaltic motion, and thereby producing the frequent •'V flammation, with the morbid irritation and spasm attending it, to procure a free discharge of the contents of the bowels, and to re- store the healthy action of the skin. The relief of paiais a su- bordinate indication, and its completion follows, of course', when the principal ones are accomplished. Thus analyzed, the practice, we think, becomes plain and easy. If the inflammatory symptoms be high, and the patient ple- thoric and vigorous—and sometimes even independently of the* existence of this latter condition—blood-letting is essential; and the operation must be repeated as often as circumstances may re- quire. In some cases blood must be taken away to a considerable amount. The early exhibition of an emetic, either accompanied, or speedily followed, by a cathartic, is, in most instances, important. Besides discharging from the stomach such matters as might be morbidly irritating, the operation of the emetic aids in resolving the spasm of the intestines, and in effecting a free evacuation of their contents. If an emetic be given alone, tartarized antimony is most suit- able; and, as a cathartic to succeed it, nothing is preferable to castor oil, or Glauber's, Rochelle, or Epsom salts. If an emetic and cathartic be given in combination, a solution of tartarized an- timony and Glauber's salts is an excellent preparation. The usual effect of it is a free and copious evacuation, of the alimentary canal. If the bowels cannot be moved by the oily or saline purgatives, atrial must be made with some of the more active. Of these, calomel and jalap, jalap and cream of tartar, a strong decoction of senna holding Glauber's salts in solution, or a purgative prepara- tion composed of balsam copaiva, mucilage of gum arabic, and lavender wajer, will be found to be highly efficacious and useful. Large and repeated doses of calomel, combined with opium, have sometimes succeeded in procuring a passage when other things had failed. VOL. II. I 66 PRACTICE OF PHYSIC. stools which occur in this disease. But this supposi- tion cannot be admitted; for in all the instances known These purgatives must be repeated daily, changes being made from one to another of them, as circumstances may require, as long as the disease shall continue violent. To aid their operation, injec- tions will be requisite; and, perhaps the most powerful injection that can be employed, will consist of from fifteen to twenty grains of tartarizeu' antimony, dissolved in about three gills of tepid water, with the addition of two or three table spoonfuls of sweet oil. This, if well administered,and retained for a time in the rectum, seldom fails to produce a discharge of faecal contents. By the action of the tartarized antimony, whether it be exhibited by the mouth, or by injection, but especially when given in the former mode, something will be done towards a restoration of the healthy action of the skin. This object may be still further pro- moted, by giving the same article occasionally in nauseating doses, accompanied by the use of diluting drinks. For the same purpose, ipecacuanha, combined with opium, is sometimes exhibited with the happiest effect.—Such is the practice necessary to be pursued during the first, or most inflammatory stage of dysentery. When the febrile symptoms have been considerably subdued, and the bowels freely evacuated, opiates must be administered for the twofold purpose of relieving pain, and procuring sleep. When exhibited in the evening they are most useful; sleep during the night being more salutary and restorative, than that which is en- joyed in the course of the day. Anodyne injections, consisting of opium dissolved in mucilage of gum arabic or flax-seed tea, are sometimes better retained and prove more efficacious, than opiates by the mouth. These points, however, must be regulated entire- ly by the judgment of the practitioner. In relation to them, no abstract and binding rule can possibly be laid down. We shall only observe, that opiates in some form should be administered, as often as they are called for by the severity of the pain, provided their operations do not too much interfere with the evacuation of the bowels. After the bowels have been sufficiently evacuated, an excellent remedy to allay irritation and tenesmus, is an injection composed PRACTICE OF PHYSIC. 67 of acrid substances applied to the intestines and produ- cing frequent stools, they at the same time produce co- of from half a pint to three gills of melted butter, free from salt This may be repeated every three or four hours; or oftener, should circumstances require it. It is important that the butter be free from rancidity as well as salt. If the pain continue obstinate, and the abdomen be tumefied, hard and sore to the touch, in addition to fomentations and anodyne liniments, the application of cups or leeches and blisters to it, will be found indispensable. In the treatment of such a case, a gentle mercurial phyalism has sometimes been induced with the happiest effect. In every case, where the disease is likely to assume a chronic form, more especially if there be reason to apprehend the exist- ence of a hepatic affection, a moderate salivation is the most pro- mising remedy. On various occasions, throughout the course of the disease, mu- cilaginous injections will be useful and necessary. They may con- sist of flax-seed tea, barley water, a solution of gum arabic in water, or a decoction of starch. The proper time of their admi- nistration the judgment of the practitioner alone can direct. An important object to be attained by them is an alleviation of tenes- mus. From the commencement to the close of the complaint, the drinks in general should be diluting, mucilaginous, and mild. In the latter stages, when fever and inflammation have disappeared, and debility is considerable, a small quantity of wine may be ad- vantageously allowed. So may light broths and animal jellies. But, until a considerable progress shall have been made in con- valescence, solid animal food is totally inadmissible. When a great disposition to ascency prevails in the stomach, preparations of rice, crackers, and well baked bread, are highly useful as articles of diet. When solid animal food has become admissible, salted meal is usually found to be preferable to fresh. In the treatment of dysentery, the article of clothing is of no small importance. Flannel should be worn next to the skin in general, with one or two additional folds of it over the abdomen. 68 PRACTICE OF PHYSIC, pious stools, as might be expected from acrid sub- stances applied toany length of the intestines. This, Certain late writers recommend the use of a broad flannel roller, passed several times around the abdomen, with some degree of tightness. This answers the twofold purpose of promoting per- spiration, and giving the necessary support to the weakened in- testines. A strong solution of muriate of soda in vinegar, has been given in this disease; and, as report represents, with very salutary ef- fects. We tried the preparation once, in the case of a boy about nine years old, and thought it useful. Pain and tenesmus appeared certainly to be relieved by it: the bowels, moreover, were kindly opened. We simply state the fact; but shall not attempt its ex- planation. Nor can we venture to recommend the remedy on a single trial. When the convalescence proves lingering and unsteady, ac- companied by a constant or occasional diarrhoea, opiates, astrin- gents, and mild tonics may be given with advantage. A very va- luable astringent is a decoction of logwood. But the chief reli- ance must be placed on regimen; and,in the more obstinate cases, on a change of climate. When dysentery degenerates into a chronic state, a grain or two of ipecacuanha, combined with a little opium, may be given several times a day, to suspend irritation and determine to the skin. To this add a steady use of an infusion of Colombo, and riding on horseback, if the pati.-nt be possessed of sufficient strength. From this practice great benefit has bean oftentimes derived. Of late pulverized charcoal has been recommended in dysen- tery, in the quantity of a table spoonful three or four times a day. Dr. Moseley, a very respectable West India writer, concurs wit'. Di. Sydenham in considering d>sentery as the ftver of the season thrown on the bowels, by means of a great and sudden sup- pression of perspiration. The restoration of perspiration, there- fore, constitutes nis leading, indeed almost his sole object, in the treatment of the disease. Hence, after preparing the way for them by b.ood-.cuing, it requisite, and cleansing the bowels of their ir- ritating contents; he places his reliance almost exclusively on tne PRACTICE OF PHYSIC. 69 however, is not the case in dysentery; * in which the stools, however frequent, are generally in very small quantity, and such as may be supposed to proceed from the lower parts of the rectum only. With ^respect to the superior portions of the intestines, and particularly those of the colon, it is probable they are under a pre- ternatural and considerable degree of constriction: For, as I have observed above, the natural faeces are seldom voided; and when they are, it is in a form which gives reason to suppose, they have been long retained in the cells of the colon, and consequently that the colon had been affected with a preternatural constriction. This is confirmed by almost all the dissections which have been made of the bodies of dysenteric patients, in which, when gangrene had not entirely destroyed the tex- ture and form of the parts, considerable portions of the great guts have been found affected with a very con- siderable constriction. 1077. I apprehend, therefore, that the proximate cause of dysentery, or at least the chief part of the proximate cause, consists in a preternatural constriction of the colon, occasioning at the same time those spas- modic efforts which are felt in severe gripings, and which employmen of sudorifics. We apprehend that he pushes his theory too far. For much learned, curious and interesting matter on the subject of dysentery, the reader is referred to the last edition of Dr. Mose- ley's u Treatise on Tropical Diseases." Those who are desirous of still further information, may consult with advantage the follow- ing writers:—Pringle Dis. Arm. Huxham de aere—Cleghorn Minor. Hillary Barbad. Akenside de Dysenteria. Monro Dis. Arm. Stark Historic Dysenteric. Wardrop de Dysenteria con- tagiosa. Hoilo on acute Dysentery, with various valuable papers in t. e per odical publications of Europe, and the Medical Repo- sitory ot this country. 70 PRACTICE OF PHYSIC. efforts, propagated downwards to the rectum, occasion there the frequent mucous stools and tenesmus. But, whether this explanation shall be admitted or not, it will still remain certain, that hardened faeces retained in the colon are the cause of the griping, frequent stools, and tenesmus; for the evacuation of these faeces, whether by nature or by art, gives relief from the symptoms mentioned; and it will be more fully and usefully con- firmed by this, that the most immediate and successful cure of dysentery is obtained by an early and constant attention to the preventing the constriction, and the fre- quent stagnation of faeces in the colon. 1078. In this manner I have endeavoured to as- certain the proximate cause of dysentery, and therefore to point out also the principal part of the cure, which, from want of the proper view of the nature of the dis- ease, seems to have been in several respects fluctuating and undetermined among practitioners. 1079. The most eminent of our late practitioners, and of the greatest experience in this disease, seem to be of opinion, that the disease is to be cured most effect- ually by purging assiduously employed. The means may be various; but the most gentle laxatives are usu- ally sufficient; and as they must be frequently repeated, the most gentle are the most safe; the more especially as an inflammatory state so frequently accompanies the disease. Whatever laxatives produce an evacuation of natural faeces, and a consequent remission of the symptoms, will be sufficient to effectuate the cure. But if gentle laxatives shall not produce the evacuation now mentioned, some more powerful medicines must be em- ployed; and I have found nothing more proper or convenient than tartar emetic, given in small doses, and PRACTICE OF PHYSIC. 71 at such intervals as may determine their operation tobe chiefly by stool. 'Rhubarb, so frequently employed, is in several respects amongst the most improper purga- tives. 1080. Vomiting has been held a principal remedy in this disease; and may be usefully employed in the beginning of it, with a view to both the state of the stomach and of the fever; but it is not necessary to re- peat it often; and unless the emetics employed operate also by stool they are of little service. Ipecacuanha seems to possess no specific power; and it proves only useful when so managed as to operate chiefly by stool. 1081. For relieving the constriction of the colon, and evacuating the retained faeces, glysters may some- times be useful; but they are seldom so effectual as laxatives given by the mouth; and acrid glysters, if they be not effectual in evacuating the colon, may prove hurtful by stimulating the rectum too much. 1082. The frequent and severe griping attending this disease, leads almost necessarily to the use of opi- ates, and they are very effectual for the purpose of re- lieving from the gripes; but by occasioning an inter- ruption of the action of the small guts, they favour the constriction of the colon, and thereby sometimes aggra- vate the disease; and if at the same time the use of them supersede in any measure the employing of purgatives, it commonly dees much mischief; I believe it indeed to be only the neglect of purging that renders the use of opiates very necessary. 1083. When the gripes are both frequent and severe, they may sometimes be relieved by the employment of a semicupium, or by a fomentation of the abdomen, continued for some time. In the same case, the pains 72 PRACTICE OF PHYSIC. may be relieved, and, as I think, the constriction of the colon may be taken off, by blisters applied to the lower belly. 1084. At the beginning of this disease, when the fe- ver is any way considerable, blood-letting, in patients of tolerable vigour, may be proper and necessary; and, when the pulse is full and hard, with other symptoms often inflammatory disposition, blood-letting ought to be repeated. But, as the fever attending dysentery is often of a putrid kind, or does, in the course of the dis- ease, besome soon of that nature, blood-letting must be employed with great caution. 1085. From the account now given of the nature of this dibease, it will be sufficiently obvious, that the use of astringents in the beginning of it must be absolutely pernicious. 1086. Whether an acrid matter be the original cause of this disease may be uncertain; but from the indi- gestion and the stagnation of fluids in the stomach which attend the disease, it may be presumed, that some acrid matters are constantly present in the sto- mach and intestines, and therefore that demulcents may be always usefully employed. At the same time, from this consideration that mild oily matters thrown into the intestines in considerable quantity always prove laxa- tive. I am of opinion that the oleaginous demulcents are the most useful. 1087. As this disease is so often of an inflammatory or of a putrid nature, it is evident that the diet em- ployed in it should be vegetable and acescent. Milk in its entire state is of doubtful quality in many cases; but some portion of the cream is often allowable, and whey is always proper. PRACTICE OF PHYSIC. 73 In the first stages of the disease, the sweet and sub- acid fruits are allowable, and even proper. It is in the more advanced stages only that any morbid acidity seems to prevail in the stomach, and to require some reserve in the use of acescents. At the beginning of the disease, absorbents seem to be superfluous; and by their astringent and septic powers they may be hurt- ful. 1088. When this disease is complicated with an in- termittent fever, and is protracted from that circum- stance chiefly, it is to be treated as an intermittent, by administering the Peruvian bark, which, however, in the earlier periods of the disease, is hardly to be ad- mitted. PART II. OF NEUROSES,* OR NERVOUS DISEASES. 1089. JN a certain view, almost the whole of the dis- eases of the human body might be called nervous: but there would be no use for such a general appella- * We have already stated as our opinion, which we beg leave to repeat, that the whole, or at least the greater part, of our au- thor's class of neuroses or nervous diseases, have their seat in the stomach. Nor is this to be regarded as a mere speculative notion. It is a point which we consider eminently important in the practice of medicine. It is calculated to give our attention, in the treatment of those diseases, the proper direction. It points, in a particular manner, to the stomach and bowels, as the organs to which we should apply our remedies. It presses on us a truth, of which practitioners of physic are becoming daily more and more convinced, that emetics, cathartics, and tonics, VOL. II. K 74 PRACTICE OF PHYSIC. tion; and on the other hand, it seems improper to limit the term, in the loose inaccurate manner in which it has been hitherto applied, to hysteric or hypochondriacal disorders, which are themselves hardly to be defined with sufficient precision. 1090. In this place I propose to comprehend, under the title of neuroses, all those preternatural affections of sense or motion which are without pyrexia, as a part of the primary disease; and all those which do not de- pend upon a topical affection of the organs, but upon a more general affection of the nervous system, and of those powers of the system upon which sense and mo- tion more especially depend. 1091. Of such diseases I have established a class, under the title of neuroses or nervous diseases. These I again distinguish, as they consist, either in the interruption and debility of the powers of sense and motion, or in the irregularity with which these powers are exercised; and have accordingly arranged them un- der the four orders of Comata, Adynamia, Spasmi, and Vesania, to be defined as we proceed to treat of them more particularly. constitute the remedies on which we must chiefly rely, in the cure of what are denominated nervous diseases. Such diseases are most certainly induced by whatever disorders and debilitates the stomach, and removed by those things which restore to it its healthy action. PRACTICE OF PHYSIC. 75 BOOK I. OF COMATA, OR THE LOSS OF VOLUNTARY MO TION. 1092. UNDER this title are comprehended those af- fections which have been commonly called the Sopo- rose diseases; but they are most properly distinguished by their consisting in some interruption or suppression of the powers of sense and voluntary motion, or of what are called the animal functions. These are indeed usually suspended in the time of natural sleep: But of all the diseases to be comprehended under our title, sleep, or even the appearance of it, is not constantly a symptom. Of such diseases I can mark and properly explain two genera only, which come under the title of Apoplexy and Palsy. CHAPTER I. OF APOPLEXY. 1093. APOPLEXY is that disease in which the whole of the external and internal senses, and the whole of the voluntary motions, are in some degree abolished; while respiration and the action of the heart continue to be performed. By its being an affection of the whole of the powers of sense and of voluntary motion, we dis- tinguish it from Palsy: and by its being with the con- tinuum e of respiration and the action of the heart, it is distinguished from Syncope. I have further added to 76 PRACTICE OF PHYSIC. the ordinary definition of Apoplexy, that the abolition of the powers of ^ense and motion is in some degree onlv;-meaning by this to impl\, that under the title of Apoplexy, are here comprehended those diseases which, as differing from it in degree only, cannot with a view either to pathology or practice, be properly distinguish- ed from it: Such are the diseases sometimes treated of under the names of Carus, Cataphora, Coma, and Le- thargus.* 1094. Apoplexy, in all its different degrees, most commonly affects persons advanced in life, and especi- ally those above sixty years of age. It most usually affects persons of large heads and short necks, persons of a corpulent habit, persons who have passed an indo- lent lile anome transitory degree of numbness or loss of motion in the extremities, some faulteringof the tongue in speaking, a loss of memory, a frequent drow- siness, and frequent fits of incubu^.* 1096. An attention to these symptoms, and to the predisponent circumstances (1094.) will often enable us to foresee the more violent attacks of this disease. 1097. When the disease comes on suddenly to a considerable degree, it has been frequently ol 'served to have been immediately induced by violent exercise, by a full and long continued inspiration; by a fit of anger; by much external heat, especially that arising from a crowded assembly of people; by warm bathing; by in- toxication; by long stooping with the head down; and by a tight ligature about the neck. The disease has been remarked to make its attacks most frequently in the spring season, and especially when the vernal heat suddenly succeeds to the winter cold.f 1098. The symptoms denoting the presence of this disease will be sufficiently known from the definition given 1093. Although the whole of the body is affected with the loss of sense and motion, it sometimes takes place more upon one side of the body than the other; and in that case the side least affected with palsy is some- * Incubus is an affection of the stomach. Its being, therefore, a precursor of apoplexy, shows the latter to be a gastric disease. When this complaint is induced by a " long continued inspiration, violent exercise, or long stooping with the head down," its excit- ing cause is altogether mechanical. Still, however, even here, we believe the stomach concerned in creating the predisposition. t Facts, we think, are wanting to establish the position, that apoplexy is p articularly a vernal disease. 78 PRACTICE OF PHYSIC. times affected with convulsions. In this disease there is often a stertorous breathing: and this has been said to be a mark of the most violent state of the disease: but it is not always present even in the most complete form or most violent degree of the disease. 1099. The proximate cause of this disease may be, in general, whatever interrupts the motion of the nervous power from the brain to the muscles, from voluntary motion; or in so far as sense is affected, whatever in- terrupts the motion of the nervous power from the sen- tient extremities of the nerves to the brain. 1100. Such an interruption of the motions of the nervous power may be occasioned, either by some compression of the origin of the nerves, or by something destroying the mobility of the nervous power. Both these causes we must treat of more particularly; and, first, that of compression, seemingly the most frequent occasion of apoplexy, and perhaps the occasion of all those apoplexies arising from internal causes. 1101. The loss of sense and motion in particular parts of the body, may be occasioned by a compression, either of the origin of certain nerves only, or of the same nerves in some part of their course from the brain to the organs of sense and motion. Such cases of partial compression will be more properly considered hereafter; and the affection I am now to treat of being general, it must depend upon a very general compression of the origin of the nerves, or medullary portion of the brain; and therefore, this more general compression only is to be considered here. 1102. This compression of the origin of the nerves; PRACTICE OF PHYSIC. 79 or medullary portion of the brain, may be produced in different ways; as, 1. By external violence fracturing and pressing in a part of the cranium. 2. By tumors, sometimes soft, sometimes bony, formed in different parts of the brain, or in its mem- branes, and becoming of such a bulk as to compress the medullary substance of the brain. 3. By the blood being accumulated in the blood-ves- sels of the brain, and distending them to such a degree as to compress the medullary portion of the same. 4. By fluids effused in different parts of the brain, or into the cavity of the cranium, and accumulated in such a quantity as to occasion the compression we treat of. And as to this last, it is to be remarked here, that the fluids effused may be of two kinds; that is, they may be either a portion of the common mass of blood, poured out from red vessels; or a portion of serum or colourless fluid poured out cihefly by exha- lants. 1103. Of these several causes of compression, the first is not to be considered here, because the removing1 it does not belong to our province; and the considera- tion of the second may be omitted, as in most instances it is neither to be discerned nor cured by any means yet known. The third and fourth causes of compres- sion, as they are the most frequent, and are also most properly the subjects of our art, so they are those which deserve our particular attention: and we shall therefore endeavour to trace them further back in the series'of causes which may produce them. 80 PRACTICE OF PHYSIC. 1104. Both the states of over distention and of effusion may be produced by whatever increases the afflux and impetus of the blood in the arteries of the head; guch-as violent exercise, a violent fit of anger, external heat applied, or any strong pressure upon the descending aorta. 1105. But both these states of over distention and of effusion, may also and seem to be more frequently produced by causes that operate by preventing the free return of the venous blood from the vessels of the head to the right ventricle of the heart. 1106. The venous vessels of the brain are of a con- formation and distribution so peculiar, as to lead us to believe, that nature intended to retard the motion of the blood, and accumulate it in these vessels; and therefore, even very small additional resistances to the motion of the blood from these towards the right ventricle of the heart, may still more readily accumulate the blood in them. Such accumulation will most readily happen in advanced life, when the venous system in general is in a plethoric state, and when this plethora takes place es- pecially in the venous vessels of the brain. It will, m like manner, be most apt to occur in persons whose heads are large with respect to the rest of the body; and in persons of a short neck, which is unfavourable to the return of the venous blood from the head. The accumulation of blood in the venous vessels of the brain, will also be most likely to occur in persons of a corpulent habit, either because these may be consider- ed to be in a plethoric state, or because obesity, by occasioning a compression of the blood-vessels in other parts of the body, more readily fills those of the brain, which are entirely free from any such compression. PRACTICE OF PHYSIC. 81 1107. These are the circumstances in the consti- tution of the body, which, producing a slower motion and return of the venous blood from the vessels of the head, favour an accumulation and distention in them; and we now proceed to mention the several occasional causes, which, in every person, may directly prevent the free return of the blood from the vessels of the head towards the heart. Such are, 1. Stooping down with the head, or other situations of the body in which the head is long kept in a depend- ing state, and in which the gravity of the blood increa- ses the afflux of it by the arteries, and opposes the re- turn of it by the veins. 2. A tight ligature about the neck, which compres- ses the veins more strongly than the arteries. 3. Any obstruction of a considerable number of the veins carrying the blood from the head, and more espe- cially any considerable obstruction of the ascending vena cava. 4. Any considerable impediment of the free passage of the blood from the veins into the right ventricle of the heart; and it is commonly by this, and the immedi- ately preceding circumstances, that polypous concre- tions in the cava, or right ventricle, are found to occa- sion apoplexy. 5. The return of blood from the veins of the head towards the heart, is especially interrupted by every circumstance that produces a more difficult transmis- sion of the blood through the vessels of the lungs. It is well known, that, at the end of every expiration, some interruption is given to the free transmission of the blood through the lungs; and that this at the same time gives an interruption to the motion of the blood VOL. II. L 82 PRACTICE OF PHYSIC. in the veins into the right ventricle of the heart. This clearly appears from that regurgitation of the blood in the veins which occasions the alternate heaving and subsi- ding that is perceived in the brain of living animals when the cranium is removed, and which is observed to be synchronous with the alternate motions of respiration. From this we readily perceive, that whatever occasions a difficulty in the transmission of the blood through the lungs, must also interrupt the free return of the venous blood from the vessels of the head; and must therefore favour, and perhaps produce, an accumulation of blood, and an over-distention in these vessels. It is further to be observed, that as a very full inspi- ration, continued for any length of time, occasions such an interruption of the free transmission of the blood through the lungs, as produces a suffusion of face, and a manifest turgescence of the blood-vessels of the head and neck; so every full and long continued in- spiration may occasion an accumulation of blood in the vessels of the head, to a very considerable degree. Thus, as every strong exertion of the muscular force of the body requires, and is attended with, a very full and long continued inspiration, we thence learn why the violent exertions of muscular force have been so often the im- mediate or exciting causes of apoplexy. It may also be remarked, that corpulency and obesity seem to operate very much, by occasioning a more difficult transmission of the blood through the vessels of the lungs. It appears, that in fat persons, from the compression of the blood vessels in many parts of the body, the vessels of the lungs are thereby kept very full; so that upon the least increase of bodily motion, which sends the blood faster into the lungs, a more fre- PRACTICE OF PHYSIC. 8S quent and laborious respiration becomes in such per- sons immediately necessary. This shows, that, in such persons, the blood is not freely transmitted through the lungs; a circumstance which, as in other instances, must give a constant resistance to the return of blood from the vessels of the head, and therefore favour or occasion an accumulation of blood in them. Is the motion of the blood in the vessels of the head rendered slower by study, care, and anxiety? 1108. It is to be observed further, that these several causes (1104.—1107.) of a preternatural fulness in the blood-vessels of the brain, may produce apoplexy in different ways, according as the fulness takes place in the arteries or in the veins. 1109. Accordingly, first, the increased afflux of blood into the arteries of the brain, and an increased action in these, may either occasion a rupture of their extremities, and thereby an effusion of red blood pro- ducing compression; or the same afflux and increased action may occasion an increased exhalation from their extremities, of a serous fluid, which, if not as quickly re-absorbed, may soon accumulate in such quantity as to produce compression. 1110. Secondly, The plethoric state of the venous vessels of the brain, may operate in three different ways, 1. The fulness of the veins may give such resistance to the blood flowing into them from the arteries, as to determine the impetus of the blood to be so much grea- ter upon the extremities of the arteries as to occasion a rupture of these, and consequently an effusion of red blood, or the Hamorrhagia cerebri, which Hoffman 84 PRACTICE OF PHYSIC. considers as a frequent cause of apoplexy, and which we have before explained in 771. 2. Whilst the same resistance to the blood flowing from the arteries into the veins, increases the impetus of the blood to the former, this may, without occasion- ing rupture, increase the exhalation from their ex- halant extremities, and produce an effusion of a se- rous fluid; in the same manner as such resistance in the *7 veins produces hydropic effusions in other parts of the body. 3. If we may suppose, as no lymphatics have been yet discovered in the brain, that the ordinary absor- bents are not present there, and that the exhaled fluids are absorbed or taken up by the extremities of the veins; this will show still more clearly that a resistance to the motion of the blood in the veins of the brain, may rea- dily produce an accumulation of serous fluid in its cavities, and consequently a compression producing apoplexy.* 1111. Besides these causes of apoplexy from afflux in the" arteries, or resistance in the veins, an effusion of serum may happen from two other causes. The one is a relaxation of the exhalants, as in other cases of hy- dropic diathesis prevailing in the body; and it is not * We cannot refrain from expressing our astonishment, at our author's admitting the possibility that veins can, under any circum- stances, perform the office of absorbents. Nor is it, indeed, less astonishing, that he should doubt the existence of absorbents in the brain. These vessels are as essential to the processes of nu- trition and growth, as the arteries themselves. It can be proved, therefore, to the perfect satisfaction of every physiologist, that whatever part of the body grows and is nourished, possesses ab- sorbents. PRACTICE OF PHYSIC. 85 unusual for a general dropsy to end in apoplexy. The second is an over proportion of watery parts in the mass of blood, which is therefore ready to run off by the ex- halants, as in the case of an ischuria renalis; which, when it proves incurable, very commonly terminates in apoplexy. 1112. We have now mentioned the several causes of apoplexy depending upon compression; and from the whole it will appear, that the most frequent of all these causes is a plethoric state, or an accumulation and con- gestion of blood in the venous vessels of the head, ope- rating, according to its degree, in producing over-dis- tention or effusion. The frequent operation of such a cause will especially appear from a consideration of the predisponent circumstances (10y4.) and from the ante- cedent symptoms. (1095.)* 1113. From the view I have now given of the causes of apoplexy arising from compression, it will readily * Notwithstanding the extensive and formidable array of the causes of apoplexy, which our author has presented to us, hi some of the foregoing articles, we venture to assert, that a. gouty affec- tion, which is only another term for a gastric affection, produces the disease more frequently than the whole of them combined. We have seen but very few cases of apoplexy, which we could not trace, in part, at least, to some kind of morbid impression on the stomach—a full meal, improper food, a debauch in drinking, ov some cause of a similar description. Most of the causes assigned by our author, being gross and me- chanical in their nature, are such, we think, as but rarely occur. We pretend to no knowledge of that particular affection which our author denominates, " an immobility of the nervous power." But no physician, we think, can be ignorant of the fact, that a sirong impression on the stomach produces an immobility of the whole system. In proof of this, we could adduce, were it neces- sary, innumerable instances. 86 PRACTICE OF PHYSIC. appear that there is a foundation for the common dis- tinction of this disease into the two kinds of Sanguine and Serous. But this distinction cannot be very use- fully applied in practice, as both kinds may often de- pend on the same cause, that is, a venous plethora, and therefore requiring very nearly the same method of cure. The only distinction that can be properly made of apo- plexies from compression, is perhaps the distinction of serous apoplexy, into that depending on the plethora mentioned (lll2.) and that depending on hydropic dia- thesis or an over proportion of water in the blood; (1111.) the former causes giving a proper idiopathic, the latter only a symptomatic disease. 1114. Beside the causes now mentioned, occasion- ing apoplexy by compression, I allege there are other causes producing the same disease, by directly destroy- ing the mobility of the nervous power. Such causes seem to be the mephitic, arising from fermenting li- quors, and from many other sources; the fumes arising from burning charcoal; the fumes of mercury, of lead, and of some other metallic substances; opium, alcohol, and many other narcotic poisons: to all which I would add the power of cold, of concussion, of electricity, and of certain passions of the mind. 1115. None of these poisons or noxious powers seem to kill by acting first upon the organs of respiration, or upon the sanguiferous system; and I believe their im- mediate and direct action to be upon the nervous power, destroying its mobility, because the same poisons show their power in destroying the irritability of muscles and of the nerves connected with them, when both these are entirely separated from the rest of the body. PRACTICE OF PHYSIC. 87 1116. It appears to me probable, that the apoplectic state in some degree accompanying, and. almost always succeeding, an epileptic paroxysm, does not depend upon compression, but upon a certain state of immobi- lity of the nervous power, produced by certain cir- cumstances in the nervous system itself, which some- times seem to be communicated from one part of the body to another, and at length to the brain. 1117. The same observation may be made with re- spect to many instances of hysteric paroxysm; and the circumstances, both of epileptic and hysteric paroxysms, ending in coma, or a degree of apoplexy, lead me to think, that also the apoplexy proceeding from retroce- dent or atonic gout is of the same kind, or that it de- pends upon an immobility of the nervous power, rather than upon compression. 1118. It may indeed happen, that as the apoplectic and gouty predispositions do often concur in the same person; so it may consequently happen, that the apoplexy coming upon gouty persons, may sometimes depend upon compression; and dissections may, accordingly, discover that the circumstances of such a cause had preceded. But, in many cases of the apoplexy follow- ing a retrocedent or atonic gout, no such antecedent or concomitant circumstances, as commonly occur in cases of compression, do distinctly or clearly appear; while others present themselves, which point out an affection of the nervous power alone. 1119. With respect, however, to the circumstances which may appear upon the dissection of persons dead of apoplexy, there may be some fallacy in judging, from those circumstances, of the cause of the disease. Whatever takes off or diminishes the mobility of the 88 PRACTICE OF PHYSIC. nervous power, may very much retard the motion of the blood in the vessels of the brain; and that perhaps to the degree of increasing exhalation, or even of occa- sioning rupture and effusion: so that, in such cases, the marks of compression may appear, upon dissection, though the disease had truly depended on causes de- stroying the mobility of the nervous power. This seems to be illustrated and confirmed from what occurs in many cases of epilepsy. In some of these, after a repetition of fits, recovered from in the usual manner, a fatuity is induced, which commonly depends upon a watery inundation of the brain: and in other cases of epilepsy, when fits have been often repeated without any permanent consequence, there happens at length a fatal paroxysm; and upon dissection it appears, that an effusion of blood had happened. This, I think, is to be considered as a cause of death, not as a cause of the disease: for in such cases, I suppose that the disease had diminished the action of the vessels of the brain, and thereby given occasion to a stagnation, which pro- duced the appearances mentioned. And I apprehend the same reasoning will apply to the cases of retroce- dent gout, which, by destroying the energy of the brain, may occasion such a stagnation as will produce rup- ture, effusion, and death; and in such a case, the ap- pearances upon dissection might lead us to think that the apoplexy had depended entirely upon compres- sion. 1120. The several causes mentioned in 1114, are often of such power as to occasion immediate death; and therefore have not commonly been taken notice of as affording instances of apoplexy; but, as the operation of the whole of these causes is similar and analogous, PRACTICE OF PHYSIC. 89 and as in most instances of the operation of these causes an apoplectic state is manifestly produced, there can be little doubt in considering most of the instances of their effects as cases of apoplexy, and therefore such as fall properly under our consideration here. 1121. This disease of apoplexy is sometimes entire- ly recovered from; but more frequently it ends in death, or in a hemiplegia. Even when an attack of the dis- ease is recovered from, we generally find it disposed to return; and the repeated attacks of it almost always, sooner or later, bring on the events we have men- tioned. 1122. The several events of this disease, in health, death, or another disease, may be expected and foreseen from a consideration of the predisponent circumstances (1094.) of the antecedent symptoms (1095) of the ex- citing causes (1097.) of the violence and degree of the symptoms when the disease has come on (1093.) of the duration of the disease; and the effects of the remedies employed. 1123. From the great danger attending this disease when it has come on (1121.) it will readily appear, that our care should be chiefly directed to the prevention of it. This, 1 think, may be often done by avoiding the remote and exciting causes; and how this may be ac- complished, will be obvious from the enumeration of those causes given above (1097.) But it will also ap- pear from what is said above, that the prevention of this disease will especially depend upon obviating the pre- disponent cause; which, in most cases, seems to be a plethoric state of the blood-vessels of the brain. This, I think, may be obviated by different means; and, in VOL. II. M 90 PRACTICE OF PHYSIC. the first place, by a proper management of exercise and diet.* 1124. The exercise ought to be such as may support the perspiration, without heating the body or hurrying respiration; and, therefore, commonly by some mode of gestation. In persons not liable to frequent fits of giddiness, and who are accustomed to riding on horse- back, this exercise is, of all others, the best. Walking, and some other modes of bodily exercise, may be em- ployed with the restrictions just now mentioned; but in old men, and in men of corpulent habits, bodily ex- ercise ought always to be very moderate. 1125. In persons who pretty early in life show the predisposition to apoplexy, it is probable that a low diet, with a good deal of exercise, might entirely pre- vent the disease; but, in persons who are advanced in life before they think of taking precautions, and are at the same time of a corpulent habit, which generally sup- poses their having been accustomed to full living, it might not be safe to put them upon a low diet; and it may be enough that their diet may be rendered more moderate than usual, especially with respect to animal food; and that, at supper, such food should be abstain- ed from altogether.! * Let those who are predisposed to apoplexy, and are anxious to escape an attack, avoid intemperance of every description, and avail themselves of the enjoyment of free air and moderate ex- ercise. t Our author is perfectly correct in forbidding the use of sup- pers of animal food. To persons of apoplectic habits, they arc peculiarly dangerous, and should be, therefore, avoided with firm- ness and resolution. PRACTICE OF PHYSIC. 91 In drinking, all heating liquors are to be abstained from, as much as former habits will allow, and the smallest approach to intoxication is to be carefully shunned. For ordinary draught, small beer is to be preferred to plain water, as the latter is more ready to occasion costiveness, which in apoplectic habits is to be carefully avoided. The large use of tobacco in any shape may be hurtful; and except in cases where it has been accustomed to, occasion a copious excretion from the head, the interruption of which might not be safe, the use of tobacco should be avoided; and even in the circumstance mentioned, where it may be in some mea- sure necessary, the use of it should at least be rendered as moderate as possible. 1126. Evacuations by stool may certainly contribute to relieve the plethoric state of the vessels of the head; and, upon an appearance of any unusual turgescence in these, purging will be very properly employed: but, when no such turgescence appears, the frequent repeti- tion of large purging might weaken the body too much; and, for preventing apoplexy, it may for the most part be enough to keep die belly regular, and rather open, by gentle laxatives. In the summer season, it may be useful to drink, every morning, of a gentle laxative mi- neral water, but never in large quantity.* 1127. In the case of a plethoric state of the system, it might be supposed that blood-letting would be the most effectual means of diminishing the plethora, and of preventing its consequences; and, when an attack of * The keeping of the bowels regularly free, is highly import- ant to apoplectic patients, and cannot be neglected without jeo- pardy, even for a day. 92 PRACTICE OF PHYSIC. apoplexy is immediately threatened blood-letting is certainly the remedy to be depended upon: and blood should be taken largely, if it can be done, from the ju- gular vein, or temporal artery. But when no threaten- ing turgescence appears, the obviating plethora is not judiciously attempted by blood-letting, as we have en- deavoured to demonstrate above, (786.) In doubtful circumstances, leeches applied to the temples, or scari- fications of the hind-head, may be more safe than ge- neral bleedings.* 1128. When there are manifest symptoms of a ple- thoric state in the vessels of the head, a seton, or pea- issue, near the head, may be very useful in obviating any turgescence of the blood. 1129. These are the means to be employed for pre- venting the apoplexy which might arise from a plethoric state of the vessels of the brain; and if, at the same time, great care is taken to avoid the exciting causes (1097.) these means will be generally successful. In the cases proceeding from other causes (1114.) as their application is so immediately succeeded by the disease, they hardly allow any opportunity for preven- tion. 1130. For the cure of apoplexies from internal causes, and which I suppose to be chiefly those from compression, the usual violence and fatality of it require that the proper remedies be immediately and largely employed. * When an attack of apoplexy is seriously threatened, we know of nothing that can be safely relied on as a substitute for venesec- tion. That remedy offers by far the best security from immedi- ate danger, until other means can be brought into operation to break the strength of predisposition for the time. <. PRACTICE OF PHYSIC. 93 The patient is to be kept as much as possible in somewhat of an erect posture, and in cool air; and there- fore neither in a warm chamber, nor covered with bed clothes, nor surrounded with a crowd of people.* 1131. In all cases of a full habit, and where the disease has been preceded by marks of a plethoric state, blood-letting is to be immediately employed, and * If muscular debility be very great, the keeping of the patient in an erect posture will prove injurious, by inducing fatigue and further exhaustion. In such a case, therefore, the body of the dis- eased should be suffered to recline, while his head is kept as erect as convenient, by pillows or otherwise. Care ought to be taken, however, that the head be not bent too much forward, as, by such a posture, the free return of blood from the vessels of the brain will be somewhat impeded. As a general rule, the drawing of blood from the arm or the jugular vein, is preferable to the open- ing of the temporal artery. When the apoplectic stroke has expended its force chiefly on one side, it usually appears on dissection, that the congestion of the brain, when any exists, is on the opposite side. Hence the propriety of our author's direction in relation more particularly to topical blood-letting. The side on which the operation of ge- neral blood-letting is performed, is of less moment. Nor ought we, even in topical blood-letting, to confine our operation exclu- sively to one side. If the system be plethoric, and the case se- vere, cups may be applied to all parts of the head—not only on the sides; but on the back and front. To our author's directions for the treatment of apoplexy, which are judicious, full, and forcible, we have but little to add. If com- * plied with promptly, and pursued to the proper extent, they are, perhaps, calculated to do all that is practicable in the disease. When the patient is capable of swallowing, we have found Glauber's salts alone, or a solution of them in an infusion of senna, to be a very valuable remedy. Besides operating speedily, and removing from the bowels their focal contents, these purgative pre- parations evacuate a larger portion of liquid matter, than, perhaps, any others. Hence their effect in unloading the blood vessels. 94 PRACTICE OF PHYSIC. very largely. In my opinion, it will be most effectual when the blood is taken from the jugular vein; but, if that cannot be properly done, it may be taken from the arm. The opening of the temporal artery, when a large branch can be opened, so as suddenly to pour out a considerable quantity of blood, may also be an effectu- al remedy; but in execution, it is more uncertain, and may be inconvenient. It may be in some measure sup- plied, by cupping and scarifying on the temples or hind- head. This, indeed, should seldom be omitted; and these scarifications are always preferable to the applica- tion of leeches. With respect to every mode of blood-letting, this is to be observed, that when in any case of apoplexy, it can be perceived that one side of the body is more af- fected with the loss of motion than the other, the blood- letting, if possible should be made on the side oppo- site to that most affected. 1132. Another remedy to be employed is purging, to be immediately attempted by acrid glysters; and, at the same time, if any power of swallowing remain, by drastic purgatives given by the mouth. These, how- ever, lest they may excite vomiting, should be given in divided portions at proper intervals. 1133. Vomiting has been commended by some practitioners and writers: but, apprehending that this might impel the blood with too much violence into the vessels of the head, I have never employed it* * In like manner with our author, and, for the same reason, we have never employed emetics as a remedy in apoplexy. Yet, from a spontaneous vomiting, we have oftentimes witnessed the happiest effects. Hence, venesection in apoplexy does most good, PRACTICE OF PHYSIC. 95 1134. Another remedy to be immediately employ- ed is blistering; and I judge that this is more effectual when applied to the head, or near to it, than when it is applied to the lower extremities. This remedy I do not consider as a stimulant, or capable of making any considerable revulsion; but, applied to the head, I suppose is useful in taking off the hemorrhagic disposi- tion so often prevailing there. 1135. It has been usual with practitioners, together with the remedies already mentioned, to employ stimu- lants of various kinds; but I am disposed to think them generally hurtful; and they must be so, wherever the fulness of the vessels, and the impetus of the blood in these, is to be diminished. Upon this principle it is therefore agreed, that stimulants are absolutely impro- per in what is supposed to be a sanguine apoplexy; but w they are commonly supposed to be proper in the serous. If, however, we be right in alleging that this also com- monly depends upon a plethoric state of the blood-ves- sels of the brain, stimulants must be equally improper in the one case as in the other. 1136. It may be urged from the almost universal when it procures an evacuation of the contents of the stomach. Still, however, if employed at all, emetics should be exhibited with the utmost caution. Purging is certainly the safer remedy; and, unless under very peculiar circumstances, should be always preferred. If apoplexy appear to have been induced by a suppression of hemorrhois or epistaxis, the application of leeches to the nostrils or hemorrhoidal vessels should not be neglected. Sternutatories, although strongly recommended by some, we consider as a remedy of no efficacy. 96 PRACTICE OF PHYSIC. employment of stimulants, and sometimes with seem- ing advantage, that they may not be so hurtful as my notions of the causes of apoplexy lead me to suppose. But this argument is, in several respects, fallacious; and particularly in this, that in a disease which, under eve- ry management, often proceeds so quickly to a fatal termination, the effects of remedies are not to be easily ascertained. 1137. I have now mentioned the several remedies which I think, adapted to the cure of apoplexy arising from compression, and should next proceed to treat of the cure of apoplexy arising from those causes that directly destroy the mobility of the nervous power. But many of those causes are often so powerful, and there- by so suddenly fatal in their effects, as hardly to allow of time for the use of remedies; and such cases, there- fore, have been so seldom the subjects ofpractice, that the proper remedies are not so well ascertained as to enable me to say much of them here.