Practise of Physick by Dr Fordyce No 1 Practise of Physick Index Page No Treatment of the small pox 1 Treatment after the small pox 6 Measles and treatment 8 Chicken pox 10 Miliary fever 11 Scarlet fever 13 Herpes miliares, or shingles 14 Causes of [exaleratn] of the lungs 14 Symptoms of the disease 15 Causes of pulmonary hemorrhage 17 Treatment of Haem of [illegible] 21 Hectic fever chronic general Inflamatn causes of consumptn 23 Symptoms, treatment etc. 25 Rheumatism 29 Treatment of the rheumatism 34 Chronic diseases 46 Weakness of the system, causes, treatment etc. 47 Menstruation, theory of 50 Treatment of obstructed menses 56 Modes of strengthening the habit 60 1 Lect: 91st May 18th 1772 Treatment of the small pox one general observation is that there is no means of shortening the disease or putting a stop to it when it has once taken place it must be gone through, all to be done then, is to avoid, or prevent and dangerous symptoms that may arise in the course of the disease. 1st When the fever takes place it is usefull to clear the prima viae of any matter they may contain by the exhibition of an emetic & gentle laxative to prevent the [lodgement] of any mucus or harden’d excrements that may be contain’d in the intestines as of any acidity that may be lodged in the stomach [These] remeds cannot be used so properly after the eruption. If the fever be attended with considerable symptoms of general inflamatn if the patient be plethoric or young & every strong it will be of use to take away a quantity of blood & this cannot be done with equal propriety after the eruption has taken place 10, or 12 ounces of blood is generally suffict. and it is very seldom necessary to repeat the operation. this evactn to be made previous to the eruption of the pustules 2 unless in the circumstances mention’d. Bleeding & evacuations are hurtfull. The more violent the fever in general the more violent the eruption and vice versa. we might then suppose, that by the diminishing the fever, by the use of relaxants etc. the eruption should be more mil this however does not appear to be the case altho’ relaxants in general do no mischief & are very usefull if the fever shd not be the small pox. There never can be a case where strengthening remedies can be wasted to support the patient curing the fever, all stimulants then etc. should be avoided. the eruptive fever is almost never fatal, generally going off upon the eruption In children, previous to the eruption convulsions sometimes take place, or disappear upon the eruption very seldom continue after remarks that the pox in this case are almost always of the distinct kind. do nothing for the convulsions, trust to nature they almost always go off themselves. 3 Then the eruption has taken place if the symptoms of inflamation do not run high if no symptoms of irritability take place, if the pustules gradually fill with yellow pus, if the hands, feet are inflamed as the face subsides, if no difficulty of respiratn nor costiveness takes place we must then let nature alone & not disturb her by medicines. [but] suppose the patient to be costive it is apt to encrease all the dangerous symptoms. the intestines should be evacuated by glysters, purgatives should by no means be exhibited before the period of maturation as the pustules are apt to sink by their operation Sleep may be procured by opium if the patient be restless. If the patient has an evacuation in 48 hours we should make no evacuation by medicines as too great discharges that way are very apt to do mischief If symptoms of great inflamation take place, if the pulse be hard & strong, if the face and eyes be inflamed, if delirium, or symptoms of oppress’d brain take place bleeding becomes necessary. Dr. Boerhave has supposed that the variolous fever has been carried off & the patient cured without any eruption taking place, this however we deny. 4 We should not be too rash in making evacuations by bleeding etc. as the pustules have sometimes immediately sank & the patient been cut off unless then the brain be affected we should rather avoid using the lancet. When necessary 10 or 12 ounces is generally sufficient, and we should not repeat the evacuation. The bad effects of evacuations are particularly evident in pregnant women If absorption takes place, as often happens, the evacuation in consequence is almost always fatal If the pustules continue watry, stimulate the skin, with erysipelatous inflamation between them or little blisters arise with great soreness Bark is the best medicine for filling the pustules with good pus but it is very apt at the same time to produce disorder in the breast difficulty of breathing & rendering the mucous secretion of the throat so thick as not to be evacuated. If the brain be affected, or the breast as above we should by no means be induced to exhibit the bark & ought immediately to leave it off it if produces these symptoms 5 Opium tends also to produce good suppuration & is therefore in such cases very properly exhibited, if no symptoms of general inflamation take place If the patient should want sleep for 3 or 4 nights it produces very great mischief & opium should be [illegible] [upon] [even] although general inflamation should take place opium tho is very apt to increase the oppression of the [evacuation] viscidity of the secretions from the trachea & dispositn to suffocation shd never be used then, but when absolutely necessary If the throat should be very sore gargles may be used, if the [illegible] sweet kind, and oily if mucilaginous draughts freely used to defend the parts. at the time of maturation the matter becomes often so thick as entirely to stop up the trachea, the patient has in some instances been saved under the present circumstances by the exhibition of an emetic expectorants [illegible] even to be usefull in this disease The thorax is very apt to be loaded with blood hence diff. of respiration impurity of the air greatly encreases this symptom & shd be avoided, by keeping the windows open, letting the patient walk out etc. (6) The variolous effluvia seem to defray the perspirable air in an extraordinary degree & of course require a greater supply of it fresh. We should remember that the patient is subject as well during this disease as at other times to catarrh, colds, pulmonary consumption etc. by exposure to too great a degree of cold, such exposure then should be avoided as dangerous. If the extremities do not swell when the face subsides about the period of maturation, blisters in such cases are of the greatest use & sinapisms apply’d to the parts which by their stimulus encrease the external circulation & prevent the blood from affecting the brain & chest If the small pox at any time subside we should employ some quick acting stimulus as wine with a little spice, volatile alkali etc. & blisters should be apply’d externally to throw the circulation upon the skin again stimulants however are by no means necessary during the [illegible] of the disease. Lect: 92d May 18th 1772 after the disease is at the hight the absorption of the pus produces general inflamation & the matter being deposited in difft. parts produces inflamation & abscess. this topical inflamation & general inflamation are to be got rid of by evacuations, purging seems much preferable to the bleeding in most habits that shd be freely exhibited& makes the pus [illegible] 7 If the pulse be very hard as is sometimes the case when the pustules have been very numerous, it is necessary to make evacuations by bleeding. this is but seldom necessary. Purging should be always used as well to take off the general inflamatn, as to carry off the matter out of the system by weakening the system in general they produce the first & by hardening the general change of the fluids they produce the [illegible] pus is capable of passing through the urinary vessels & the vessels of the skin also by encreasing any of the secretions then we procure a greater evacuation of the pus than of the thicker parts of the humours proportionally hence evacuation of every kind may be of use If the small pox leave a disposition in the body of producing inflamation, [absorp] etc. periodically at that time of the year in which the small pox happened in this case this particular disposition is best overcome by the exhibition of the bark in considerable quants for about a month before we expect the disease to take place, which by diminishing the irritability [illegible] the inflamatn from taking place or if the inflamatn does take place good pus is formed & the disease carried off. 8 Measles arise from an infection similar to the small pox as there is no matter formed in the disease, it cannot be communicated by inoculat. but is always apply’d in form of vapour never [illegible] to the body, [illegible] always [propagated & [be] [produced] [by] [illegible] The infection is received for some time before the disease is produced & is preceded by greater inflamatory symptoms of the mucous membrane, hence there is such an encreas’d secretion from the glands of the eyes, nose, throat etc. as to have the disease mistaken often for a catarrh. The fever is much more frequently attended with symptoms of general inflamation & the breast is more dangerously affected than in the small pox The eruption is not so uniform, but may appear in the 2, 3, or 4 day & the disease be qually mild when the eruption takes place the fever abates, but the symptoms of general inflamation as hardness quickness of the pulse, affection of the brain etc. are apt to continue In eruption is more of the erysipelatous kind than the small pox. The pustules seldom appear above the surface of the skin, and are never filled with pus as the small pox, but vanish without coming to suppuration, contain only a watry fluid 9 There is not the same costiveness symptoms of genl inflamation run much higher & are attended with great danger purgings being more frequent than in the small pox. The eruption does not go off regularly sometimes continues for 24 hours & from that to 5 or 6 days but seldom continues longer and the danger is not over at this time as is the case in the small pox. The great danger arises at the period when the measles disappear. the breast, & lungs are apt at this time to be affected, and pulmonary consumption is at times the consequence. blisters are of use in relieving the complaints of the breast We may bleed with great safety during the eruptive fever, at the time of the eruption, & more particularly at the disappearing of the measles which at this time should not be neglected in short bleeding is the cure for almost every bad symptoms that arises in the disease & should never be neglected at its termination if there remain any symptoms of inflamatn in the general habit Authors have described measles in which symptoms of irritation, and not of general inflamat. took place such cases are never [illegible] 10 The danger in this disease universally arises from general inflamatn so that the removal of almost every bad symptom depends upon bleeding In affections of the breast, blisters are of use, & purgatives may be used without any danger of the pustules sinking, because they never contain any fluid matter we have no danger to apprehend then, from this cause as we have in the small pox. Purgatives should never be omitted at the end of the disease as they are of great [illegible] to carry of the inflamatory symptoms remaining. Chicken pos of still less [illegible] appears to arise from infection certainly in some cases, probably always though not ascertained is always propagated by vapour, tho’ there is great reason to suppose it might be communicated by [???culatn] the pustules being filled with fluid matter which might easily be collected. The eruption generally takes place at the first paroxysm of the fever, but one series of eruptions will continue to succeed another as soon as the foregoing have disappeared, for so long a