* * The affections treated of in this and the following article, are not to be considered as cases of apoplexy, but of suspended ani- mation. Some of the remedies proposed for them by our author are sufficiently judicious. From the stimulating effects of the external use of cold water in them, much benefit has been often- times derived. We feel persuaded, however, that, for the pur- poses of revival, in cases of suspended animation, remedies judi- ciously and perseveringly directed to the alimentary canal, will be ultimately found to be most efficacious. But this is not the proper place for the consideration of this subject. Those who wish to inquire further on the subject of apoplexy, are referred to the writings of Ballonius—Willis—Bellini__Lan- cisi—Hoffman—-Baglivi--MQrgagni—and De Haen. PRACTICE OF PHYSIC. 97 1138. When, however, the application of the causes, (1114,) is not so powerful as immediately to kill, and induces only an apoplectic state, some efforts are to be made to obviate the consequences, and to recover the patient; and even in some cases where the causes re- ferred to from the ceasing of the pulse and of respira- tion, and from a coldness coming upon the body, have induced an appearance of death; yet, if these appearan- ces have not continued long, there may be means of recovering the person to life and health. I cannot, in- deed, treat this subject completely; but for the cure of apoplexy from several of the causes mentioned (1114.) shall offer the following general directions. 1. When a poison capable of producing apoplexy has been recently taken into the stomach, if a vomiting spontaneously arises, it is to be encouraged; or, if it does not spontaneously come on, a vomiting is to be immediately excited by art, in order that the poison may be thrown out as quickly as possible. If, however, the poison has been taken into the stomach long before its effects have appeared, we judge that, upon their ap- pearance, the exciting of vomiting will be useless, and may perhaps be hurtful. 2. When the poison taken into the stomach, or other- wise applied to the body, has already induced an apo - plectic state, as those causes do commonly at the same time occasion a stagnation or slower motion of the blood in the vessels of the brain and of the lungs, so it will generally be proper to relieve this congestion by taking some blood from the jugular vein, or from the veins of the arm. 3. Upon the same supposition of a congestion in the brain or lungs, it will generally be proper to relieve it VOL. II. N 98 PRACTICE OF PHYSIC. by means of acrid glysters producing some evacuation from the intestines. 4. When these evacuations by blood-letting and pur- ging have been made, the various stimulants which have been commonly proposed in other cases of apo- plexy, may be employed here with more probability and safety. One of the most effectual means of rousing apoplectics of this kind, seems to be throwing cold water on several parts of the body, or washing the bo- dy all over with it. 5. Although the poison producing apoplexy happens to be so powerful as very soon to occasion the appear- ances of death above-mentioned; yet if this state has not continued long, the patient maY often be recovera- ble; and the recovery is to be attempted by the same means that* are directed to be employed for the recove- ry of drowned persons, and which are. now commonly knbwh. chapter n. OF PALSY.* 1139. PALSY is a disease consisting in a loss of the power of voluntary motion, but affecting certain parts * Palsy and apoplexy appear to be the same disease, differing only in degree. Palsy is partial apoplexy, and apoplexy, univer- sal palsy. The same proximate cause, therefore, must be regard- ed as giving rise to both; except that in one case it is more, in the other less extended and powerful. PRACTICE OF PHYSIC. 99 of the body only, and by this it is distinguished from apoplexy. (1093.) One of the most frequent forms of Apoplexy is more of an acute disease than palsy; and from this circumstance arises the principal difference in their treatment. Palsy, however, has also an acute stage, during which it re- quires to be treated precisely like apoplexy. Bleeding, topical and general, purging, and blistering, constitute now the principal remedies. The active, warm, and terebinthinate purges are those from which most advantage is derived. . ^» After the termination of its acute or febrile character, the prac- titioner must place his chief reliance on regimen, exercise, and external stimulants. The diet ought to be nutritious, but not stimulating; and great caution should be observed in the use of distilled and fermented li- quors. In the direction of these matters, former and long esta- blished habits should be allowed to have some influence; but, in the case of a paralytic patient, nothing can justify high living. That which has been instrumental in the production of a disease, can never be expected to contribute to its removal. If the patient possess sufficient strength, the exercise qf* walk- ing or riding on horseback or in a carriage, ought to be practised with constancy, but in moderation. Such exercise, in particular, as the diseased portion of the body is capable of taking, ought, on no account, to be omitted. The external stimulants, from the employment of which much benefit has been derived, are numerous and diversified. Blisters and sinapisms, with the warm and cold bath, applied immediately to the part affected, are among the most powerful. To these must be added warm clothing, consisting of flannel or fleecy hosiery worn next the skin, daily and long continued fric- tions with flannel or the flesh brush, and the application of various dry and liquid articles of a stimulating character. Of these we may mention, as amongst the most active and pro- misingj tincture of cantharides, prepared with distilled spirits, or spirits of turpentine; the saponacious, camphorated, and volatile liniments; spirits of turpentine alone, spirits of camphor alone, or a mixture of the two, forming what has been denominated essence 100 PRACTICE OF PHYSIC. palsy is when it affects the whole of the muscles on one side of the body; and then the disease is named a He- miplegia. of mustard; essential oil of cloves, of juniper, of sassafras, of thyme, and other fragrant and stimulating substances; black pepper alone, powdered mustard alone, black pepper in brandy, mustard in vinegar, and sundry other irritating articles. ■Jlfclectricity and galvanism are remedies from which much be- nefj is occasionally derived in the treatment of paralysis. But to render them efficient, their application must be frequent and long continued. The reason of their often failing even to afford re- lief, is the injudicious manner in which they are employed. The effect of each shock or single application of them is exceedingly evanescent. To be productive of good, therefore, the repetition of these shocks should be in some measure proportioned to the brevity of their time of action. Unless the part affected be kept under the influence of these subtle agents from three to six hours each day; and this course be pursued for several months, the trial cannot be considered as a fair one. Fortt ought never to be forgotten, that the remedy should be alw*ji as chronic as the disease. The vapour bath, both dry and moist, has been found very use- ful in the treatment of palsy. So has bathing in salt water, more especially in the water of the ocean. Urtication, or stinging with nettles, has been recommended not a little in this disease. Travelling and change of climate, espe- cially the exchange of a colder for a warmer climate, have proved useful. Various internal remedies have been used with advantage. When not forbidden by the existence of fever: the most active of these are, Peruvian bark, combined with certain aromatic sub- stances, chalybeates, mustard seed, garlic, flowers of zink, and some of the most stimulating of the essential oils—such as, oil of cloves, of mint, of rosemary, of thyme, of sassafras, and of juni- per; to which may be added, the spirits of turpentine. PRACTICE OF PHYSIC. 101 1140. The loss of the power of voluntary motion may be owing either to a morbid affection of the mus- cles or organs of motion, by which they are rendered unfit for motion; or to an interruption of the influx of the nervous power into them, which is always necessa- ry to the motions of those that are under the power of the will. The disease, from the first of these causes, as consisting in an organic and local affection, we re|cr entirely to the class of local diseases. I am here to Con- sider that disease only which depends upon the inter- rupted influx of the nervous power; and it is to this disease alone I would give the appellation of Palsy. A disease depending on an interrupted influx of the ner- vous power, may indeed often appear as merely a lo- cal affection; but as it depends upon an affection of the most general powers of the system, it cannot be properly separated from the systematic affections. 1141. In palsy, the loss of motion is often accom- panied with the loss of sense; but as tjjis, is not con- stantly the case, and as therefore the loss of sense is not an essential symptom of palsy, I have not tSkeh it into my definition (1139.) and I shall not think it ne- cessary to take any further notice of it in this treatise; What has been said of electricity and galvanism is equally ap- plicable to all other remedies in relation to the treatment of palsy. To prove efficacious, their exhibition must be long continued. When other means had failed, a gentle ptyalism, kept up for a considerable time; or suffered to decline, and again renewed through several repetitions, has effected a cure.—On the whole, we think we have seen most good effected in chronic palsy, by- flannel and friction, moderate exercise, and a well regulated diet. For further information on this disease, see Willis—Morgagni —Monro Dis. Arm.—Home—De Haen—Wardrobe—and Chan- dler. 102 PRACTICE OF PHYSIC. because, in so far as it is in any case a part of the pa- ralytic affection, it must dependaipon the same causes, and will be cured also by the very same remedies, as the loss of motion. 1142. The palsy then or loss of motion, which is to be treated of here, may be distinguished as of two kinds; one of them depending upon an affection of the origin of the nerves in the brain, and the other depending up- on an affection of the nerves in some part of their course between the brain and'the organs of motion. Of the lat- ter, as appearing in a very partial affection, I am not to speak particularly here; I shall only treat of the more general paralytic affections, and especially of the hemi- plegia (1139.) At the same time I expect, that what I shall say upon this subject will readily apply to both the pathology and practice in the cases of affections more limited. 1143. The hemiplegia (1139.) usually begins with, or follows, a paroxysm of apoplexy; and when the he- miplegia, after subsisting for some time becomes fatal, it is commonly by passing again into the state of apo- plexy. The relation therefore or affinity between the two diseases, is sufficiently evident; and is further strong- ly confirmed by this, that the hemiplegia comes upon persons of the same constitution (1094.) and is prece- ded by the same symptoms (1097.) that have been ta- ken notice of with respect to apoplexy. 1144. When a fit of apoplexy has gone off, and there remains a state of palsy appearing as a partial affection only, it might perhaps be supposed that the origin of the nerves is in a great measure relieved; but in so far as commonly there still remain the symptoms of the loss of memory, and of some degree of fatuity, these, I think, PRACTICE OF PHYSIC. 10S show that the organ of intellect, or the common origin of the nerves, is still considerably affected. 1145. Thus, the hemiplegia, from its evident con- nexion with, and near relation to apoplexy, may be pro- perly considered as depending upon like causes; and consequently either upon a compression preventing the flow of the nervous power from the brain into the or- gans of motion, or upon the application of narcotic or, other powers (1114.) rendering the nervous poweirun- fit to flow in the usual and proper manner. 1146. We begin with considering the cases depend- ing upon compression. The compression occasioning hemiplegia may be of the same kind, and of all the different kinds that produce apoplexy; and therefore either from'tumor, over-disten- tion, or effusion. The existence of tumor giving com- pression, may often be better discerned in the case of palsy than in that of apoplexy, as its effects often appear at first in a very partial affection. "''/'■ 1147. The other modes of compression, that is, of over-distention and effusion, may, and commonly do, take place, in hemiplegia: and when they do, their ope- ration here differs from that producing apoplexy, by its effects being partial, and on one side of the body only. It may seem difficult to conceive that an over-disten- tion can take place in the vessels on one side of the brain only; but it may be understood: and in the case of a palsy which is both partial and transitory, it is perhaps the only condition of the vessels of the brain that can be supposed. In a hemiplegia, indeed, which subsists for any length of time, there is probably always an ef- fusion, either sanguine or serous: but it is likely that 104 PRACTICE OF PHYSIC. even the latter must be supported by a remaining con gestion in the blood-vessels. 1148. That a sanguine effusion can happen without becoming very soon general, and thereby occasioning apoplexy and death, may also seem doubtful: but dis- sections prove that in fact it does happen, occasion- ing palsy only; though it is true, that this more com- monly depends upon an effusion of serous fluid, and of this only. 1149. Can a palsy, occasioned by a compression re- main though the compression be removed? 1150. From what has been said, (1143.) it will be obvious, that the hemiplegia may be prevented by all the several means proposed (1124. etseq.) for the pre- vention of apoplexy. 1151. Upon the same grounds, the cure of palsy must be very much the same with that of apoplexy (1129. etseq.) and when palsy has begun as an apoplexy, it is presumed, that, before it is to be considered as pal- syr all those several remedies have been employed. In- deed, even when it happens that on the first attack of the disease the apoplectic state is not very complete, and that the very first appearance of the disease is as a he- miplegia, the affinity between the two diseases (1143.) is such as to lead to the same remedies in both cases. This is certainly proper in all those cases in which we can with much probability impute the disease to com- pression; and it is indeed seldom that a hemiplegia from internal causes comes on but with a considerable affec- tion of the internal, and even of the external senses, to- gether with other marks of a compression of the origin of the nerves. PRACTICE OF PHYSIC. 105 1152. Not only, however, where the disease can be imputed to compression, but even where it can be im- puted to the application of narcotic powers, if the dis- ease come on with the appearances mentioned at the end of the last paragraph, it is to be treated in the same man- ner as an apoplexy by 1130—llo8. 1153. The cure of hemiplegia, therefore, on its first attack, is the same, or nearly the same, with that of apo- plexy: and it seems requisite that it should be different only, 1. When the disease has subsisted for some time; 2. When the apoplectic symptoms, or those marking a considerable compression of the origin of the nerves, are removed; and particularly, 3. When there are no evident marks of compression, and it is at the same time known that narcotic powers have been applied. 1154. In all these cases, the question arises, Whe- ther stimulants may be employed, or how far the cure may be entirely trusted to such remedies? Upon this question, with respect to apoplexy, I have offered my opinion in 1135. And, with respect to hemiplegia,' I am of opinion, that stimulants are almost always equal- ly dangerous as in the cases of complete apoplexy; and particularly, 1. In all the cases of hemiplegia succeed- ing to a paroxysm of complete apoplexy; 2. In all the cases coming upon persons of the temperament men- tioned in 1094, and after the same antecedents as those of apoplexy, 1115, and 3. In all the cases coming on with symptoms of apoplexy from compression. 1155. It is, therefore, in the cases 1153, only, that stimulants are properly admissible: and even in the two first of these cases, in which a plethoric state of the blood-vessels of the brain may have brought on the disease; in which a disposition to that state may still VOL. II. o 10G PRACTICE OF PHYSIC. continue; and in which even some degree of congestion may still remain, the use of stimulants must be an am- biguous remedy; so that perhaps it is in the third of these cases only that stimulants are clearly indicated and admissible. 1156. These doubts with respect to the use of stimu- lants, may perhaps be overlooked or disregarded by those who allege that stimulants have been employed with advantage even in those cases 1154, in which I have said they ought to be avoided. 1157. To compromise this contrariety of opinion, 1 must observe, that even in the cases of hemiplegia de- pending upon compression, although the orig-.n of the nerves be so much compressed as to prevent so full a flow of the nervous power as is necessary to muscular motion, yet it appears from the power of sense still re- maining, that the nerves are, to a certain degree, still pervious; and therefore it is possible that stimulants ap- plied, may excite the energy of the brain so much, as in some measure to force open the compressed nerves, and to show some return of motion in paralytic mus- cles. Nay, further, it may be allowed, that if these stimulants be such as act more upon the nervous than upon the sanguiferous system, they may possibly be employed without any very hurtful consequence. 1158. But still it will be obvious, that although cer- tain stimulants act chiefly upon the nervous system, yet they also act always in some measure upon the sangui- ferous; so that, when they happen to have the latter ef- fect in any considerable degree, they may certainly do much harm; and in a disease which they do not entire- ly cure, the mischief arising from them may not be dis- cerned. PRACTICE OF PHYSIC. 107 1159. Whilst the employment of stimulants is so of- ten an ambiguous practice, we may perhaps go some length towards ascertaining the matter, by considering the nature of the several stimulants which may be em- ployed, and some of the circumstances of their admini- stration. With this view, therefore, I shall now men- tion the several stimulants that have been commonly em- ployed, and offer some remarks upon their nature and use. 1160. They are in the first place to be distinguished as external or internal. Of the first kind, we again dis- tinguish them as they are applied to particular parts of the body only, or as they are more generally applied to the whole system. Of the first kind are, 1. The concentrated acids of vitriol or nitre; involv- ed however, in oily or unctuous substances, which may obviate their corrosive, without destroying their stimu- lant power. 2. The volatile alkaline spirits, especially in their caustic state; but involved also in oils, for the purpose just now mentioned. 3. The same volatile spirits are frequently employed by being held to the nose, when they prove a powerful stimulus to the nervous system; but it is at the same time probable, that they may also prove a strong stimu- lant to the blood-vessels of the brain. 4. A brine or strong solution of sea-salt. 5. The essential oils of aromatic plants, or of their parts. 6. The essential oils of turpentine, or of other such resinous substances. 108 PRACTICE OF PHYSIC. 7. The distilled oils of amber, or of other bitumi- nous fossils. 8. The rectified empyreumatic oils of animal or vege- table substances. 9. Various vegetable acrids, particularly mustard. 10. The acrid matter found in several insects, parti- cularly cantharides. Some of these stimulants may be either applied in substance; or may be dissolved in ardent spirits, by which their stimulant power may be increased, or more conveniently applied. 1161. The greater part of the substances now enu- merated show their stimulant power by inflaming the skin of the part to which they are applied; and when their application is so long continued as to produce this effect, it interrupts the continuance of their use; and the inflammation of the part does not seem to do so much good as the frequent repetition of a more mode- rate stimulus. 1102. Analagous to these stimulants is the stinging of nettles, which has been frequently commended. Among the external stimulants, the mechanical one of friction with the naked hand, the flesh-brush, or flan- nel, is justly to be reckonerl. Can the impregnation of the flannels to be employed, with the fumes of burning mastic, olibanum, &c. be of any service? 116 >. With respect to the whole of these external stimulants, it is to be observed, that they affect the part to which they are applied much more than thev do the whole system, and they are therefore indeed safer in am- biguous cases; but for the same reason, they are of less efficacy in curing a general affection. PRACTICE OF PHYSIC. 109 1164. The external applications which may be ap- plied to affect the whole system, are the powers of heat and cold, and of electricity. Heat, as one of the most powerful stimulants of the animal economy, has been often employed in palsies, especially by w.rm bathing. But as, both by stimulat- ing the solids and rarefying the fluids, this proves a strong stimulus to the sanguiferous system, it is often an ambiguous remedy; and has frequently been mani- festly hurtful in palsies depending upon a congestion of blood in the vessels of the brain. The most certain, and therefere the most proper use of warm bathing in palsies, seems to be in those that have been occasioned by the application of narcotic powers. Are the natural baths more useful by the matters with which they may be naturally impregnated? 1165. Cold applied to the body for any length of time, is always hurtful to the paralytic persons; but if it be not very intense, nor the application long continued, and if at the ame time the body be capable of a brisk' re- action, such an application of cold is a powerful sti- mulant of the whole system, and has often been useful in curing palsy. But, if the power of reaction in the body be weak, any application of cold may prove very hurtful. 1166. Electricity, in a certain manner applied, is certainly one of the most powerful stimulants that can be employed to act upon the nervous system of animals; and therefore much has been expected from it in the cure of palsy. But, as it stimulates the sanguiferous as well as the nervous system, it has been often hurtful in palsies depending upon a compression of the brain; and especially when it has been so applied as to act upon no PRACTICE OF PHYSIC. the vessels of the head. It is safer when its operation is confined to particular parts somewhat remote from the head; and, further, as the operation of electricity, when very strong can destroy the mobility of the ner- vous power, I am of opinion, that it is always to be em- ployed with caution, and that it is only safe when ap- plied with moderate force, and when confined to certain parts of the body remote from the head. , It is also my opinion, that its good effects are to be expected from its repetition rather than from its force, and that it is particularly suited to the cure of those palsies which have been produced by the application of narcotic powers. 1167. Amongst the remedies of palsy, the use of ex- ercise is not to be omitted. In a hemiplegia, bodily exercise cannot be employed; and in a more limited affection, if depending upon a compression of some part of the brain, it would be an ambiguous remedy: but, in all cases where the exercise of gestation can be em- ployed, they are proper; as, even in cases of compres- sion, the stimulus of such exercise is moderate, and therefore safe; and, as it always determines to the sur- face of the body, it is a remedy in all cases of internal congestion. 1168. The internal stimulants employed in palsy are various, but chiefly the following. 1. The volatile alkaline salts, or spirits, as they are called, are very powerful and diffusive stimulants, ope- rating especially on the nervous system; and even al- though they operate on the sanguiferous, yet, if given in frequently repeated small rather than in large doses, their operation being transitory, is tolerably safe. PRACTICE OF PHYSIC. 1 i \ 2. The vegetables of the class named Tetradynamia, are many of them powerful diffusive stimulants; and at the same time, as quickly passing out of the body, and therefore a transitory operation, they are often employed with safety. As they commonly prove diuretic, they may in this way also be of service in some cases of se- rous palsy. 3. The various aromatics, whether employed in sub- stance, in tincture, or in their essential oils, are often powerful stimulants; but being more adhesive and in- flammatory than those last mentioned, they are, there- fore, in all ambiguous cases, less safe. 4. Some other acrid vegetables have been employed; but we are not well acquainted with their peculiar vir- tues, or proper use. 5. Some resinous substances, as guaiacum, and the terebinthinate substances, or their essential oils, have been with some probability, employed; but they are apt to become inflammatory. Decoctions of guaiacum, and some other sudorifics, have been directed to excite sweating by the application of the fumes of burning spirit of wine in the laconicum, and have in that way been found useful. 6. Many of the fetid antispasmodic medicines have been frequently employed in palsy; but I do not per- ceive in what manner they are adapted to the cure of this disease, and I have not observed their good effects in any case of it. 7. Bitters and the Peruvian bark, have, also been employed, but with no propriety or advantage that I can perceive. 1169. W ith respect to the whole of these internal stimulants, it is to be observed, that they seldom prove 112 PRACTICE OF PHYSIC. very powerful; and wherever there is any doubt con* cewiing the nature or state of the disease, they may readily do harm, and are often therefore of ambiguous use. BOOK II. QF ADYNAMIC; OR DISEASES CONSISTING IN A WEAKNESS OR LOSS OF MOTION IN EITHER THE VITAL OR NATURAL FUNCTIONS. CHAPTER L* OF SYNCOPE, OR FAINTING. 1170. 1 HIS is a disease in which the action of the heart and respiration become considerably weaker than usual, or in which for a certain time these functions cease altogether. * The few cases of the disease, treated of in, this chapter, which •we have had an opportunity of witnessing, appeared evidently to originate in some gastric or uterine affection—but most frequently in the former. Hence the nausea or sickness which almost al- ways precedes the paroxysm. Any exceptions to this rule that may present themselves, consist most probably in such cases of syncope, as arise from an aneurism, polypi, ossifications, or other organic affections of the heart and large blood vessels. We have never seen an instance of the complaint which we could consider as the product of a cause seated originally in the brain. The affection of the brain we believe to be secondary. The disease attacks that organ, in common with others, in its march from the stomach throughout the system. The heart, arteries, PRACTICE OF PHYSIC. 113 1171. Physicians having observed that this affection occurs in different degrees, have endeavoured to distiti- guish these by different appellations: but as it is not and muscles of voluntary motion, it assails in the same way through the medium of sympathy. Our author's attempt to disclose the nature, or as he denomi- nates it, the proximate cause of this disease, is not only unsatisfac- tory; it is to us unintelligible. Nor is it very probable that we ourselves would be more successful, should we make an essay on the subject. It is not our intention, therefore, to engage in the undertaking. When further light shall have been thrown on the different kinds of impression of which the stomach is susceptible, and when the laws of sympathy shall have been more completely unfolded, then may the nature of syncope be better understood, In the meantime, its cure, as far as we are acquainted with it, consists principally in the judicious and long continued employ- ment of tonics. That the stomach may be the better prepared for the action of these remedies, it is proper, in most cases, that they be preceded by an emetic. The tonics best suited to the nature of this disease are, bark, bitters, chalybeates combined with aromatics, elixir of vitrioi, and wine, used in moderation. The cold bath, moderate exercise in the open air, travelling and change of climate are also useful. So are a sea voyage and the constant use of the flesh-brush. A generous diet is adviseable; but it should never consist of a great variety of articles. In a particular manner, nothing should be eaten that is not known to be very easily digested. If any thing be known ty be offensive to the stomach, that ought to be stildi- ously avoided. A perpetual blister on the region of the stomach has been found, if not entirely to remove, at least greatly to weaken a lia- bility to syncope. So has a gentle ptyalism; and more especially, still, the use of arsenic, until an itching and eruption have been produced on th» skin. VOL. II. P 114 PRACTICE OF PHYSIC. possible to ascertain these different degrees with any precision, so there can be no strict propriety in employ- ing those different names; and I shall here comprehend the whole of the affections of this kind under the title of Syncope. 1172. This disease sometimes comes on suddenly to a considerable degree, but sometimes also it comes on gradually; and in the latter case, it usually comes on with a sense of languor, and of anxiety about the heart, accompanied at the same time, or immediately after, with some giddiness, dimness of sight, and sounding in the ears. Together with these symptoms, the pulse and respiration become weak; and often so weak, that the pulse is scarcely to be felt, or the respiration to be perceived; and sometimes these motions, for a certain time, cease altogether. While these symptoms take place, the face and whole surface of the body become pale, and more or less cold according to the degree Fainting fits have been for a long time suspended by an attack of podagra. This shows the disease to be, at least in such cases, of a gouty character. Some females experience fainting fits only during their preg- nancy; while others, subject to them at other times, are then free from them. In such cases, syncope is certainly connected with the uterus; but the first link of the chain of diseased action may be fixed in the stomach. If syncope make its attack at stated periods, it may, like other periodical complaints, be prevented by the exhibitionT)f opium or laudanum, a few hours before the time of its occurrence. For further information respecting this disease, see the writings of Vesalius—Ballonius—Forestus—Schenkius—Boretus—Ra- mazzini—Lancisi—Senac du ooeur—Morgagni—De Haen. rat. med.—Hare de Syncope—Stoll rat. med. and'Chevalier on As- phyxia Idiopathica. PRACTICE OF PHYSIC. 115 and duration of the paroxysm. Very commonly -at the beginning of this, and during its continuance,* a cold sweat appears, and perhaps continues, on the fore- head, as well as on some other parts of the body. Dur- ing the paroxysm, the animal functions, both of sense and motion, are always in some degree impaired, and very often entirely suspended. A paroxysm of syn- cope is often, after some time, spontaneously recovered from; and this recovery is generally attended with a sense of much anxiety about the heart. Fits of syncope are frequently attended with, or end in, vomiting; and sometimes with convulsions, or an epileptic fit. 1173. These are the phenomena in this disease; and from every view of the greatest part of them, there cannot be a doubt that the proximate cause of this dis- ease is a very weak or total ceasing of the action of the heart. But it will be a very difficult matter to explain in what manner the several remote causes operate in producing the proximate cause. This, however, I shall attempt though with that diffidence which becomes me in attempting a subject that has not hitherto been treated with much success. 1174. The remote causes of syncope may, in the first place, be referred to two general heads. The one is, of those causes existing and acting in the brain/or in parts of the body remote from the heart, but acting upon it by the intervention of the brain. The other general head of the remote causes of syncope, is of those existing in the heart itself, or in parts very immediately connected with it, and thereby acting more directly upon it in producing this disease. 1175. In entering upon the consideration of the first set of those causes (1174.) I must assume a proposition 116 PRACTICE OF PHYSIC. which I suppose to be fully established in physiology. It is this: That, though the muscular fibres of the heart be endowed with a certain degree of inherent power, they are still, for such action as is necessary to the motion of the blood, very constantly dependent upon a nervous power sent into them from the brain. At least this is evident, that there are certain powers acting primarily, and perhaps only in the brain, which influence and va- riously modify the action of the heart. I suppose there- fore, a force very constantly during life exerted in the brain, with respect to the moving fibres of the heart, as well as of every part of the body; which force I shall call the energy of the brain: and which I suppose may be, on different occasions, stronger or weaker with re- spect to the heart. 1176. Admitting these propositions, it will be obvi- ous, that if I can explain in what manner the first set of remote causes (1174.) diminish the energy of the brain, I shall at the same time explain in what manner these causes occasion a syncope. 1177. To do this, I observe, that one of the most evident of the remote causes of syncope is a hemorrha- gy, or an evacuation of blood, whether spontaneous or artificial. And as it is very manifest that the energy of the brain depends upon a certain fulness and tension of its blood-vessels, for which nature seems to have indus- triously provided by such a conformation of those blood- vessels as retards the motion of the blood both in the arteries and veins of the brain; so we can readily per- ceive, that evacuations of blood, by taking off the ful- ness and tension of the blood-vessels of the brain, and thereby diminishing its energy with respect to the heart, may occasion a syncope. In many persons, a small evacuation of blood will have this effect; and in such PRACTICE OF PHYSIC. 117 cases there is often a clear proof of the manner in which the cause operates, from this circumstance, that the ef- fect can be prevented by laying the body in a horizon- tal posture; which, by favouring the afflux of the blood by the arteries, and retarding the return of it by the veins, preserves the necessary fulness of the vessels of the brain. It is farther to be remarked here, that not only an evacuation of blood occasions syncope, but that even a change in the distribution of the blood, whereby a lar- ger portion of it flows into one part of the system of blood-vessels, and consequently less into others, may occasion a syncope. It is thus I explain the syncope, that readily occurs upon the evacuation of hydropic wa- ters, which had before filled the cavities of the abdomen or thorax. It is thus also I explain the syncope that sometimes happens on blood-letting, but which does not happen till the ligature which had been employed is untied, and admits a larger afflux of blood into the blood-vessels of the arm. Both these cases of syncope show, than an evacuation of blood does not always oc- casion the disease by any general effect on the whole system, but often merely by taking off the requisite ful- ness of the blood-vessels of the brain. 1178. The operation of some others of the remote causes of syncope, may be explained on the following principles. Whilst the energy of the brain is, upon dif- ferent occasions, manifestly stronger or weaker, it seems to be with this condition, that a stronger exertion*of it is necessarily followed by a weaker state of the same. It seems to depend upon this law in the constitution of the nervous power, that the ordinary contraction of a muscle is always alternated with a relaxation of the 118 PRACTICE OF PHYSIC same; that, unless a contraction proceeds to the degree of spasm, the contracted state cannot be long continued: and it seems to depend upon the same cause that the vo- luntary motions, which always require an unusual in- crease of exertion, occasion fatigue, debility, and at length irresistible sleep. From this law, therefore, of the nervous power, we may understand why a sudden and violent exertion of the energy of the brain is sometimes followed by such a diminution of it as to occasion a syncope; and it is thus I suppose that a violent fit of joy produces syncope, and even death. It is upon the same principle also, I suppose, that an exquisite pain may sometimes excite the energy of the brain more strongly than can be sup- ported, and is therefore followed by such a diminu- tion as must occasion fainting. But the effect of this principle appears more clearly in this, that a fainting readily happens upon the sudden remission of a consi- derable pain; and thus I have seen a fainting occur up- on the reduction of a painful dislocation. 117y. It seems to be quite analogous when a syncope immediately happens on the finishing of any great and long continued effort, whether depending on the will, or upon a propensity; and in this way a fainting sometimes happens to a woman on the bearing of a child. This may be well illustrated by observing, that in persons already much weakened, even a very moderate effort will sometimes occasion fainting. 1180. To explain the operation of some other cau- ses of syncope, it may be observed, that as the exer- tions of the energy of the brain are especially under the influence of the will, so it is well known that those modifications of the will which are named Passions and Emotions, have a powerful influence on the energy of PRACTICE OF PHYSIC. 119 the brain in its action upon the heart, either in increas- ing or diminishing the force of that energy. Thus, an- ger has the former, and fear the latter effect; and thence it may be understood how terror often occasions a syn- cope sometimes of the most violent kind, named As- phyxia, and sometimes death itself. 1181. As, from what I have just mentioned, it ap- pears, that the emotions of desire increase, and those of aversion diminish the energy of the brain; so it may be understood, how a strong aversion, a horror, or the feel- ing which arises upon the sight of a very disagreeable object, may occasion fainting. As an example of this, I have known more than one instance of a person's faint- ing at the sight of a sore in another person. 1182. To this head of horror and disgust, I refer the operation of those odours which in certain persons occasion syncope. It may be supposed, that those odours are endowed with a directly sedative power, and may thereby occasion syncope; but they are, many of them, with respect to other persons, evidently of a contrary quality; and it appears to me, that those odours occa- sion syncope only in those persons to whom they are extremely disagreeable. 1183. It is, however, very probable, that among the causes of syncope, there are some which, analogous to all those we have already mentioned, act by a directly sedative power; and such may either be diffused in the mass of blood, and thereby communicated to the brain; or may be only taken into the stomach, which so readi- ly and frequently communicates its affections to the brain. 1184. Having now enumerated, and, as I hope, ex- plained the most part of the remote causes of syncope, that either operate immediately upon the brain, or whose operation upon other parts of the body is communicated 120 PRACTICE OF PHYSIC. to the brain, it is proper to observe, that the most part of these causes operate upon certain persons more rea- dily and more powerfully than upon others; and this circumstance, which may be considered as the predis- ponent cause of syncope, deserves to be inquired into. It is in the first place, obvious, that the operation of some of those causes depends entirely upon an idiosyn- crasy in the persons upon whom they operate; which, however, I cannot pretend to explain. But in the next place, with respect to the greater part of the other cau- ses, their "effects seem to depend upon a temperament which is in one degree or other in common to many persons. This temperament seems to consist in a great degree of sensibility and mobility, arising from a state of debility, sometimes depending upon original confor- mation, and sometimes produced by accidental occur- rences in the course of life. 1185. The second set of the remote causes of syn- cope (1174.) or those acting directly upon the heart it- self, are certain organic affections of the heart itself, or of the parts immediately connected with it, particular- ly the great vessels which pour blood into, or immedi- ately receive it from, the cavities of the heart. Thus a dilatation or aneurism of the heart, a polypus in its cavi- ties, abscesses or ulcerations in its substance, a close adherence of the pericardium to the surface of the heart, aneurisms of the great vessels near to the heart, polypus in these, and ossifications in these or in the valves of the heart, are one or other of them conditions which, upon dissection, have been discovered in those persons who had before laboured under frequent syncope. 1186. It is obvious, that these conditions are all of them, either such as may, upon occasion, disturb the free and regular influx into, or the free egress of the PRACTICE OF PHYSIC. 121 blood from, the cavities of the heart; or such as may otherwise disturb its regular action, by sometimes in- terrupting it, or sometimes exciting it to more violent and convulsive action. The latter is what is named the Palpitation of the Heart, and it commonly occurs in the same persons who are liable to syncope. 1187. It is this, as I judge, that leads us to perceive in what manner these organic affections of the heart and great vessels may occasion syncope; for it may be supposed, that the violent exertions made in palpitations may either give occasion to an alternate great relaxa- tion, (1178.) or to a spasmodic contraction; and in ei- ther way suspend the action of the heart, and occasion syncope. It seems to me probable, that it is a spas- modic contraction of the heart that occasions the inter- mission of the pulse so frequently accompanying palpi- tation and syncope. 1188. Though it frequently happens that palpitation and syncope arise, as we have said, from the organic affections above mentioned, it is proper to observe, that these diseases* even when in a violent degree, do not always depend on such causes acting directly on the heart, but are often dependent on some of those causes which we have mentioned above as acting primarily on the brain. 1189. I haVe thus endeavoured to give the pathology of syncope; and of the cure I can treat very shortly. The cases of syncope depending on the second set of causes, (1174.) and fully recited in 1185, I suppose to be generally incurable; as our art, so far as I know, has not yet taught us to cure any one of those several causes of syncope (1185.) ▼ OL. II. n 122 PRACTICE OF PHYSIC The cases of syncope depending on the first set of causes, (1174.) and whose operation I have endeavour- ed to explain in 1177. et seq. I hold to be generally curable, either by avoiding the several occasional causes there pointed out, or by correcting the predisponent causes (1184.) The latter, I think, may generally be done by correcting the debility or mobility of the sys- tem, by the means which I have already had occasion to point out in another place. CHAPTER II. OF DYSPEPSIA, OR INDIGESTION. 1190. A WANT of appetite, a squeamishness, some- times a vomiting, sudden and transient distentions of the stomach, eructations of various kinds, heartburns, pains in the region of the stomach, and a bound belly, are symptoms which frequently concur in the same per- sons and therefore may be presumed to depend upon one and the same proximate cause. In both views, therefore, they may be considered as forming one and the same disease, to which we have given the appella- tion of Dyspepsia, set at the head of this chapter. 1191. But as this disease is also frequently a secon- dary and sympathic affection, so the symptoms above- mentioned are often joined with many others; and this has given occasion to a very confused and undetermin- ed description of it, under the general title of Nervous Diseases, or under that of Chronic Weakness. It is proper, however, to distinguish them; and I apprehend PRACTICE OF PHYSIC. 123 the symptoms enumerated above are those essential to the idiopathic affection I am now to treat of. 1192. It is indeed to be particularly observed, that these symptoms are often truly accompanied with a certain state of mind which may be considered as a part of the idiopathic affection: but I shall take no fur- ther notice of this symptom in the present chapter, as it will be fully and more properly considered in the next, under the title of Hypochondriasis. 1193. That there is a distinct disease attended al- ways with the greater part of the above symptoms, is rendered very probable by this, that all these several symptoms may arise from one and the same cause; that is, from an imbecility, loss of tone, and weaker action in the muscular fibres of the stomach: and I conclude, therefore, that this imbecility may be considered as the proximate cause of the disease I am to treat of under the name of Dyspepsia.* 1194. The imbecility of the stomach, and the con- sequent symptoms, (1190) may, however, frequently depend upon some organic affection of the stomach it- self, as tumor, ulcer, or schirrosity; or upon some af- fection of other parts of the body communicated to the stomach, as in gout, amenorrhoea, and some others. In all these cases, however, the dyspeptic symptoms are to be considered as secondary or sympathic affections, * It is not from a loss of tone in the muscular fibres of the sto- mach, that the symptoms of dyspepsia«arise. Healthy digestion is not the result of muscular action. As far as the stomach is con- cerned in it, it is the result of a kind of glandular action; or, rather, of an action sui generis; for there is no other organ in the system to the action of which that of the stomach can be rightfully com- pared. 124 PRACTICE OF PHYSIC. to be cured only by curing the primary disease. Such secondary and sympathic cases, cannot, indeed, be trea- ted of here: but as i presume that the imbecility of the stomach may often take place without either any orga- nic affection of this part, or any more primary affection in any other part of the body; so I suppose and expect it will appear, from the consideration of the remote causes, that the dyspepsia may be often an idiopathic affection, and that it is therefore properly taken into the system of methodical Nosology, and becomes the subject of our consideration here.* 1195. There can belittle doubt, that in most cases, the weaker action of the muscular fibres of the stomach, is the most frequent and chief cause of the symptoms mentioned in (1190.) but I dare not maintain it to be the only cause of idiopathic dyspepsia. There is, pret- ty certainly, a peculiar fluid in the stomach of animals, or at least a peculiar quality in the fluids, that we know to be there, upon which the solution of the aliments ta- ken into the stomach chiefly depends: and it is at the same time probable, that the peculiar quality of the dis- solving or digesting fluids may be variously changed, or that their quantity may be, upon occasion, diminish- ed. It is, therefore, sufficiently probable, that a change in the quality or quantity of these fluids may produce a considerable difference in the phenomena of digestion, and particularly may give occasion to many of the mor- bid appearances mentioned in 1190.f * In as far as dyspepsia possesses an arthritic character, it may be considered an idiopathic disease; gout itself being originally a gastric affection. t The peculiar fluid to which our author alludes in this article is the liquor gastric**. To the physiologists of the present dav. PRACTICE OF PHYSIC. 125 1196. This seems to be very well founded, and points out another proximate cause of dyspepsia beside that we have already assigned: but, notwithstanding this, as the peculiar nature of the digestive fluid, the changes which it may undergo, or the causes by which it may be changed, are all matters so little known, that I can- not fo-j.nd any practical doctrine upon any supposition with respect to them; and as, at the same time, the im- becility of the stomach, either as causing the change in the digestive fluid, or as being induced by that change, seems always to be present, and to have a great share in occasioning the symptoms of indigestion; so I shall still consider the imbecility of the stomach as the proximate and almost sole cause of dyspepsia. And I more rea- dily admit of this manner of proceeding; as, in my opinion, the doctrine applies very fully and clearly to the explaining the whole of the practice which expe- rience has established as the most successful in this disease.* 1197. Considering this, then, as the proximate cause of dyspepsia, I proceed to mention the several remote the solvent powers of this liquor, and the general fiart it performs in the process of digestion are well understood. There can be no doubt that in dyspepsia its qualities are changed. But this change is not the sole cause of indigestion, although it must cer- tainly be considered as an auxiliary cause. The gastric liquor being itself secreted by the stomach, any morbid change which it sustains must be attributed to a previously existing diseased state of action in that organ. * That in dyspepsia the muscular fibres of the stomach are de- bilitated is probably true—perhaps the same thing may be tru * of the whole organ. But we repeat, that Lid gesti .n cannot fce re- garded as the immediate result of this debility, in as much as di- gestion is not a muscular process. '* 126 PRACTICE OF PHYSIC. causes of this disease; as they are such, as, on different occasions, seem to produce a loss of tone in the mus- cular fibres of the stomach. They may, I think, be considered under two heads. The first is, of those which act directly and immediately upon the stomach itself: The second is, of those which act upon the whole body, or particular parts of it, but in consequence of which the stomach is chiefly or almost only affected. 1198. Of the first kind are, 1. Certain sedative or narcotic substances taken into the stomach; such as tea, coffee, tobacco, ardent spirits, opium, bitters, aromatics, putrids, and acescents. 2. The large and frequent drinking of warm water, or of warm watery liquids. 3. Frequent surfeit, or immoderate repletion of the stomach. 4. Frequent vomiting, whether spontaneously aris- ing, or excited by art. 5. Very frequent spitting, or rejection of saliva. 1199. Those causes which act upon the whole body, or upon particular parts and functions of it, are, 1. An indolent and sedentary life. 2. Vexation of mind, and disorderly passions of any kind. 3. Intense study, or close application to business too long continued. 4. Excess in venery. 5. Frequent intoxication; which partly belongs to this head, partly to the former. 6. The being much exposed to moist and cold air when without exercise.* * 1198—9. These t >w; articles contain an excellent summary of the remote causes, of indigestion, which ought to be strictly at- PRACTICE OF PHYSIC. 127 1200. Though the disease, as proceeding from the last set of causes, may be considered as a symptomatic affection only; yet as the affection of the stomach is ge- nerally the first, always the chief, and often the only effect which these causes produce or discover, I think the affection of the stomach may be considered as the disease to be attended to in practice; and the more pro- perly so, as in many cases the general debility is only to be cun*d by restoring the tone of the stomach, and by remedies first applfed to this organ. 1201. For the cure of this disease, we form three se- veral indications; a preservative, a palliative, and a cu- rative. The first is, to avoid or remove the remote causes just now enumerated. The second is, to remove those symptoms which especially contribute to aggravate and continue the dis- ease. And, The third is, to restore the tone of the stomach; that is, to correct or remove the proximate cause of the dis- ease. 1202. The propriety and necessity of the first indi- cation is sufficiently evident, as the continued applica- tion, or frequent repetition of those causes, must con- tinue the disease; may defeat the use of the remedies: or, in spite of these, may occasion the recurrence of the disease. It is commonly the neglect of this indica- tion which renders this disease so frequently obstinate. —How the indication is to be executed, will be suffici- tended to and carefully remembered by all who wish to escape the disease. Our only objection in relation to them, is, that there is not among them, as our author alleges, a single sedative. ..They all possess properties highly stimulating. 128 PRACTICE OF PHYSIC. ently obvious from the consideration of the several causes: but it is proper for the practitioner to attend to this, that the execution is often exceedingly difficult, because it is not easy to engage men to break in upon established habits, or to renounce the pursuit of plea- sure; and particularly, to persuade men that these prac- tices are truly hurtful which they have often practised with seeming impunity. 1203. The symptoms of this disease which especially contribute to aggravate and continue it, and therefore require to be more immediately corrected or removed, are, first, the crudities of the stomach already produ- ced by the disease, and discovered by a loss of appetite, by a sense of weight and uneasiness in the stomach, and particularly by the eructation of imperfectly digested matters. Another symptom to be immediately corrected, is an unusual quantity, or a higher degree than usual, of aci- dity present in the stomach, discovered by various dis- orders in digestion, and by other effects to be mention- ed afterwards. The third symptom aggravating the disease, and ' otherwise in itself urgent, is costiveness, and therefore constantly requiring to be relieved. 1204. The first of these symptoms is to be relieved by exciting vomiting; and the use of this remedy, there- fore, usually and properly begins the cure of this dis- ease. The vomiting may be excited by various means, more gentle or more violent. The former may answer the purpose of evacuating the contents of the stomach: but emetics, and vomiting, may also excite the ordinary action of the stomach; and both, by variously agitating the system, and particularly by determining to the sur- PRACTICE OF PHYSIC. 129 face of the body, may contribute to remove the causes of the disease. But these latter effects can only "be ob- tained by the use of emetics of the more powerful kind, such as the antimonial emetics especially are.* 1205. The second symptom to be palliated, is an ex- cess of acidity, either in quantity or quality, in the con- tents of the stomach. In man there is a quantity of acescent aliment almost commonly taken in, and, as I think, always undergoes an acetous fermentation in the stomach;, and it is, therefore, that, in the human sto- mach, and in the stomachs of all animals using vegetable food, there is always found an acid present. This acid, however, is generally innocent, and occasions no disor- der, unless either the quantity of it is large, or the acidi- ty proceeds to a higher degree than usual. But, in either of these cases, the acid occasions various disor- ders, as flatulency, eructation, heartburn, gnawing pains of the stomach, irregular appetites and cravings, loose- ness, griping, emaciation, and debility. To obviate or remove these effects aggravating and continuing the disease, it is not only necessary to correct the acid pre- sent in the stomach; but, especially as this acid proves a ferment determining and increasing the acescency of the aliments afterwards taken in, it is proper also, as soon as possible, to correct the disposition to excessive acidity. | * Vomiting alone, by exciting a new action in the stomach, contributes, at times, very much to the removal of dyspepsia. t It is now very well known that, in healthy digestion, the ace- tous fermentation never prevails. But in indigestion, the case is otherwise. There, an acid, said to be the acetous—for we have never ourselves particularly examined it—greatly superabounds; and requires to be neutralized by alkaline absorbents. VOL. II. iR 130 PRACTICE OF PHYSIC. 1206. The acidity present in the stomach may be corrected by the use of alkaline salts, *or absorbent earths; or by such substances, containing these, as can be decomposed by the acid of the stomach. Of the al- An excellent preparation for this purpose consists of equal parts of lime water and sweet milk; of which a table spoonful.may be taken every hour, or oftener, should circumstances require it. Lime yvater and mucilage of gum arabic, used in the same way, are also useful. Besides neutralizing the superabundant acidity, these preparations furnish the stomach with alimentary matter very easy of digestion. When acidity and constipation prevail at once, calcined magne- sia.is the most suitable remedy. It neutralizes the former, by its absorbent, and removes the latter by its purgative, qualities. When acidity and diarrhoea are predominant symptoms, the cretaceous j ulap, with he addition of a little laudanum, may be administered with advantage. This julap may be prepared ac- cording to the following formula. Take of prepared chalk and powdered gam arabic, each half an ounce; of cinnamon, or mint, and spring water, each four ounces; of laudanum, sixty drops; and of loaf sugar, a sufficient quantity to rendu* the pre- paration agreeable. These articles being neatly incorporated with each other, give of the mixture a table spoonful, according to circumstances. In cases of dyspepsia, accompanied with painful spasmodic af- fections of the stomach, the following remedy, although coarse and nomely, has been found, on experience, to be highly effica- cious. Take of hickory ashes, a quart; of powdered soot, a table spoonful; and of spring water, one gallon. Put the ingredients into an unglazed earthen vessel, where they must be permitted to remain from three to five days, being, in the mean time, repeated- ly stirred and mixed together with a wooden or silver instrument; the scum rising to the surface being carefully removed. The process being finished, strain the liquor through coarse filtering paper, or allow it to settle, and administer it in doses of from two to four table spoonfuls^to be repeated five or six times a day. PRACTICE OF PHYSIC. 131 kalines, the caustic is mor** effectual than the mild; and this accounts for the effects of lime-water. -By em- ploying absorbents, we avoid the excess of alkali, which might sometimes take place. The absorbents are dif- ferent, as they form a neutral more or less laxative; and hence the difference between magnesia alba and other absorbents. It is to be observed, that alkalines, and absorbents may be employed to excess; as, when em- ployed in large quantity, they may deprive the animal fluids of the acid necessary to their proper composi- tion. 1207. The disposition to acidity may be obviated by avoiding acescent aliments, and using animal food little capable of acescency. This, however, cannot be long continued without corrupting the state of our blood; and as vegetable food cannot be entirely avoided, the excess of their acescency may in some measure be avoided, by choosing vegetable food the least disposed to a vinous fermentation, such as leavened bread and well fermented liquors, and, instead of fresh native acids, employing vinegar. 1208. The acid arising from acescent matters in a sound state of the stomach, does not proceed to any high degree, or is again soon involved and made to disappear: but this does not always happen; and a more copious acidity, or a higher degree of it, may be pro- duced, either from a change in the digestive fluids, be- come less fit to moderate fermentation and to cover aci- dity, or from their not being supplied in due quantity. How the former may be occasioned, we do not well un- derstand; but we can readily perceive that the latter, perhaps the former also, may proceed from a weaker action of the muscular fibres of the stomach. In certain 132 PRACTICE OF PHYSIC. cases, sedative passions, immediately after they arise, occasion the appearance of acidity in the stomach which did not appear before; and the use of stimulants often corrects or obviates an acidity that would otherwise have appeared. From these considerations, we conclude, that the production and subsistence of acidity in the stomach, is to be especially prevented by restoring and exciting the proper action of it, by the several means to be mentioned hereafter.* 1209. But it is also to be further observed, that though there are certain powers in the stomach for pre- venting a too copious acidity, or a high degree of it, they are not however always sufficient for preventing aces- cency, or for covering the acidity produced; and there- fore, as long as vegetable substances remain in the sto- mach, their acescency may go on and increase. From hence we perceive, that a special cause of the excess of acidity may be, the too long retention of acescent mat- ters in the stomach; whether this may be from these matters being of more difficult solution, or from the weakness of the stomach more slowly discharging its contents into the duodenum, or from some impediment to the free evacuation of the stomach by the pylorus. The latter of these causes we are well acquainted with, in the case of a scirrhous pylorus, producing common- ly the highest degree of acidity. In all the instances of this scirrhosity I have met with, I have found it incur- able: but the first of these causes is to be obviated by * We have already observed, and beg leave here to repeat, that no passion is or can be a sedative. Every passion is itself the re- sult of impression, and, at the same time, makes an imfiression on the individual who sustains it. But the terms, imfiression and se- dative are the opposites of each other. PRACTICE OF PHYSIC. 133 avoiding such aliments as are of difficult solution; and the second is to be mended by the several remedies for exciting the action of the stomach, to be mentioned af- terwards. 1210. The third symptom commonly accompanying dyspepsia, which requires to be immediately removed, is costiveness. There is so much connection between the several portions of the alimentary canal with respect to the peristaltic motion, that, if accelerated or retarded in any one part, the other parts of it are commonly af- fected in the same manner. Thus, as the brisker ac- tion of the stomach must accelerate the action of the intestines, so the slower action of the intestines must in some measure retard that of the stomach. It is there- fore of consequence to the proper action of the stomach, that the peristaltic motion of the intestines determining their contents downwards, be regularly continued; and that all costiveness, or interruption of that determina- tion, be avoided. This may be done by the various means of exciting the action of the intestines: but it is to be observed here, that as every considerable evacua- tion of the intestines weakens their action, and is ready therefore to induce costiveness when the evacuation is over; so those purgatives which produce a large evacu- ation, are unfit for correcting the habit of costiveness. This, therefore, should be attempted by medicines which do no more than solicit the intestines to a more ready discharge of their present contents, without either hurrying their action, or increasing the excretions made into their cavity; either of which effects might produce a purging. There are, I think, certain medicines pe- culiarly proper on this occasion, as they seem to stimu- 134 PRACTICE OF PHYSIC. late especially the great guts, and to act little on the higher parts of the intestinal canal.* 1211. We have thus mentioned the several means of executing our second indication; and I proceed to the thirds which is, as we have said, the proper curative; and it is to restore the tone of the stomach, the loss of which we consider as the proximate cause of the dis- ease, or at least as the chief part of it. The means of satisfying this indication we refer to two heads. One is, of those means which operate directly and chiefly on the stomach itself; and the other is, of those means which, operating upon the whole system, have their tonic effects thereby communicated to the stomach. 1212. The medicines which operate directly on the stomach are either stimulants or tonics. The stimulants are saline or aromatic. The saline are acids or neutrals. Acids of all kinds seem to have the power of stimu- lating the stomach, and therefore often increase appetite: but the native acids, as liable to fermentation, may other- wise do harm, and are therefore of ambiguous use. The acids, therefore, chiefly and successfully employed are the vitriolic, muriatic, and the distilled acid of vege- tables, as it is found in tar-water, which are all of them antizymics. The neutral salts answering this intention are especi- ally those which have the muriatic acid in their com- * Anderson's, or plain rhubarb pills, are valuable laxatives in cases of dyspepsia. Injections, however, appear to be the only remedies that can act efficiently on the great intestines, without at all disturbing the small ones. PRACTICE OF PHYSIC. 135 position, though it is presumed that neutrals of all kinds have more or less of the same virtue.* 1213. The aromatics, and perhaps some other acrids, certainly stimulate the stomach, as they obviate the acescency and flatulency of vegetable food: but their stimulus is transitory; and if frequently repeated, and taken in large quantities, they may hurt the tone of the stomach. 1214. The tonics employed to strengthen the stomach are bitters, bitters and astringents combined, and chaly- beates. Bitters are undoubtedly tonic medicines, both with respect to the stomach and the whole system: but their long-continued use has been found to destroy the tone of the stomach and of the whole system; and, whether this is from the mere repetition of their tonic operation, or from some narcotic power joined with the tonic in them, I am uncertain, f 1215. Bitters and astringents combined are probably more effectual tonics than either of them taken singly; and we suppose such a combination to take place in * Of the vitriolic acid, the dose ought not to exceed ten drops, and should be well diluted with water. The elixir of vitriol we think a more pleasant remedy. The tinctui-a martis, exhibited in doses of from ten to twenty drops, three times a day, is highly re- commended as a tonic in indigestion. We ourselves have never employed it. As an aid to digestion, we believe that the muriate of soda sur- passes all other saline preparations. t 1213—14. The caution enjoined in these articles is highly im- portant. Even in the soundest stomach, an immoderate use of aromatics may induce indigestion. The deleterious effect of a long continued course of bitters, is also a truth too well known to need confirmation. 136 PRACTICE OF PHYSIC. the Peruvian bark; which therefore proves a powerful tonic, both with respect to the stomach and to the whole system. But I have some ground to suspect that the long continued use of this bark may, like bitters, de- stroy, both the tone of the stomach and of the whole system. 1216. Chalybeates may be employed as tonics in va- rious forms, and in considerable quantities, with safe- ty. They have been often employed in the form of mineral waters, and seemingly with success: but, whe- ther this is owing to the chalybeate in the composition of these waters, or to some other circumstances attend- ing their use, 1 dare not positively determine; but the latter opinion seems to me the more probable.* 1217. The remedies which strengthen the stomach, by being applied to the whole body, are, exercise and the application of cold. As exercise strengthens the whole body, it must also strengthen the stomach; but it does this also in a parti- cular manner, by promoting perspiration, and exciting * Chalybeates may be administered under the same formulae which have been heretofore directed in relation to other diseases. They appear, however, to be most efficacious, when taken at watering places, where their operation is aided by cheerful socie- ty, wholesome air, moderate exercise, exemption from business, and freedom from care. The exercises of gestation recommended by our author, with the use of cold air and cold water, are, if judiciously employed, important remedies in the treatment of dyspepsia. So is the keeping up the action of the skin by means of the flesh brush, and a covering of flannel. A long journey and a sea voyage, have been known to cure cases of this disease, which had withstood the use of every other reme- dy. The excitement of an active military campaign has produced a similar effect. PRACTICE OF PHYSIC. 137 the action of the vessels on the surface of the body, which have a particular consent with the muscular fibre/s of the stomach. This particularly explains why the exercises of gestation, though not the most powerful in strengthening the whole system, are, however^ very powerful in strengthening the stomaph; of which we have a remarkable proof in the effects of sailing. In strengthening the general system, as fatigue must J^e avoided, so bodily exercise is of ambiguous use,; and perhaps it is thereby that riding,on horseback has been so often found to be one of tl?e most powerful means of strengthening the stomach, and thereby of curing dyspepsia. 1218. The other general remedy of dyspepsia is the application of cold; which may be in two ways; - that is, either by the application of cold air, or of cold water. It is probable, that, in the atmosphere constantly sur- rounding our bodies, a certain degree of cold, consi- derably less than the temperature of our bodies them- selves, is necessary to the health of the human ,body. Such a degree of cold seems to strengthen-.the vessels on the surface of the body, and therefore the muscular fibres of the stomach. But, further, it is well jknown, that if the body is in exercise sufficient to support such a determination to the surface, as to prevent the cqjd from producing an entire constriction of tjie pores; a certain degree of cold in the atmosphere, with such ex- ercise, will render the perspiration more considerahklef From the sharp appetite that in such circumstances is commonly produced, we can have no doubt, that by the application of such cold, the tone of the stomach is considerably strengthened. Cold air, therefore, applied with exercise, is a most powerful tonic w?ith respect to VOL. II. s 138 PRACTICE OF PHYSIC the stomach; and this explains why, for that purpose, no exercises within doors, or in close carriages, are so useful as those in the open air. 1219. From the same reasoning, we can perceive, that the application of cold water, or cold bathing, while it is a tonic with respect to the system in general, and especially as exciting the action of the extreme vessels, must in both respects be a powerful means of strength- ening the tone of the stomach. 1220. These are the remedies to be employed to- wards a radical cure of idiopathic dyspepsia; and it might be, perhaps, expected here, that I should treat also of the various cases of the sympathic disease. But it will be obvious that this cannot be properly done without treating of all the diseases of which dyspepsia is a symptom, which cannot be proper in this place. It has been partly done already, and will be further treat- ed of in the course of this work. In the mean time, it may be proper to observe, that there is not so much oc- casion for distinguishing between the idiopathic and Sympathic dyspepsia, as there is in many other cases of idiopathic and sympathic diseases. For, as the sympathic cases of dyspepsia are owing to a loss of tone in some other part of the system, which is from thence commu- nicated to the stomach: so the tone of the stomach re- stored, may be communicated to the part primarily affected; and therefore the remedies of the idiopathic ma^ be often usefully employed, and are often the re- medies chiefly employed in sympathic dyspepsia. 1221. Another part of our business here might be to say, how some other* of the urgent symptoms, besides those.above-mentioned, are to be palliated. On this subject, I think it is enough to say, that the symptoms PRACTICE OF PHYSIC. 139 chiefly requiring to be immediately relieved, are flatu- lency, heartburn, other kinds of pain in the region of the stomach, and vomiting. The dyspeptic are ready to suppose that the whole of their disease consists in a flatulency. In this it will be obvious that they are mistaken; but, although the fla- tulency is not to be entirely cured, but by mending the imbecility of the stomach by the means above-mention- ed; yet the flatulent distention of the stomach may be relieved by carminatives, as they are called, or medi- cines that produce a discharge of wind from the stomach; such are the various antispasmodics, of which the most effectual is the vitriolic aether. The heartburn may be relieved by absorbents, antis- pasmodics, or demulcents. The other pains of the stomach may be sometimes relieved by carminatives, but most certainly by opi- ates. Vomiting is to be cured most effectually by opiates thrown by injection into the anus.* * Of absorbents we have already spoken. Of the good effects of antispasmodics, usually so called, in dyspepsia, we are very doubtful. As demulcents, mucilage of gum arabic, and new milk, are the best and most pleasant we have ever employed. The extract of liquorice, although much recommended, we have ne- ver used—oil of anise, in doses of ten drops, and of mint, in three, are valuable as carminatives—laudanum, in doses of from twenty to thirty drops, both removes acidity and relieves pain. In dyspepsia, late sitting is an injurious practice. The patient should always, therefore, retire to bed at an early hour. Let him, in a particular manner, decline to participate in the evening en. joyment and riot of the table. An exchange of a city for a country, a luxurious for a frugal, and a sedentary for an -active life, has proved oftentimes effectual in the cure of indigestion. 14G PRACTICE OF PHYSIC CHAPTER HI. OF HYPOCHONDRIASIS, OR THE HYPOCHONDRIAC AFFECTION, COMMONLY CALLED VAPORS, OR LOW SPIRITS.* 1222. IN certain persons there is a state of mind dis- tinguished by a concurrence of the following circum- stances: A languor, listlessness, or want of resolution A blister, kept open for a considerable lime, on the epigastric region, is a very promising remedy. If, as is sometimes the case, the disease be connected with chronic hepatitis, the use of mercury becomes indispensable. Un- der this form of the complaint, the nitric acid, given in doses often drops, from three to six times a day, and sometimes to a larger amount, is highly recommended. See on this disease—Forestus—Bonetus—Whytt—Black de hu- more acido a cibis—Richter—Temple de dyspepsia—Stoll. rat. med.—Abernethy—and Stone on diseases of the stomach. * Respecting the nature and character of hypochondriasis, it is not our intention to enter into a detailed and protracted discussion. We shall simply state, that, from the most deliberate view we are able to take of it, we consider it as truly a gastric disease, as any one to which our systems are liable. We feel persuaded that the depression of spirits, the groundless fears, the gloom of mind, the spurious sensations, and the wild intellectual hallucination attend- ing it, originate in a morbid condition of the stomach. On that organ is produced, by some cause, an irritation sui generis, which constitutes the actual source of the disease; whatever else may be experienced, whether mental or corporeal, being nothing but se- condary and sympathetic affections. Were we asked our reasons for considering hypochondriasis as a gastric affection, we might reply, that they are numerous. I. The causes which produce it are such as are known to disorder the stomach. II. The sallowness of the complexion marks the PRACTICE OF PHYSIC. 141 and activity with respect to all undertakings; a disposi- tion to seriousness, sadness, and timidity; as to all fu- gastric, or as it is usually denominated, the bilious character of the complaint. III. The flatulent and dyspeptic state of the stomach, with the obstinate constipation of the bowels, which accompany it, show it to be a disease of the primae vice, IV. Evidence to the same amount may be derived from the dark and disordered ap- pearance, which the bile in the course of it frequently assumes. V. We shall only add, that the gastric character of the disease very strongly appears from the fact, that those who are subject to it, usually refer their morbid sensations to the abdominal region. Men fancy themselves pregnant, sometimes of a human being; at other times of some inferior animal. They believe that a mechanic is at work in their stomach, or that that organ is the kennel of a pack of hounds; that a wind-mill is in full career in their bowels, or that a flock of birds is there, consuming the aliment and drinks that are swallowed. At other times, the same organs are the fan- cied residence of snakes or lizards, scorpions or frogs. If our view of hypochondriasis be correct, the curative reme. dies should be directed to the stomach. We, accordingly, believe that emetics, very frequently repeated, would be ultimately pro- ductive of very salutary effects. So, we conceive, would arsenic, carried to such an extent, as to create great nausea, with an erup- tion and troublesome itching on the skin. A moderate and long continued salivation, which might revo- lutionize the stomach, would contribute, we are persuaded, to the removal of the disease. From the sympathy that exists between the stomach and the skin, whatever produces on the latter organ a strong and lasting impression, is calculated for the relief of the hypochondriacal af- fection. Hence that complaint has been removed by an attack of the itch, of erysipelas, and of the nettle-rash. What would be the effect of severe and frequent urtication? or of the long continued use of sulphur, which is known to act with some force on the skin? A real morbid affection removes such as are only, or in part, imaginary. Hence, a gonorrhea and a broken bone have dissipated entirely the illusions of hypochondriasis. 142 PRACTICE OF PHYSIC. ture events, an apprehension of the. worst or most un- happy state of them; and therefore, often upon slight grounds, an apprehension of great evil. Such persons are particularly attentive to the state of their own health, to even the smallest change of feeling in their bodies; and from any unusual feeling, perhaps of the slightest kind, they apprehend great danger, and even death it- self. In respect to all these feelings and apprehensions, there is commonly the most obstinate belief and per- suasion. 1223. This state of mind is the Hypochondriasis of medical writers. See Linnaei Genera Morborum, Gen. 76. et Segari Systema Symtomaticum, Class XIII. Gen. 5. The same state of mind is what has been common- ly called Vapors and Low Spirits. Though the term Vapors may be founded on a false theory, and therefore improper, I beg leave, for a purpose that will immedi- ately appear, to employ it for a little here. 1224. Vapors, then, or the state of mind described above, is, like every other state of mind, connected with a certain state of the body, which must be inquired into in order to its being treated as a disease by the art of physic. 1225. This state of the body, however, is not very easily ascertained: for we can perceive, that on different occasions it is very different; vapours being combined What might be the effect of producing an artificial gonorrhea, by throwing up the urethra an acrid injection?—These things are worthy of attention. For further particulars touching this disease, consult, Ballonius —Willis—Fracassinus de morbo hypochondriaco—Hoffman— Baglivi—Cheyne's English malady—Turner de morbo hypochon* driaco—Stoll. rat. med. and Baynes de hypochondriasi. PRACTICE OF PHYSIC. 143 sometimes with dyspepsia, sometimes with hysteria, and sometimes with melancholia, which are diseases seem- ingly depending on very different states of the body. 1226. The combination of vapors with dyspepsia is very frequent, and in seemingly very different cir- cumstances. It is, especially, these different circum- stances that I would wish to ascertain; and I remark, that they are manifestly of two different kinds. First, as the disease occurs in young persons of both sexes, in persons of a sanguine temperament, and of a lax and flaccid habit. Secondly, as it occurs in elderly persons of both sexes, of a melancholy temperament, and of a firm and rigid habit. 1227. These two different cases of the combination of vapors and dyspepsia, I consider as two distinct dis- eases, to be distinguished chiefly by the temperament prevailing in the persons affected. As the dyspepsia of sanguine temperaments is often without vapors; and as the vapors when joined with dyspepsia in such temperaments, may be considered as, perhaps, always a symptom of the affection of the sto- mach; so to this combination of dyspepsia and vapors, I would still apply the appellation of Dyspepsia, and consider it as strictly the disease treated of in the pre- ceding chapter. But the combination of dyspepsia and vapors in me- lancholic temperaments, as the vapors or the turn of mind peculiar to the temperament, nearly that describ- ed above in 1222, are essential circumstances of the disease; and as this turn of mind is often with few, or only slight symptoms of dyspepsia; and, even though the latter be attending, as they seem to be rather the 144 PRACTICE OF PHYSIC. effects of the general temperament* than of any primary ©C topical affection of the stomach; I consider this com- bination as a very different disease from the former, and would apply to it strictly the appellation of Hypochon- driasis. 1228. Having thus pointed out a distinction between Dyspepsia and Hypochondriasis, I shall now, using these terms in the strict sense above mentioned, make some observations which may, I think, illustrate the subject, and more clearly and fully establish the distinc- tion proposed. 1229. The dyspepsia often appears early in life, and is frequently much mended as life advances: but the hypochondriasis seldom appears early in life, and more usually in more advanced years only; and more certain- ly still, when it has once taken place, it goes on increas- ing as life advances to old age. This seems to be particularly well illustrated, by our observing the changes in the state of the mind which usually take place in the course of life. In youth, the mind is cheerful, active, rash, and moveable: but, as life advances, the mind by degrees becomes more seri- ous, slow, cautious, and steady; till at length, in old age, the gloomy, timid, distrustful, and obstinate state of melancholic temperaments, is more exquisitely form- ed. In producing these changes, it is true, that moral causes have a share; but it is at the same time obvious, that the temperament of the body determines the opera- tion of these moral causes, sooner or later, and in a greater or lesser degree, to have their effects. The san- guine temperament retains longer the character of youth, while the melancholic temperament brings on more early the manners of old age. PRACTICE OF PHYSIC. 145 1230. Upon the whole,. it appears, that the state of the mind which attends, and especially distinguishes hypochondriasis, is the effect of that same rigidity of the solids, torpor of the nervous power, and peculiar ba- lance between the arterial and venous systems which occur in advanced life, and which at all times take place more or less in melancholic temperaments. If, there- fore, there be also somewhat of a like state of mind at- tending the dyspepsia which occurs early in life in san- guine temperaments and lax habits, it must depend up- on a different state of the body, and probably upoh a weak and moveable state of the nervous power. 1231. Agreeable to all this in dyspepsia, there is more of spasmodic affection, and the affection of the mind (1222.) is often absent, and, when present, is per- haps always of a slighter kind; while in hypochondri- asis the affection of the mind is more constant, and the symptoms of dyspepsia, or the affections of the sto- mach, are often absent, or, when present, are in a slighter degree. I believe the affection of the mind is commonly dif- ferent in the two diseases. In dyspepsia, it is often lan- guor and timidity only, easily dispelled; while, in hy- pochondriasis, it is generally the gloomy and rivetted apprehension of evil. The two diseases are also distinguished by some othei; circumstances. Dyspepsia, as I have said, is often a symptomatic affection; while hypochondriasis is, per- haps, always a primary and idiopathic disease. As debility may be induced by many different causes, dyspepsia is a frequent disease; while hypochondriasis, depending upon a peculiar temperament, is more rare. vol. ir. t T 146 PRACTICE OF PHYSIC. 1232. Having thus endeavoured to distinguish the two diseases, I suppose the peculiar nature and proxi- mate cause of hypochondriasis will be understood; and I proceed, therefore, to treat of its curb. So far as the affections of the body, and particularly of the stomach, are the same here as in the case of dys- pepsia, the method of cure might be supposed to be also the same; and accordingly the practice has been carried on with little distinction: but I am persuaded that a distinction is often necessary. -T.233. There may be a foundation here for the same preservative indication as first laid down in the cure of dyspepsia; (1202.) but I cannot treat this subject so clearly or so fully as I could wish, because I have not yet had so much opportunity of observation as I think necessary to ascertain the remote causes; and I can hardlv make use of the observations of others, who have seldom or never distinguished between the two diseases, What, indeed, Thas been said with respect to the remote causes of melancholia, will often apply to the hypochon- driasis, which I now treat of; but the subject of the former has been so much involved in a doubtful theory, that I find it difficult to select the facts that might pro- perly and strictly apply to the latter. I delay this sub- ject, therefore, till another occasion; but in the mean- time trust, that what I have said regarding the nature of the disease, and some remarks I shall have occasion to offer in considering the method of cure, may in some measure supply my deficiency on this subject of the re- mote causes. 1234. The second indication laid down in the cure of dyspepsia (1201.) has properly a place here; but it is still to be executed with some distinction. PRACTICE OF PHYSIC. 147 1235. An anorexia, and accumulation of crudities in the stomach, does not commonly occur in hypochondri- asis as in dyspepsia; and therefore vomiting (1204.) is not so often necessary in the former as in the latter. 1236. The symptom of excess of acidity* from the slow evacuation of the stomach in melancholic tempe- raments, often arises to a very high degree in the hy- pochondriasis; and therefore, for the same reason as in 1205, it is to be obviated and corrected with the utmost care. It is upon this aecount that the several antacids, and the other means of obviating acidity, are to be em- ployed in hypochondriasis, and with the same attentions and considerations as in 1206, and following; with this reflection, however, that the exciting the action of the stomach there mentioned, is to be a little differently un- derstood, as shall be hereafter explained. 1237. As costiveness, and that commonly to a con- siderable degree, is a very constant attendant of hypo- chondriasis, so it is equally hurtful as in dyspepsia. It may be remedied by the same means in the former as in the latter, and they are to be employe^ with the same restrictions as in 1210. 1238. It is especially with respect to' the third indica- tion laid down in the cure of dyspepsia (1201.) that there is a difference of practice to be observed in the cure of hypochondriasis; and that often one directly op- posite to that in the case of dyspepsia, is to be followed. 1239. In dyspepsia, the chief remedies are the tonic medicines, which to me seem neither necessary nor safe in hypochondriasis; for in this there is not a loss of tone, but a want of activity that is to be remedied. Chalybeate mineral waters have commonly been em- ployed in hypochondriasis, and ^eemijQgly with success. 148 PRACTICE OF PHYSIC. But this is probably to be.imputed to the amusement and exercise usually accompanying the use of these waters, rather than to the tonic power of the small quantity of iron which they contain. Perhaps the ele- mentary water, by favouring the excretions, may have a share in relieving the disease. 1240. Cold bathing is often highly useful to the dyspeptic, and, as a general stimulant, may sometimes seem useful to the hypochondriac; but it is not com- monly so to the latter; while, on the other hand, warm bathing, hurtful to the dyspeptic, is often extremely useful to the hypochondriac. 1241. Another instance of a contrary practice neces- sary in the two diseases, and illustrating their respec- tive natures, is, that the drinking tea and coffee is al- ways hurtful to the dyspeptic, but is commonly ex- tremely useful to the hypochondriac. 1242. Exercise, as it strengthens the system, and thereby the stomach, and more especially, as by in- creasing the perspiration, it excites the action of the stomach, it proves one of the most useful remedies in dyspepsia; and further, as, by increasing the perspira- tion, it excites the activity of the stomach, it likewise proves an useful remedy in the hypochondriasis. How- ever, in the latter case, as I shall explain presently, it is still a more useful remedy by its operation upon the mind than by that upon the body. 1243. It is now proper that we proceed to consider the most important article of our practice in this dis- ease, and which is, to consider the treatment of the mind; an affection of which sometimes attends dyspepsia, but is always the chief circumstance in hypochondriasis. What I am to suggest here, will apply to both diseases; PRACTICE OF PHYSIC. 149 but it is the hypochondriasis that I am to keep most constantly in view. 1244. The management ot the mind in hypochon- driacs, is often nice and difficult. The firm persuasion that generally prevails in such patients, does not allow their feelings to be treated as imaginary, nor their ap- prehension of danger to be considered as groundless, though the physician may be persuaded that it is the case in both respects. Such patients, therefore, are not to be treated either by raillery, or by reasoning. It is said to be the manner of hypochondriacs, to change often their physician; and indeed they often do it consistently; for a physician who does not admit the reality of the disease, cannot be supposed to take much pains to cure it, or to avert the danger of which he en- tertains no apprehension. If in any case the pious fraud of a placebo be allowa- ble, it seems to be in treating hypochondriacs; who, anxious for relief, are fond of medicines, and, though often disappointed, will still taste every new drug that can be proposed to them. * 1245. As it is the nature of man to. indulge every present emotion, so the hypochondriac cherishes his fears; and, attentive to every feeling, finds in trifles light as air, a strong confirmation of his apprehensions. His cure, therefore, depends especially upon the inter- ruption of his attention, or upon its being diverted to other objects than his own feelings. 1246. Whatever aversion to application of any kind may appear in hypochondriacs, there is nothing more pernicious to them than absolute idleness, or a vacan- cy from all earnest pursuit. It is owing to wealth ad- mitting of indolence, and leading-to t^e pursuit of tran- 150 PRACTICE OF PHYSIC. sitory and unsatisfying amusements, or to that of ex- hausting pleasures only, that the present times exhibit to us so many instances of hypochondriacism. The occupations of business suitable to their cir- cumstances and situation in life, if neither attended with emotion, anxiety, nor fatigue, are always to be admitted, and persisted in by hypochondriacs. But occupations upon which a man's fortune depends, and which are al- ways, therefore, objects of anxiety to melancholic men; and more particularly where such occupations are ex- posed to accidental interruptions, disappointments, and failures, it is from these that the hypochondriac is cer- tainly to be withdrawn. 1247. The hypochondriac who is not necessarily, by circumstance or habits, engaged in business, is to be drawn from his attention to his own feelings by some amusement. The various kinds of sport and hunting, as pursued with some ardor, and attended with exercise, if not too violent, are amongst the most useful. Al^ those amusements which are in the open air* joined with moderate exercise, and requiring some dex- terity, are generally of use. Within doors, company which engages attention", which is willingly yielded to, and is at the same time of a cheerful kind, will be always found of great service. Play, in which some skill is required, and where the stake is not an object of much anxiety, if not too long protracted, may often be admitted. In dyspeptics, however, gaming, liable to sudden and considerable emotions, is dangerous; and the long con- tinuance of it, with night watching, is violently debili- tating. But in melancholies, who commonly excel in PRACTICE OF PHYSIC. 151 akill, and are less susceptible of violent emotions, it is more admissible, and is often the only amusement that can engage them. «, Music to a nice ear, is a hazardous amusement, as long attention to it is very fatiguing. 1248. It frequently happens, that amusements of every kind are rejected by hypochondriacs; and in that case, mechanical means of interrupting thought are the remedies to be sought for. Such is to be found in brisk exercise, which requires some attention in the conduct of it. Walking is seldom of this kind; though, as gratify- ing to the restlessness of hypochondriacs, it has some- times been found useful. The required interruption of thought is best obtain- ed by riding on horseback, or in driving a carriage of any kind. The exercise of sailing, except it be in an open boat engaging some attention, does very little service. Exercise in an easy carriage, in the direction of which the traveller takes no part, unless it be upon rough roads, or driven pretty quickly, and with long continuance, is of little advantage, 1249. Whatever exercise may be employed, it will be most effectual when employed in the pursuit of a journey; first, because it withdraws a person from ma- ny objects of uneasiness and care which might present themselves at home; secondly, as it engages in more constant exercise, and in a greater degree of it than is commonly taken in airings about home; and lastly, as it is constantly presenting new objects which call forth a person's attention. 152 PRACTICE OF PHYSIC. 1250. In our system of Nosology we have, next to Hypochondriasis, placed the Chlorosis, because 1 once thought it might be considered as a genus, comprehend- ing, besides the Chlorosis of Amenorrhoea, some spe- cies of Cachexy: but, as I cannot find this to be well founded, and cannot distinctly point out any such dis- ease, I now omit considering Chlorosis as a genus here; and as a symptom of Amenorrhoea, I have endeavour- ed before to explain it under that title. BOOK III. OF SPASMODIC AFFECTIONS WITHOUT FEVER. 1251. Under this title I am to comprehend all the dis- eases which consist in motu abnormi; that is, in a pre- ternatural state of the contraction and motion of the muscular or moving fibres in any part of the body. 1252. It will hence appear, why, under this title, I have comprehended many more diseases than Sauvages and Sagar have comprehended under the title of Spas- mi, or than Linnaeus has done under the title of Moto- rii. But I expect it will be obvious, that upon this oc- casion, it would not be proper to confine our view to the affections of voluntary motion only; and if those Nosologists have introduced into the class: of Spasmi, Palpitatio and Hysteria, it will be with equal propriety that Asthma, Colica, and many other diseases, are ad- mitted. 1253. It has been hitherto the method of our Noso- logists to divide the Spasmi into the two orders of Toni- ci and Clonici, Spastici, and Agitatorii; or, as many at present use the terms, into Spasms strictly so called, and PRACTICE OF PHYSIC. 153 convulsions. I find, however, that many, and indeed most of the diseases to be considered under our title of Spasmodic affections, in respect to Tonic or Clonic con- tractions, are of a mixed kind: and, therefore, I cannot follow the usual general division; but have attempted another, by arranging the several Spasmodic diseases according as they affect the several functions, Animal, Vital, or Natural. SECTION I. OF THE SPASMODIC AFFECTIONS OF THE ANI- MAL FUNCTIONS. 1254. AGREEABLE to the language of the ancients, the whole of the diseases to be treated of in this section might be termed Spasmi; and many of the moderns con- tinue to apply the term in the same manner: but I think it convenient to distinguish the terms Of Spasm and Convulsion, by applying the former, strictly to what has been called the Tonic; and the latter, to what has been called the Clonic spasm. There is certainly a founda- tion for the use of those different terms, as there is a remarkable difference in the state of the contraction of moving fibres upon different occasions. This I have indeed pointed out before in my treatise of Physiology, but must also repeat it here. 1255. In the exercise of the several functions of the animal economy, the contractions of the moving fibres are excited by the will, or by certuL ether causes spe- cially appointed by nature for exciting those contrac- tions; and these other causes I name the natural causes. In a state of health, the moving fibres are contracted by the power of the will and by the natural causes only VOL. II. u 154 PRACTICE OF PHYSIC. At the same time, the contractions produced are, hi force and velocity, regulated by the will, or by the cir- cumstances of the natural causes; and the contractions, whether produced by the one or the other, are always soon succeeded by a state of relaxation, and are not re- peated but when the power of the will or of the natu- ral causes is again applied. 1256. Such are the conditions of the action of the moving fibres in a state of health: but in a morbid state the contractions of the muscles and moving fibres ordina- rily depending upon the will are excited without the con- currence of the will or contrary to what the will intends; and in the other functions they are excited by the ac- tion of unusual and unnatural causes. In both cases the contractions produced may be in two different states. The one is, when the contractions are to a more violent degree than is usual in health, and are neither succeed- ed by a spontaneous relaxation, nor even readily yield to an extension either from the action of antagonist muscles, or from other extending powers applied. This state of contractions is what has been called a tonic spasm, and is what I shall name simply and strictly a spasm* The other morbid state of contraction is, when they are succeeded by a relaxation, but are immediately again repeated without the concurrence of the will or of the repetition of natural causes, and are at the same time commonly, with respect to velocity and force, more vio- lent than in a healthy state. This state of morbid con- traction is what has been named a clonic spasm, and what I shall name simply and strictly a convulsion. In this section I shall follow nearly the usual division of the spasmodic diseases into those consisting in Spasm, PRACTICE OF PHYSIC. 155 and those consisting in Convulsion; but it may not per- haps be in my power to follow such division exactly. CHAPTER I. OF TETANUS.* 1257. BOTH Nosologists and practical writers have distinguished Tetanic complaints into the several spe- cies of Tetanus, Opisthotonos, and Emprosthotonos; and I have in my Nosology put the Trismus, or Lock- ed Jaw, as a genus distinct from the Tetanus. All this, however, I now judge to be improper; and am of opin- ion that all the several terms mentioned denote, and are applicable only to, different degrees of one and the same disease; the history and cure of which I shall endea- vour to deliver in this chapter. 1258. Tetanic complaints may, from certain causes, occur in every climate that we are acquainted with; but they occur most frequently in the warmest climates, and most commonly in the warmest seasons of such climates. These complaints affect all ages, sexes, temperaments, and complexions. The causes from whence they com- monly proceed, are cold and moisture applied to the body while it is very warm, and especially the sudden vicissitudes of heat and cold. Or, the disease is produ- ced by punctures, lacerations, or other lesions of nerves in any part of the body. There are, probably some * In the United States, especially in the middle and northern sections of it, Tetanus rarely occurs, except as the result of a mechanical injury Punctured and lacerated wounds are its usual .source. 156 PRACTICE OF PHYSIC. other causes of this disease; but they are neither dis- tinctly known, nor well ascertained. Though the cau- ses mentioned do, upon occasion, affect all sorts of per- sons, they seem however to attack persons of middle age more frequently than the older or younger, the male sex more frequently than the female, and the robust and vigorous more frequently than the weaker. 1259. If the disease proceed from cold, it common- ly comes on in a few days after the application of such cold; but, if it arise from a puncture or other lesion of a nerve, the disease does not commonly come on for many days after the lesion has happened, very often when there is neither pain nor uneasiness, remaining in the wounded or hurt part, and very frequently when the wound has been entirely healed up. 1260. The disease sometimes comes on suddenly to a violent degree, but more generally it approaches by slow degrees to its violent state. In this case it comes on with a sense of stiffness in the back part of the neck, which, gradually increasing, renders the motion of the headdiffi- cult and painful. As the rigidity of the neck comes on and increases, there is commonly at the same time a sense of uneasiness felt about the root of the tongue; which by degrees, becomes a difficulty of swallowing, and at length an entire interruption of it. While the rigidity of the neck goes on increasing, there arises a pain, often violent, at the lower end of the sternum, and from thence shooting into the back. When this pain arises, all the muscles of the neck, and particularly those of the back part of it, are immediately affected with spasm, pulling the head strongly backwards. At the same time, the muscles that pull up the lower jaw, which upon the first approaches of the disease were affected PRACTICE OF PHYSIC. 157 with some spastic rigidity, are now generally affected with more violent spasm, and set the teeth so closely to- gether that they do not admit of the smallest opening. This is what has been named the Locked Jaw, and is often the principal part of the disease. When the disease has advanced thus far, the pain at the bottom of the sternum returns very frequently; and with it the spasms of the hind neck and lower jaw are renewed with violence and much pain. As the disease thus proceeds, a greater number of muscles come to be affected with spasms. After those of the neck, those along the whole of the spine become affected, bending the trunk of the body strongly backwards; and this is what has been named the Opisthotonos. In the lower extremities, both the flexor and exten- sor muscles are commonly at the same time affected, and keep the limbs rigidly extended. Though the exten- sors of the head and back are usually the most strong- ly affected, yet the flexors, or those muscles of the neck that pull the head forward, and the muscles that should pull down the lower jaw are often at the same time strong- ly affected with spasm. During the whole of the disease, the abdominal muscles are violently affected with spasm, so that the belly is strongly retracted, and feels hard as a piece of board. At length the flexors of the head and trunk become so strongly affected as to balance the extensors, and to keep the head and trunk straight, and rigidly extended, incapable of being moved in any way; and it is to this state the term of Tetanus has been strictly applied. At the same time, the arms, little affected before, are now rigidly extended; the whole of the muscles belonging to them being affected with spasms, except those that 158 PRACTICE OF PHYSIC. move the fingers, which often to the last retain some mobility. The tongue also long retains its mobility; but at length it also becomes affected with spasms, which, attacking certain of its muscles only, often thrusts it vio- lently out between the teeth. At the height of the disease, every organ of volunta- ry motion seems to be affected; and amongst the rest, the muscles of the face. The forehead is drawn up in- to furrows, the eyes, sometimes distorted, are common- ly rigid, and immoveable in their sockets; the nose is drawn up, and the cheeks are drawn backwards towards the ears, so that the whole countenance expresses the most violent grinning. Under these universal spasms a violent convulsion commonly comes on, and puts an end to life. 1261. These spasms are every where attended with most violent pains. The utmost violence of spasm is however, not constant; but, after subsisting for a min- ute or two, the muscles admit of some remission of their contraction, although of no such relaxation as can allow the action of their antagonists. This remission of contraction gives also some remission of pain; but nei- ther is of long duration. From time to time, the vio- lent contractions and pains are renewed sometimes every ten or fifteen minutes, and that often without any evi- dent exciting cause. But such exciting causes frequent- ly occur; for almost every attempt to motion, as attempt- ing a change of posture, endeavouring to swallow, and even to speak, sometimes gives occasion to a renewa of the spasms over the whole body. 1262. The attacks of this disease are seldom attend- ed with any fever. When the spasms are general and violent, the pulse is contracted, hurried, and irregular; PRACTICE OF PHYSIC. 159 and the respiration is affected in like manner: but, dur- ing the remission, both the pulse and respiration usual- ly return to their natural state. The heat of the body is commonly not increased; frequently the face is pale, with a cold sweat upon it; and very often the extremi- ties are cold, with a cold sweat over the whole body. When, however, the spasms are frequent and violent, the pulse is sometimes more full and frequent than na- tural: the face is flushed, and a warm sweat is forced out over the whole body.* 1263. Although fever be not a constant attendant of this disease, especially when arising from a lesion of nerves; yet, in those cases proceeding from cold, a fe- ver sometimes has supervened, and is said to have been attended with inflammatory symptoms. Blood has been often drawn in this disease, but it never exhibits any inflammatory crust; and all accounts seem to agree, that the blood drawn seems to be of a looser texture than ordinary, and that it does not coagulate in the usual manner. 1264. In this disease the head is seldom affected with delirium, or even confusion of thought, till the last stage of it; when, by the repeated shocks of a violent distemper, every function of the system is greatly dis- ordered. 1265. It is no less extraordinary, that, in this violent disease, the natural functions are not either immediately or considerably affected. Vomitings sometimes appear * We do not recollect ever to have seen a case of tetanus, in which the patient was entirely exempt from febrile action. At the commencement of the disease, the pulse is oftentimes full and frequent, tense and strong. Blood drawn at this time throws up a covering of coagulating lymph, 160 PRACTICE OF PHYSIC. early in the disease, but commonly they are not conti- nued; and it is usual enough for the appetite of hunger to remain through the whole course of the disease; and what food happens to be taken down, seems to be re- gularly enough digested. The excretions are some- times affected, but not always. The urine is sometimes suppressed, or is voided with difficulty and pain. The belly is costive: but, as we have hardly any accounts excepting of those cases in which opiates have been largely employed, it is uncertain whether the costive- ness has been the effect of the opiates or of the disease. In several instances of this disease, a miliary eruption has appeared upon the skin; but whether this be a symp- tom of the disease, or the effect of a certain treat- ment of it, is undetermined. In the meanwhile, it has not been observed to denote either safety or danger, or to have any effect in changing the course of the dis- temper. 1266. This disease has generally proved fatal; and this indeed may be justly supposed to be the conse- quence of its nature: but, as we know, that till very lately, physicians were not well acquainted with a pro- per method of cure; and that since a more proper me- thod has been known and practised, many have reco- vered from this disease; it may be therefore concluded, that the fatal tendency of it is not so unavoidable as has been imagined. In judging of the tendency of this disease, in parti- cular cases, we may remark, that, when arising from lesions of the nerves, it is commonly more violent, and of more difficult cure, than when proceeding from cold; that the disease which comes on suddenly, and advances quickly to a violent degree, is always more dangerous PRACTICE OF PHYSIC. 161 than that which is slower in its progress. Accordingly, the disease often proves fatal before the fourth day; and, when a patient has passed this period, he may be supposed to be in greater safety, and in general the dis- ease is the safer the longer it has continued. It is, how- ever, to be particularly observed, that, even for many days after the fourth, the disease continues to be dan- gerous; and, even after some considerable abatement of its force, it is ready to recur again with its former vio- lence and danger. It never admits of any sudden, or what is called critical solution; but always recedes by degrees only, and it is often very long before the whole of the symptoms disappear. 1267. From the history of the disease now described, it will be evident, that there is no room for distinguish- ing the tetanus, opisthotonos, and trismus, or locked jaw, as different species of this disease, since they all arise from the same causes, and are almost constantly con- joined in the same person. I have no doubt that the emprosthotonos belongs also to the same genus; and as the ancients have frequently mentioned it, we can have no doubt of its having occurred: but, at the same time, it is certainly in these days a rare occurrence; and, as I have never seen it, nor find any histories in which this particular state of the spasms is said to have prevailed, I cannot mention the other circumstances which parti- cularly attend it, and may distinguish it from the other varieties of tetanic complaints. 1268. This disease has put on still a different form from any of those above mentioned. The spasms have been sometimes confined to one side of the body only, and which bend it strongly to that side. This is what VOL. II. x 162 PRACTICE OF PHYSIC. has been named by Sauvages the Tetanus Laterals, and by some late writers the Pleurosthotonos. This form of the disease has certainly appeared very seldom; and, in any of the accounts given of it, I cannot find any circumstances that would lead me to consider it as any other than a variety of the species already mention- ed, or to take further notice of it here.* 1269. The pathology of this disease I cannot in any measure attempt; as the structure of moving fibres, the state of them under different degrees of contraction, and particularly the state of the sensorium, as variously de- termining the motion of the nervous power, are all matters very imperfectly, or not all, known to me. In such a situation, therefore, the endeavouring to give any rules of practice, upon a scientific plan, appears to me vain and fruitless; and towards directing the cure of this disease, we must be satisfied with having learned something useful from analogy, confirmed by experience. 1270. When the disease is known to arise from the lesion of a nerve in any part of the body, the first, and as I judge, the most important step to be taken towards the cure, is, by every possible means, to cut off that part from all communication with the sensorium, either by cutting through the nerves in their course, or perhaps * Another variety or modification of tetanus consists in its as- sumption of an intermitting character. We once saw a case, in which the spasms ceased to be troublesome about twelve o'clock each night, and did not return until near twelve the next day. The patient took, in the intervals, large quantities of bark, wine, and laudanum, and finally recovered. In this instance, mercurial oint- ment was also used until a salivation was produced. In no case pf tetanus ought niercury tobe omitted. PRACTICE OF PHYSIC. 168 by destroying, to a certain length, their affected part or extremity. 1271. When the cure off the disease is to be attempt- ed by medicinej experience has taught us that opium has often proved an effectual remedy; but that, to ren- der it such, it must be given in much larger quantities than have been employed in any other case; and in these larger quantities, it may, in this disease, be given more safely than the body has been known to bear in any other condition. The practice has been, to give the opium either in a solid or liquid form, not in any very large dose at once, but in moderate doses, frequently repeat- ed, at the interval of one, two, three, or more hours, as the violence of the symptoms seem to require. Even when large quantities have been given in this way, it appears that the opium does hot operate here in the same manner as in most other cases; for, though it procure some remission of the spasms and pains, it hardly in- duces any sleep, or occasions that stupor, intoxication, or delirium, which it often does in other circumstances, when much smaller quantities only have been given. It is, therefore, very properly observed, that, in tetanic af- fections, as the opium shows none of those effects by which it may endanger life, there is little or no reason for being sparing in the exhibition of it; and it may be given, probably should be given, as largely and as fast as the symptoms of the disease may seem to de- mand. It is particularly to be observed, that though the first exhibition of the opium may have produced some re- mission of the symptoms, yet the effects of opium do not long continue in the system; and this disease being for some time ready to recur, it is commonly very ne- 164 PRACTICE OF PHYSIC. cessary, by the time that the effects of the opium given may be supposed to be wearing off, and especially upon the least appearance of the return of the spasms, to re- peat the exhibition of the opium in the same quantities as before. This practice is to be continued while the disease continues to show any disposition to return; and it is only after the disease has already subsisted for some time, and when considerable and long-continued remis- sions have taken place, that the doses of the opium may be diminished, and the intervals of exhibiting them be more considerable. 1272. The administering of opium in this manner, has in many cases been successful; and probably would have been equally so in many others, if the opium had not been too sparingly employed, either from the timi- dity of practitioners, or from its exhibition being pre- vented by that interruption of deglutition which so often attends this disease. The latter circumstance directs, that the medicine should be immediately and largely employed upon the first approach of the disease, before the deglutition becomes difficult; or that, if this oppor- tunity be lost, the medicine, in sufficient quantity, and with due frequency, should be thrown into the body by glysters; which, however, does not seem to have been hitherto often practised. 1273. It is highly probable, that, in this disease, the intestines are affected with the spasm that prevails so much in other parts of the system; and therefore that costiveness occurs here as a symptom of the disease. It is probably also increased by the opium, which is here so largely employed; and, from which ever of these causes it arises, it certainly must be held to aggravate the disease, and that a relaxation of the intestinal canal PRACTICE OF PHYSIC. 165 will contribute to a relaxation of the spasms elsewhere. This consideration directs the frequent exhibition of laxatives while the power of deglutition remains, or the frequent exhibition of glysters when it does not; and the good effects of both have been frequently ob- served.* 1274. It has been with some probability supposed, that the operation of opium in this-disease, maybe much assisted by joining with it some other of the most powerful antispasmodics. The most promising are musk and camphor; and some practitioners have been of opinion, that the former has proved very useful in tetanic complaints. But, whether it be from its not ha- ving been employed of a genuine kind, or in sufficient quantity, the great advantage and propriety of its use are not yet clearly ascertained. It appears to me pro- bable, that analogous to what happens with respect to opium, both musk and camphor might be employed in this disease, in much larger quantities than they com- monly have been in other cases. * Of the exhibition of purgatives in this disease, we have our- selves never witnessed the salutary effects. Nor, in cases where it arises from external injuries, do we perceive the grounds on which they can be useful. We know they are recommended by respectable authority. Dr. Hamilton, of Edinburgh, represents them as entitled to our highest confidence. But, if they be so, it must, we think, be in cases of tetanus resulting, not from exter- nal but internal irritation—cases where the disease originates in the alimentary canal. In such instances, emetics combined with pur- gatives might add not a little, perhaps, to their efficacy; for, be- sides giving aid in the removal of irritation, they would contribute o the relaxation and resolution of spasm. But, to be useful in this disease, emetics ought to be frequently administered. 166 PRACTICE OF PHYSIC 1275. Warm bathing has been commonly employed as a remedy in this disease, and often with advantage; but, so far as I know, it has not alone proved a cure; and, in some cases, whether it be from the motion of the body here required, exciting the spasms, or from the fear of the bath, which some persons were seized with, I cannot determine; but it is allowed, that the warm bath hath in some cases done harm, and even oc- casioned death. Partial fomentations have been much commended, and, I believe, upon good grounds: and I have no doubt but that fomentations of the feet and legs, as we now usually apply them in fevers, might, without much stirring of the patient be very assiduously em- ployed with advantage.* 1276. Unctuous applications were very frequently employed in this disease by the ancients; and some modern practitioners have considered them as very use- ful. Their effects, however, have not appeared to be considerable; and, as a weak auxiliary only, attended with some inconvenience, they have been very much neglected by the British practitioners. 1277. Bleeding has been formerly employed in this disease; but of late it has been found prejudicial, ex- cepting in a few cases, where, in plethoric habits, a fe- ver has supervened. In general, the state of men's bo- dies in warm climates is unfavourable to blood-letting: and, if we may form indications from the state of the blood drawn out of the veins, the state of this in tetanic diseases would forbid bleeding in them.f * We believe the remedies recommended in this article to be wholly unavailing. ,t At the commencement of this disease, w6 have seen blood- letting practised, in plethoric subjects, with evident advantage; PRACTICE OF PHYSIC. 167 1278. Blistering also has been formerly employed in this disease; but several practitioners assert, that blisters are constantly hurtful, and they are now generally omit- ted. 1279. These are the practices that hitherto have been, generally employed; but of late we are informed by several West India practitioners, that in many in- stances they have employed mercury with great ad- vantage. We are told, that it must be employed early in the disease; that it is most conveniently administered by unction, and should be applied in that way in large quantities, so that the body may be soon filled with it, and a salivation raised, which is to be continued till the symptoms yield. Whether this method alone be ge- nerally sufficient for the cure of the disease, or if it may be assisted by the use of opium, and require this in a certain measure to be joined with it, I have not yet cer- tainly learned. 1280. I have been further informed, that the tetanus, in all its different degrees, has been cured by giving internally the Pisselaeum Barbadense, or, as it is vul- garly called, the Barbadoes Tar. I think it proper to take notice of this here, although I am not exactly in- formed what quantities of this medicine are to be given, or in what circumstances of the disease it is most pro- perly to be employed. 1281. In the former edition of this work, among the remedies of tetanus I did not mention the use of cold and, as already mentioned, the blood was sizy. Hence, as in other complaints, regard must be paid to the state of the system. Be- sides, blood-letting is known to facilitate the operation of other re- medics. . 168 PRACTICE OF PHYSIC. bathing; because, though I heard of this, I was not in- formed of such frequent employment ol it as might confirm my opinion of its general efficacy; nor was I sufficiently informed of the ordinary and proper admin- istration of it. But now, from the information of ma- ny judicious practitioners who have frequently employ. ed it, I can say, that it is a remedy which in numerous trials has been found to be of great service in this dis- ease; and that, while the use of the ambiguous remedy of warm bathing is entirely laid aside, the use of cold bathing is over the whole of the West Indies commonly employed. The administration of it is sometimes by bathing the person in the sea, or more frequently by throwing cold water from a bason or bucket upon the patient's body, and over the whole of it: when this is done, the body is carefully wiped dry, wrapped in blan- kets, and laid abed, and at the same time a large dose of an opiate is given. By these means a considerable remission of the symptoms is obtained; but this remis- sion, at first, does not commonly remain long, but re- turning again in a few hours, the repetition both of the bathing and the opiate becomes necessary. By these repetitions, however, longer intervals of ease are obtain- ed, and at length the disease is entirely cured; and this even happens sometimes very quickly. I have only to add, that it does not appear to me, from any accounts I have yet had, that the cold bathing has been so frequent- ly employed, or has been found so commonly success- ful in the cases of tetanus in consequence of wounds, as in those from the application of cold.* * We believe the remark of our author at the close of this article to be correct. The use of the cold bath has not been PRACTICE OF PHYSIC. 169 1282. Before concluding this chapter, it is proper for me to take some notice of that peculiar case of the te- found so successful in tetanus from wounds, as in that arising from other causes. Whatever may be the case elsewhere, it is well known, that, in the United States, cold bathing cannot be relied on for the cure of tetanus. Although the spasms may appear to be, for a short time, relaxed by the shock, they soon return with equal, if not augment- ed violence. As far as the experience of the physicians of Philadelphia en- ables us to speak, opium, wine, and mercury, appear to, be the only remedies on which any confident reliance can be placed in the treatment of tetanus. Of these, the two former retard the progress of the disease, preventing exhaustion and death, from the violence of the spasms, until the latter has had time to eradi- cate it entirely, by converting the tetanic into the mercurial ac- tion. Opium and wine, being, in their natures, rather palliative than curative remedies, are insufficient of themselves without mercury; while, without their aid, mercury is too slow in its ope- ration to arrest the rapid march of the disease. Hence, we neither know of any one case of tetanus in this city being cured by the exhibition of mercury alone, nor of many, in which the mercurial action did not take effect. The usual and best preventives of tetanus from external in- juries, consist in the conversion of punctured into incised wounds, by means of the scalpel, and the excitement of suppuration in wounds that are lacerated. These things, if done immediately after the injuries have been received, and before the occurrence of tetanic symptoms, are of high importance; but, they are worse, perhaps, than nugatory—'they are nothing, in general, but useless torture, if delayed until the disease shall have made its appear- ance. When the tetanic diathesis is fairly formed, all local appli- cations to the injured part, are unavailing: even the amputation of the limb itself has been found insufficient to arrest the com- plaint. Should circumstances exist lo prevent the dilatation of a punc- tured wound, the application of ley, blisters, or sinapisms to the VOL. It. X 17© PRACTICE OF PHYSIC. tanus, or trismus, which attacks certain infants soon af- ter their birth, and has been properly enough named the part, is thebest substitute. Whatever is calculated to excite com- mon inflammation, is now useful. For the production of the suppurative action, in lacerated wounds, ley, spirits of turpentine, or a solution of corrosive sublimate, fol- lowed by poultices frequently repeated, are the best applications. Tincture of cantharides and lunar caustic, have been successfully used for the same purpose. When, from a neglect of preventive remedies, or in spite of their use, tetanus has made its appearance, a different course of practice must be commenced and pursued. It is now, that, to the state of the system, a strict and steady attention is to be paid. If the patient be plethoric, and the excitement high; or, if the latter condition exist, even without the former, blood must be drawn, and the operation repeated, as circumstances may re- quire. If costiveness prevail, and any irritation in the bowels be suspected, purgatives are to be administered, as in other cases. But, as already stated, as soon as the condition of the system will admit of them, wine, opium, and mercury, are the remedies on which we must chiefly rely. On some occasions, tetanus is reported to have been cured by wine alone. But such cases we have never witnessed. The quantity of wine used, in these instances, is said to have been great. In the treatment of this disease, opium and mercury must be administered, not with a rigid regard to quantity, but according to their effects. They must be pushed until the system shall have forcibly felt their action, or their exhibition will be unavail- ing. Unless opium be given, until the prevailing spasms shall have been subdued by it, that the mercury may have an opportunity to act, it is given to no purpose: and, if the mercury be not adminis- tered in such quantities as to salivate, the tetanic diathesis will not be removed. It is Dr. Physick's practice—and we cannot cite higher autho- rity—to administer opium in injections, in doses of from five to PRACTICE OF PHYSIC. 171 Trismus Nascentium. From the subjects it affects, it seems to be a peculiar disease: for these are infants not above two weeks, and commonly before they are nine days, old; insomuch that, in countries where the disease is frequent, if children pass the period now mentioned, they are considered as secure against its attacks. The symptom of it chiefly taken notice of, is the trismus, or locked jaw, which is by the vulgar improperly named eight grains, repeated at short intervals, until the spasms be over- come, and somewhat of a soporific effect produced; applying, in the meantime, to various parts of the body, large quantities of mercurial ointment. The spasms being subdued, he relaxes in the use of opium, un- til they manifest a disposition to return; wh n he immediately re- curs to the same remedy, and in similar doses. In the meantime, the application of the mercurial ointment is continued, until a ptyalism be produced; when the patient is considered, in some measure, out of danger. Still, however, great vigilance is necessary on the part of the practitioner, lest, as is sometimes the case, the salivation should cease, and the disease return; under which circumstances, the same course must be again pursued, even, at times, with aug. mented vigour. Dr. Physick prefers giving the opium by injection, in conse - quence of the difficulty of swallowing, which the patient usually experiences. If requisite, he conveys aliment into the stomach by means of a tube, which he carefully introduces into that or- gan. The action of opium is said to be increased, if the exhibition of that remedy be alternated with that of the carbonate of pot- ash. As aids to opium, in the treatment of tetanus, musk and cam- phor have been exhibited, in large doses, and, according to report, with beneficial effects. We have ourselves made trial of them, but never with any decided advantage. Believing all minor remedies to be useless, in our attempts to subdue this disease, we leave the reader to acquire a knowledge of them from other sources. 172 PRACTICE OF PHYSIC. the falling of the jaw. But this is not the only sympv torn, as, for the most part, it has all the same symptoms as the Opisthotonos and Tetanus strictly so called, and which occur in the other varieties of tetanic complaints above described. Like the other varieties of tetanus, this is most frequent in warm climates, but it is not, like those arising from the application of cold, entirely confined to such warm climates, as instances of it have occurred in most of the northern countries of Europe. In these latter it seems to be more frequent in certain districts than in others; but in what manner limited, I cannot determine. It seems to be more frequent in Switzerland than in France. I am informed of its fre- quently occurring in the highlands of Scotland; but I lhave never met with any instance of it in the low coun- try. The particular causes of it are not well known; and various conjectures have been offered; but none of them are satisfying. It is a disease that has been almost con- stantly fatal; and this, also, commonly in the course of a few days. The women are so much persuaded of its inevitable fatality, that they seldom or never call for the assistance of our art. This has occasioned our being little acquainted with the history of the disease, or with the effects of remedies in it. Analogy, however, would lead us to employ the same remedies that have proved useful in the other cases of tetanus; and the few experi- ments that are yet recorded, seem to approve of such a practice. PRACTICE OF PHYSIC. 173 CHAPTER II. OF EPILEPSY.* 1283. IN what sense 1 use the term Convulsion, \ have explained above in 1256. The convulsions mat affect the human body are in several respects various; but I am to consider here only * It is unfortunate for our author, that the obscurity and insuf- ficiency of his reasonings on the nature of diseases, are oftentimes great, in proportion to his zeal and exertions to render them other- wise. Nor is this more strikingly the case in any instance, than in that which is, at present, immediately before us. To say the least, his failure to shed light on the pathology of Epilepsy, is not surpassed by any other that occurs in the compass of his works. We acknowledge our inability to supply, in a manner satisfac- tory to ourselves, the professor's deficiency. With the philoso- phy of epilepsy, which has hitherto eluded the keenest investiga- tions, we are far from possessing a particular acquaintance. Of this point, we may truly, and with propriety, say, adhuc latet; al- though it would be wrong in us to add, in a spirit of despondency, semfierque latebit. We shall not, however, by dwelling on the subject, add to the number of unsuccessful efforts, that have been already made wi•.:. a view to iu eluc dation. We shall simply observe, that epilepsy is one of those diseases, supposed to be connected with lunar influence, on account of its occurring, in many cases, with a precise correspondence to the position of the moon. Of this there are recorded innume- rable instances, in the writings of physicians. It is the result of local irritation, existing, at times, perhaps, in different parts of the body; but, ost frequently, we think, in some portion of the ali- mentary canal. Hence, the great importance of frequent and co- pious purging, in its cure; a remedy, on which some writers advise us to place our whole reliance. In infants and children, we have rarely seen a case of epilepsy, that we could not distinctly trace to the irritation of dentition, which 174 PRACTICE OF PHYSIC. the chief and most frequent form in which they appear, and which is in the disease named Etilepsy. This may be defined, as consisting in convulsions of the greater extends itself throughout the whole of the primae viae, to impro- per feeding, either as to the quantity or quality of food, or to the action of the variolous, or some other febrile poison, on the stomach. In these cases, it is well known, that the scarification of the gums, blood-letting, to guard against immediate danger, and liberal purg- ing, constitute our most efficacious, not to say, our only remedies. The indiscriminate plunging of children into warm water, under such circumstances, is, to say the least, a doubtful practice. In adults, the original irritation, although generally situated in some part of the alimentary canal, is referable, at times, to other parts of the body. In the brain, however, it very rarely, if ever exists. An extraneous body, such as a ball or a splinter, lodged in con- tact with a nerve, a tendon, a membrane, or some other highly ir- ritable organ, is known to have been frequently the cause of epi- lepsy. In such cases, the cure of the disease follows the extrac- tion of the offending substance. When the epileptic diathesis occurs in infancy, it is usually re- moved, by the changes that take place about the age of puberty. Instances of this description must fall under the notice of every physician. We know, in Philadelphia, a family consisting of four children, each one of which, when young, has been subject to epilepsy. But in none of them has the diathesis continued longer, than till about the fourteenth year. They have all enjoyed, since that period unusual health, and are all possessed of great acuteness and strength of intellect. Habitual epilepsy in an adult, is among the most obstinate and unpromising of diseases. It appears oftentimes to depend on some peculiarity of organization; and is, hence, transmitted from pa- rent to child; for, it may be included in the number of hereditary complaints. We may add, that, when inherited, the difficulty of completely eradicating it is the greater. In commencing the treatment of tins terrible malady, the first step is, to evacuate thoroughly the alimentary canal. For this pur2 PRACTICE OF PHYSIC. 175 part of the muscles of voluntary motion, attended with a loss of sense, and ending in a state of insensibility and seeming sleep. pose, active purgatives should receive a preference. If indicated by plethora, or the state of the pulse,venesection may also be employed. Then may follow, such a course of tonics, as appears tobe ac- eommodated to the state of the system. Bark and chalybeate?, exhibited in doses as large as the stomach can bear, with the oc- easional use of opium, and asafoetida, are said to have been, at times, productive of a cure. During the continuance of this course? the diet should be nutritive, but not heating. Such exercise ought also to be taken, in the open air, as may be best calculated to aid in giving strength to the system. Two cloves of garlic, taken three or four times a day, and continued for several months, are said to have proved efficacious in the removal of epilepsy. Caprum ammoniacum^ flowers of zink, and nitrate of silver, are all, in their turn, reported to have been instrumental in the eradi- cation of this disease. The same thing is said of arsenic, taken in such doses as the stomach can bear, and frequently repeated, until it shall have pro- duced on the system its characteristic effects. By certain European writers, high encomiums are bestowed on the use of spirits of turpentine, in doses of from two to four drachms a day. To be effectual, it must be continued a conside- rable time. v By Dr. Chapman, and other practitioners in this city, the same remedy has been repeatedly used, in the treatment of epilepsy, with very salutary effects. The doses here administered, have rarely, we believe, exceed- ed, in quantity, two drachms a day. In cases where epilepsy has occurred at regular periods, opi- um, taken in large doses, a few hours before the time of the ex- pected paroxysms, has been efficacious; first in the prevention of single fits, and ultimately in the entire removal of the disease. In these instances, the complaint must have been continued on the principle of habit. - A mercurial ptyalism, conti»Qed«for several weeks; then suffer- ed to decline, and again renewed; until three or four courses have 176 PRACTICE OF PHYSIC. 1284. The general form or principal circumstances of this disease, are much the same in all the different persons whom it affects. It comes by fits, which often attack persons seemingly in perfect health; and, after lasting for sometime, pass off, and leave the persons again in their usual state. These fits are sometimes preceded by certain symptoms, which to persons who have before experienced such a fit, may give notice of its approach, as we shall hereafter explain; but even been undergone, is recommended as a radical cure for epilepsy. In someinstances,we believe this practice has succeeded; in others, we know it has failed. An entire change of life, from a sumptuous to an abstemious; and from an indolent and easy to an active and laborious one, has cured epilepsy. When enjoying, at his ease, the luxuries and plea- sures of t:ie Roman capital, Caesar was subject to this disease; but never experienced a fit of it, during the toils and solicitudes of an active campaign. We once knew a case of aura epileptica to be completely cured, by the application of a caustic to the spot from which the aura appeared to proceed. A severe attack of small-pox is said to have removed the epi- leptic diathesis. The same thing is reported of measles and the itch. This shows the powerful effect of cutaneous irritation, and, of giving to action a centrifugal tendency, in the cure of diseases proceeding from within. Tue cold bath, long journies, voyages by sea, and change of country, have given relief in epilepsy: we do not know that they ever have cured it. This complaint is known to have sometimes proceeded from a suppression of piles. In such a case, the most promising reme- dy consists in the application of leeches to the hemorrhoidal ves- sels. In the treatment of epilepsy, to preserve healthy cutaneous ac- tion, is of great moment. Hence, the wearing of flannel, or fleecy hosiery, next to the skin, should never be neglected, PRACTICE OF PHYSIC. 177 these preludes do not commonly occur long before the formal attack, which in most cases comes on suddenly without any such warning. The person attacked loses suddenly all sense and power of motion; so that, if standing, he falls immedi- ately, or perhaps, with convulsions, is thrown to the ground. In that situation he is agitated with violent con- vulsions, variously moving his limbs and the trunk of his body. Commonly the limbs on one side of the bo- dy are more violently, or more considerably agitated than those upon the, other. In all cases the muscles of the face and eyes are much affected, exhibiting various and violent distortions of the countenance. The tongue is often affected, and thrust out of the mouth; while the muscles of the lower jaw are also affected; and, shut- ting the mouth with violence while the tongue is thrust out between the teeth,.that is often grievously wounded. While these convulsions continue, there is common- ly at the same time a frothy moisture issuing from the mouth. These convulsions have for some moments some remissions, but are suddenly again renewed with great violence. Generally, after no long time, the con- vulsions cease altogether; and the person for some time remains without motion, but in a state of absolute in- sensibility, and under the appearance of a profound sleep. After some continuance of this seeming sleep, the person sometimes suddenly, but for the most part by degrees only, recovers his senses and power of motion; but without any memory of what had passed from his being first seized with the fit. During the con- vulsions, the pulse and respiration are hurried and ir- regular; but, when the convulsions cease, they return to their usual regularity and healthy state. vol. ir. z 178 PRACTICE OF PHYSIC. This is the general form of the disease: and it varies only in different persons, or on different occasions in the same person," by the phenomena mentioned being more or less violent, or by their being of longer or short- er duration. 1285. With respect towthe proximate cause of this disease, I might say, that it is an affection of the ener- gy of the brain, which, ordinarily under the direction of the will, is here, without any concurrence of it, impelled by preternatural causes. But I could go no farther: for, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no distinct knowledge; and therefore must be also ignorant of the preternatural state of the same energy of the brain un- der the irregular motions here produced. To form, therefore, the indications of a cure from a knowledge of the proximate cause of this disease, I must not at- tempt, but, from a diligent attention to the remote cau- ses which first induce and occasionally excite the dis- ease, I think we may often obtain some useful directions for its cure. It shall therefore be my business now to point out and enumerate these remote causes as well as I can. 1286. The remote causes of epilepsy may be consid- ered as occasional or predisponent. There are, indeed, certain remote causes which act independently of any predisposition; but, as we cannot always distinguish these from the others, I shall consider the whole under the usual titles of Occasional or Predisponent. 1287. The occasional causes *may, I think, be pro- perly referred to two general heads; the first being of those which seem to act by directly stimulating and ex- citing the energy of the brain; and the second, of those PRACTICE OF PHYSIC. 179 which seem to act by weakening the same. With re- spect to both, for the brevity of expressing a fact, with- out meaning to explain the manner in which it is brought about, I shall use the terms of Excitement and Collapse. And though it be true, that with respect to some of the causes I am to mention, it may be a little uncertain whether they act in the one way or the other, that does not render it improper for us to mark, with respect to others, the mode of their operating, wherever we can do it clearly, as the doing so may often be of use in direct- ing our practice. 1288. First, then, of the occasional causes acting by excitement: they are either such as act immediately and directly upon the brain itself; or those which are first ap- plied to the other parts of the body, and are from thence communicated to the brain. 1289. The causes of excitement immediately and di- rectly applied to the brain, may be referred to the four heads of, 1. Mechanical Stimulants; 2. Chemical Sti- mulus; 3. Mental Stimulants; and, 4. The peculiar Stimulus of Over Distention. 1290. The mechanical stimulants may be, wounding instruments penetrating the cranium, and entering the substance of the brain; or splinters of a fractured cra- nium, operating in the same manner; or sharp pointed ossifications, either arising from the internal surface of the cranium, or formed in the membranes of the brain. 1291. The chemical stimulants (1289.) may be fluids from various causes lodged in certain parts of the brain, and become acrid by stagnation or otherwise. 1292. The mental irritations acting by excitement, are, all violent emotions of the active kind, such as joy and anger. The first of these is manifestly an exciting 180 PRACTICE OF PHYSIC. power, acting strongly, and immediately, on the energy of the brain. The second is manifestly, also, a power acting in the same manner. But it must be remarked, that it is not in this manner alone anger produces its effects: for it acts, also, strongly on the sanguiferous system, and may be a means of giving the stimulus of over-distention; as, under a fit of anger, the blood is impelled into the vessels of the head with violence, and in a larger quantity. 1293. Under the head of Mental Irritations, is to be mentioned, the sight of persons in a fit of epilepsy, which has often produced a fit of the like kind in the spectator. It may, indeed, be a question, Whether this effect be imputable to the horror produced by a sight of the seemingly painful agitations of the limbs, and of the distortions in the countenance of the epileptic per- son; or if it may be ascribed to the force of imitation merely? It is possible, that horror may sometimes pro- duce the effect: but certainly much may be imputed to that propensity to imitation, at all times so po'werful and prevalent in human nature: and so often operating in other cases of convulsive disorders, which do not pre- sent any spectacle of horror. 1294. Under the same head of Mental Irritation, I think proper to mention as an instance of it, the Epi- lepsia Simulata, or the Feigned Epilepsy, so often taken notice of. Although this, at first, may be entirely feigned, I have no doubt but that the repetition renders it at length real. The history of Quietism and of Ex- orcisms leads me to this opinion: and which receives a confirmation from what we know of the power of ima- gination, in renewing epileptic and hysteric fits. PRACTICE OF PHYSIC. J 81 1295. I come now to the fourth head of the irritations applied immediately to the brain, and which I appre- hend to be that of the Over Distention of the blood- vessels in that organ. That such a cause operates in producing epilepsy, is probable from this, that the dis- sections of persons dead of epilepsy, has commonly dis- covered the marks of a previous congestion in the blood- vessels of the brain. This, perhaps, may be supposed the effect of the fit which proved fatal: but that the congestion was previous thereto, is probable from the epilepsy being so often joined with headach, mania, palsy, and apoplexy; all of them diseases depending up- on a congestion in the vessels of the brain. The ge- neral opinion receives also confirmation from this cir- cumstance, that, in the brain of persons dead of epi- lepsy, there have been often found tumors and effusions, which, though seemingly not sufficient to produce those diseases which depend on the compression of a consi- derable portion of the brain, may, however, have been sufficient to compress so many vessels as to render the others upon any occasion of a more than usual turges- cence, or impulse of the blood into the vessels of the brain more liable to an over distention. 1296. These considerations alone might afford foun- dation for a probable conjecture with respect to the ef- fects of over distention. But the opinion does not rest upon conjecture alone. That it is also founded in fact, appears from hence, that a plethoric state is favourable to epilepsy; and that every occasional turgescence, or unusual impulse of the blood into the vessels of the brain, such as a fit of anger, the heat of the sun, or of a warm chamber, violent exercise, a surfeit, or a fit ofintoxica- 182 PRACTICE OF PHYSIC. tion, are frequently the immediate exciting causes of epileptic fits. 1297. I venture to remark further, that a piece of theory may be admitted as a confii mation of this doc- trine. As I have formerly maintained, that a certain fulness and tension of the vessels of the brain is ne- cessary to the support of its ordinary and constant energy, in the distribution of the nervous power ; so it must be sufficiently probable, that an over distention of these blood-vessels may be a cause of violent excite* ment. 1298. We have now enumerated the several remote or occasional causes of epilepsy^ acting by excitement, and acting immediately upon the brain itself. Of the causes acting by excitement, but acting upon other parts of the body, and from thence communicated to the brain, they are all of them impressions producing an exquisite or high degree either of pleasure or pain. Impressions which produce neither the one nor the other, have hardly any such effects; unless when such impressions are in a violent degree, and then their ope- rations may be considered as a mode of pain. It is, however, to be remarked, that all strong impressions which are sudden and surprising, or, in other words, unforeseen and unexpected, have frequently the effect of bringing on epileptic fits. 1299. There are certain impressions made upon dif- ferent parts of the body, which as they often operate without producing any sensation, so it is uncertain to what head they belong: but it is probable that the greater part of them act by excitement, and therefore fall to be mentioned here. The chief instances are, the teething of infants; worms; acidity or other acrimony in PRACTICE OF PHYSIC. 183 the alimentary canal; calculi in the kidneys; acrid mat- ter in abscesses or ulcers; or acrimony diffused in the mass of blood, as in the case of some contagions. 1300. Physicians have found no difficulty in com- prehending how direct stimulants, of a certain force, may excite the action of the brain, and occasion epi- lepsy: but they have hitherto taken little notice of cer- tain causes which manifestly weaken the energy of the brain, and act, as I speak, by collapse. These, how- ever, have the effect of exciting the action of the brain in such a manner as to occasion epilepsy. I might up- on this subject, speak of the vis medicatrix natura; and there is a foundation for the term; but, as I do not ad- mit the Stahlian doctrine of an administering soul, I make use of the term only as expressing a fact, and would not employ it with the view of conveying an ex- planation of the manner in which the powers of collapse mechanically produce their effects. In the mean time, however, I maintain, that there are certain powers of collapse which in effect prove stimulants, and produce epilepsy. 1301. That there are sucji powers, which may be termed Indirect Stimulants, I conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which we suppose always to depend upon causes weakening the energy of the brain, (1176.) It may give some difficulty to explain, why the same causes sometimes occasion syncope, and sometimes oc- casion the reaction that appears in epilepsy; and I shall not attempt to explain it: but this, I think, does not prevent my supposing that the operation of these causes is by collapse. That there are such causes producing 184 PRACTICE OF PHYSIC. epilepsy, will, I think, appear very clearly from the par- ticular examples of them I am now to mention. 1302. The first to be mentioned, which I suppose to be of this kind, is hemorrhagy, whether spontaneous or artificial. That the same hemorrhagy which pro- duces syncope, often at the same time produces epi- lepsy, is well known; and from many experiments and observations it appears, that hemorrhagies occurring to such a degree as to prove mortal, seldom do so without first producing epilepsy. 1303. Another cause acting, as I suppose, by col- lapse, and therefore sometimes producing syncope, and sometimes epilepsy, is terror; that is, the fear of some great evil suddenly presented. As this produces at the same time a sudden and considerable emotion, (1180.) so it more frequently produces epilepsy than syncope. 1304. A third cause acting by collapse, and produ- cing epilepsy, is horror; or a strong aversion suddenly raised by a very disagreeable sensation, and frequently arising from a sympathy with the pain or danger of ano- ther person. As horror is often a cause of syncope, there can be no doubt of its manner of operating in producing epilepsy; and it may perhaps be explained upon this general principle, That as desire excites ac- tion and gives activity, so aversion restrains from action, that is, weakens the energy of the brain; and, therefore, that the higher degrees of aversion may have the effects of producing syncope or epilepsy. 1305. A fourth set of the causes of epilepsy, which I suppose also to act by collapse, are certain odours,which occasion either syncope or epilepsy; and, with respect to the former, I have given my reasons (1182.) for sup- posing odours in that case to act rather as disagreeable PRACTICE OF PHYSIC. Igf than as sedative. These reasons will, I think, also ap- ply here; and perhaps the whole affair of odours might be considered as instances of the effect of horror, and therefore belonging to the last head. 1306. A fifth head of the causes producing epilep* sy by collapse, is the operation of many substances considered, and for the most part properly considered, as poisons. Many of these, before they prove mor- tal, occasion epilepsy, This effect, indeed, may in some cases be referred to the inflammatory operation which they sometimes discover in the stomach, and other parts of the alimentary canal; but, as the greater part of the vegetable poisons show chiefly a narcotic, of strongly sedative power, it is probably by this powef that they produce epilepsy, and therefore belong to this head of the causes acting by collapse. 1307. Under the head of the remote causes produ- cing epilepsy, we must now mention that peculiar one whose operation is accompanied with what is called the Aura Epileptica. This is a sensation of something mo* ving in some part of the limbs or trunk of the body, and from thence creeping upwards to the head; and when it arrives there, the person is immediately deprived of sense, and falls into an epileptic fit. This motion is described by the persons feeling it sometimes as a cold vapor, sometimes as a fluid gliding, and sometimes as the sense of a small insect creeping along their bodyj and very often they can give no distinct idea of their sensation, otherwise than as in general of something moving along. This sensation might be supposed to arise from some affection of the extremity or other part of a nerve acted upon by some irritating matter* and that the sensation, therefore, followed the course of such vol. n. A a 18$ PRACTICE OF PHYSIC. a nerve: but I have never found it following distinctly the course of any nerve; and it generally seems to pass along the teguments. It has been found in some in- stances to arise from something pressing upon or irri- tating a particular nerve, and that sometimes in conse- quence of contusion or wound: but instances of these lire more rare: and the more common consequence of contusions and wounds is a tetanus. This latter effect wounds produce, without giving any sensation of an aura or other kind of motion proceeding from the wound- ed part to the head; while on the other hand, the aura producing epilepsy, often arises from a part which had never been affected with wound or contusion; and in which part the nature of the irritation can seldom be discovered. It is natural to imagine that this aura epi- leptica is an evidence of some irritation or direct sti- mulus acting in the part, and from thence communica- ted to the brain, and should therefore have been men- tioned among the causes acting by excitement; but the remarkable difference that occurs in seemingly like cau- ses producing tetanus, give some doubt on this subject. 1308. Having now enumerated the occasional causes of epilepsy, I proceed to consider the predisponent. As so many of the above mentioned causes act upon cer- tain persons, and not at all upon others, there must be supposed in those persons a predisposition to this dis- ease: but in what this predisposition consists, is not easily to be ascertained. 1309. As many of the occasional causes are weak impressions, and are applied to most persons with lit- tie or no effect, I conclude, that the persons affected by those causes are more easily moved than others; and therefore that, in this case, a certain mobility gives the PRACTICE OF PHYSIC 187 predisposition. It will, perhaps, make this matter clear- er, to show, in the first place, that there is a greater mo- bility of constitution in some persons than in others. 1310. This mobility appears most clearly in the state of the mind. Iff a person is readily elated by hope, and as readily depressed by fear, and passes easily and quickly from the one state to the other; and if he is easi- ly pleased, and prone to gayety, and as easily provoked to anger, and rendered peevish; if liable, from slight impressions, to strong emotions, but tenacious of none; this is the boyish temperament qui colligit acponit iram temere, et mutater in horas; this is the varium et muta- bile fcemina; and, both in the boy and woman, every one perceives and acknowledges a mobility of mind. But this is necessarily connected with an analogous state of the brain; that is, with a mobility, in respect of every impression, and therefore liable to a ready al- teration of excitement and collapse, and of both to a considerable degree. 1311 There is, therefore, in certain persons, a mo- bility of constitution, generally derived from the state of original stamina, and more exquisite at a certain pe- riod of life than at others; but sometimes arising from, and particularly modified by, occurrences in the course of life. 1312. This mobility consists in a greater degree of either sensibility or irritability. These conditions, in- deed, physicians consider as so necessarily connected that the constitution with respect to them, may be con- sidered as one and the same: but I am of opinion that they are different; and that mobility may sometimes depend upon an increase of the one and sometimes on that of the other. If an action excited, is, by repetition 188 PRACTICE OF PHYSIC. rendered more easily excited, and more vigorously per- formed, I consider this as an increase of irritability only, I go no further on this subject here, as it was only ne- cessary to take notice of the case just now mentioned, for the purpose of explaining why epilepsy, and convul- sions of all kinds, by being repeated, are more easily excited, readily become habitual, and are therefore of more difficult cure. 1313. However we may apply the distinction of sen- sibility and irritability, it appears that the mobility, which is the predisponent cause of epilepsy, depends more par- ticularly upon debility, or upon a plethoric state of the body, 1314. What share debility, perhaps by inducing sen. gibility, has in this matter, appears clearly from hence, thafchildren, Women, and other persons of manifest de. bility, are the most frequent subjects of this disease. 1315. The effects of a plethoric state in disposing to this disease appears from hence, that plethoric persons are frequently the subjects of it: that it is commonly ex. cited, as I have said above, by the causes of any unusu. al turgescence of the blood; and that it has been fre- quently cured by diminishing the plethoric state of the fcody. That a plethoric state of the body should dispose to this disease, we may understand from several considers* tfons. 1st, Because a plethoric state implies, for the most part, a laxity of the solids, and therefore some de- bljity in the moving fibres. 2dly, Because, in a pletho. ric state, the tone of the moving fibres depends more upon their tension, than upon their inherent power: and as their tension depends upon the quantity and impetus ©f the fluids in the blood-vessels, which are very change* PRACTICE OF PHYSIC. 189 able, and by many causes frequently changed, so these frequent changes must give a mobility to the system. 3dly, Because a plethoric state is favourable to a con- gestion of blood in the vessels of the brain, it must ren- der these more readily affected by every general tur- gescence of the blood in the system, and therefore more especially dispose to this disease. 1316. There is another circumstance of the body disposing to epilepsy, which I cannot so well account for; and that is, the state of sleep: but whether I can account for it or not, it appeafe, in fact, that this state gives the disposition I speak of; for, in many persons liable to this disease, the fits happen only in the time of sleep, or immediately upon the person's coming out of it. In a case related by De Haen, it appeared clearly, that the disposition to epilepsy depended entirely upon the state of the body in sleep. 1317. Having thus considered the whole of the re- mote causes of epilepsy, I proceed to treat of its cure, as I have said it is from the consideration of those re- mote causes only that we can obtain any directions for our practice in this disease. I begin with observing, that as the disease may be considered as sympathic or idiopathic, I must treat of these separately, and judge it proper to begin with the former. 1318, When this disease is truly sympathic, and de. pending upon a primary affection in some other part of the body, such as acidity or worms in the alimentary canal, teething, or other similar causes, it is obvious, that such primary affections must be removed for the cure of the epilepsy; but it is not our business here to say how these primary diseases are to be treated. 190 PRACTICE OF PHYSIC. 1319. There is, however, a peculiar case of sympa- thic epilepsy; that is, the case accompanied with the aura epiieptica, as described in 1307, in which, though We can perceive by the aura epiieptica arising from a particular part, that there is some affection in that part; yet, as in many such cases, we cannot perceive of what nature the affection is, I can only offer the following general directions. 1st, When the part can with safety be entirely de- stroyed, we should endeavour to do so by cutting it out, or by destroying it by ^ie application of an actual or potential cautery. 2dly, When the part cannot be properly destroyed, that we should endeavour to correct the morbid affec- tion in it by blistering, or by establishing an issue up- on the part. 3dly, When these measures cannot be executed, or do not succeed, if the disease seems to proceed from the extremity of a particular nerve which we can easily come at in its course, it will be proper to cut through that nerve, as before proposed on the subject of tetanus. Atthly, When it cannot be perceived that the aura arises from any precise place or point, so as to direct to the above-mentioned operations; but, at the same time, we can perceive its progress along the limb; it frequent- ly happens that the epilepsy can be prevented by a liga- ture applied upon the limb, above the part from which the aura arises; and this is always proper to be done, both because the preventing a fit breaks the habit of the disease, and because the frequent compression renders the nerves less fit to propagate the aura. 1320. The cure of idiopathic epilepsy, as I have said above, is to be directed by our knowledge of the remote PRACTICE OF PHYSIC. 191 tauses. There are therefore two general indications to be formed. The first is, to avoid the occasional causes; and the second is, to remove or correct the predisponent. This method, however, is not always purely pallia- tive; as in many cases the predisponent may be consid^ ered as the only proximate cause, so our second indica- tion may be often considered as properly curative. 1321. From the enumeration given above, it will be manifest, that for the most part the occasional causes, so far as they are in our power, need only to be known, in order to be avoided; and the means of doing this will be sufficiently obvious. I shall here, therefore, of- fer only a few remarks. 1322. One of the most frequent of the occasional causes is that of over distention, (1314.) which, so far as it depends upon a plethoric state of the system, I shall say hereafter how it is to be avoided. But as, not only in the plethoric, but in every moveable constitution, occasional turgescenee is a frequent means of exciting epilepsy, the avoiding therefore of such turgescence is what ought to be most constantly the object of attention to persons liable to epilepsy. 1323. Another of the most frequent exciting causes of this disease are, all strong impressions suddenly made upon the senses; for as such impressions, in moveable constitutions, break in upon the usual force, velocity, and order of the motions of the nervous system, they thereby readily produce epilepsy. Such impressions therefore, and especially those which are suittd to ex- cite any emotion or passion of the mind, are to be most carefully guarded against by persons liable to epilepsy. l.>24. In many cases of epilepsy, where the predis- ponent cause cannot be corrected or removed, the re- 192 PRACTICE OF PHYSIC. currence of the disease can only be prevented, by the strictest attention to avoid the occasional; and as the disease is often confirmed by repetition and habit, so the avoiding the frequent recurrence of it is of the ut- most importance towards its cure. These are the few remarks I have to offer with res- pect to the occasional causes; and must now observe, that, for the most part, the complete, or, as it is called, the radical cure, is only to be obtained by removing or correcting the predisponent cause. 1325. I have said above, that the predisponent cause of epilepsy is a certain mobility of the sensorium; and that this depends upon a plethoric state of the system, or upon a certain state of the debility in it. 1326. How the plethoric state of the system is to be corrected, I have treated of fully above in (781. et. seq.) and I need not repeat it here. It will be enough to say, that it is chiefly to be done by a proper management of exercise and diet; and, with respect to the latter, it is particularly to be observed here, that an abstemious course has been frequently found to be the most certain means of curing epilepsy. 1327. Considering the nature of the matter poured out by issues, these may be supposed to be a constant means of obviating the plethoric state of the system? and it is, perhaps, therefore, that they have been so of- ten found useful in epilepsy. Possibly, also, as an open issue may be a means of determining occasional tur- gescences to such places, and therefore of diverting them in some measure from their action upon the brain; so also, in this manner, issues may be useful in epilepsy. 1328. It might be supposed that blood-letting would be the most effectual means of correcting the plethoric PRACTICE OF PHYSIC. 193 state of the system; and such it certainly proves when the plethoric state has become considerable, and imme- diately threatens morbid effects. It is therefore, in such circumstances, proper and necessary: but as we have said above, that blood-letting is not the proper means of obviating a recurrence of the plethoric state, and, on the contrary, is often the means of favouring it; so it i& not a remedy advisable in every circumstance of epi- lepsy. There is, however, a case of epilepsy in which there is a periodical or occasional recurrence of the ful- ness and turgescence of the sanguiferous system, giv- ing occasion to a recurrence of the disease. In such cases, when the means of preventing plethora have been neglected, • or may have proved ineffectual, it is abso- lutely necessary for the practitioner to watch the returns of these turgescences, and to obviate their effects by the only certain means of doing it, that is, by a large blood-letting. 1329. The second cause of mobility which we have assigned, is a state of debility. If this is owing, as it frequently is, to original conformation, it is perhaps not possible to cure it; but when it has been brought on in the course of life, it possibly may admit of being mend- ed; and, in either case, much may be done to obviate and prevent its effects. 1330. The means of correcting debility, so far as it can be done, are, the person's being much in cool air; the frequent use of cold bathing; the use of exercise, adapted to the strength and habits of the person; and, perhaps, the use of astringent and tonic medicines. These remedies are suited to strengthen the inherent power of the solids or moving fibres: but as the strength of these depends also upon their tension, so when de- VOL. II. b b 194 PRACTICE OF PHYSIC. bility has proceeded from inanition, the strength may be restored, by restoring the fulness and tension of the vessels by a nourishing diet; and we have had instances of the propriety and success of such a practice. 1331. The means of obviating the effects of debili- ty, and of the mobility depending upon it, are the use of tonic and antispasmodic remedies. The tonics are, fear, or some degree of terror; as- tringents; certain vegetable and metallic tonics; and cold-bathing. 1332. That fear, or some degree of terror, may be of use in preventing epilepsy, we have a remarkable proof in Boerhaave's cure of the epilepsy, which hap-. pened in the Orphan-house at Haerlem. See Rauu Boer- haave's treatise, entitled Impetum Faciens, § 406. And we have met with several other instances of the same. As the operation of horror is in many respects analo- gous to that of terror, several seemingly superstitious remedies have been employed for the cure of epilepsy; and, if they have ever been successful, I think it must be imputed to the horror they had inspired. 1333. Of the astringent medicines used for the cure of epilepsy the most celebrated is the viscus quercinus, which, when given in large quantities, may possibly be useful; but I believe it was more especially so in ancient times, when it was an object of superstition. In the few instances in which I have seen it employed it did not prove of any effect. 1334. Among the vegetable tonics, the bitters are to be reckoned; and it is by this quality that I suppose the orange-tree leaves to have been useful: but thev are not always so. PRACTICE OF PHYSIC. 195 1335. The vegetable tonic, which from its use in analogous cases is the most promising, is the Peruvian bark; this, upon occasion, has been useful, but has al- so often failed. It is especially adapted to those epilep- sies which recur at certain periods, and which are at the same time without the recurrence of any plethoric state or turgescence of the blood; and in such periodical ca- ses, if the bark is employed some time before the ex- pected recurrence, it may be useful; but'it must be giv- en in large quantity, and as near to the time of the ex- pected return as possible. 1336. The metallic tonics seem to be more power- ful than the vegetable, and a great variety of the former have been employed. riven arsenic has been employed in the cure of epi- lepsy; and its use in intermittent fevers gives an analo- gy in its favour. Preparations of tin have been formerly recommend- ed in the cure of epilepsy, and in the cure of the analo- gous disease of hysteria; and several considerations render the virtues of tin, with respect to these diseases, probable: but I have had no experience of its use in such cases. A much safer metallic tonic is to be found in the pre- parations of iron; and we have seen some of them em- ployed in the cure of epilepsy, but have never found them to be effectual. This, however, I think, may be imputed to their not having been always employed in the circumstances of the disease, and in the quantities of the medicine, that were proper and necessary. 1337. Of the metallic tonics, the most celebrated and the most frequently employed is copper, under various preparation. What preparation of it may be the most 196 PRACTICE OF PHYSIC. effectual, I dare not determine; but of late the cuprum ammoniacum has been frequently found successful. 1338. Lately the flowers of zinc have been recom- mended by a great authority as useful in all convulsive disorders; but in cases of epilepsy, I have not hitherto found that medicine useful. 1339. There have been of late some instances of the cure of epilepsy by the accidental use of mercury; and if the late accounts of the cure of tetanus by this reme- dy are confirmed, it will allow us to think that the same may be adapted also to the cure of certain cases of epi- lepsy. 1340. With respect to the employment of any of the above mentioned tonics in this disease, it must be ob- served, that in all cases where the disease depends upon a constant or occasional plethoric state of the system, these remedies are likely to be ineffectual; and if suffi- cient evacuations are not made at the same time, these medicines are likely to be very hurtful. 1341. The other set of medicines which we have mentioned as suited to obviate the effects of the too great mobility of the system, are the medicines named antispasmodics. Of these there is a long list in the wri- ters on the Materia Medica, and by these authors re- commended for the jure of epilepsy. The greater part, however, of those taken from the vegetable, kingdom, are manifestly inert and insignificant. Even the root of the wild valerian hardly supports its credit. 1342. Certain substances taken from the animal king- dom seem to be much more powerful: and of these the chief, and seemingly the most powerful, is musk; which employed in its genuine state, and in due quantity, has often been an effectual remedy. PRACTICE OF PHYSIC. 197 It is probable also, that the oleum animate, as it has been named, when in its purest state, and exhibited at a proper time, may be an effectual remedy. 1343. In many diseases, the most powerful antispas- modic is certainly opium; but the 'propriety of its use in epilepsy has been disputed among physicians. When the disease depends upon a plethoric state in which bleeding may be necessary, the employment of opium is likely to be very hurtful: but, when there is no ple- thoric or inflammatory state present, and the disease seems to depend upon irritation or upon increased irri- tability, opium is likely to prove the most certain reme- dy. Whatever effects in this and other convulsive dis- orders have been attributed to the hyoscyamus, must probably be attributed to its possessing a narcotic pow- er similar to that of opium. 1344. With respect to the use of antispasmodics, it •is to be observed, that they are always most useful, and perhaps only useful, when employed at a time 'when' epileptic fits are frequently recurring, or near to the^ times of the accession of fits which recur after conside- rable intervals. 1345. On the subject of the cure of epilepsy, I have only to add, that as the disease in many cases is con- tinued by the power of habit only, and that in all cases habit has a great share in increasing mobility, and there- fore in continuing this disease; so the breaking in upon such habit, and changing the whole habits of the sys- tem, is likely to be a powerful remedy in epilepsy. Ac- cordingly, a considerable change of climate, diet, and other circumstances in the manner of life, has often pro- ved a cure of this disease. 198 PRACTICE OF PHYSIC. 1346, After treating of epilepsy, I might here treat of particular convulsions, which are to be distinguish- ed from epilepsy by their being more partial: that is, affecting certain parts of the body only, and by their not being attended with a loss of sense, nor ending in such a comatose state as epilepsy always does. 1347. Of such convulsive affections many different instances have been observed and recorded by physi- cians. But many of these have been manifestly sym- pathic affections, to be cured only by curing the prima- ry disease upon which they depend, and therefore not to be treated of here: or, though they are such as can- not be referred to another disease, as many of them however have not any specific eharacter with which they occur in different persons, I must therefore leave them to be treated upon the general principles I have laid down with respect to epilepsy, or shall lay down with respect to the following convulsive disorder; which, as having very constantly in different persons a peculiar character, I think necessary to treat of more particu- larly. chapter in. "*7 OF THE CHOREA OR DANCE OF ST. VITUS. 1348. THIS disease affects both sexes, and almost only young persons. It generally happens from the age of ten to that of fourteen years. It comes on always before the age of puberty, and rarely continues beyond that period.* * We have known persons advanced in years to be severely af- flicted with St. Vitus's dance. PRACTICE OF PHYSIC. 199 1349. It is chiefly marked by convulsive motions, somewhat varied in different persons, but nearly of one kind in all; affecting the leg and arm on the same side, and generally on one side only. 1350. These convulsive motions commonly first af- fect the leg and foot. Though the limb be at rest, the foot is often agitated by convulsive motions, turning it alternately outwards and inwards. When walking is at- tempted, the affected leg is seldom lifted as usual in walk- ing, but is dragged along as if the whole limb were para- lytic; and, when it is attempted to be lifted, this motion is unsteadily performed, the limb becoming agitated by irregular convulsive motions. 1351. The arm of the same side is generally affected at the same time; and, even when no voluntary motion is attempted, the arm is frequently agitated with various convulsive motions. But especially when voluntary mo- tions are attempted, these are not properly executed, but are variously hurried or interrupted by convulsive motions in a direction contrary to that intended. The most common instance of this is in the persons attempt- ing to carry a cup of liquor to his mouth, when it is on- ly after repeated efforts, interrupted by frequent convul- sive retractions and deviations, that the cup can be car- ried to the mouth. 1352. It appears to me, that the will often yields to these convulsive motions, as to a propensity, and there- by they are often increased, while the person affected seems to be pleased with increasing the surprise and amusement which his motions occasion in the by- standers. 1353. In this disease the mind is often affected with some degree of fatuity; and often shows the same va- 200 PRACTICE OF PHYSIC. ried, desultory, and causeless emotions which occur in hysteria. 1354. These are the most common circumstances of this disease; but at times, and in different persons, it is varied by some difference in the convulsive motions, particularly by these affecting the head and trunk of she body. As in this disease there seem to be propensities to motion, so various fits of leaping and running occur in the persons affected; and there have been instances of this disease, consisting of such convulsive motions, appearing as an epidemic in a certain corner of the coun- try. In such instances, persons of different ages are af- fected, and may seem to make an exception to the gene- ral rule above laid down; but still the persons are, for the most part, the young of both sexes, and of the more manifestly moveable constitutions. 1355. The method of curing this disease has been variously proposed. Dr. Sydenham proposed to cure it by alternate bleeding and purging. In some pletho- ric habits 1 have found some bleeding useful; but in ma- ny cases I have found repeated evacuations, especially by bleeding, very hurtful. In many cases, I have found the disease, in spite of remedies of all kinds, continue for many months; but I have also found it often readily yield to tonic remedies, such as the Peruvian bark, and chalybeates. The late Dr. De Haen found several persons labour- ing under this disease cured by the application of elec- tricity.* * In the treatment of this disease, we have had but little expe- rience, having never attended more than three or four cases of it. Bloodletting has, at times, been practised in it with advantage. As far as we are informed on the subject, very salutary effects have PRACTICE OF PHYSIC. 201 SECTION II. ©F THE SPASMODIC AFFECTIONS OF THE VITAL FUNCTIONS. CHAPTER IV. OF THE PALPITATION OF THE HEART.* 1356. THE motion thus named is a contraction or systole of the heart, that is performed with more rapidi- resulted in it from active and copious purging, succeeded by to- nic and antispasmodic remedies. One of the most promising to- nics, in this disease, consists in a saturated solution of the sulphate of copper in water. The dose of this is from six to ten drops, to be repeated three or four times a-day. The shower bath and country air ought not to be neglected. In some instances, the disease appears to proceed Irom the irri- tation of teething; in others, from that of worms in the alimenta- ry canal. In the former case, scarification 6f the gums; in the latter, drastic purgatives, constitute the most efficacious remedy. Believing the complaint to be seated in the stomach, some phy- sicians promise themselves great advantage from the use of emet- ics, frequently repeated, alternating with tonics. As antispasmodics, and to allay irritation in this disease, opi- um, musk, and castor, camphor, assafoetida and cicuta, have most reputation. When not forbidden by the presence of inflammation, the to- nics commonly administered in other diseases, of great irritability, are useful in this. When the irregular motions are confined principally to the low- er extremities, tight bandaging of t em with flannel rollers is said to have proved serviceable. We apprehend, however, that this remedy is, at best, but a palliative; unless, indeed, it may possi- bly act as a counter-irritation to that which originally produces the disease. * Palpitation of the heart is oftentimes an arthritic affection, and, as such, has its origin in the stomach. Its treatment, when vol, II. c c 202 PRACTICE OF PHYSIC. ty, and generally also with more force than usual, and when at the same time the heart strikes with more than u$ual violence against the inside of the ribs, producing often a considerable sound. 1357. This motion, or palpitation, is occasioned by a great variety of causes, which have been recited with great pains by Mr. Senac and others; whom, however, I cannot follow in all the particulars with sufficient dis- cernment, and therefore shall here only attempt to refer all the several cases of this disease to a few general heads. 1S58. The first is of those arising from the application of the usual stimulus to the heart's contraction; that is, the influx of the venous blood into its cavities, being made with more velocity, and, therefore, in the same time, in greater quantity than usual. It seems to be in this manner that violent exercise occasions palpitation. 1359. A second head of the cases of palpitation, is of those arising from any resistance given to the free and entire evacuation of the ventricles of the heart. Thus a ligature made upon the aorta occasions palpitations of the most violent kind. Similar resistances, either in the aorta or pulmonary artery, may be readily imagined; and such have been of en found4in the dead bodies of persons who during life, had been much affected with palpitations. To this head are to be referred all those cases of pal- pitation arising from causes producing an accumulation of blood in the great vessels near to the heart. 1360. A third head of the cases of palpitation, is of those arising from a more violent and rapid influx of the nervous power into the muscular fibres of the heart. It thus produced, will be readily understood, from what has been said on the subject of atonic gout, An emctir has sometimes com- pletely removed it. PRACTICE OF PHYSIC. 5203 is in this manner that I suppose various causes acting in the brain, and particularly certain emotions of the mind occasion palpitation. 1361. A fourth head of the cases of palpitation, is of those arising from causes producing a weakness in the action of the heart, by diminishing the energy of the brain with respect to it. That such causes operate in producing palpitation, 1 presume from hence, that all the several causes mentioned above (1177. et. seq.) as in this manner producing syncope, do often produce palpitation. It is on this ground that these two diseases are affections frequently occurring in the same person, as the same causes may occasion the one or the other, according to the force of the cause and mobility of the person acted upon. It seems to be a law of the human economy, that a degree of debility occurring in any function, often produces a more vigorous exertion of the same, or at least an effort towards it, and that commonly in a convulsive manner. I apprehend it to be the convulsive action, frequent- ly ending in some degree of a spasm, that gives occa- sion to the intermittent pulse so frequently accompany- ing palpitation. 1362. A fifth head of the cases of palpitation may perhaps be of those arising from a peculiar irritability or mobility of the heart. This, indeed, may be con- sidered as a predisponent cause only, giving occasion to the action of the greater part of the causes recited above. But it is proper to observe, that this predisposition is of- ten the chief part of the remote cause; insomuch that many of the causes producing palpitation would not have this effect but in persons peculiarly predisposed. This head, therefore, of the cases of palpitation, often requires to be distinguished from all the rest. a04 PRACTICE OF PHYSIC 1363. After thus marking the several cases and cau- ses of palpitation, I think it necessary, with a view to the cure of this disease, to observe, that the several causes of it may be again reduced to two heads. The first is, of those consisting in, or depending upon, cer- tain organic affections of the heart itself, or of the great vessels immediately connected with it. The second is, of those consisting in, or depending upon, certain af- fections subsisting and acting in other parts of the bo* dy, and acting either by the force of the cause, or in consequence of the mobility of the heart. 1364. With respect to the cases depending upon the first set of causes, I must repeat here what I said with respect to the like cases of syncope that I do not know any means of curing them. They, indeed, admit of* some palliation, first, by avoiding every circumstance that may hurry the circulation of the blood; and, second- ly, by every means of avoiding a plethoric state of the system, or any occasional turgescence of the blood. In many of these cases, blood-letting may give a tempora- ry relief: but in so far as debility and mobility are con- cerned, in such cases this remedy is likely to do harm. 1365. With respect to the cases depending upon the other set of causes, they may be various, and require ve- ry different measures; but I can here say in general, that these cases may be considered as of two kinds; one de- pending upon primary affections in other parts of the body, and acting by the force of the particular causes; and another depending upon a state of mobility in the heart itself. In the first of these, it is obvious, that the cure of palpitation must be obtained by curing the primary affection; which is not to be treated of here. In the second, the cure must be obtained, pardy by PRACTICE OF PHYSIC. 205 diligently avoiding the occasional causes, partly and chief!} by correcting the mobility of the system, and of the heart in particular; for doing which we have treat- ed of the proper means elsewhere. chapter v. OF DYSPNCEA, OR DIFFICULT BREATHING* 1366. THE exercise of respiration, and the or- gans of it, have so constant and considerable a connec- tion with almost the whole of the other functions and parts of the human body, that upon almost every occa- sion of disease, respiration must be affected. According- ly, some difficulty and disorder in this function, are in fact symptoms very generally accompanying disease. 1367. Upon this account, the symptom of difficult breathing deserves a chief place and an ample consider- ation in the general system of Pathology; but what share of consideration it ought to have in a treatise of Practice, I find it difficult to determine. 1368. On this subject, it is, in the first place, neces- sary to distinguish between the symptomatic and idio- pathic affections; that is, between those difficulties of breathing which are symptoms only of a more general affection, or of a disease subsisting primarily in other parts than the organs of respiration, and that difficulty of breathing which depends upon a primary affection of * The various affections enumerated in this chapter, being nc thing but symptoms of more general diseases, do not require a distinct consideration. They can be cured only by the ewe of the complaints of which they form a part. 206 PRACTICE OF PHYSIC. the lOngs themselves. The various cases of sympto- matic dyspnoea I have taken pains to enumerate in my Methodical Nosology, and it will be obvious they are such as cannot be taken notice of here. 1369. In my Nosology I have also taken pains to point out and enumerate the proper, or at least the great- er part of the proper, idiopathic cases of the dyspnoea: but from that enumeration it will, I think, readily ap- pear, ihat few, and indeed hardly any, of these cases, will admit or require much of our notice in this place. 1370. The Dyspnoea Sicca, species 2d, the Dyspnoea Aerea, sp. 3d, the Dyspnoea Terrea, sp. 4>th, and Dysp- noea Thoracica, sp. 7th, are some of them with difficulty known, and are all of them diseases which in my opinion do not admit of cure. All, therefore, that can be said concerning them here is, that they may admit of some palliation; and this, I think, is to be obtained chiefly by avoiding a plethoric state of the lungs, and every cir- cumstance that may hurry respiration. 13*71. Of the Dyspnoea Extrinseca, sp. 8th, I can say no more, but that these external causes marked in the Nosology, and perhaps some others that might have like effects, are to be carefully avoided; or, when they have been applied, and their effects have taken place, the disease is to be palliated by the means mentioned in the last paragraph. 1372. The other species though enumerated as idio- pathic, can hardly be considered as such, or as requiring to be treated of here. The Dyspnoea Catarrhalis, sp. 1st, may be consider- ed as a species of catarrh, and is pretty certainly to be cured by the same remedies as that species of catarrh which depends rather upon the increased afflux of mucus PRACTICE OF PHYSIC. O.Q7 to the bronchiae, than upon any inflammatory state in them. The Dyspnoea Aquosa, sp. 5th, is certainly to be con- sidered as a species of dropsy, and is to be treated by the same remedies as the other species of that disease. The Dyspnoea Pinguedinosa, sp. 6th, is in like man- ner to be considered as a symptom or local effect of the Polysarcia, and is only to be cured by correcting the general fault of the system. 1373. From this view of those idiopathic cases of dyspnoea, which are perhaps all I could properly arrange under this title, it will readily appear that there is little room for treating of them here: but there is still one case of difficult breathing, which has been properly dis- tinguished from every other under the title of Asthma; and as it deserves our particular attention, I shall here separately consider it. CHAPTER VI. OF ASTHMA." 1374. 1 HE term of asthma has been commonly applied by the vulgar, and even by many writers on * To our author's description of asthma, as exhibited in this chapter, nothing, perhaps, can be added, that would, in any mea- sure, improve it. In relation to the treatment of it, we shall brief- ly offer the following remarks. The practice in this disease is naturally divided into that which is requisite during the existence of a paroxysm; and that which is suitable during the interval. Asthmatic paroxysms are frequently induced by improprieties iii the quantity or quality of food, and probably also of drink. 208 PRACTICE OF PHYSIC. the Practice of Physic, to every case of difficult breath- ing, that is, to every species of Dyspnoea. The Me- In such a case, the first indication is, a thorough evacuation of the alimentary canal. If nothing exist to forbid an emetic, its exhibition may be highly useful. Even a repetition of it may per- haps be advisable. Purgatives will, at all events, be safe and proper. If the habit of the patient be full, and the febrile symptoms con- siderable, blood-letting is necessary, to relieve congestion in the lungs, and prevent effusion, the rupture of blood-vessels, or other effects which might thence ensue. This operation must be re- peated, or not, according to circumstances. Should blood-letting be inadmissible, or fail to give relief, the application of cups to the breast, or along the spine, and of blis- ters also, in case the febrile symptoms have sufficiently subsided, may prove beneficial- It is now that the various expectorants are recommended. Of these, tartarized antimony, or ipecacuanha, in nauseating doses, gum ammoniac, powdered squills, combined with nitre, a combi- nation of camphor and myrrh, and the radix Senekae, in powder or decoction, are in high repute. So, of late, is the digitalis pur- purea, exhibited in powder, or the saturated tincture. By certain British writers, this last mentioned remedy is greatly preferred to either of the others. It is reported t© be productive of the hap- piest effects, in regulating the pulse, and facilitating expectoration;: at the same time that it diminishes the matter expectorated, in quantity, by weakening the force of the determination to the lungs. We have never used it in this disease; and are, therefore, unable to speak of it from experience. To promote expectoration and remove spasm, the smoking of the leaves and root of the datura stromonium, is strongly recom- mended. We believe that this remedy has proved, in many cases, | exceedingly useful. In one case reporied to us, it was followed by violent pains in the groins; which, however, soon disappeared, A well known remedy is the use of Mudge's inhaler, or the in- halation of the steams of warm water, from any other apparatus. Breathing over the fumes of turpentine, thrown on burning coalsv is alsp recommended. From neither of these processes, however, PRACTICE OF PHYSIC. 209 thodical nosologists, also, have distinguished Asthma from Dyspnoea chiefly, and almost solely, by the for- have we observed much benefit to be, at any time, derived. Yet others have spoken of them in the highest terms. The same remedies that have been recommended as expecto- rants, may be made to act the part of sudorifics. In this latter intention, if properly regulated, they may be rendered highly useful. Of antispasmodics in this disease, opiates hold the foremost rank. If united to ether, their efficacy is thought to be materially increased. In cases where an acid prevails in the stomach, a com- bination of opium and prepared chalk, is a remedy of high reput- ed efficacy. We have never ourselves been witness to its effects. In the resolution of spasm, ether alone may be administered with advantage. So may assafoetida, musk, and castor; especial- ly if given in large doses. Although a coarse and homely reme- dy, the juice of garlic is by no means inefficient. A table-spoon- ful of it may be given at a dose, in mixture with an equal quanti- ty of water. What would be the influence of arsenic, in shortening the con- tinuance of a paroxysm of asthma?—Mercury has been tried with but little effect. As a remedy in this disease, the breathing of factitious airs has been tried. But report, on the subject, differs with regard to the effects of the different kinds. Some practitioners speak favoura- bly of oxygenous gas, while others give a preference to an atmos- phere containing a superabundance of azote or hydrogen. We are inclined to believe, that, in this complaint, no permanent ad- vantage has ever been derived from the use of either. Whole- some atmospheric air is the best medium for the respiratory process. As remedies in the interval, for the prevention of asthmatic pa- roxysms, tonics are alone, or chiefly, in vogue. Nor are we sensible of any of them being specifically appli- cable to this complaint. Bark and bitters, chalybeates and zink, cuprum vitriolatuin and the nitrate of silver, may be exhibited as the practitioner maw deem expedient. VOL. II. *> d 210 PRACTICE OF PHYSIC. mer being the same affection with the latter, but in a higher degree. Neither of these applications of the term seems to have been correct or proper. I am of opinion, that the term asthma may be most properly applied, and should be confined, to a case of diffi- cult breathing that has peculiar symptoms, and depends upon a peculiar proximate cause, which I hope to as- sign with sufficient certainty. It is this disease I am now to treat of, and, it is nearly what practical writers have generally distinguished from the other cases of dif- ficult breathing, by the title of Spasmodic Asthma, or of Asthma convulsivum; although, by not distinguish- ing it with sufficient accuracy from the other cases of Dyspnoea, they have introduced a great deal of confu- sion into their treatises on this subject. Issues, setons, and perpetual blisters, are remedies which we think deserving of a trial. The flesh-brush should be used, flannel or fleecy hosiery worn next to the skin, and exercise taken freely in the open air. If the patient be able to bear it, riding on horseback is the mode of ex- ercise that ought to be preferred. As a tonic in this disease, the cold bath has, by some, been strongly recommended. It ought not, however, to be used with- out great caution. If it be followed by a pleasant glow on th« surface of the body, accompanied with sprightliness, and an in- crease of vigour, it is admissible and may be useful. But, if suc- ceeded by a sensation of chilliness, dulness, or lassitude, let it be immediately abandoned. An abstract choice of a place of residence for asthmatic patients appears to be impracticable. Some are most comfortable and healthy in the city, others in the country; some in an elevated and dry, and others in a low and humid situation. In this respect} therefore, let each individual choose for himself, provided nil means be such as to entitle him to a choice. Asthmatic patients should use a diet nutritious and easily digest- ed; and be exceedingly temperate inthe use of wine and other fermented liquors. PRACTICE OF PHYSIC. 211 1375. The disease I am to treat of, or the Asthma tq be strictly so called, is often a hereditary disease. It seldom appears very early in life, and hardly till the time of puberty, or after it. It affects both sexes, but most frequently the male. I have not observed it to be more frequent in one kind of temperament than in anoth- er; and it does not seem to depend upon any general tem- perament of the whole body, but upon a particular con- stitution of the lungs alone. It frequently attacks per- sons of a full habit: but it hardly ever continues to be re- peated for some length of time without occasioning an emaciation of the whole body. 1376. The attacks of this disease are generally in the night-time, or towards the approach of night; but there are also some instances of their coming on in the course of the day. At whatever time they come on, it is for the most part suddenly, with a sense of tightness and stricture across the breast, and a sense of straitness in the lungs impeding inspiration. The person thus attack- ed, if in a horizontal situation is immediately obliged to get into somewhat of an erect posture, and requires a free and cool air. The difficulty of breathing goes on for some time increasing; and both inspiration and expi- ration are performed slowly, and with a wheezing noise. In violent fits, speaking is difficult and uneasy. There is often some propensity to coughing, but it can hardly be executed. 1377. These symptoms often continue for many hours together, and particularly from midnight till the morning is far advanced. Then commonly a remission takes place by degrees; the breathing becomes less la- borious and more full, so that the person can speak and cough with more ease; and, if the cough brings up some 212 PRACTICE OF PHYSIC. mucus, the remissions becomes immediately more con- siderable, and the person falls into a much wished for sleep. 1378. During these fits the pulse often continues in its natural state; but in some persons the fits are atten- ded with a frequency of pulse, and with some heat and thirst, as marks of some degree of fever. If urine be voided at the beginning of a fit, it is commonly in con- siderable quantity, and with little colour or odour; but, after the fit is over, the urine voided is in the ordinary quantity, of a high colour, and sometime deposits a sedi- ment. In some persons, during the fit, the face is a lit- tle flushed and turgid; but more commonly it is some- what pale and shrunk. 1379. After some sleep in the morning; the patient, for the rest of the day, continues to have more free and easy breathing, but it is seldom entirely such. He still feels some tightness across his breast, cannot breathe easily in a horizontal posture, and can hardly bear any motion of his body, without having his breathing render- ed more difficult and uneasy. In the afternoon he has an unusual flatulency of his stomach, and an unusual drowsiness; and, very frequently, these symptoms pre- cede the first attacks of the disease. But, whether these symptoms appear or not, the difficulty of breathing re- turns totvards the evening; and then sometimes gradu- ally increases, till it becomes as violent as in the night before: or if, during the day, the difficulty of breathing has been moderate, and the person got some sleep in the first part of the night, he .is, however, waked about midnight, or at sometime between midnight and two o'clock in the morning; and is then suddenly seized with a fit of difficult breathing, which runs the same course as the night before. PRACTICE OF PHYSIC. 213 1380. In this manner fits return for several nights successively: but generally, after some nights passed in this way, the fits suffer more considerable remissions. This especially happens when the remissions are attend- ed with a more copious expectoration in the mornings, and that this continues from time to time throughout the day. In these circumstances, asthmatics, for a long time after, have not only more easy days, but enjoy also nights of entire sleep, without the recurrence of the dis- ease. 1381. When this disease, however, has once taken place in the manner above described, it is ready to re- turn at times for the whole of life after. These returns, however, happen with different circumstances in differ- ent persons. 1382. In some persons the fits are readily excited by external heat, whether of the weather or of a warm cham- ber, and particularly by warm bathing. In such per- sons fits are more frequent in summer, and particularly during the dog-days, than at other colder seasons. The same persons are also readily affected by changes of the weather; especially by sudden changes made from a colder to a warmer, or what is commonly the same thing, from a heavier to a lighter atmosphere. The same per- sons are also affected by every circumstance straitening the capacity of the thorax, as by any ligature* made, or even by a plaster laid upon it; and a like effect happens from any increased bulk of the stomach, either by a full meal, or by air collected in it. They are likewise much affected by exercise, or whatever else can hurry the circulation of the blood. 1383. As asthmatic fits seem thus to depend upon some fulness of the vessels of the lungs, it is probable 214 PRACTICE OF PHYSIC. that an obstruction of perspiration, and the blood being less determined to the surface of the body, may favour an accumulation in the lungs, and thereby be a means of ex- citing asthma. This seems to be the case of those asth- matics who have fits most frequently in the winter sea- son, and who have commonly more of a catarrhal affec- tion accompanying the asthma; which therefore occurs more frequently in winter, and more manifestly from the application of cold. 1384. Beside these cases of asthma excited by heat or cold, there are others, in which the fits are especially excited by powers applied to the nervous system; as by passions of the mind; by particular odours, and by irrita- tion of smoke and dust. That this disease is an affec- tion of the nervous system, and depending upon a mo- bility of the moving fibres of the lungs, appears pretty clearly from its being frequently attended with other spasmodic affections depending upon mobility; such as hysteria, hypochondriasis, dyspepsia, and atonic gout. 1385. From the whole of the history of asthma now delivered, I think it will readily appear, that the proxi- mate cause of this disease is a preternatural, and in some measure a spasmodic constriction of the muscular fibres of the bronchia?; which not only prevents the dilatation of the bronchiae necessary to a free and full inspiration, but gives also a rigidity which prevents a full and free exspiration. This preternatural constriction, like many other convulsive and spasmodic affections, is readily ex- cited by a turgescence of the blood, or other cause of any unusual fulness and distention of the vessels of the lungs. 1386. This disease, as coming by fits, may be gen- erally distinguished from most other species of dyspnoea, whose causes being more constantly applied, produce PRACTICE OF PHYSIC. 215 therefore a more constant difficulty of breathing. There may, however, be some fallacy'in this matter, as some of these causes may be liable to have abatements and intensities, whereby the dyspnoea produced by them may seem to come by fits; but I believe it is seldom that such fits put on the appearance of the genuine asthmatic fits described above. Perhaps, however, there is still another case that may give more difficulty; and that is when several of the causes, which we have as- signed as causes of several of the species of difficult breathing referred to the genus of Dyspnoea, may have the effect of exciting a genuine asthmatic fit. Whether this can happen to any but the peculiarly predisposed to asthma, I am uncertain; and therefore, whether in any such cases, the asthma may be considered as symptomat- ic; or if, in all such cases, the asthma may not still be con- sidered and treated as an idiopathic disease. 1387. The asthma, though often threatening imme- diate death, seldom occasions it, and many persons have lived long under this disease. In many cases, however, it does prove fatal; sometimes very quickly, and perhaps always at length. In some young persons it has ended soon, by occasioning a phthisis pulmonalis. After a long continuance, it often ends in a hydrothorax; and commonly, by occasioning some aneurism of the heart or great vessels, it thereby proves fatal. 1388. As it is seldom that an asthma has been entire- ly cured; I therefore cannot propose any method of cure which experience has approved as generally successful. But the disease admits of alleviation in several respects from the use of remedies; and my business now shall be chiefly to offer some remarks upon the choice and 216 PRACTICE OF PHYSIC. use of the remedies which have been commonly employ. ed in cases of asthma. 1389. As the danger of an asthmatic fit arises chiefly from the difficult transmission of the blood through the vessels of the lungs, threatening suffocation; so the most probable means of obviating this seems to be blood-let- ting: and therefore, in all violent fits, practitioners have had recourse to this remedy. In first attacks, and es. pecially in young and plethoric persons, blood-letting may be very necessary, and is commonly allowable. But it is also evident, that, under the frequent recur- rence of fits, blood-letting cannot be frequently repeated without exhausting and weakening the patient too much. It is further to be observed that blood-letting is not so necessary as might be imagined, as the passage of the blood through the lungs is not so much interrupted as has been commonly supposed. This I particularly con- clude from hence, that, instead of the suffusion of face, which is the usual effect of such interruption, the face, in asthmatic fits, is often shrunk and pale. I conclude the same also from this, that, in asthmatic fits, blood- letting does not commonly give so much relief as, up- on the contrary supposition, might be expected. 1390. As I have alleged above, that a turgescence of the blood is frequently the exciting cause of asth- matic fits, so it might be supposed, that a plethoric state of the system might have a great share in producing a turgescence of the blood in the lungs; and especially, therefore, that blood-letting might be a proper remedy in asthma. I allow it to be so in the first attacks of the disease: but as the disease, by continuing, generally takes off the plethoric state of the system; so, after the PRACTICE OF PHYSIC. 217 disease has continued for some time, I allege that blood- letting becomes less and less necessary. 1391. Upon the supposition of asthmatics being in a plethoric state, purging might be supposed to prove a remedy in this disease: but, both because the supposi- tion is not commonly well founded, and because pur- ging is seldom found to relieve the vessels of the thorax, this remedy has not appeared to be well suited to asth- matics; and large purging has always been found to do much harm. But as asthmatics are always hurt by the stagnation and accumulation of matters in the alimen- tary canal, so costiveness must be avoided, and an open belly proves useful. In the time of fits, the employ- ment of emollient and moderatively relaxative glysters has been found to give considerable relief. 1392. As a flatulency of the stomach, and other symp- toms of indigestion, are frequent attendants of asthma, and very troublesome to asthmatics; so, both for remov- ing these symptoms, and for taking of all determination to the lungs, the frequent use of gentle vomits is pro- per in this disease. In certain cases, where a fit was expected to come on in the course of the night, a vom- it given in the evening has frequently seemed to pre- vent it. 1393. Blistering between the shoulders, or upon the breast, has been frequently employed to relieve asthma- tics; but in the pure spasmodic asthma we treat of here, I have rarely found blisters useful, either in preventing or relieving fits. 1394. Issues are certainly useful in obviating pletho- ra; but as such indications seldom arise in cases of asth- ma, so issues have been seldom found useful in this disease. vol. n. e e 218 PRACTICE OF PHYSIC. 1395. As asthmatic fits are so frequently excited by a turgescence of the blood, so the obviating and allaying of this bv acids and neutral salts, seems to h.ive been at all times the object of practitioners. See Floyer on the asthma. 1396. Although a plethoric state of the system may seem to dispose to asthma, and the occasional turges- cence of the blood may seem to be frequently the exci- ting cause of the fits; yet it is evident, that the disease must have arisen chiefly from a peculiar constitution in the moving fibres of *he bronchiae, disposing them upon various occasions to fall into a spasmodic constric- tion; and therefore, that the entire cure of the disease can only be expected from the correcting of that pre- disposition, or from correcting the preternatural mobili- ty or irritability of the lungs in that respect. 1397. In cases wherein this predisposition depends upon original conformation, the cure must be difficult, and perhaps impossible, but it may perhaps be modera- ted by the use of antispasmodics. Upon this footing, various remedies of that kind have been commonly em- ployed, and particularly the fetid gums; but we have not found them of any considerable efficacy, and have observed them to be sometimes hurtful by their heating too much. Some other antispasmodics which might be supposed powerful, such as musk, have been properly tried. The vitriolic ether has been found to give relief, but its effects are not lasting. 1398. As in other spasmodic affections, so in this, the most certain and powerful antispasmodic is opium. I have often found it effectual, and generally safe; and if there have arisen doubts with respect to its safety, I believe they have arisen from not distinguishing between certain plethoric and inflammatory cases of dyspnoea im- PRACTICE OF PHYSIC. 219 properly named asthma, and the genuine spasmodic asthma we treat of here. 1399. As in many cases this disease depends upon a predisposition which cannot be corrected by our art, so in such cases the patient can only escape the disease by avoiding the occasional or exciting causes, which I have endeavoured to point out above. It is, however, diffi- cult to give any general rules here, as different asthma- tics have their different idiosyncrasies with respect to externals. Thus, one asthmatic finds himself easiest living in the midst of a great city, while another cannot breathe but in the free air of the country. In the latter case, however, most asthmatics bear the air of a low ground, if tolerable free and dry, better than that of the mountains. 1400. In diet, also, there is some difference to be made with respect to different asthmatics. None of them bear a large or full meal, orany food that is of slow and difficult solution in the stomach; but many of them bear animal food of the lighter kinds, and in moderate quantity. The use of vegetables which readily prove flatulent, are always very hurtful. In recent asthma, and especially in the young and plethoric, a spare, light, and cool diet is proper, and commonly necessary; but after the disease has continued for years, asthmatics com- monly bear, and even require, a tolerable full diet, though in all cases a very full diet is very hurtful. 1401. In drinking, water, or cool watery liquors, are the only safe and fit drinks for asthmatics; and all liquors ready to ferment, and become flatulent, are hurtful to them. Few asthmatics can bear any kind of strong drink; and any excess in such is always very hurt- ful to them. As asthmatics are commonly hurt by ta- 220 PRACTICE OF PHYSIC. king warm or tepid drink; so, both upon that account and upon account of the liquors weakening the nerves of the stomach, neither tea nor coffee is proper in this disease. 1402. Asthmatics commonly bear no bodily motion easily but that of the most gentle kind. Hiding, how- ever, on horseback, or going in a carriage, and espe- cially sailing, are very often useful to asthmatics. CHAPTER VII: OF THE CHINCOUGH, OR HOOPINGCOUGH' 1403. THIS disease is commonly epidemic, and manifestly contagious. It seems to proceed from a con- * In relation to the contagion of hooping-cough, we have al- ready made a frank expression of our doubts. We would not be understood as positively denying to it that property; but we are at a loss for facts to prove its possession of it. The mere occur- rence of the disease, in a number of individuals belonging to the same family or neighbourhood, at once, or in succession, is by no means sufficient for the purpose. It is well known that this may take place, and still the complaint be nothing but an efiidemic. That hooping-cough does exist and spread, independently of contagion, is a position which we cannot, for a moment, hesitate to believe. It often appears suddenly, in the country, without any ob- vious cause, and prevails throughout neighbourhoods of considera- ble extent, where the inhabitants are thinly scattered, and the chil- dren have no communication with each other. In these instances, it frequently attacks, at the same time, families remotely situated, between which no kind of intercourse exists. With facts of this description, no one can long reside in the country, and not be fa- miliar. The disease must, therefore, originate in a common source; and that source must necessarily be the atmosphere. Besides, in passing through a neighbourhood, hooping-cough never pbserves PRACTICE OF PHYSIC. 221 cagion of a specific nature, and of a singular quality. It does not, like most other contagions, necessarily pro- that regular march, which would justify a belief that it is commu- nicated only from the sick to the well. It does not, for example, commence in the north, and travel to the south; in the east, and tra- vel to the west; nor are its movements the reverse of these. It at- tacks scatteringly and promiscuously, as if it proceeded from a common source; and were governed, in its march, by the different susceptibilities of those who become subject to it; or, by the va* riety in their exposure to exciting causes. To our author's mode of treatment, which is highly judicious, we have but little to subjoin. The complaint being slight, is, com- paratively speaking, but rarely the subject of medical advice. In such cases, however, as it may have obstinately resisted other means, the following remedies are worthy of a trial. A preparation composed of opium, ipecacuanha, and the carbo- nate of soda. The proportions of this mixture recommended for a child of two years old, are one drop of laudanum, five drops of ipecacuanha wine, and two grains of the carbonate of soda, exhibit- ed, in a'pleasant vehicle, every fourth hour, for several days, obvia- ting costiveness by calomel or rhubarb. To children older or young- er, the remedy must be apportioned according to their ages. The acetate of lead, in doses of from the fourth to the eighth of a grain, exhibited, in some agreeable menstruum, every fourth or fifth hour, is recommended as a safe and useful remedy. The production of a slight strangury, by means of the tincture of cantharides, and the compound tincture of camphor combined, has acquired some reputation, as a measure calculated to moderate the cough and shorten its continuance. Artificial musk, dissolved in rectified spirits of wine, and exhibit- ed in small but repeated doses, is also spoken of as highly effica- cious. Of this remedy we have no knowledge. Hemlock, tincture of digitalis, hyosciamus, and arsenic, have all been proposed as remedies in hooping-cough. None of these hare we ourselves exhibited, except the latter, which, given in the dose of the twelfth or sixteenth of a grain, and repeated every tiiree or four hours, we have found to be advantageous. To mo* derate the cough, paregoric elixir is highly useful. 222 PRACTICE OF PHYSIC. duce a fever; nor does it, like most others, occasion any eruption, or produce otherwise any evident change in the state of the human fluids. It has, in common with the catarrhal contagion, and with that of the mea- sles, a peculiar determination to the lungs; but with particular effects there, very different from those of the other two; as will appear from the history of the disease now to be delivered. 1404. This contagion, like several others, affects persons but once in the course of their lives; and there- fore, necessarily, children are most commonly the sub- jects of this disease: but there are many instances of it occurring in persons considerably advanced in life; though it is probable, that the further that persons are advanced in life, they are the less liable to be affected with this contagion. 1405. The disease commonly comes on with the ordi- nary symptoms of a catarrh arising from cold; and often, for many days keeps entirely to that appearance; and I have had instances of a disease which, though evidently arising from the chincough contagion, never put on any other form than that of a common catarrh. This, how- Convalescence, in hoopingcough, is best promoted by pure air, exercise in the country, the use of the flesh-brush, or the wearing of flannel next to the skin, and a mild and plain but nourishing diet. As a tonic, in this complaint, after the removal of inflam- matory symptoms, tincture of bark, chalybeates, and infusion of Colombo, in doses suited to the age and strength of the patient, are recommended. Let those who wish to be further informed on the subject of hoopingcough, consult Willis—Sydenham—Morton de tussi con- vulsiva—Hoffman, Suppl. ii.—Huxham—Fothergill—Stoll. rat. med.—Butler on the kinckcough, and on hemlock—Kirkland de pcrtussi—and R. Pearson. PRACTICE OF PHYSIC. 223 ever seldom happens; for, generally in the second, and at farthest in the third week after the attack, the disease puts on its peculiar and characteristic symptom, a con- vulsive cough. This is a cough in which the expiratory motions peculiar to coughing are made with more fre- quency, rapidity, and violence, than usual. As these circumstances, however, in different instances of cough- ing, are in very different degrees; so no exact limits can be put to determine when the cough can be strictly said to be convulsive; and it is therefore especially by ano- ther circumstance that the chincough is distinguished from every other form of cough. This circumstance is, when many expiratory motions have been convulsive- ly made, and thereby the air is in great quantity thrown out from the lungs, a full inspiration is necessarily and suddenly made; which, by the air rushing in through' the glottis with unusual velocity, gives a peculiar sound. This sound is somewhat different in different cases, but is in general called a Hoop; and from it the whole of the disease is called the Hooping Cough. When this sono- rous inspiration has happened, the convulsive coughing is again renewed, and continues in the same manner as before, till a quantity of mucus is thrown up from the lungs, or the contents of the stomach are thrown up by vomiting. Either of these evacuations commonly puts an end to the coughing, and the patient remains free from it for some time after. Sometimes it is only after several alternate fits of coughing and hooping that ex- pectoration or vomiting takes place; but it is commonly after the second coughing that these happen, and put an end to the fit. 1406. When the disease, in this manner, has taken its proper form, it generally continues for a long time 224 PRACTICE OF PHYSIC. after, and generally from one month to three; but some- times much longer, and that with very various circum- stances. 1407. The fits of coughing return at various inter- vals, rarely observing any exact period. They happen frequently in the course of the day, and more frequently still in the course of the night. The patient has com- monly some warning of their coming on; and, to avoid that violent and painful concussion which the coughing gives to the whole body, he clings fast to any thing that is near to him, or demands to be held fast by any per- son that he can come at. When the fit is over, the patient sometimes breathes fast, and seems fatigued for a little after: but in many this appears very little; and children are commonly so entirely relieved, that they immediately return to their play, or what else they were occupied in before. 1408. If it happens that the fit of coughing ends in vomiting up the contents of the stomach, the patient is commonly immediately after seized with a strong cra- ving and demand for food, and takesut in very greedily. 1409. At the first coming on of this disease, the ex- pectoration is sometimes none at all, or if a thin mucus only; and while this continues to be the case, the fits of coughing are more violent, and continue longer; but commonly the expectoration soon becomes consider- able, and a very thick mucus, often in great quantity, is thrown up; and as this is more readily brought up, the fits of coughing are of shorter duration. 1410. The violent fits of coughing frequently inter- rupt the free transmission of the blood through the lungs, and thereby the free return of blood from the ves- sels of the head. This occasions that turgescence and PRACTICE OF PHYSIC. 225 \ suffusion of face which commonly attends the fits of coughing, and seems to occasion also those eruptions of blood from the nose, and even from the eyes and ears which sometimes happen in this disease. 1411. This disease often takes place in the manner we have now described, without any pyrexia attending it; but, though Sydenham had seldom observed it, we have found the disease very frequently accompanied with pyrexia, sometimes from the very beginning, but more frequently only after the disease had continued for some time. When it does accompany the disease, we have not found it appearing under any regular intermittent form. It is constantly in some degree present; but with evident exacerbations towards evening, continuing till next morning. 1412. Another symptom very frequently attending the chincough, is a difficulty of breathing; and that not only immediately before and after fits of coughing, but as constantly present, though in different degrees in differ- ent persons. I have hardly ever seen an instance of a fatal chincough, in which a considerable degree of py- rexia and dyspnoea had not been for some time constant- ly present. 1413. When by the power of the contagion this dis- ease has once taken place, the fits of coughing are often repeated, without any evident exciting cause: but in ma- ny cases, the contagion may be considered as giving a predisposition only; and the frequency of fits depends in some measure upon various exciting causes; such as, violent exercise; a full meal; the having taken in food of difficult solution; irritation of the lungs by dust, smoke or disagreeable odours of a strong kind: and es- pecially any considerable emotion of the mind. VOL. II. f f 22*6 PRACTICE OF PHYSIC. 1414. Such are the chief circumstances of this dis- ease, and it is of various event; which, however, may be commonly foreseen by attending to the following considerations. The younger that children are, they are in the great- er danger from this disease; and of those to whom it proves fatal, there are many more under two years old than above it. The older that children are, they are the more secure against an unhappy event; and this I hold to be a very general rule, though I own there are many exceptions to it. Children born of phthisical and asthmatic parents are in the greatest danger from this disease. When the disease beginning in the form of a catarrh, is attended with fever and difficult breathing, and with little expectoration, it often proves fatal, without taking on the form of the hoopingcough; but, in most of such cases, the coming on of the convulsive cough and hoop- ing, bringing on at the same time a more free expecto- ration, generally removes the danger. When fcthe disease is fully formed, if the fits are nei- ther frequent nor violent, with moderate expectoration, and the patient, during the intervals of the fits, is easy, keeps his appetite, gets sleep, and is without fever or difficult breathing, the disease is attended with no dan- ger; and these circumstances becoming daily more fa- vourable, the disease very soon spontaneously termin- ates. An expectoration, either very scanty or very copious, is attended with danger; especially if the latter circum- stance is attended with great difficulty of breathing. PRACTICE OF PHYSIC. 227 Those cases in which the fits terminate by a vomit- ing, and are immediately followed by a craving of food, are generally without danger. A moderate hemorrhagy from the nose often proves salutary; but very large hemorrhagies are generally very hurtful. This disease coming upon persons under a state of much debility, has very generally an unhappy event. The danger of this disease sometimes arises from the violence of the fits of coughing, occasioning apoplexy, epilepsy, or immediate suffocation: but these accidents are very rare: and the danger of the disease seems gene- rally to be in proportion to the fever and dyspnoea at- tending it. 1415. The cure of this disease has been always con- sidered as difficult, whether the purpose be to obviate its fatal tendency when it is violent, or merely to short- en the course of it when it is mild. When the conta- gion is recent, and continues to act, we neither know how to correct, nor how to expel it; and therefore the disease necessarily continues for some time: but it is probable, that the contagion in this as in other instances ceases at length to act; and that then the disease con- tinues, as in other convulsive affections, by the power of habit alone. 1416. From this view of the matter I maintain,, that the practice must be different, and adapted to two differ- ent indications, according to the period of the disease. At the beginning of the disease, and for some time after, the remedies to be employed must be such as may ob- viate the violent effects of the disease, and the fatal ten- dency of it; but, after the disease has continued for some time, and is without any violent symptoms, the only 228 PRACTICE OF PHYSIC. remedies which can be required are those which may interrupt its course, and put an entire stop to it sooner than it would have spontaneously ceased. 1417. For answering the first indication. In pleth- oric subjects, or in others, when from the circumstances of the cough and fits it appears that the blood is diffi- cultly transmitted through the lungs, blood-letting is a necessary remedy; and it may be even necessary to re- peat it, especially in the beginning of the disease; but, as spasmodic affections do not commonly admit of much bleeding, so it is seldom proper in the chincough to re- peat this remedy often. 1418. As costiveness frequently attends this disease, so it is necessary to obviate or remove it by laxatives employed; and keeping an open belly is generally use- ful: but large evacuations in this way are commonly hurtful. 1419. To obviate or remove the inflammatory deter- mination to the lungs that sometimes occur in this dis- ease, blistering is often useful, and even repeated blis- tering has been of service; but issues have not so much effect, and should by no means supersede the repeated blistering that may be indicated. When blisters are proper, they are more effectual when applied to the tho- rax, than when applied to any distant parts. 1420. Of all other remedies, emetics are the most useful in this disease; both in general by interrupting the return of spasmodic affections, and in particular by de- termining very powerfully to the surface of the body, and thereby taking off determinations to the lungs. For these purposes, 1 think, full vomiting is frequently to be employed; and, in the intervals necessary to be left between the times of full vomiting, nauseating doses of PRACTICE OF PHYSIC. 229 the antimonial emetics may be useful. I have never found the sulphur auratum, so much praised by Clossius, to be a convenient medicine, on account of the uncer- tainty of its dose; and the tartar emetic employed in the manner directed by the late Dr. Fothergill, has appeared to be more useful. 1421. These are the remedies to be employed in the first srage of the disease for obviating its fatal tendency, and putting it into a safe train. But in the second stage, when I suppose the contagion has ceased to act, and that the disease continues merely by the power of habit, a different indication arises, and different remedies are to be employed. 1422. This disease, which often continues for a long time, does not, in my opinion, continue during the whole of that time in consequence of the contagion's remain- ing in the body, and continuing to act in it. That the disease does often continue long after the contagion has ceased to act, and that too by the power of habit alone, appears to me probable from hence, that terror has fre- quently cured the disease; that any considerable change in the state of the system, such as the coming on of the small-pox, has also cured it; and lastly, that it has been cured by antispasmodic and tonic medicines; whilst none of all these means of cure can be supposed either to cor^ feet or to expel a morbific matter, though they are evi- dently suited to change the state and habits of the ner- vous system. 1423. From this view we are directed to the indi- cation that may be formed, and in a great measure to the remedies which may be employed in what we suppose to be the second stage of the disease. It may perhaps be alleged, that this indication of shortening the course 23G PRACTICE OF PHYSIC. of the disease is not very important or necessary, as it supposes that the danger or violence is over, and in con- sequence, that the disease will soon spontaneously cease* The last supposition, however, is not well founded; as the disease, like many other convulsive and spasmod- ic affections, may continue for a long time by the pow- er of habit alone, and by the repetition of paroxysms, may have hurtful effects; more especially as the violence of paroxysms, and therefore their hurtful effects, may be much aggravated by various external causes that may be accidentally applied. Our indication, therefore, is proper; and we proceed to consider the several remedies which may be employed to answer it. 1424. Terror may possibly be a powerful remedy, but it is difficult to measure the degree of it that shall be produced; and, as a slight degree of it may be ineffectual, and a high degree of it dangerous, I cannot propose to - employ it. 1425. The other remedies which we suppose suited to our second indication, and which indeed have been frequently employed in this disease, are antispasmodic or tonics. Of the antispasmodics, castor has been particularly recommended by Dr. Morris; but in many trials we have not found it effectual. With more probability musk has been employed: but whether it be from our not having it of a genuine kind, or not employing it in sufficiently large doses, I cannot determine; but we have not found it commonly successful. Of antispasmodics, the most certainly pow- erful is opium: and when there is no considerable fe- ver or difficulty of breathing present, opium has often proved useful in moderating the violence of the chin- PRACTICE OF PHYSIC. 231 cough; but I have not known it employed so as entire- ly to cure the disease. If hemlock has proved a remedy in this disease, as we must believe from Dr. Butter's accounts, I agree with that author, that it is to be considered as an anti- spasmodic. Upon this supposition, it is a probable reme- dy; and from the accounts of Dr. Butter and some others, it seems to have been often useful: but, in our trials, it has often disappointed us, perhaps from the preparation of it not having been always proper. 1426. Of the tonics, I consider the cupmoss, for- merly celebrated, as of this kiiid; as also the bark of the misletoe; but I have had no experience of either, as I have always trusted to the Peruvian bark. I consider the use of this medicine as the most certain means of cu- ring the disease in its second stage; and when there has been little fever present, and a sufficient quantity of the bark has been given, it has seldom failed of soon putting an end to the disease. 1427. When convulsive disorders may be supposed to continue by the force of habit alone, it has been found that a considerable change in the whole of the circum- stances and manner of life has proved a cure of such diseases; and analogy has supplied this in the case of the chincough so far, that a change of air has been em- ployed, and supposed to be useful. In several instan- ces I have observed it to be so; but I have never found the effects of it durable, or sufficient to put an entire stop to the disease. 232 PRACTICE OK PHYSIC. SECTION III. OF THE SPASMODIC AFFECTIONS IN THE NATU- RAL FUNCTIONS. CHAPTER VIII. OF THE PYROSIS, OR WHAT IS NAMED IN SCOT- LAND, THE WATER-BRASH.* 1428. THE painful sensations referred to the sto- mach, and which are probably occasioned by real affec- tions of this organ, are of different kinds. Probably they proceed from affections of different natures, and should therefore be distinguished by different appella- tions; but I must own that the utmost precision in this matter will be difficult. In my essay towards a me- thodical nosology, I have, however, attempted it. For those pains that are either acute and pungent, or accom- panied with a sense of distention, or with a sense of * We have known a few cases of pyrosis to be successfully treated by a mixture of equal quantities of lime water and new milk, in the dose of a table-spoonful five or six times a day; with the occasional use of opiates, and of blisters to the epigastric region. For the cure of this disease, the oxyd of bismuth is highly re- commended. Five grains of that medicine, with a scruple of gum tragacanth, may be taken, by an adult, three or four times a day. The nux vomica, recommended by Linnaeus, may be exhibited in ten grain doses, to be repeated twice or three times a day. A good rule for persons subject to this disease is, never to allow their stomachs to become entirely empty, but to eat, occasionally, even on awaking at night, if the disease attack them in the morn- ing, a cracker or a bit of crust of bread. PRACTICE OF PHYSIC. 233 constriction, if they are at the same time, not attended with any sense of acrimony or heat, I employ the ap- pellation of gastrodynia. To express those painful or uneasy sensations which seem to arise from a sense of acrimony irritating the part, or from such a sense of heat as the application of acrids, whether externally or inter- nally applied, often gives, I employ the term of cardi- algia; and by this I particularly mean to denote those feelings which are expressed by the term heartburn in the English language. I think the term soda has been commonly employed by practical writers to express an affection attended with feelings of the latter kind. 1429. B'eside the pains denoted by the terms gastrcv dynia, periadynia, cardialgia, and soda, there is> I think, another painful sensation different from all of these, which is named by Mr. Sauvages, pyrosis suecica; and his account of it is taken from Linnaeus, who names it cardialgia sputatoria. Under the title of pyrosis, Mr. Sauvages has formed a genus, of which the whole of the species, except the eighth, which he gives under the title of Pyrosis suecica, are all of them species of the gastrody- nia or of the,cardialgia; and if there is a genus to be for- med under the title of pyrosis, it can in my opinion com- prehend only the species I have mentioned. In this case, indeed, I own that the term is not very proper; but my aversion to introduce new na.-nes has made me continue to employ the term of Mr. Sauvages. 1.430. The Gastrodynia and Cardialgia I judge to be for the most part symptomatic affections; and therefore have given them noplace in this work: but the Pyrosis, as an idiopathic disease, and never before treated of in any system, I propose to treat of here* vol. ir. g g 234 PRACTICE OF PHYSIC. 1431. It is a disease frequent among people in lower life; but occurs also, though more rarely, in people of better condition. Though frequent in Scotland, it is by no means so frequent as Linnaeus reports it to be in Lapland. It appears most commonly in persons un- der middle age, but seldom in any persons before the age of puberty. When it has once taken place, it is ready to recur occasionally for a long time after; but it seldom appears in persons considerably advanced in life It affects both sexes but more frequently the female. It sometimes attacks pregnant women, and some women only when they are in that condition. Of other women, it more frequently affects the unmarried; and of the mar- ried, most frequently the barren. I have had many in- stances of its occurring in women labouring under a fluor albus. 1432. The fits of this disease usually come on in the morning and forenoon, when the stomach is empty. The first symptom of it is a pain at the pit of the stom- ach, with a sense of constriction, as if the stomach was drawn towards the back; the pain is increased by raising the body into an erect posture, and therefore the body is bended forward. This pain is often very severe; and after continuing for some time, it brings on an eructa- tion of a thin watery fluid in considerable quantity. This fluid has sometimes an acrid taste, but is very of- ten absolutely insipid. The eructation is for some time frequently repeated; and does not immediately give re- lief to the pain which preceded it, but does so at length, and puts an end to the fit. 1433. The fits of this disease commonly come on without any evident exciting cause: and I have not found it steadily connected with any particular diet. It attacks persons using animal food, but I think more frequently ! hose living on milk and farinacea. It seems often to be PRACTICE OF PHYSIC. 235 excited by cold applied to the lower extremities; and is readily excited by any considerable emotion of mind. It is often without any symptoms of dyspepsia. 1434. The nature of this affection is not very obvi- ous; but I think it may be explained in this manner: It seems to begin by a spasm of the muscular fibres of the stomach; which is afterwards, in a certain manner, com- municated to the blood-vessels, and exhalants, so as to increase the impetus of the fluids in these vessels, while a constriction takes place on their extremites. While therefore the increased impetus determines a greater quantity than usual of fluids into these vessels, the con- striction upon their extremities allows only the pure wa- tery parts to be poured out, analogous, as I judge, in every respect to what happens in the diabetes hystericus. 1435. The practice in this disease is as difficult as the theory. The paroxysm is only to be certainly re- lieved by opium. Other antispasmodics, as vitriolic ether and volatile alkali, are sometimes of service, but not constantly so. Although opium and other antispas- modics relieve the fits, they have no effect in preven- ting their recurrence. For this purpose, the whole of the remedies of dyspepsia have been employed without success. Of the use of the nux vomica, mentioned as a remedy by Linnaeus, I have had no experience. CHAPTER IX. OF THE COLIC* -* 1436. THE principal symptom of this disease, is a pain felt in the lower belly. It is seldom fixed and pun- * Bilious colic is always a febrile disease, and, like other# forms of pyrexia, is ushered in by a chill. It may be regarded as a bi- lious fever thrown on the bowels. The chill, by which it is in- troduced, distinguishes it from other kinds of colic. 236 PRACTICE OF PHYSIC. gent in one part, but is a painful distention in some measure spreading over the whole of the belly; and par- ticularly with a sense of twisting or wringing round the navel. At the same time, with this pain, the navel and teguments of the belly are frequently drawn inwards, and often the muscles of the belly are spasmodically contracted, and this in separate portions, giving the ap- pearance of a bag full of round balls. 1437. Such pains in a certain degree, sometimes oc- cur in cases of diarrhoea and cholera; but these are less violent and more transitory, and are named Gripings. It is only when more violent and permanent, and attended with costiveness, that they constitute colic. This is al- so commonly attended with vomiting, which in many cases is frequently repeated, especially when any thing is taken down into the stomach; and in such vomitings, not only the contents ,of the stomach are thrown up, but also the contents of the duodenum, and therefore fre- quently a quantity of bile. 1438. In some cases of colic, the paristaltic motion is inverted though the whole length of the alimentary canal, in such a manner that the contents of the great guts, and therefore, stercoraceous matter, is thrown up by vomi- ting; and the same inversion appears still more clearly from this, that what is thrown into the rectum by glyster is igain thrown out by the mouth. In these circum- stances of inversion the disease has been named Ileus, or the Iliac Passion; and this has been supposed to be a peculiar disease distinct from colic; but to me it ap- pears that the two diseases are owing to the same prox- imate* cause, and have the same symptoms, only in a different degree. PRACTICE OF PHYSIC. 237 1439. The colic is often without any pyrexia atten- ding it. Sometimes, however, an inflammation comes upon the part of the intestine especially affected; and this inflammation aggravates all the symptoms of the dis- ease, being probably what brings on the most consid- erable inversion of the peristaltic motion; and, as the stercoraceous vomiting is what especially distinguishes the ileus, this has been considered as always depending on an inflammation of the intestines. However, I can affirm, that as there are inflammations of the intestines without stercoraceous vomiting, so I have seen instanc- es of stercoraceous vomiting without inflammation; and there is therefore no ground for distinguishing ileus from colic, but as a higher degree of the same affection. 1440. The symptoms of the colic, and the dissections of bodies dead of this disease, show very clearly that it depends upon a spasmodic constriction of a part of the intestines, and that this therefore is to be considered as the proximate cause of the disease. In some of the dissections of persons dead of this disease, an intus-sus- ception has been remarked to have happened; but wheth- er this be constantly the case in all the appearances of Ileus, is not certainly determined. 1441. The colic has commonly been considered as being of different species, but I cannot follow the writers on this subject in the distinctions they have established. So far, however, as a difference of the remote cause con- stitutes a difference of species, a distinction may per- haps be admitted; and accordingly in my Nosology I have marked seven different species: but I am well persua- ded, that in all these different species the proximate cause is the same, that is, a spasmodic constriction of a part 238 PRACTICE OF PHYSIC. of the intestines: and consequently, that in all these ca- ses the indication of cure is the same, that is, to re- move the constriction mentioned. Even in the several species named Stercorea, Callosa, and Calculosa, in which the disease depends upon an obstruction of the intestine, I am persuaded that these obstructions do not produce the symptoms of colic, excepting in so far as they produce spasmodic constrictions of the intestines; and therefore, that the means of cure in these cases, so far as they admit of cure, must be obtained by the means which the general indication above-mentioned suggests. 1442. The cure, then, of the colic universally, is to be obtained by removing the spasmodic constrictions of the intestines; and the remedies suited to this purpose may be referred to three general heads. 1. The taking off the spasm by various antispasmodic powers. 2. The exciting the action of the intestines by pur- gatives. 3. The employing mechanical dilatation.* * The leading indication of cure, in the treatment of colic, is, to evacuate thoroughly the alimentary canal. Opiates, and other remedies, employed previously to this process, are useful only, or principally, as far as they facilitate the retention of purgatives on the stomach, and in their operation. The complete evacuation of the alimentary canal, with blood-letting, and blisters to the ab- domen, to prevent intestinal inflammation, and the judicious em- ployment of opiates, seldom fail to effect a cure. Opiates should seldom be administered previously to purga- tives, unless with a view to suppress vomiting, or relieve pain, which cannot be tolerated. In cases, however, that have not been preceded by costiveness, or which have been brought on by PRACTICE OF PHYSIC. 239 1443. Before entering upon a particular account of these remedies, it will be proper to observe, that in all cases of violent colic, it is advisable to practise blood- letting; both as it may be useful in obviating the in- flammation which is commonly to be apprehended, and even as it may be a means of relaxing the spasm of the intestine. This remedy may perhaps be improper in persons of a weak and lax habit, but in all persons of tolerable vigour it will be a safe remed\; and in all cases where there is the least suspicion of an inflamma- tion actually coming on, it will be absolutely necessary. Nay, it will be even proper to repeat it perhaps several times, if, with a full and hard pulse, the appearance of blood drawn, and the relief obtained by the first bleed- ing, shall authorise such repetition. 1444. The antispasmodic powers that may be em- ployed, are, the application of heat in a dry or humid form, the application of blisters, the use of opium, and the use of mild oils. The application of heat, in a dry form, has been em- ployed by applying to the belly of the patient a living animal, or bladders filled with warm water, or bags of substances which long retain their heat; and all these have sometimes been applied with success; but none of them seem to me so powerful as the application of heat in a humid form. This may be employed either by the immersion of a great part of the body in warm water, or by fomenting the belly with cloths wrung out of hot water. The im- mersion has advantages from the application of it to a greater part of the body, and particularly to the lower ex- passk-ns or affections of the mind, or by the immediate action of cold, opiates maybe safely and uscfuily administered, even before the exhibition of purgatives. 240 PRACTICE OF PHYSIC. tremities: but immersion cannot always be conveniently practised, and fomentation may have the advantage of being longer continued; and it may have nearly all the benefit of immersion, if it be at the same time applied both to the belly and to the lower extremities. 1445. From considering that the teguments of the lower belly have such a connection with the intestines, as at the same time to be affected with spasmodic con- traction, we perceive that blisters applied to the belly may have the effect of taking off the spasms both from the muscles of the belly and from the intestines; and ac- cordingly, blistering has often been employed in the colic with advantage. Analogous to this, rubefacients applied to the belly have been frequently found useful. 1446. The use of opium in the eolic may seem to be an ambiguous remedy. Very certainly it may for some time relieve the pain, which is often so violent and ur- gent that it is difficult to abstain from the use of such a remedy. At the same time, the use of opium retards or suspends the peristaltic motion so much, as to allow the intestines to fall into constrictions; and may there- fore, while it relieves the pain, render the cause of the disease more obstinate. On this account, and further as opium prevents the operation of purgatives so often necessary in this disease, many practitioners are averse to the use of it, and some entirely reject the use of it as hurtful. There are, however, others who think they can employ opium in this disease with much advantage. In all cases where the colic comes on without any previous costiveness, and arises from cold, from pas- sions of the mind, or other causes which operate espe- cially on the nervous system, opium proves a safe and certain remedy; but in cases which have been preceded PRACTICE OF PHYSIC. 241 by costiveness, has however continued for some days without a stool, so that a stagnation of fasces in the colon is to be suspected, the use of opium is of doubtful ef- fect. In such cases, unless a stool has been first pro- cured by medicine, opium cannot be employed but with some hazard of aggravating the disease. However, even in those circumstances of costiveness, when, without in- flammation, the violence of the spasm is to be suspected, when vomiting prevents the exhibition of purgatives, and when with all this the pain is extremely urgent, opi- um is to be employed, not only as an anodyne, but also as an antispasmodic, necessary to favour the operation of purgatives; and may be so employed, when, either at the same time with the opiate, or not long after it, a purgative can be exhibited. Is the hyoscyamus, as often showing, along with its narcotic, a purgative quality, better suited to this dis- ease than opium? 1447. It is seemingly on good grounds that several practitioners have recommended the large use of mild oils in this disease, both as antispasmodics and as laxa- tives; and, where the palate and stomach could admit them, I have found them very useful. But as there are few Scottish stomachs that can admit a large use of oils, I have had few opportunities of employing them. 1448. The second set of remedies adapted to the cure of colic, are purgatives; which, by exciting the action of the intestines, either above or below the ob- structed place, may remove the constriction; and there- fore these purgatives may be given e ither by the mouth or thrown by glysters into the anus. As the disease is often seated in the great guts; as glysters, by having a more sudden operation, may give more immediate relief; VOL. II. h h 242 PRACTICE OF PHYSIC. and as purgatives given by the mouth are ready to be rejected by vomiting; so it is common, and indeed pro- per, to attempt curing the colic in the first place by glysters. These may at first be of the mildest kind, consisting of a large bulk of water, with some quantity of mild oil; and such are sometimes sufficiently efficacious: however, they are not always so; and it is commonly ne- cessary to render them more powerfully stimulant by the addition of neutral salts, of which the most powerful is the common or marine salt. If these saline glysters, as sometimes happens, are rendered again too quickly, and on this or otherwise are found ineffectual, it may be proper instead of these salts, to add to the glys- ters an infusion of senna, or of some other purgative that can be extracted by water. The antimonial wine, may be sometimes employed in glysters with advantage. Hardly any glysters are more effectual than those made of turpentine properly prepared. When all other injec- tions are found ineffectual, recourse is to be had to the injection of tobacco smoke; and, when even this fails, recourse is to be had to the mechanical dilatation to be mentioned hereafter.* * We repeat, that our author is mistaken, in representing pur- gatives as the " second set of remedies" in the treatment of colic. When the stomach can retain them, and no peculiarities exist to prevent their use, they are unquestionably the first. If the sto- mach be altogether unretentive, injections constitute the best sub- stitute for the use of purgatives. The antimonial injection, con- sisting of, from fifteen to twenty grains, of tartarized antimony, dissolved in a suitable quantity of water, and carefully adminis- tered, is an important remedy. So is the turpentine injection, composed of from half an ounce, to six drachms, of Venice tur- pentine, mixed in a pint of tepid water, by means of the yolks of two or three eggs. PRACTICE OF PHYSIC. 243 1449. As glysters often fail altogether in relieving this disease, and as even when they give some relief they are often imperfect in producing a complete cure; so it is generally proper, and often necessary, to attempt a more entire and certain cure by purgatives given by the mouth. The more powerful of these, or, as they are called, the drastic purgatives, may be sometimes neces- sary; but their use is to be avoided, both because they are apt to be rejected by vomiting, and because when they do not succeed in removing the obstruction, they are ready to induce an inflammation. Upon this ac- count it is usual, and indeed proper, at least in the first place, to employ the milder and less inflammatory pur- gatives. None have succeeded with me better than the crystals of tartar, because this medicine may be given in small but repeated doses to a considerable quantity; and under this management it is the purgative least ready to be rejected by vomiting, and much less so than the other neutral salts. If a stronger purgative be required, jalap properly prepared, is less offensive to the palate, and sits better upon the stomach, than most other powerful pur- gatives. On many occasions of colic, nothing is more effectually purgative than a large dose of calomel. Some practitioners have attempted to remove the obstruction of the intestines by antimonial emetics exhibited in small doses, repeated at proper intervals; and when these An injection more powerful, perhaps, than either, may be pre- pared, by boiling half a drachm of tobacco, in a quart of water, un- til it be reduced to a pint. This may be used at once, or twice, as circumstances may require. An excellent common injection, consists of a solution of Glau- ber's salts, in water or camomile tea, or of balsam capivi, mixed in water, by means of the yolk of an egg. 244 PRACTICE OF PHYSIC. doses are not entirely rejected by vomiting, they often prove effectual purgatives. When every purgative has failed, the action of the intestines has been effectually excited by throwing cold water on the lower extremities.* 1450. The third means of overcoming the spasm of the intestines in this disease, is by employing a mechani- cal dilatation; and it has been frequently supposed that quicksilver, given in large quantity, might operate in this manner. I have not, however, found it successful; and the theory of it is with me very doubtful. Some authors have mentioned the use of gold and silver pills, or, balls, swal- lowed down; but I have no experience of such practices, and I cannot suppose them a probable means of relief. 1451. Another means of mechanical dilatation and a more probable measure, is by injecting a large quantity of warm water by a proper syringe, which may throw it with some force, and in a continued stream, into the rectum. Both from the experiments reported by the late Mr. De Haen, and from those I myself have had occasion to make, I judge this remedy to be one of the most powerful and effectual.! * A purgative, which we have found to answer exceedingly well, and of which the stomach is usually retentive, consists of Glauber's, Rochelle, or Epsom salts, dissolved in Seltzer water, and taken in moderate doses, repeated every hour, until it shall have operated. When the stomach can retain it, castor oil is a very valuable purgative. So is calomel, followed, in an hour or two, by jalap and cream of tartar. Injections of cold water have succeeded in moving the bowels,. in colic, when other remedies have failed. t Two gallon* of tepid water are said to have been thrown into the intestines of some patients, with the happiest effects. Of this mode of practice we have had no experience. PRACTICE OF PHYSIC. 245 1452. I have now mentioned all the several means that may be employed for the cure of the colic, consid- ered as a genus; but before I quit this subject, it may be expected that I should take notice of some of the species which may seem to require a particular conside- ration. In this view it may be expected that I should especially take notice of that species named the colic of Poitou, and particularly known in England by the name of the Devonshire colic* 1453. This species of the disease is certainly a peculi- ar one, both in respect of its cause and its effects; but, as to the first, it has been lately so much the subject of in- vestigation, and is so well ascertained by the learned physicians Sir George Baker and Dr. Hardy, that it is unnecessary for me to say any thing of it here. With respect to the cure of it, so far as it appears in the form of a colic, my want of experience concerning it does not allow me to speak with any confidence on the subject; but, so far as I can learn from others, it ap- pears to me, that it is to be treated by all the several means that I have proposed above for the cure of colic in general. How far the peculiar effects of this disease are to be certainly foreseen and obviated, I have not properly learned; and I must leave the matter to be determined by those who have had sufficient experience in it. * The most prompt and certain remedy, we have ever seen employed, in the treatment of colica pictonum, is a mercurial ptyalism. When adopted early in the disease, it seldom fails to effect a cure. 246 PRACTICE OF PHYSIC CHAPTER X. OF THE CHOLERA. 1454. IN this disease, a vomiting and purging con- curring together, or frequently alternating with one an- other, are the chief symptoms. The matter rejected both upwards and downwards appears manifestly to con- sist chiefly of bile. 1455. From this last circumstance I conclude, that the disease depends upon an increased secretion of bile, and its copious effusion into the alimentary canal: and, as in this it irritates and excites the motions above men- tioned, I infer, that the bile thus effused in larger quan- tity is at the same time also of a more acrid quality. This appears likewise from the violent and very painful gripings that attend the disease, and which we can im- pute only to the violent spasmodic contractions of the intestines that take place here. These spasms are com- monly communicated to the abdominal muscles, and very frequently to those of the extremities.* * Cholera morbus is as completely a gastric affection, as any one in the whole catalogue of diseases. Gastritis itself is not more so. The original irritation is in the stomach; and the aug- mented secretion of bile follows as a consequence. Our author, therefore, has evidently mistaken the effect for the cause—a mere symptom, for the original disease. In evidence of the truth of what we have said, we would ob- serve, that the first discharges, in this disease, are not bilious; but consist merely of the contents of the stomach and bowels. No bile is evacuated, until it has been first secreted, as an effect of the disease—at least, it is not evacuated in large quantities until thus produced. Nor does that fluid appear to be characterized by any unusual acrimony in cholera. It is probably more bland than even in health; being discharged, as soon as secreted; and having, therefore, no time to acquire acrid qualities, by the absorp- tion of its aqueous portion. PRACTICE OF PHYSIC. 247 1456. In the manner now described, the disease fre- quently proceeds with great violence, till the strength of the patient is greatly, and often suddenly, weakened; while a coldness of the extremities, cold sweats, and faintings, coming on, an end is put to the patient's life, sometimes in the course of one day. In other cases the disease is less violent, continues for a day or two, and then ceases by degrees; though such recoveries seldom happen without the use of remedies. 1457. The attacks of this disease are seldom accom- panied with any symptoms of pyrexia; and though, during the course of it, both the pulse and respiration are hurried and irregular, yet these symptoms are gene- rally so entirely removed by the remedies that quiet the spasmodic affection peculiar to the disease, as to leave no ground for supposing that it had been accompanied by any proper pyrexia. 1458. This is a disease attending a very warm state of the air; and" in very warm climates, it may perhaps appear at any time of the year: but even in such climates it is most frequent during their warmest seasons; and in temperate climates, it appears only in the warm sea- sons. Dr. Sydenham considered the appearances of this disease in England to be confined to the month of August; but he himself observed it to appear sometimes towards the end of summer, when the season was unu- sually warm; and that, in proportion to the heat, the violence of the disease was greater. Others have ob- served that it appeared more early in summer, and al- ways sooner or later, according as the great heats soon- er or later set in. 1459. From all these circumstances, it is, I think, very evident, that this disease is the effect of a warm at- 248 PRACTICE OF PHYSIC. mosphere, producing some change in the state of the bile in the human body: and the change may consist, either in the matter of the bile being rendered more acrid, and thereby fitted to excite a more copious se- cretion; or, in the same matter, its being prepared to pass of in larger quantity than usual. 1460. It has been remarked, that in warm climates and seasons, after extremely hot and dry weather, a fall of rain cooling the atmosphere seems especially to bring on this disease; and it is very probable that an obstruc- ted perspiration may have also a share in this, though it is also certain that the disease does appear when no change in the temperature of the air, nor any applica- tion of cold has been observed. 1461. It is possible, that, in some cases, the heat of the season may give only a predisposition, and that the disease may be excited by certain ingesta or other cau- ses; but it is equally certain, that the disease has occur- red without any previous change or errof, either in diet, or in the manner "of life, that could be observed.* 1462. The Nosologists have constituted a genus under the title of Cholera, and under this have arranged as a species every affection in which a vomiting and purging of any kind happened to concur. In many of these species, however, the matter evacuated is not bili- ous; nor does the evacuation proceed from any cause * The appearance of cholera, independently of improper ex- posure, or some impropriety in diet or drink, is a rare occur- rence. In an adult, we have never witnessed an event of this kind; it being always practicable to derive the disease from some ex- citing cause. In relation to children, we are persuaded the fact would be found equally true, were we able to obtain the necessary information. PRACTICE OF PHYSIC. 249 in the state of the atmosphere. Further, in many of these species also, the vomiting which occurs is not an essential, but merely an accidental symptom from the particular violence of the disease. The appellation of Cholera, therefore, should, in my opinion, be confined to the disease I have described above; which by its peculiar cause, and perhaps also by its symptoms, is very different from all the other species that have been associated with it. I believe that all the other species arranged under the title of Cholera by Sauvages or Sagar, may be properly enough referred to the genus of Diarrhoea; which we are to treat of in the next chap- ter. The distinction I have endeavoured to establish be- tween the proper Cholera, and the other diseases that have sometimes got the same appellation, will, as I judge, supersede the question, Whether the Cholera, in temperate climates, happens at any other season than that above assigned? 1463. In the case of a genuine cholera, the cure of it has been long established by experience. In the beginning of the disease, the evacuation of the redundant bile is to be favoured by the plentiful exhi- bition of mild diluents, both given by the mouth, and injected by the anus; and all evacuant medicines, em- ployed in either way, are not only superfluous, but com- monly hurtful.* * In the United States, it is rarely, we think, necessary to give any thing for the purpose ol " favouring the evacuation;" the emotions excited by the complaint itself, being amply sufficient for that purpose. The exhibition of a little tepid water, to faci- litate the operation of vomiting, and thus, the more speedily and completely to evacuate the contents of the alimentary canal, is, vol. II. t i 250 PRACTICE OF PHYSIC. 1464. When the redundant bile appears to be suffi- ciently washed out, and even before that, if the spas- modic affections of the alimentary canal become very violent, and are communicated in a considerable degree to other parts of the body, or when a dangerous debili- ty seems to be induced, the irritation is to be immedi- ately obviated by opiates in sufficiently large doses, but in small bulk, and given either by the mouth, or by glyster.* perhaps, occasionally useful. But, as soon as the irritating ingesta are discharged, the indication is, to allay the commotion, and thus prevent any further evacuation. * Opium, in substance, is preferable to any liquid preparation of it. We have found a pill, consisting of half a grain, exhibited every half hour, to be productive of very salutary effects. Should this practice fail to check the disease, in three or four hours, let from two to three drachms of laudanum, mixed in a little flax- seed tea or barley water, be given by injection, and repeated as circumstances may require. In the mean time, external applications are not without their use. Let flannel, wet in some spirits or brandy, be placed on the ab- domen, and wrapt round the extremities. The efficacy of this remedy appears to be increased, by mixing with the liquor used, some oil or essence of mint. Blisters and sinapisms may be advantageously applied to the same parts. So may pulverized pepper, ginger, or other spices, formed into a plaster, by means of soap, and moistened with spirits. A patient in cholera, should never swallow more of any liquid than a mouthful or two at a time. Nor ought even that to be fre- quently repeated. The mere mechanical distension of the sto- mach will produce vomiting. We have known much relief to be derived, in this disease, from swallowing, every half hour, or oftener, half a wine-glassful of soda or seltzer water. PRACTICE OF PHYSIC. 251 1465. Though the patient be in this manner relieved, it frequently happens, that when the operation of the An infusion of dried mint is also a very pleasant and useful be- verage. After the stomach and bowels have been thoroughly evacuated of their irritating contents,' a flannel roller, passed, with some de- gree of tightness, round the abdomen, is found to be a useful re- medy. CHOLERA INFANTUM. One of the most troublesome diseases, with which the physi- cians of the United States are called to contend, is the Cholera Infantum. This is a disease of the summer season, and is productive of great mortality. It occurs principally in large cities; and is most troublesome to children, from about the fifth or sixth month, until the close of the second year of their age. It attacks them, occa- sionally, at a later period; but not with such violence, nor in so dangerous a form. The predisposing cause of Cholera Infantum, is the warmth and impurity of the air of a large city, during the summer months; the chief exciting causes, improprieties in articles of clothing and food. Sudden changes in the atmosphere, from heat to cold, and from dryness to humidity, are also calculated to bring it into action. The fruits of the season are a most prolific source of this dis- ease. Children, under their third year, should never be suffered to touch them. It is a popular belief, that ripe fruits are innocent: some think salutary. This is an error fraught with mischief. Whether ripe or green—although most so in the latter state—they are certainly productive of the complaint we are considering. Cholera Infantum is most obstinate and fatal during dentition: by which it, therefore, appears to be aggravated. In a large city, the most efficacious mode of treating this dis- ease, is to send the subjects of it to reside in the pure air of the country, where they speedily recover. If this measure be adopt- 252 PRACTICE OF PHYSIC. opium is over, the disease shows a tendency to return; and, for at least some days after the first attack, the ir- ed early in the complaint, the cure is certain: and it often suc- ceeds, even when appearances are almost hopeless. In cases were a removal tg the country, if not impracticable, is highly inconvenient, the following course of practice may be ad- vantageously pursued. Evacuate completely the alimentary canal, of all its offensive and irritating contents. This may be best effected by ipecacu- anha, as an emetic, and calomel or castor oil as a purgative. If the pulse be active and strong, as is sometimes the case, a few ounces of blood may be drawn with advantage. These things being done, let irritation be calmed by means of opiates; and, if no febrile symptoms forbid, tone restored to the stomach and bowels, by a decoction of Colombo, quassia, or cen- taury. The first of these remedies we think entitled to a pre- ference. The most suitable articles of diet are, liquid farinaceous pre- parations; such as rice or barley water, gruel, made of oat-meal parched, panado, prepared from well-baked biscuit, arrow-root or tapioca. These preparations should be sweetened with loaf sugar; and, provided no febrile symptoms exist, a small quan- tity of some grateful aromatic may be advantageously added to them. In case the puking continue obstinate, external applications become indispensable. Green peppermint, stewed in brandy, applied to the wrists and stomach, and frequently renewed, is highly useful. So are plas- ters of Venice treacle, or of soap and powdered cloves, applied to the same parts. If these remedies fail to check the vomiting, recourse must be had to blisters; which are also to be applied to the stomach and wrists. A pleasant and useful drink, under these circumstances, is, an infusion of the dried leaves of peppermint, or weak brandy and water, sweetened with loaf sugar. Care should, however, be taken, that too much drink be not swallowed at a time; otherwise the stimulus of distension will prove injurious. PRACTICE OF PHYSIC. 253 ritability of the intestines, and their disposition to fall into painful spasmodic'contractions, seem to continue. In this situation, the repetition of the opiates, for per- haps several days, may come to be necessary; and as the debility commonly induced by the disease favours the disposition to spasmodic affections, it is often use- ful and necessary, together with the opiates, to employ the tonic powers of the Peruvian bark. Anodyne injections, judiciously administered, are service- able. When the stomach becomes retentive, and nothing but a trou- blesome diarrhoea remains, astringent preparations may be tried with advantage. Of these, a decoction of cinnamon, of logwood, of the root of the dew-berry briar, and of pomegranate peel, are among the most useful. Saccharum Saturni, combined with opium, may be also advan- tageously employed. In the treatment of children, it is highly important, to render medicines, as far as practicable, agreeable to the palate. When, in the disease we are considering, sweetening is used, for this pur- pose, it should be of the best refined loaf sugar. To relieve griping, and determine to the skin, the warm bath may, at times, be usefully employed. This is more especially the case, when the complaint immediately succeeds the disap- pearance of a cutaneous eruption. The efficacy of the warm bath is increased, by impregnating the water with muriate of soda. If there be a coldness and torpor of the skin, warm spirituous fomentations to the abdomen prove somewhat advantageous. The patient should, in the mean time, be clothed in flannel. 254 PRACTICE OF PHYSIC. CHAPTER XI. OF DIARRHOEA, OR LOOSENESS* 1466. THIS disease consists in evacuation by stool, more frequent and of more liquid matter than usual. This leading and characteristic symptom is so diversi- fied in its degree, in its causes, and in the variety of matter evacuated, that it is almost impossible to give any general history of the disease. 1467. It is to be distinguished from dysentery, by not being contagious; by being generally without fever; and by being with the evacuation of the natural excre- ments, which are, at least, for some time, retained in dysentery. The two diseases have been commonly dis- tinguished by the gripings being more violent in the dysentery; and they are commonly less violent and less frequent in diarrhoea: but as they frequently do occur in this also, and sometimes to a considerable degree, s« they do not afford any proper distinction. 1468. A diarrhoea is to be distinguished from cholera chiefly by the difference of their causes; which, in cholera, is of one peculiar kind; but in diarrhoea is prodigiously diversified, as we shall see presently. It has been common to distinguish cholera by the evacua- tion downwards being of bilious matter, and by this being always accompanied with a vomiting of the same kind; but it does not universally apply, as a diarrhoea is sometimes attended with vomiting, and even of bi- lious matter. * Both diarrhoea and cholera ought to stand under the order Profluvia, instead of that of Spasmi. PRACTICE OF PHYSIC. 255 1469. The disease of diarrhoea, thus distinguished, is very greatly diversified; but in all cases, the frequency of stools is to be imputed to a preternatural increase of the peristaltic motion in the whole, or at least in a con- siderable portion, of the intestinal canal. This increa- sed action is in different degrees, is often convulsive and spasmodic, and at any rate is a motus abnormis: for which reason, in the Methodical Nosology, I have re- ferred it to the order of Spasmi, and accordingly treat of it in this place. 1470. Upon the same ground, as I consider the dis- ease named Lientery to be an increased peristaltic mo- tion over the whole of the intestinal canal, arising from a peculiar irritability, I have considered it as merely a species of diarrhoea. The idea of a laxity of the intes- tinal canal being the cause either of lientery, or other species of diarrhoea, appears to me to be without foun- dation, except in the single case of frequent liquid stools from a palsy of the sphincter ani. 1471. The increased action of the peristaltic motion, I consider as always the chief part of the proximate cause of diarrhoea: but the disease is further, and in- deed chiefly, diversified by the different causes of this increased action; which we are now to inquire into. 1472. The several causes of the increased action of the intestines may be referred, I think, in the first place, to two general heads. The first is, of the diseases of certain parts of the body which, either from a consent of the intestines with these parts, or from the relation which the intestines have to the whole system," occasion an increased action in the intestines, without the transference of any stimulant matter from the primary diseased part to them. 256 PRACTICE OF PHYSIC. The second head of the causes of the increased action of the intestines is the stimuli t)f various kinds, which are applied directly to the intestines themselves. 1473. These affections of other parts of the system may affect the intestines without transference or appli- cation of any of the stimulant matter, we learn from hence that the passions of the mind do in some persons excite diarrhoea. 1474. That diseases in other parts may in like man- ner affect the intestines, appears from the dentition of infants frequently exciting diarrhoea. I believe that the gout often affords another instance of the same kind; and probably there are others also, though not well as- certained. 1475. The stimuli (1472.) which may be applied to the intestines are of very various kinds; and are either, 1. Matters introduced by the mouth. 2. Matters poured into the intestines by the several excretories opening into them. 3. Matters poured from certain preternatural open- ings made into them in certain diseases. 1476. Of those (1475, 1.) introduced by the mouth, the first to be mentioned are the aliments commonly taken in. Too great a quantity of these taken in, often prevents their due digestion in the stomach; and by being thus sent in their crude, and probably acrid, state to the intestines, they frequently excite diarrhoea. The same aliments, though in proper quantity, yet having too great a proportion, as frequently happens, of saline or saccharine matter along with them, prove sti- mulant to the intestines, and excite diarrhoea. PRACTICE OF PHYSIC. 257 But our aliments prove especially the causes of diar- rhoea, according as they, from their own nature, or from the weakness of the stomach, are disposed to undergo an undue degree of fermentation there, and thereby be- come stimulant to the intestines. Thus acescent ali- ments are ready to produce diarrhoea; but whether from theit having any directly purgative quality, or only as mixed in an over proportion with the bile, is not well determined. 1477. Not only the acescent, but also the putrescent disposition of the aliments, seems to occasion a diar- rhoea; and it appears that even the effluvia of putrid bodies, taken in any way in large quantity, have the same effect. Are oils or fats, taken in as part of our aliments, ever the cause of diarrhoea? and if so, in what manner do they operate?* 1478. The other matters introduced by the rriouth, which may be causes of diarrhoea, are those thrown in either as medicines, or poisons that have the faculty of stimulating the alimentary canal. Thus, in the list of the Materia Mediea, we have a long catalogue of those named purgatives; and in the list of poisons, we have many possessed of the same quality. The former, given in a certain quantity, occasion a temporary diarrhoea; and given in very large doses, may occasion it in excess, and continue it longer than usual, producing that species of diarrhoea named a Hypercatharsis. 1479. The matters (1475, 2.) poured into the cavity of the intestines from the excretories opening into them, and which may occasion diarrhoea, are either those from * If oils or fats prove indigestible, they may certainly product diarrhoea. VOL. II. K k 258 PRACTICE OF PHYSIC. the pancreatic or biliary duct, or those from the excre- tories in the coats of the intestines themselves. 1480. What changes may happen in the pancreatic juice I do not exactly know; but I suppose that an acrid fluid may issue from the pancreas, even while still entire in its structure; but more especially when it is in a sup- purated, scirrhous, or cancerous state, that a very acrid matter may be poured out by the pancreatic duct, and occasion diarrhoea. 1481. We know well, that from the biliary duct the bile may be poured out in greater quantity than usual: and there is little doubt of its being also sometimes pour- ed out of a more than ordinary acrid quality. It is very probable, that in both ways the bile is frequently a cause of diarrhoea. Though I have said above that diarrhoea may be com- monly distinguished from cholera, I must admit here, that as the causes producing that state of the bile which occasions cholera, may occur in all the different possible degrees of force, so as, on one occasion, to produce the most violent and distinctly marked cholera; but, upon another, to produce only the gentlest diarrhoea: which, however, will be the same disease, only varying in de- gree: so I think it probable, that in warm climates, and in warm seasons, a diarrhoea biliosa of this kind may fre- quently occur, not to be always certainly distinguished from cholera. However this may be, it is sufficiently probable, that, in some cases, the bile, without having been acted up- on by the heat of the climate or season, may be redun- dant and acrid, and prove therefore a particular cause of diarrhoea. PRACTICE OF PHYSIC. 259 1482. Beside bile from the several causes and in the conditions mentioned, the biliary duct may pour out pus, or other matter from abscesses in the liver, which may be the cause of diarrhoea. Practical writers take notice of a diarrhoea wherein a thin and bloody liquid is discharged; which they sup- pose to have proceeded from the liver, and have there- fore given die disease the name of Hepatirrhoea: but we have not met with any instance of this kind; and there- fore cannot properly say any thing concerning it. 1483. A second set of excretories, from which mat- ter is poured into the cavity of the intestines, are those from the coats of the intestines themselves; and are either the exhalants proceeding directly from the extremities of arteries, or the excretories from the mucous follicles: and both these sources occur in prodigious number over the internal surface of the whole intestinal canal. It is probable that it is chiefly the effusion from these sources which, in most instances, gives the matter of the liquid stools occurring in diarrhoea.* * When the cutaneous perspiration is suppressed by cold, the secretory action of the vessels of the intestines is increased by sympathy, not by a mechanical determination of a greater quan- tity of fluids to the part. We do not believe, that either urine or pus is ever taken up into the blood-vessels, and thrown off, by the intestines, in the form of a diarrhoea. It is certain that they may both be absorb- ed; but not in their formal character. They undergo a digestion or change, in consequence of the action of the absorbents, and, being thus received into the blood vessels, pass off again, in the common mass of excreted fluids—partly by the intestines, partly by the skin, and in part, perhaps, by the kidneys themselves. Even when the water of dropsies passes off by the intestines, it must be through the regular medium of absorption and secretion 2ptj PRACTICE OF PHYSIC. 1484. The matter from both sources may be poured out in larger quantity than usual, merely by the increas- ed action of the intestines, whether that be excited by the passions of the mind (1473.) by diseases in other parts of the system (1472, 1.) or by the various stimu- lants mentioned 1476, and following; or the quantity of matter poured out may be increased, not so much by the increased action of the intestines, as by an increased afflux of fluids from other parts of the system. Thus, cold applied to the surface of the body, and suppressing perspiration, may determine a greater quan- tity of fluids to the intestines. Thus, in the ischuria renalis, the urine taken into the blood-vessels is sometimes determined to pass off again by the intestines. In like manner, pus or serum may be absorbed from the cavities in which they have been stagnant, and be again poured out into the intestines, as frequently hap- pens, in particular with respect to the water of dropsies. 1485. It is to be observed here, that a diarrhoea may be excited not only by a copious afflux of fluids from other parts of the system, but likewise by the mere de- termination of various acrid matters from the mass of blood into the cavity of the intestines. Thus it is sup- posed that the morbific matter of fevers is sometimes thrown out into the cavity of the intestines, and gives a critical diarrhoea: and whether I do or do not admit the doctrine of critical evacuations, I think it is probable that the morbific matter of the exanthemata is frequently thrown upon the intestines, and occasions diarrhoea. 1486. U is to me further probable, that the putres- cent matter diffused over the mass of blood in putrid diseases, is frequently poured out by the exhalants into PRACf ICE OF PHYSIC. 261 the intestines, and.proves there the cause, at least in part, of the diarrhoea so commonly attending these diseases.* 1487. Upon this subject of the matters poured into the cavity of the intestines, I have chiefly considered them as poured out in unusual quantity, but it is pro- bable that, for the most part, they are also changed in their quality, and become of a more acrid and stimu- lant nature; upon which account especially it is that they excite, or at least increase a diarrhoea. 1488. How far, ^and in what manner, the exhalant fluid may be changed in its nature and quality, we do not certainly know; but with respect to the fluid from the mucous excretories, we know, that when poured out in unusual quantity, it is commonly, at the same time, in a more liquid and acnid form; and may prove, therefore, considerably irri%ting, 1489. Though the copious effusion of a more liquid and acrid matter from the mucous excretories, be pro- bably owing to the matter being poured out immediate- ly as it is secreted from the blood into the mucous folli- cles, without being allowed to stagnate in the latter, so as to acquire that milder quality and thicker consistence we commonly find in the mucus in its natural state; and although we might suppose the excretions of a thin and acrid fluid should always be the effect of every de- termination to the mucous follicles, and of every stimu- lant applied to them; yet it is certain, that the reverse * 1485-6. The intelligent reader will at once perceive, that the doctrine, contained in these two articles, participates too much, of the humoral pathology, to be correct. Nor are we inclined to think much more favourably of the pathological sentiments, ex- pressed, in the four succeeding articles. They are mostly anti- quated, obsolete and erroneous.. 262 PRACTICE OF PHYSIC. is sometimes the case; and that from the mucous folli- cles, diere is frequently an increased excretion of a mu- cus, which appears in its proper form of a mild, viscid, and thickish matter. This commonly occurs in the case of dysentery; and it has been observed to give a spe- cies of diarrhoea, which has been properly named the Diarrhoea Mucosa. 1490. A third source of matter poured into the cavi- ty of the intestines, and occasioning diarrhoea (1475, 3.) is from those preternatural openings produced by dis- eases in the intestines or neighbouring parts. Thus the blood-vessels on the internal surface of the intestines may be opened by erosion, rupture, or anastomosis, and pour into the cavity their blood, which, either by its quantity, or by its acrimony, whether inherent, or acqui- red by stagnation, may sometimes give a diarrhoea eva- cuating bloody matter. This is what I think happens in that disease which has been called the Melana or Morbus Niger. 1491. Another preternatural source of matter poured into the cavity of the intestines, is the rupture of ab- scesses seated either in the coats of the intestines them- selves, or in any of the contiguous viscera, which, du- ring an inflamed state, had formed an adhesion with some part of the intestines. The matter thus poured into their cavity may be various; purulent, or sanious, or both together, mixed at the same time with more or less of blood; and in each of these states may be a cause of diarrhoea. 1492. Amongst the stimuli that may be directly ap- plied to the intestines, and which, by increasing their peristaltic motion, may occasion diarrhoea, I must not PRACTICE OF PHYSIC. 263 omit to mention worms as 'having frequently that ef- fect.* 1493. I must also mention here a state of the intes- tines, wherein their peristaltic motion is preternaturally increased, and a diarrhoea produced; and that is, when they are affected with an erythematic inflammation. With respect to the existence of such a state, and its occasioning diarrhoea, sec what is said above in 398, and following. Whether it is to be considered as a particu- lar and distinct case of diarrhoea, or is always the same with some of those produced by one or other of the causes above-mentioned, I have not been able to de- termine. 1494. Lastly, by an accumulation of alimentary 6r of other matter poured into the cavity of the intestines from several of the sources above-mentioned, a diarr- hoea may be especially occasioned when the absorption of the lacteals, or of other absorbents, is prevented, ei- ther by an obstruction of their orifices, or by an ob- struction of the mesenteric glands through which alone the absorbed fluids can be transmitted. In one instance of this kind, when the chyle prepared in the stomach and duodenum is not absorbed in the course of the intestines, but passes off in considerable quantity by the anus, the disease has been named Mor- bus Cceliacus, or simply and- more properly Coeliaca; * When, by cold, or any other cause, the irritability of the in- testines is increased, the presence of worms, by augmenting irri- tation, may produce a diarrhoea. But we are not certain that the disease can be thus produced, without such an increase of tht irritability. 264 PRACTICE OF PHYSIC. which accordingly I have considered as a species of di- arrhoea.* 1495. I have thus endeavoured to point out the va- rious species of disease that may come under the gene- ral appellation of diarrhoea; and from that enumeration it will appear, that many, and indeed the greater part of the cases of diarrhoea, are to be considered as sympa- thetic affections, and to be cured only by curing the primary disease upon which they depend; of which, however, I cannot properly treat here. From our enu- meration it will also appear, that many of the cases of diarrhoea which may be considered as idiopathic, will not require my saying much of them here. In many instances, the disease is ascertained, and also the cause assigned, by the condition of the matter evacuated; so that what is necessary to correct or remove it will be sufficiently obvious to practitioners of any knowledge. In short I do not find that I can offer any general plan for the cure of diarrhoea; and all that I can pretend to do on this subject, is to give some general remarks on the practice that has been commonly followed in the cure of this disease. 1496. The practice in this disease has chiefly pro- ceeded upon the supposition of an acrimony in the fluids* or of a laxity in the simple and moving fibres of the in- testines; and the remedies employed have accordingly been, correctors of particular acrimony, general demul- cents, evacuants by vomiting or purging, astringents, * Chyle, strictly so called, is not, we think, prepared either in the stomach or duodenum. These organs contain the materials, of which chyle is to be formed; but not the chyle itself. That fluid receives the finishing touch of its elaboration from the lac- teak. PRACTICE OF PHYSIC. 265 or opiates. Upon each of these kinds of remedies I shall now offer some remarks* * In point of correctness and verity, the doctrines of « acri- mony in the fluids," and " laxity in the simple and moving fibres," stand precisely on the same footing. They are both erroneous. Of the doctrine of acrimony, we have already spoken and shall not, therefore, dwell on it at present. The idea of laxity, as here used, is meehanical, and applicable only to dead matter. Of living matter, particularly of the state or structure of secretory vessels, it is not predicable. The term irritability, would be much more suitable in this place; and would convey an idea nearer to the truth than that of laxity. The treatment of diarrhoea must correspond to the nature and causes of the disease: and, these being various, it is obvious that the treatment must be various also. Even a brief view of the mode of treating every form and description of diarrhoea, would occupy, perhaps, an entire volume. Nor is this necessary, inas- much as most varieties of the complaint, being nothing but symp- toms of other diseases, are included, of course, in the accounts of these diseases. In the treatment of this complaint, whatever may be its cause or character, an attention to diet is of the utmost moment. No- thing, as an article of food, is admissible, unless it be light, bland in its qualities, free from ascency, and easily digested. Rice, sago, tapioca, gum arabic, powdered arrow-root, and-well-baked bread and crackers, made into panado, may be used without in- jury. They may also be rendered savoury, by the additionof some agreeable aromatic. If animal food be used, salted meat is bet- ter than fresh. Fruit is inadmissible. Milk, if boiled, may be taken with safety, and sometimeb with advantage. As a general rule, in diarrhoea, tea is preferable to coffee, and black tea pre- ferable to green. In some cases, well prepared chocolate is pre- ferable to either. In diarrhoea, it is important that every article of diet be thoroughly cooked. As drinks, malt liquors and cider are improper. So, in gene- ral, are wines; because, although not really acid, they are some- what acescent. Well prepared spirits or brandy, mixed with wa- fer, form a beverage which is less exceptionable. VOL. II. I. 1 266 PRACTICE OF PHYSIC. 1497. An acid acrimony is, upon several occasions, the cause of diarrhoea, particularly in children; and in If the diarrhoea proceed from a suppression of perspiration, the indication of cure is obvious. Let the cutaneous action be restored, and the disease will be at an end. This indication may be answered by an emetic, followed by su- dorifics, of which opium shall constitute a part. In the treatment of this form of the disease, it is necessary that flannel be worn next the skin. A flannel roller, passed several times round the abdomen, so as to make a gentle and uniform pressure, is highly useful. If requisite, let the warm bath be resorted to, with the application of blisters, to the abdomen and extremities. This practice, with the proper use of opiates, will seldom fail to effect a cure. If acidity prevail in the stomach, let absorbents be used. In this case, lime water, either alone, or mixed with new milk, is an efficacious remedy. So is the common cretaceous julap, combin- ed with laudanum. This mixture is known to consist of prepared chalk, mucilage of gum arabic, cinnamon, mint or lavender wa- ter, common water, laudanum and loaf sugar. As much of this preparation, as may contain from five to ten drops of laudanum, may be administered three or four times a day, or oftener, if ne- cessary. If diarrhoea be produced, by the sudden disappearance of some cutaneous eruption, as of prickly heat, in hot weather, let means be adopted for its immediate restoration. The remedies, here, will be nearly the same, as under suppressed perspiration. In such a case, we have seen a little spiced brandy productive of an excellent effect. If any fever, however, be present, this article is inadmissible. Does the disease proceed from bad water, or unwholesome food? Let these articles be abandoned or corrected. The mode of cor- rection will depend on the nature of the qualities to be removed. If diarrhoea arise from repelled gout; let that complaint be recalled to the extremities, by such remedies, as are calculated for the purpose; most of which we have mentioned on a former occasion. If the disease prove obstinate, let astringents be tried, in com- PRACTICE OF PHYSIC. 267 such cases the absorbent earths have been very properly employed. The common, however, and promiscuous use of these,hath been very injudicious; and where there is any putrescency, they must be hurtful. 1498. The cases in which there is a putrid or putre- scent acrimony prevailing, have been, I think, too sel- dom taken notice of; and, therefore, the use of acids too seldom admitted. The acrimony to be suspected in bilious cases, is probably of the putrescent kind. bination with opiates. The astringents, most in vogue, are, allum, catechu, galls, logwood, gum kino, and saccharum saturni. This latter article, given to the amount of, from two to three grains, combined with half a grain of opium, and repeated, if requisite, every two or three hours, is highly efficacious. We have exhibited, with much advantage, in this disease, as well as in the latter stages of dysentery, a strong decoction of the peel of the pomegranate, and also of the root of the blackberry, or, as it is usually termed, the dewberry, of our own country. These articles may be rendered, we think, more efficacious, by the addition of a small quantity of some pleasant aromatic. As an astringent, they are particularly useful, in the diarrhoeas of children. If the stomach fail to retain opiates, let them be given by in- jection. If the disease be in children, and dentition the cause, the scari- fication of the gums, to remove irritation, will be useful. If it proceed from worms, give the wormseed oil, and purge copiously, with calomel and rhubarb. As a tonic, to strengthen the bowels, after diarrhoea has disap- peared, Colombo root, quassia, bark, or chalybeates, may be used. The mode of preparing and exhibiting these remedies, is known to every one. In this complaint, aromatics, combined with opium and astrin- gents, make an important remedy. Should other remedies fail, a journey on horseback, a sea voy- age, or a change of climate, may be tried. Ipecacuanha, in small, but repeated doses, to promote perspiration, is highly useful. 268 PRACTICE OF PHYSIC. 1499. The general correctors of acrimony are the mild diluents and demulcents. The former have not been so much employed in diarrhoea as they ought; for, joined with demulcents, they very much increase the effects of the latter: and although the demulcents, b.oth mucilaginous and oily, may by themselves be useful, yet without the assistance of diluents they can hardly be introduced in such quantity as to answer the purpose. 1500. As indigestion and crudities present in the stomach are so often the cause of diarrhoea, vomiting must, therefore, be frequently very useful in this dis- ease. In like manner, when the disease proceeds, as it often does, from obstructed perspiration, and increased afflux of fluids to the intestines, vomiting is perhaps the most effectual means of restoring the determination of the fluids to the surface of the body. It is possible also, that vomiting may give some in- version of the peristaltic motion, which is determined too much downwards in diarrhoea; so that upon the whole it is a remedy which may be very generally use- ful in this disease. 1501. Purging has been supposed to be more univer- sally necessary, and has been more generally practised. This, however, in my opinion, proceeds upon very mis- taken notions with respect to the disease; and such a practice seems to me for the most part superfluous, and in many cases very hurtful. It goes upon the supposi- tion of an acrimony present in the intestines, that ought to be carried out by purging: but, if that acrimony has either been introduced by the mouth, or brought into the intestines from other parts of the body, purging can PRACTICE OF PHYSIC 269 neither be a means of correcting nor of exhausting it; and must rather have the effect of increasing its afflux, and of aggravating its effects. From whatever source the acrimony which can excite a diarrhoea proceeds, it may be supposed sufficient to evacuate itself, so far as that can be done by purging; and as in cholera, so in the same kind of diarrhoea, it will be more proper to assist the evacuation by diluents and demulcents, than to in- crease the irritation by purgatives. 1502 If, then, the use of purgatives in diarrhoea may be considered, even when an acrimony is present, as superfluous, there are many other cases in which it may be extremely hurtful. If the irritability of the intes- tines shall, from affections in other parts of the system, or other causes, have been already very much increas- ed, purgatives must necessarily aggravate the disease. In the case of lientery, nobody thinks of giving a pur- gative; and in many cases of diarrhoea approaching to that, they must be equally improper. I have already observed, that when diarrhoea proceeds from an afflux of fluids to the intestines, whether in too great quanti- ty, or of an acrid quality, purgatives may be hurtful; and, whoever, therefore, considers the numerous and various sources from which acrid matter may be pour- ed into the cavity of the intestines, will readily perceive, that in many cases of diarrhoea, purgatives may be ex- tremely pernicious. There is one case in particular to be taken notice of. When, from a general and acrid dissolution of the blood, the serous fluids run off too copiously in the ca- vity of the intestines; and excite that diarrhoea which attends the advanced state of hectic fever, and is pro- 270 PRACTICE OF PHYSIC perly called a Colliquative Diarrhoea; I have, in such cases, often seen purgatives given with the most bane- ful effects. There is still another case of diarrhoea in which pur- gatives are pernicious; and that is, when the disease de- pends, as we have alleged it sometimes may, upon an erythematic inflammation of the intestines. I need hardly add, that if there be a case of diarrhoea depending upon a laxity of the solids, purgatives cannot there be of any service, and may do much harm. Upon the whole, it will, I think, appear, that the use of pur- gatives in diarrhoea is very much limited; and that the promiscuous use of them, which has been so common, is injudicious, and often pernicious. I believe the practice has been chiefly owing to the use of purgatives in dysenteric cases, in which they are truly useful; be- cause, contrary to the case of diarrhoea, there is in dy- sentery a considerable constriction of the intestines. 1503. Another set of remedies employed in diarrhoea are astringents. There has been some hesitation about the employment of these in recent cases, upon the sup- position that they might occasion the retention of an acrid matter that should be thrown out. I cannot, how- ever, well understand or assign the cases in which such caution is necessary, and I think that the power of astringents is seldom so great as to render their use very dangerous. The only difficulty which has occurred to me, with respect to their use, has been to judge of the circum- stances to which they are especially adapted. It appears to me to be only in those where the irritability of the intestines depends upon a loss of tone; and this, I think, PRACTICE OF PHYSIC. 271 may occur from the debility of the whole system, or from causes acting on the intestines alone. All violent or long continued spasmodic and convulsive affections of the intestinal canal necessarily induce a debility there; and such causes often take place, from violent irritation, in colic, dysentery, cholera, and diarrhoea. 1504. The last of the remedies of diarrhoea that re- main to be mentioned are opiates. The same objec- tions have been made to the use of these, in recent cases of diarrhoea, as to that of astringents; but on no good grounds: for the effect of opiates, as astringent, is never very permanent; and an evacuation depending upon irritation, though it may be for some time suspended by opiates, yet always returns very soon. It is only by taking off irritability that opiates are useful in diarrhoea; and, therefore, when the disease depends upon an in- crease of irritability alone, or when, though proceeding from irritation, that irritation is corrected or exhausted, opiates are the most useful and certain remedy. And though opiates are not suited to correct or remove an irritation applied, they are often of great benefit in sus- pending the effects of that irritation whenever these are violent: and, upon the whole, it will appear, that opiates may be very frequently, and with great propriety, em- ployed in the cure of diarrhoea. 272 PRACTICE OF PHYSIC. CHAPTER XII. OF THE DIABETES.* 1505. THIS disease consists in the voiding of an un- usually large quantity of urine. * It is much to be regretted, that, in diabetes, neither the pa- thology, nor the practice, is settled, as yet, on satisfactory prin- ciples. While some consider the disease, as arising out of a morbid and imperfect state of action of the stomach, and the several as- similating organs, others regard it, as consisting in an inflamma- tory affection of the kidneys. Out of these two different opi- nions, different modes of practice must necessarily arise. Our own experience, in this complaint, being exceedingly limited—for, fortunately, its occurrence, in the United States, is not very frequent—we can do nothing better, at present, than be- come the organ for communicating to our readers, a brief state- ment of the practice of others. For the cure of diabetes, which he appears to have studied with much attention, Dr. Rollo prescribes, " a diet, consisting wholly of animal food, abstaining rigidly f&m every kind of ve- getable matter, from which sugar may be produced: he likewise enjoins the hepatized ammonia, to be taken daily, in doses ol three or four drops, to be taken, three or four times a day, and gradually increased, until a giddiness be produced; exerci*e to be avoided; antimonial wine, with opium, to be taken, at night; an ulceration, about the size of half a crown, to be formed, oppo- site to each kidney; and the bowels, to be kept open, by aloes and soap." " A case of diabetes mellitus, is recorded, in the thirteenth vo- lume of the Medical Journal, by Mr. Earnest, surgeon to the Sheffield general infirmary, which was successfully treated, by putting the patient on a diet, consisting, principally, of animal food, with a generous allowance of porter; giving, at the same time, the nitric acid, in the proportion of, from two to three PRACTICE OF PHYSIC. 273 As hardly any secretion can be increased without an increased action of the vessels concerned in it, and as some instances of this disease are attended with affec- tions manifestly spasmodic, I have had no doubt of ar- ranging the diabetes under the order of spasmi. drachms, of the acid* to two pounds of water, with about aa^ounce of sugar, daily." " We are informed, by Dr. Ferriar, that he has cured three confirmed cases of this disease, by a combination of chincona, uva ursi, and opium, taken, three times a day, in the proportion of a scruple, of each of the former, to half a grain of the latter, and, that, from the great success he had met with, from this me- dicine, he found it unnecessary to try Dr. Rollo's plan. The doses were taken, with lime-water, which was also directed, for the patient's common drink." By those, who, from the vascular appearance, and enlarged size, which the kidneys present, on dissection, consider diabetes, as consisting in an inflammatory affection of those organs, a dif- ferent mode of treatment is, of course, adopted. It appears that, by those physicians, " several cases, of this dis- ease, were successfully treated, by an antiphlogistic regimen, and very copious depletion, by venesection, employed, under the most unpromising circumstances, such as a low, feeble pulse, loss of strength and spirits, and cold and cedematous extremities. These cases seem to support the opinion, that an inflammatory action does really take place, in the kidneys of those, labouring under- this disease. In one of the cases recorded, it appears that venesection was repeated, until one hundred and eighty ounces of blood had been taken away; and that the result was, a perfect restoration of health. " A very visible change was observed, in the appearance of the blood, during the process: at first, it was black, and had only a very small proportion of crassamentum; but, as more and more of it was taken away, it gradually acquired the appearance, which it exhibits in persons, who labour under inflammatory fever. The same practice was followed, with the same result, in all the othe* VOL. II. m m fi74 PRACTICE OF PHYSIC. 1506. This disease is always accompanied with a great degree of thirst, and therefore with the taking in of a great quantity of drink. This in some measure ac- counts for the very extraordinary quantities of urine voided: but still, independent of this, a peculiar disease certainly takes place; as the quantity of urine voided does almost always exceed the whole of the liquids, and sometimes the whole bodi of solids and liquids ta- ken in. 1507. The urine voided in this disease is always very cleat* and at first sight appears entirely without any co- lour; but viewed in a certain light, it generally appears to be slightly tinged with a yellowish green, and in this respect has been very properly compared to a solution of honey in a large proportion of water. Examined by the taste, it is very generally found to be more or less sweet; and many experiments that have now been made in different instances of the disease show clearly that such urine contains, in considerable quantity, a saccharine matter which appears to be very exactly of the nature of common sugar. 1508. Doctor Willis seems to me to have been the cases: the condition of the blood was changed, and the health was restored, as in the instance recited; and it is to the bleeding, alone, that any essential benefit is attributed." It has been proposed to treat diabetes, by purging and puking, alone, giving a cathartic and an emetic, alternately, until the dis- ease be removed, or,jit be clearly ascertained, that the remedies are insufficient. Of the efficacy of this practice, we are unable to speak, and propose it, therefore, only for consideration. We think it likely to be improved by an occasional interposition of tonics. For further information, on this disease, see Bartholin—Syden- ham—Ruysch—Fothergill—Meyers de Diabete—-Rollo on Dia- betes—Watt on Diabetes—Latham on Diabetes, and Girdlestone on Diabetes. PRACTICE OF PHYSIC. 275 first who took notice of the sweetness of the urine in dia- betes, and almost every physician of England has since taken notice of the same. It is to be doubted, indeed, if there is any case of idiopathic diabetes in which the urine is of a different kind. Though neither the ancients, nor, in the other countries of Europe, the moderns, till the latter were directed to it by the English* have taken no- tice of the sweetness of the urine, it does not persuade me, that either in ancient or in modern times the urine in diabetes was of another kind. I myself, indeed, think I have met with one instance of diabetes in which the urine was perfectly insipid; and it would seem that a like observation had occurred to Dr. Martin Lister. I am persuaded, however, that such instances are very rare; and that the other is by much the more common, and perhaps the almost universal occurrence. I judge, therefore, that the presence of such a saccharine matter may be considered as the principal circumstance in idi- opathic diabetes; and it gives at least the only case of that disease that I can properly treat of here, for I am on- ly certain that what I am further to mention relates to such a case. 1509. The antecedents of this disease, and conse- quently the remote causes of it, have not been well ascertained. It may be true that it frequently happens to men who, for a long time before, had been intempe- rate in drinking; that it happens to persons of a broken constitution, or who, as we often express it, are in a ca- chectic state; that it sometimes follows intermittent fe- vers; and that it has often occurred from excess in drinking of mineral waters. But none of these causes apply very generally to the cases that occur: such cases are not always, nor even frequently, followed by a dia- betes; and there are many instances of diabetes, which 276 PRACTICE OF PHYSIC. could not be referred to any of them. In most of the cases of this disease which I have met with, I could not refer it to any particular cause. 1510. This disease commonly comes on slowly, and almost imperceptibly, without any previous disorder. It often arises to a considerable degree, and subsists long without being accompanied with evident disorder in any particular part of the system. The great thirst which always, and the voracious appetite which frequent- ly, occur in it, are often the only remarkable symptoms. Under the continuance of the disease, the body is often greatly emaciated; and a great weakness also prevails. The pulse is commonly frequent; and an obscure fever is for the most part present. When the disease proves fatal, it generally ends with a fever, in many circumstan- ces, particularly those of emaciation and debility, re- sembling a hectic. 1511. The proximate cause of this disease is not cer- tainly or clearly known. It seems to have been some- times connected with calculous affections of the kidneys; and it is possible, that an irritation applied there may increase the secretion of urine. It perhaps often does so; but how it should produce the singular change that takes place in the state of the urine, is not to be easily explained. It certainly often happens, that calculous matters are long present in the urinary passages, with- out having any such effect as that of producing diabe- tes in any shape. Some have supposed that the disease occurs from a relaxed state of the secretory vessels of the kidneys; and indeed the dissections of persons who had died of this disease have shown the kidneys in a very flaccid state. This, however, is probably to be considered as rather the effect than the cause of the disease. PRACTICE OF PHYSIC. 277 That no topical affection of the kidneys has a share in producing this disease, and that a fault in the assimi- lation of the fluids is rather to be blamed, I conclude from hence, that even the solid food taken in, increases the quantity of the urine voided, at the same time with an increase of the saccharine matter above-mentioned. 1512. The diabetes has been supposed to be owing to a certain state of the bile: and it is true, that this dis- ease has sometimes occurred to persons who were at the same time affected with diseases of the liver: but this occurrence does not often take place; and the diabetes frequently occurs separately from any affection of the liver. In twenty instances of diabetes which I have seen, there was not in any one of them any evident affection of the liver. The explanation that has been offered of the nature and operation of the bile, in producing diabetes, is very hypothetical, and no wise satisfying. 1513. As I have already said, I think it probable, that in most cases the proximate cause of this disease is some fault in the assimilatory powers, or in those em- ployed in converting alimentary matters into the proper animal fluids. This I formerly hinted to Dr. Dobsoh, and it has been prosecuted and published by him; but I must own that it is a theory embarrassed with some difficulties which I cannot at present very well remove. 1514. The proximate cause of diabetes being so lit- tle known or ascertained, I cannot propose any rational method of cure in the disease. From the testimony of several authors, I believe that the disease has been cu- red: but I believe also, that this has seldom happened; and when the disease has been cured, I doubt much if it was effected by the several remedies to which thest 278 PRACTICE OF PHYSIC. cures have been ascribed. In all the instances of this disease which I myself have seen, and in several others of which I have been informed, no cure of it has ever heen made in Scotland, though many instances of it have occurred, and in most of them the remedies recommen- ded by authors have been diligently employed. I can- not, therefore, with any advantage, enter into a detail of these remedies; and as the disease, together with its se- veral circumstances, when they shall hereafter occur, is likely to become the subject of diligent investigation, I avoid going farther at present, and judge it pru- dent to suspend my opinion till I shall have more ob- servations and experiments upon which I can form it more clearly. chapter xiir. OF THE HYSTERIA, OR THE HYSTERIC DISEASE. 1515. THE many and various symptoms which have been supposed to belong to a disease under this appellation, render it extremely difficult to give a general character or definition of it. It is, however, proper in all cases to attempt some general idea; and therefore, by taking the most common form, and that concurrence of symptoms by which it is principally dis- tinguished, I have formed a character in my system of methodical nosology, and shall here endeavour to illus- trate it by giving a more full history of the phenomena. 1516. The disease attacks in paroxysms or fits. These commonly begin by some pain and fullness felt in the left side of the belly. From this a ball seems to move with a grumbling noise into the other parts of the belly; and, making as it were various convulsions there, PRACTICE OF PHYSIC. 279 seems to move into the stomach; and more distinctly still rises up to the top of the gullet, where it remains for some time and by its pressure upon the larynx gives a sense of suffocation. By the time that the disease has proceeded thus far, the patient is affected with a stupor and insensibility, while at the same time the body is agitatated with various convulsions. The trunk of the body is wreathed to and fro, and the limbs are variously agitated; commonly the convulsive motion of one arm and hand, is that of beating with the closed fist upon the breast very violently and repeatedly. This state con- tinues for some time, and has during that time some remissions and renewals of the convulsive motions; but they at length cease, leaving the patient in a stupid and seemingly sleeping state. More or less suddenly, and frequently with repeated sighing and sobbing, together with a murmuring noise in the belly, the patient returns to the exercise of sense and motion, but generally with- out any recollection of the several circumstances that had taken place during the fit.* 1517. This is the form of what is called an hysteric paroxysm, and is the most common form; but its pa- roxysms are considerably varied in different persons, and even in the same person at different times. It differs, by having more or fewer of the circumstances above-mentioned; by these circumstances being more or less violent; and by the different duration of the whole fit. Before the fit there is sometimes a sudden and un- usually large flow of limpid urine. At the coming on of the fit, the stomach is sometimes affected with vo- miting, the lungs with considerable difficulty of breath- * The ball, spoken of, in this article, is called the globus hy~ sjeric us. 280 PRACTICE OF PHYSIC ing, and the heart with palpitations. During the fit^ the whole of the belly, and particularly the navel, is drawn strongly inwards; the spincter ani is sometimes so firm- ly constricted as not to admit a small glyster-pipe, and there is at the same time an entire suppression of urine. Such fits are, from time to time, ready to recur; and during the intervals, the patients are liable to involun- tary motions, to fits of laughing and crying, with sudden transition from the one to the other; while sometimes false imaginations, and some degree of delirium, also occur. 1518. These affections have been supposed peculiar to the female sex; and indeed they most commonly ap- pear in females: but they sometimes, though rarely, at- tack also the male sex; never, however, that I have ob- served, in the same exquisite degree. In the female sex, the disease occurs especially from the age of puberty to that of thirty-five years; and though) it does sometimes, yet it very seldom appears before the former or after the latter of these periods. At all ages, the time at which it most readily occurs is that of the menstrual period. The disease more especially affects the females of the most exquisitely sanguine and plethoric habits, and fre- quently affects those of the most robust and masculine constitutions. It affects the barren more than the breeding women, and therefore frequently young widows. It occurs especially in those females who are liable to the Nymphomania; and the Nosologists have pro- perly enough marked one of the varieties of this disease by the title of Hysteria Libidinosa. PRACTICE OF PHYSIC. 281 In the persons liable to the fits of tnis disease, it is readily,excited by the passions of the mind, and by every considerable emotion, especially those brought on by surprise. The persons liable to this disease acquire often such a degree of sensibility, as to be strongly affected by every impression that comes upon them by surprise. 1519. In this history, there appears to be a concur- rence of symptoms and circum.stances properly marking a very particular disease, which I think may be distin- guished from all others. It seems to me to have been improperly considered by physicians as the same with some other diseases, and particularly with hypochon- driasis. The two diseases may have some symptoms in common, but for the most part are considerably dif- ferent. Spasmodic affections occur in both diseases: but nei- ther so frequently, nor to so great a degree, in hypo- chondriasis as in hysteria. Persons liable to hysteria are sometimes affected at the same time with dyspepsia. They are often, how- ever, entirely free from it; but I believe this never hap- pens to persons affected with hypochondriasis. These different circumstances mark some difference in the two diseases; but they are still more certainly distinguished by the temperament they attack, and by the time of life at which they appear to be most exqui- sitely formed. It has been generally supposed, that the two diseases differ only in respect of their appearing in different sexes. But this is not well founded: for although the hysteria appears most commonly in females, the male sex is not absolutely free from it, as I have observed vol. ii. n n 282 PRACTICE OF PHYSIC. above; and although the hypochondriasis may be most frequent in men, the instances of it in the female sex are very common.* * Hysteria attacks, most frequently, the sanguine and plethoric; hypochondriasis, the melancholic. Hypochondriasis seldom appears early, nor hysteria late, in life. Hypochondriasis becomes aggravated, hysteria relieved, by an advancement in years. Hysteria, although so called, from its being supposed to have its seat in the uterus, is, notwithstanding, much of a gastric dis- ease. It, for the most part, originates in the alimentary canal, and always affects that part, in a very prominent degree. Hence the great flatulency of the stomach and bowels, with which it is, usually, accompanied. An incontestible proof, that it is not, necessarily, a uterine dis- ease, is, that men are subject to it, as well as women. In the male sex, however, it is, neither so frequent, nor so strongly marked. The treatment of this complaint must vary, according to the object, the practitioner has in view—to resolve a paroxysm, or to prevent its recurrence. To answer the former indication, blood-letting is, usually, ne- cessary; especially if the subject be young, and plethoric. In constitutions of greater delicacy, that remedy is less requisite. In every case, however, it is safe, and, in most, useful. The patient is, sometimes, roused from the paroxysm, by the application of powerful odours to the nostrils; as those of musk, assafoetida, camphor, ether, or volatile salts. The dashing of cold water, on ihe extremities, is, occasionally, productive of a similar effect. If the bowels be constipated, a laxative injection, with the ad- dition of assafoetida, castor, or musk, may be usefully administer- ed. In case of the insensibility proving obstinate, let blisters, or sinapisms, be applied to the ancles or wrists. As soon as the patient is able to swallow, let tincture of assafoe- tida, or castor, ether, or the volatile spirits of ammonia, be freely administered. In cases of unusual violence, opium or lauda- num, may be advantageously given, in large doses. In hysteric PRACTICE OF PHYSIC. 283 1520. From all these considerations, it must, I think, appear, that the hysteria may be very well, and proper- ly, distinguished from hypochondriasis. Further, it seems to me to have been with great im- propriety, that almost every degree of the irregular mo- tions of the nervous system has been referred to the one or other of these two diseases. Both are marked by a peculiarity of temperament, as well as by certain symp- toms commonly accompanying that; but some of these, and many others usually marked by the name of ner- vous symptoms may, from various causes, arise in tem- peraments different from that which is peculiar to either hysteria or hypochondriasis, and without being joined with the peculiar symptoms of either the one or the other disease: so that the appellations of Hysteric and Hypochondriac are very inaccurately applied to them. affections, this latter remedy is justly regarded, as the most pow- erful of antispasmodics. For the prevention of the paroxysms of hysteria, the indica- tion is, to communicate tone to the stomach and bowels, and, through the medium of these organs, to the system at large. This object is to be attained, by nearly the same measures and means, that have been already prescribed, for the cure of dys- pepsia—bark, chalybeates, and bitters; wholesome air, moderate, but continued exercise, freedom from care, and cheerful so- ciety. Hysteric patients will derive benefit from rising early, keep- ing the mind agreeably occupied, riding on horseback, frequent- ing water-places, the practice of cold bathing, and the use of a plain, but nutritive diet. Let this diet consist of articles free from acescency. The preservation of a regular habit of body, is an object of great importance, in the treatment of hysteria; and, if the disease arise, from the obstruction of the catamenia, that secretion ought to be promptly restored. 284 PRACTICE OF PHYSIC. Under what view these symptoms are otherwise to be considered, I am not ready to determine; but must re- mark, that the appellation of Nervous Diseases is too vague and undefined to be of any useful application. 1521. Having thus endeavoured to distinguish hys- teria from every other disease, I shall now attempt its peculiar pathology. With respect to this, I think it will, in the first place, be obvious, that its paroxysms begin by a convulsive and spasmodic affection of the alimentary canal, which is afterwards communicated to the brain, and to a great part of the nervous system. Although the disease appears to begin in the alimentary canal, yet the connexion which the paroxysms so often have with the menstrual flux, and with the diseases that depend on the state of the genitals, shows, that the phy- sicians have at all times judged rightly in considering this disease as an affection of the uterus and other parts of the genital system. 1522. With regard to this, however, I can go no far- ther. In what manner the uterus, and in particular the ovaria, are affected in this disease; how the affection of these is communicated, with particular circumstances, to the alimentary canal; or how the affection of this, rising upwards, affects the brain, so as to occasion the particular convulsions which occur in this disease, I cannot pretend to explain. But although I cannot trace this disease to its first causes, or explain the whole of the phenomena, I hope, that with respect to the general nature of the disease, I may form general conclusions, which may serve to di- rect our conduct in the cure of it. 1523. Thus, from a consideration of the predispo- nent and occasional causes, it will, I think, appear, that PRACTICE OF PHYSIC. 285 the chief part of the proximate cause is a mobility of the system, depending generally upon its plethoric state. 1524. Whether this disease ever arises from a mo- bility of the system, independent of any plethoric state of it, I cannot positively determine; but in many cases that have subsisted for some time, it is evident that a sensibility, and consequently a mobility, are acquired, which often appear when neither a general plethora can be supposed to subsist, nor an occasional turgescence to have happened. However, as we have shown above, that a distention of the vessels of the brain seems to oc- casion epilepsy, and that a turgescence of the blood in the vessels of the lungs seems to produce asthma; so analogy leads me to suppose, that a turgescence of blood in the uterus, or in other parts of the genital system, may occasion the spasmodic and convulsive motions which appear in hysteria. It will, at the same time, be evident, that this affection of the genitals must especi- ally occur in plethoric habits; and every circumstance mentioned in the history of the disease serves to confirm this opinion with respect to its proximate cause. 1525. From this view of the subject, the analogy of hysteria and epilepsy will readily appear; and why, therefore, I am to say that the indications of cure are the same in both. As the indications, so the several means of answering them are so much the same in both diseases, that the same observations and directions, with regard to the choice and employment of these remedies, that have been delivered above on the subject of epilepsy, will apply pretty exactly to hysteria; and therefore need not to be repeated here. 286 PRACTICE OF PHYSIC. CHAPTER XIV. OF CANINE MADNESS AND HYDROPHOBIA.* 1526. THIS disease has been so exactly and fully , described in books that are in every body's hands, that it is on no account necessary for me to give any history of it here; and with respect to the pathology of it, I find that I can say nothing satisfying to myself, or that * This disease is, properly enough, denominated canine mad- ness: for, although man, and various animals, are liable to suffer from it, the dog alone, appears to be capable of communicat- ing it. It is true, that we both hear and read, of the complaint being produced, by the bite and scratch of the cat: but, we know of no well authenticated instance, where this event has occurred. We doubt whether any such instance exist. Nor is it true, that any one of the human race, has, ever yet, communicated it to another. The poisonous saliva of the dog, appears to be necessary for the communication of the disease. If a disease, somewhat similar to canine madness, has ever resulted injuries, effected by the teeth or claws of the cat, it appears to have been, on the principle of a fiunctured or lacerated wound—such a wound, as proves, on other occasions, productive of tetanus. The length of time, at which canine madness appears, after the reception of the injury producing it, varies, in dogs, and other domestic animals, from six or seven days, to as many x weeks: in man, it is, usually, from twenty to forty days. Instances are, however, on record, wherein several years are said to have elapsed, between the injury, and the occurrence of the disease. In these cases, we feel persuaded, that an error exists; and that the disease must have been imputed, to too distant a cause. Some more recent, but unobserved, source of irritation, must have been its real origin. " Madness, in the dog, is, usually, preceded by a dull, heavy PRACTICE OF PHYSIC. 287 I can expect to prove so to others. I find also, with respect to the cure of this disease, that there is no sub- look, hanging of the ears and tail, stupor, surliness, and snapping at by-standers; soon after which, his breathing becomes quick and laborious, his tongue hangs out of his mouth, and changes to a leaden colour; he discharges a frothy saliva, refuses all food and drink, runs about, bites at every thing, that comes near him, and, at last, becomes quite furious. This is the last stage, in which he seldom lives above thirty hours. The nearer to this state, the more dangerous is the bite, and the more direful its effects." In man, the symptoms, usually attendant on the bite of a mad dog, are as follows " The part bitten begins, after some time, to be painful; then come on wandering pains, with an uneasiness and heaviness, dis- turbed sleep, and frightful dreams, accompanied with great rest- lessness, sudden startings and spasms, sighing, anxiety, and a love of solitude. These symptoms, continuing to increase, daily, the cicatrix of the wound becomes hard and elevated; a peculiar tingling sensation is felt, in the part, and pains begin to shoot, from the place which was wounded, all along, up to the throat, with a straitness, and sensation of choking, and a horror and dread, at the sight of water, and other liquids, together with tre- mors, and a loss of appetite. The patient is, however, capable of swallowing any solid substance, with tolerable ease; but, the mo- ment that a fluid is brought in contact with his lips, it causes him to start back, with dread and horror, although he labours, per- haps, under distressing thirst." Real hydrophobia appears to be peculiar to the human race; for rabid animals do not manifest any dread of water. On the nature of canine madness, dissections have, hitherto, thrown no definitive light; appearances being widely different, in different cases. .. All agree, that the only certain mode of prevention, 1s the ex- cision of the part, as speedily as possible, after the reception of the injury. Where this cannot be effected, let the wound be tho- roughly washed, with soap and water, have a blister, or a caustic applied to it, and be kept open, and a free mercurial ptyalism be 288 PRACTICE OF PHYSIC. ject in which the fallacy of experience appears more strongly than in this. From the most ancient to the produced. As a preventive, this latter remedy has strong recom- mendations. In relation to the treatment of the disease, after it has actually made its appearance, we regret that much less unanimity prevails. As physicians differ much, in their views, respecting its nature; some considering it of a nervous and spasmodic, others of a vas- cular and inflammatory character; a corresponding difference must, necessarily, mark their methods of cure. For the removal of this disease, some practitioners place their reliance, almost exclusively, on a mercurial ptyalism, and cite many instances of the success of that remedy. Others depend on very copious blood-letting, as the most effec- tual means for the cure of hydrophobia. Instances are recorded, wherein, from one to three hundred ounces of blood, have been drawn, in a very short time, with perfect success. Another class of physicians speak, in high commendation, of the effects of opium, administered in large, and repeated doses. With this article, musk, castor, assafoetida, and other powerful antispasmodics, are directed to be combined. If, in any way, opium can prove really useful, in this disease, it is by being ex- hibited, in such quantities, as to be productive of its own specific effects: to throw the system into somewhat of a soporose state, by subduing the powerful irritation it experiences; and to keep it thus, until the action of the morbific cause be extinguished. Arsenic is another remedy, which is said to have been effica- cious, in the treatment of hydrophobia. This article, when given in sufficient quantities, possesses great power, to overcome ex- isting action, in the system, and to introduce its own. Its opera- tion, moreover, may be rendered very rapid. In relation, there- fore, to the treatment of hydrophobia, we regard it as a medicine, of considerable promise. Various other remedies have been proposed, for the cure of this disease; but not, we believe, on a very solid foundation. Among these may be mentioned, the cuprum ammoniacum, tinc- ture of cantharides, in quantities, sufficient to produce strangury, PRACTICE OF PHYSIC. 289 predenrtimes, many remedies for preventing and curing this disease have been recommended under the sanction of pretended experience, and have perhaps also kept their credit for some time: but succeeding times have generally, upon the same ground of experience, de- stroyed that credit entirely; and most of the remedies formerly employed are now fallen into absolute neglect. In the present age, some new remedies have been pro- posed, and have experience alleged to vouch for their efficacy; but many doubts still remain with respect to this: and though I cannot determine in this matter from my own experience, I think it incumbent on me to give the best judgment I can form with respect to the choice of the remedies at present recommended. 1527. I am, in the first place, firmly persuaded, that the most certain means of preventing the consequences of the bite, is to cut out, or otherwise destroy, the part in which the bite has been made. In this every body agrees; but with this difference, that some are of opi- nion that it can only be effectual when it is done very soon after the wound has been made, and they therefore neglect it when this opportunity is missed. There have been, however, no experiments made proper to deter- mine this matter: and there are many considerations which lead me to think, that the poison is not immedi- ately communicated to the system; and, therefore, that this measure of destroying the part may be practised the hot and cold bath, either separately, or alternated with^each other, and the general ami frequent inunction of the body, with sweet oil Having never witnessed the effects of these means, we are not prepared to siv, what confidence they deserve. Al- though powerful, in themselves, we doubt their sufficiency, to arrest the course of the disease in question. VOL. II. O 0 290 PRACTICE OF PHYSIC. with advantage, even many days after the bite has been given. 1528. Whilst the state of our experience, with re- spect to several remedies now in use, is uncertain, I can- not venture to assert that any of these is absolutely in- effectual; but I can give it as my opinion, that the effi- cacy of mercury, given very largely, and persisted in for a long time, both as a means of preventing the disease, and of curing it when it has actually come on, is better supported by experience than that of any other remedy now proposed or commonly employed. BOOK IV. OF VESANIA, OR, OF THE DISORDERS OF THE IN- TELLECTUAL FUNCTIONS. CHAPTER I. OF VESANIiE IN GENERAL.* 1529. THE Nosologists, Sauvages, and Sagar, in a class of diseases under the title of VesanijE, have * Although, by no means, satisfied, with what Dr. Cullen has left us, on the subject; yet, neither on the theory, nor treatment, of madness, do we feel ourselves prepared to go into detail. As far as a corporeal affection is concerned, the disease has, oftentimes, its seat, in the primae viae—as often, perhaps, as in the brain itself. Hence, in its treatment, the efficacy of emetics, nauseating medicines, and drastic purgatives. But, that it does, also, originate in the brain, is a position, too strongly fortified, to admit of a doubt. In the present state of medical science, madness, when here- ditary, may be deemed incurable. The only means, on which, in PRACTICE OF PHYSIC. 291 comprehended the two orders, of Hallucinationes, or False Perceptions, and of Morositates or Erroneous in this case, reliance can be placed, are those of prevention. These consist, of course, in a strict avoidance of exciting causes. In general, let the descendants deviate, as much as practicable, from the course of life, which their predecessors have pursued; and, in this way, endeavour to change their constitutions. Did the ancestors live luxuriously?—let the descendants live abstemiously: Did the former lead a sedentary?—let the latter lead an active, or, even, a laborious life: Were those devoted to intense thinking?—let these inflexibly avoid the habit: Was the father given to late hours, and inclined to morning indulgence, on Jiis pillow?—let the son go to bed early, and never fail to rise, with the dawn. Madness, being, in every case, a disease of great obstinacy, re- quires, for its cure—where a cure can be effected—a determined treatment, with medicines, of a powerful, and revolutionary cha- racter. Bleeding, cupping, and leaching; vomiting, and severe purg- ing; perpetual blisters, setons, or caustics; the hot and cold bath, alone, or, in alternation with each other; opium and camphor, mercury, saccharum saturni, and arsenic, digitalis and tobacco, in extract or decoction. Such are the principal remedies, by which, under a skilful and vigorous administration, insanity has been cured. If remedies be applied to the mind, they, too, must be of a re- volutionizing character: they must beguile the lunatic of himself, and sever his predominant train of thought: such are, some pleas- ing, but constant occupation, or hard labour; the excitement of strong feeling, a sea-voyage, or a long journey: or, they must be such, as harmonize with his course of thought, and appear to him, calculated to remove evils or maladies, under which he fan- cies himself to be labouring. In confirmation of the propriety of this latter mode of treatment, the following case is recorded, in the writings of a German author. " A madman, who, believing that he wore a pair of large bull's horns, would, sometimes, menace, with his head, those who approached him, was assured, that, on a certain day, these ex- 292 PRACTICE OF PHYSIC. Appetites and Passions; and, in like manner, Linnaeus in his class of JMentales, corresponding to the Ve- saniae of Sauvages, has comprehended the two orders of Imaginarii and Pathetici, nearly the same with the Hallucinationes and Morositates of that author. This, however, from several considerations, appears to me improper; and I have therefore formed a class of Vesa- nize nearly the same with the Paranoia? of Vogel, ex- cluding from it the Hallucinationes and Morositates, which I have referred to the Morbi Locales. Mr. Vogel has done the like, in separating from the Paranoia? the false perceptions and erroneous appetites; and has thrown these into another class, to which he has given the title of Hyperaestheses. 1530. It is indeed true, that certain hallucinationes and morositates are frequently combined with what I propose to consider as strictly a vesania or an erroneous judgment; and sometimes the hallucinationes seem to lay the foundation of, and to form almost entirely, the vesania. But as most part of the hallucinationes enu- merated by the nosologists are affections purely topical, and induce no other error of judgment beside that which relates to the single object of the sense or particular or- gan affected; so these are certainly to be separated from crescences should be amputated. In the mean time, having, on the preceding night, been thrown into a very profound sleep, by a large dose of opium, a pair of horns, were fixed on his head, and dextrously removed, in the morning, by the surgeon. The effect was, an immediate exemption from the strange hallucination, un- der which he laboured. For further, and very extensive information, on the subject of madness, see Rush—Crichton—Crowther—Pinel—Withering— Arnold—Haslam—Morgagni—Willis—Battic—tnd a number of other practical writers. PRACTICE OF PHYSIC. 293 the diseases which consist in a more general affection of the judgment. Even when the hallucinationes con- stantly accompany or seem to induce the vesania, yet being such as arise from internal causes, and may be presumed to arise from the same cause as the more general affection of the judgment, they are therefore to be considered as symptoms of this only. In like manner I judge with respect to the morosi- tates, or erroneous passions, that accompany vesania; which, as consequences of a false judgment, must be considered as arising from the same causes, and as symp- toms only, of the more general affection. There is, indeed, one case of a morositas which seems to induce a vesania, or more general affection of the judgment; and this may lead us to consider the vesania, in this case, as a symptom of an erroneous appetite, but will not afford any good reason for comprehending the morositates in general under the vesaniae, considered as primary diseases. The limitation, therefore, of the class of vesanias to the lesions of our judging faculty, seems from every consideration to be proper. The particular diseases to be comprehended under this class, may be distinguished according as they af- fect persons in the time of waking or sleeping. Those which affect men awake, may again be considered as Uiey consist in an erroneous judgment, to which I shall give the appellation of Delirium; or as Uiey consist in a weakness or imperfection of judgment, which I shall name Fatuity. I begin with the consideration of de- lirium. 1531. As men differ greatly in the soundness and force of their judgment, so it may be proper here to 294 PRACTICE OF PHYSIC. ascertain more precisely what error or imperfection of our judging faculty is to be considered as morbid, and to admit of the appellations of delirium and fatuity. In doing this, I shall first consider the morbid errors of judgment under the general appellation of delirium, which has been commonly employed to denote every mode, of such error. 1532. As our judgment is chiefly exercised in dis- cerning and judging of the several relations of things, I apprehend that delirium may be defined to be—In a per- son awake, a false or mistaken judgment of those re- lations of things, which, as occurring most frequently in life, are those about which the generality of men form the same judgment; and particularly when the judgment is very different from what the person Himself had be- fore usually formed. 1533. With this mistaken judgment of relations there is frequently joined some false perception of ex- ternal objects, without any evident fault in the organs of sense, and which seems therefore to depend upon an internal cause; that is, upon the imagination arising from a condition in the brain presenting objects which are not actually present. Such false perceptions must ne- cessarily occasion a delirium, or an erroneous judgment, which is to be considered as the disease. 1534. Another circumstance, commonly attending delirium, is a very unusual association of ideas. As, with respect to most of the affairs of common life, the ideas laid up in the memory are, in most men, associa- ted in the same manner; so a very unusual association, in any individual, must prevent his forming the ordina- ry judgment of those relations which are the most com- mon foundation of association in the memory: and there- PRACTICE OF PHYSIC. 295 fore this unusual and commonly hurried association of ideas, usually is, and may be considered as, a part of de- lirium. In particular it may be considered as a certain mark of a general morbid affection of the intellectual organs, it being an interruption or perversion of the or- dinary operations of memory, the common and neces- sary foundation of the exercise of judgment. 1535. A third circumstance attending delirium, is an emotion or passion, sometimes of the angry, sometimes of the timid kind; and from whatever cause in the per- ception or judgment, it is not proportioned to such cause, either in the manner formerly customary to the person himself, or in the manner usual with the gene- rality of other men. 1536. Delirium, then, may be more shortly defined —In a person awake, a false judgment arising from perceptions of imagination, or from false recollection, and commonly producing disproportionate emotions. Such delirium is of two kinds; as it is combined with pyrexia and comatose affections; or, as it is entire- ly without any such combination. It is the latter case that we name Insanity; and it is this kind of delirium only that I am to treat of here. 1537. Insanity may perhaps be properly considered as a genus comprehending many different species, each of which may deserve our attention; but before proceed- ing to the consideration of particular species, I think it proper to attempt an investigation of the cause of in- sanity in general. In doing this, I shall take it for granted, as demon- strated elsewhere, that although this disease seems to be chiefly, and sometimes solely, an affection of the mind; yet the connexion between the mind and body in this 296 PRACTICE OF PHYSIC. case is such, that these affections of the mind must be considered as depending upon a certain state of our cor- poreal part. See Halleri Prim. Lin. Physiolog. §570. See Boerhaavii Inst. Med. fr 581. 696. 1539. Admitting this proposition, I must in the next place assume another, which I likewise suppose to be demonstrated elsewhere. This is, that the part of our body more immediately connected with the mind, and therefore more especially concerned in every affection of the intellectual functions, is the common origin of the nerves; which I shall, in what follows, speak of un- der the appellation of the brain. 1540. Here, however, in assuming this last proposi- tion, a very great difficulty immediately presents itself. Although we cannot doubt that the operations of our intellect always depend upon certain motions taking place in the brain, (see Gaub. Peth. Med. & 523;) yet these motions have never been the objects of our sen- ses, nor have we been able to perceive that any parti- cular part of the brain has more concern in the opera- tions of our intellect than any other. Neither have we attained any knowledge of what share the several parts of the brain have in that operation; and therefore, in this situation of our science, it must be a very difficult mat- ter to discover those states of the brain that may give occasion to the various state of our intellectual func- tions. 1541. It may be observed, that the different state of the motion of the blood in the vessels of the brain has some share in. affecting the operations.of the intellect: and physicians, in seeking for the causes of the different states of our intellectual functions, have hardly looked further than into the state of the motion of the blood, PRACTICE OF PHYSIC. 29? or into the condition of the bloocl itself: but it is evident that the operations of the intellectual functions ordina- rily go on, and are often considerably varied, without our being able to perceive any difference either in the motions or'in the conditions of the blood. 1542. Upon the other hand, it is very probable that the state of the intellectual functions depends chiefly upon the state and condition of what is termed the ner- vous power, or, as we suppose,' of a subtile very movea- ble fluid, included or inherent, in a manner we do not clearly understand in every part of the medullary sub- stance of the brain aud nerves, and which in a living and healthy man is capable of being moved from every one part to every other of the nervous system. 1543. With respect to this power, we have pretty clear proof that it frequently has a motion from the sen- tient extremities of the nerves towards the brain, and thereby produces sensation; and we have the same proof, that in consequence of volition the nervous power has a motion' from the brain into the muscles or organs of motion. Accordingly, as sensation excites our intellec- tual operations, and volition is the effect #of these, and as„the connexion between sensation and volition is al- ways by the intervention of the brain and of intellectu- al operations; so we can hardly doubt, that these latter depend upon certain motions, and the various modifica- tion of these motions, in the brain. 1544. To ascertain the different states of these mo- tions may be very difficult; and physicians* have com- monly considered it to be so very mysterious, that they have generally despaired of attaining any knowledge with regard to it: but I consider such absolute despair, and the negligence it inspires, to be always very blame- vol. n. p p 298 PRACTICE OF PHYSIC. able; and I shall now'venture to go some length in the inquiry, hoping that some steps made with tolerable firmness may enable us to go still further. 1545. To this purpose, I think it evident, that the nervous power, in the whole as well as in^he several parts of the nervous system, and particularly in the brain, is, at different times in different degrees of mobility and force. To these different states, I beg leave to apply the terms of Excitement and Collapse. To that state in which the mobility and force are sufficient for the ex- ercise of the functions, or when these states are any way preternaturally increased, I give the name of Excite- ment; and to that state in which the mobility and force are not sufficient for the ordinary exercise of the func- tions, or when they are diminished from the state in which they had been before, I give the name of Collapse. I beg, however, it may be observed, that by these terrhs I mean to express matters of fact only; and without in- tending, by these terms, to explain the circumstance or condition, mechanical or physical, of the nervcus pow- er or fluid in these diffetent states.- 1546. That these different states of excitement and collapse take place on different occasions, must, I think, be manifest from numberless phenomena of the animal economy: but it is especially to our present purpose to observe, that the different states of excitement and col- lapse, are in no instance more remarkable, than in the different states of waking and sleeping. In the latter, when quite complete, the motion and mobility of the nervous power, with respect to the whole of what are called the animal functions, entirely cease, or, as I would express it, are in a state of collapse; and are very dif- ferent from the state of waking, which in healthy per PRACTICE OF PHYSIC. 299 sons I would call a state of general and entire excite- ment. 1547. This difference in the states of the nervous power in sleeping and waking being admitted, I must in the next place observe, that when these states are changed from the one into the other, as commonly hap- pens every day, the change is hardly ever made instan- taneously, but almost always by degrees, and in some length of time* only: and this may be observed with respect to both sense and motion. Thus when a per- son is falling asleep, the sensibility is gradually dimin- ished: so that, although some degree of sleep has come on, slight impressions will excite sensation, and bring back excitement; which the same, or even stronger im- 'pressions, will be insufficient to produce when the state of sleep has continued longer, and is, as we may say, more complete. In like manner, the power of volun- tary motion is gradually diminished. In some members it fails sooner than in others; and it is sometime before it becomes general and considerable over the whole. The same gradual progress may be remarked in a person's coming out of sleep: the ears in this case are often awake before the eyes are opened or see clearly, and the senses are often awake before the power of vo- luntary motion is recovered; and it is curious to observe, that, in some cases, sensation may be excited without producing the ordinary association of ideas. See Mem. de Berlin, 1752. 1548. From all this, I think it will clearly appear, that not only the different states of excitement and col- lapse can take place in different degrees, but that they can take place in different parts of the brain, or at least, 300 PRACTICE OF PHYSIC with respect to the different functions, in different dc- grees. As I presume that almost every person has perceived the gradual approach of sleeping and waking, 1 like- wise suppose every person has observed, that) in such intermediate state of unequal excitement, there almost always occurs more or less of delirium, "or dreaming, if any body chooses to call it so. There are in this state false perceptions, false associations, false judgments, and disproportionate emotions; in short,' all the circum- stances by which I have.above defined delirium. This clearly shows that delirium may depend, and I shall hereafter endeavour to prove that it comjnonly does depend upon some inequality in the excitement of the brain; and that both these assertions are found- ed on this, that, in -order to the proper exercise of our intellectual functions, the excitement must be com- plete, and equal in every part of the brain. For though we cannot say that the vestiges of ideas are laid up in different parts of the brain, or that they are in some measure diffused over the whole, it will follow upon ei- ther supposition, that as our reasoning and our intellecr tual operations always require the orderly and exact re- collection or memory of associated ideas; so, if any part of the brain is not excited, or not excitable, that re- collection cannot properly take place, while at the same time other parts of the brain, more excited and excitable, may give false perceptions, associations, and judgments. 1549. It will serve to illustrate this, that the collapse in sleep is more or less complete; or that the sleep, as we commonly speak, is more or less profound; and therefore, that in many cases, though sleep takes place to a considerable degree, yet certain impressions do PRACTICE OF PHYSIC. 301 still take effect, and excite motions, or, if you will, sensations in the brain; but which sensations, upon ac- count of a collapsed state of so great a part of the brain, are generally of the delirious kind, or dreams, consisting of false preceptions, .associations, and judgments, that would have been, corrected if the^rain had been entire- ly excited. Every one, I believe, has observed, that the most imperfect sleeps, are those chiefly attended with dream- ing; that dreams, therefore, most commonly occur to- wards morning, when th* complete state of sleep is passing away; and further, that dreams are most com- monly excited by strong and uneasy impressions made upon the body. I apprehend it may also be an illustration of the same thing, that, even in waking hours, we have an instance of an unequal state of excitement inthe brain producing delirium. Such, I think, occurs in the case of fever. In this it is manifest, that the energy of the brain, or its excitement, is considerably diminished with respect to the animal functions: and it is accordingly upon this ground that I have explained above, in 45, the delirium which so commonly attends, fever. To what I have there said I shall here only add, that it may serve to confirm my doctrine, that the delirium in fever comes on at a certain period of the disease only, and that we can commonly discern its approach by a more than usual de- gree of it appearing in the time of the patient's falling into or coming out of sleep. • It appears, therefore, thatMelirium, when it first comes on in fever, depends upon an inequality of excitement; and it can hardly be doubted, that the delirium which comes at length to prevail in the entirely weakened state of fevers, depends 302 PRACTICE OF PHYSIC. upon the same cause prevailing in a more considerable degree. 1550. From what has been now delivered, I hope it will be sufficiently evident, that delirium may be, and frequently is, occasioned by an inequality in tr^e ex- citement of the brainy . How the different portions of the brain may at the same time be excited or collapsed in different degrees, or how the energy of the brain may be in different de- grees of force, with respect to the, several .animal, vital, and natural functions, I carmot pretend to explain; but it is sufficiently evident in fact, that the brain may be at one and the same time in different conditions with respect to these functions. Thus in inflammatory dis- eases, when by a stimulus applied to the brain the force, of the vital functions is preternaturally increased, that of the animal is either little changed, or considerably diminished. On the contrary, in many cases of mania, the force of the animal functions depending always on the brain, is prodigiously increased, while the state of the vital function in the heart, is very little or not at all changed. I must, therefore, say again, that how difficult soever it may be to explain the mechanical or physical condition of the brain in such cases, the facts are suffi- cient to show that there is such an inequality as may disturb our intellectual operations. 1551. I have thus endeavoured to explain the gene- ral cause of Delirium; which is of two kinds, according as it is with, or without, pyrexia. Of the first I take no further notice here, having explained it as well as I could above in 45. I proceed now to consider that delirium which pro- PRACTICE OF PHYSIC. 303 perly belongs to the class of Vesaniae, and which 1 shall tre#t of under the general title of Insanity. 155&. In entering upon this subject, it immediately occurs, that in many instances»of insanity, we find, up- on dissection after death, that peculiar Cireumstances had taken place in the general*condition of the brain. In many cases, it has been found of a drier, harder, and firmer consistence, than what it is usually of in persons * * who had not been affected with that disease. In other cases, it has been*found in a more humid, soft, and flac- cid state1; and,in the observations of-the late Mr. Meckel, it has been found* considerably changed in its density or specific gravity. Whether these different states have been observed to be uniformly the same over the whole. of the brain, I cannot certainly learn;, and I suspeCtthe dissectors have not always accurately inquired into this circumstance: but in several instances, it appears that these states had been different in different parts Of the brain; and instances of this inequality will afford a con- firmation of our general doctrine: •»' The accurate Mofgagnihas observed, that in mani- acal persons the medullary pbrtion of the brain is usual- ly dry, hard, and firm: and this he had so frequently ob- served, that he was disposed to consider it as generally the case. But in most of the particular instances which he has given, it appears,- that, for the most part, while the cerebrum was of an unusually hard and firm con- sistence, the cerebellum was of its usual softness, and • in many of the cases it was unusually soft and flaccid*. In some other cases, Morgagni observes, that while a part df the cerebrum was harder and firmer than.ordi- nary, other parts of it were preternaturally soft. 304 PRACTICE OF PHYSIC. 1553. These observations tend to confirm our gene- ral doctrine: and there are others which I think will ap- pl# to the same purpose. * ■ • Upon the dissection ot the bodies of persons who had laboured under insanity, various organic affections have been discovered in particular parts .of the brain; and it is sufficiently probable, that such'organic affections might . have produced a different degree of excitement in thf free and affected parts, and must have interrupted, in some measure the free communication between the se- yeral parts of the brain, and in eithe* way hjive occasion- ed insanity. There have occurred so many instances of this kind, that I believe physicians are generally disposed to sus- pect organic lesions of the brain to exist in almost.every case of insanity. 1554. This, however, is probably a mistake: -for we. know" that.there have been many instances of insanity, from which the persons have entirely recovered; and it is difficult to sUppdse that .any organic, lesions of the brain bad in such" case taken place. Such transitory cases, indeed, render it probable, that a-state of excite-' ment, changeable by various causes, had been the cause of such instances of insanity. 1555. It is indeed further asserted, that in many, in- stances of insane persons, thefr brain had been examin- ed after death, wiujdut showing that any organic lesions had before* subsisted in the brain, or finding that any morbid state of the brain then appeared. This*, no doubt, may serve to show, that organic lesions had not been the cause of the disease; but it does not. assure us that no morbid change had taken place in the brain: for it is probable, that the dissectors were not always aware of PRACTICE OF PHYSIC. 30$ its being the general condition of hardness and density,1 as different in different parts of the brain, that was to be attended to, in order to discover the cause of the pre- ceding disease; and therefore many of them had not with this view examined the state of the brain, as Morgagni seems carefully to have done. 1556. Having thus endeavoured to investigate the cause of insanity in general, it were to be wished that I could apply the doctrine to the distinguishing the se- veral species of it, according as they depend upon the different state and circumstances of the brain, and there- by to the establishing of a scientific and accurately adap- ted method of cure. These purposes, however, appear to me to be extremely difficult to be attained; and I cannot hope to execute them here. All I can do is to make some attempts, and offer some reflections^ which further observation, and greater sagacity, may hereafter render more useful. 1557. The ingenious Dr. Arnold has been com- mendably employed in distinguishing the different species of insanity as they appear with respect to the mind; and his labours may hereafter prove useful, when we shall come to know something more of the different states of the brain corresponding to these different states of the mind; b ■it at present I can make little applica- tion of his numerous distinctions. It appears to me that he has chiefly pointed out and enumerated distinc- tions, that are merely varieties, which can lead to little or no variety of practice: and I am especially Ted to form the latter conclusion, because these varieties appear to me to be o> j in general little understood, and in no instance less so than in that of the secretion of oil from blood which does not appear previously to have contained it. It is possible, therefore, that our theory of the deficiency of oil may be in several respects imperfect; but there are certain facts that may in the mean time apply to the pre- sent purpose. 1615. First, it is probable, that a deficiency of oil may be owing to a state of the blood in animal bodies less fitted to afford a secretion of oil, and consequently to supply the waste of it that is constantly made. This state of the blood must especially depend upon the state PRACTICE OF PHYSIC. 335 of the aliments taken in, as containing less of oil or oily matter. From many observations made, both with respect to the human body and to that of other animals, it appears pretty clearly, that the aliments taken in by men and domestic animals, according as they contain more of oil, are in general more nutritious, and in par- ticular are better fitted to fill the cellular texture of their bodies with oil. I might illustrate this, by a minute and particular consideration of the difference of alimentary matters employed; but it will be enough to give two in- stances. The one is, that the herbaceous part of vege- tables does not fatten animals, so much as the seeds of vegetables, which manifestly contain in any given weight a greater proportion of oil: and a second instance is, that in general vegetable aliments do not fatten men so much as animal food, which generally contains a larger portion of oil. It will be obvious, that upon the same principles a want of food, or a less nutritious food, may not only oc- casion a general deficiency of fluids (1605.) but must also afford less oil, to be poured into the cellular tex- ture. In such cases, therefore, the emaciation produced, is to be attributed to both these general causes. 1616. A second case of the deficiency of oil may be explained in this manner. It is pretty manifest, that the oil of the blood is secreted and deposited in the cellular texture in greater or lesser quantity, according as the circulation of the blood is faster or slower; and there- fore that exercise, which hastens the circulation of the blood, is a frequent cause of emaciation. Kxercise pro- duces this effect in two ways. 1st. By increasing the perspiration, and thereby carrying off a greater quan- tity of the nutritious matter, it leaves less of it to be de- 336 PRACTICE OF PHYSIC. poshed in the cellular texture; thereby not only pre- venting an accumulation of fluids, but, as I have said above, causing a general deficiency of these, which must also cause a deficiency of oil in the cellular tex- ture. 2dly, It is well known, that the oil deposited in the cellular texture is, upon many occasions, and for various purposes of the economy, again absorbed, and mixed or diffused in the mass of blood, to be from thence perhaps carried entirely out of the body by the several excretions. Now, among other purposes of the accumulation and reabsorption of oil, this seems to be one, that the oil is requisite to the proper action of the moving fibres in every part of the body; and therefore that nature has provided for an absorption of oil to be made according as the action of the moving fibres may demand it. It will thus be obvious, that the exercise of the muscular and moving fibres every where, must oc- casion an absorption of oil; and consequently that such exercise not only prevents the secretion of oil, as has been already said, but may also cause a deficiency of it, by occasioning an absorption of what had been de- posited; and in this way perhaps especially, does it produce emaciation. 1617. A third case of the deficiency of oil may occur from the following cause. It is probable, that one pur- pose of the accumulation of oil in the cellular texture of animals is, that it may, upon occasion, be again ab- sorbed from thence, and carried into the mass of blood, for the purpose of enveloping and correcting any unu- sual acrimony arising and existing in the state of the fluids. Thus, in most instances in which we can discern an acrid state of the fluids, as in scurvy, cancer, syphilis, poisons, and several other diseases, we find at the same time a deficiency of oil and an emaciation take place; PRACTICE OF PHYSIC. 337 which, in my apprehension, must be attributed to the absorption of oil, which the presence of acrimony in the body excites. It is not unlikely that certain poisons introduced into the body, may subsist there; and, giving occasion to an absorption of oil, may lay a foundation for the Tabes c veneno, Sauv. sp. 17. 1618. A fourth cause of emaciation, and which I would attribute to a sudden and considerable absorp- tion of oil from the cellular texture, is that of fever, which so generally produces emaciation. This may per- haps be in part attributed to the increased perspiration, and therefore to the general deficiency of fluids that may be supposed to take place: but whatever share that may have in producing the effect, we can, from the evident shrinking and diminution of the cellular sub- stance, wherever it falls under our observation, certainly conclude, that there has been a very considerable ab- sorption of the oil which had been before deposited in that substance. This explanation is rendered the more probable from this, that I suppose the absorption men- tioned is necessarily made for the purpose of envelop- ing or correcting an acrimony, which manifestly does in many, and may be suspected to arise in all cases of fever. The most remarkable instance of emaciation oc- curring in fevers, is that which appears in the case of hectic fevers. Here the emaciation may be attributed to the profuse sweatings that commonly attend the dis- ease; but there is much reason to believe, that an acri- mony also is present in the blood; which, even in the beginning of the disease, prevents the secretion and ac- cumulation of oil; and in the more advanced states of it, must occasion a more considerable absorption of VOL. II. u u 338 PRACTICE OF PHYSIC. it; which, from the shrinking of the cellular substance, seems to go farther than in almost any other instance. Upon the subject of emaciations from a deficiency of fluids, it may be observed, that every increased eva- cuation excites an absorption from other parts, and particularly from the cellular texture; and it is there- fore probable, that a deficiency of fluids, from increased evacuations, produces an emaciation, not only by the waste of the fluids in the vascular system, but also by occasioning a considerable absorption from the cellular texture. 1619. I have thus endeavoured to explain the several cases and causes of emaciation; but I could not prose- cute the consideration of these here in the order they are set down in the Methodical Nosology. In that work I was engaged chiefly in arranging the species of Sau- vages: but it is my opinion now, that the arrangement there given is erroneous, in both combining and sepa- rating species improperly: and it seems to me more proper here to take notice of diseases, and put them together, according to the affinity of their nature, rather than by that of their external appearances. I doubt, if even the distinction of the Tabes and Atrophia, at- tempted in the Nosology, will properly apply; as I think there are certain diseases of the same nature, which sometimes appear with, and sometimes without, fever. 1620. After having considered the various cases of emaciations, I should perhaps treat of their cure: but it will readily appear, that the greater part of the cases above mentioned are purely symptomatic, and conse- quently that the cure of them must be that of the pri- mary diseases upon which they depend. Of those cases that can anywise be considered as idiopathic, it will ap- PRACTICE OF PHYSIC. 339 pear that they are to be cured entirely by removing the remote causes; the means of accomplishing which must be sufficiently obvious. BOOK II. OF INTUMESENTLfi, OR GENERAL SWELLINGS. 1621. THE swellings to be treated of in this place, are those which extend over the whole or a great part of the body; or such at least, as, though of small ex- tent, are however of the same nature with those that are more generally extended. The swellings comprehended under this artificial order, are hardly to be distinguished from one another otherwise than by the matter they contain or consist of. And in this view I have divided the order into four sec- tions, as the swelling happens to contain, 1st, Oil; 2d, Air; 3d, A watery fluid; or, 4th, As the increased bulk depends upon the enlargement of the whole sub* stance of certain parts, and particularly of one or more of the abdominal viscera. h> 'St*;' ^ --&4 %■ *'&] ^ *■■ # %' ■** * •>V -''■-■ *ffc! h**** ^#H'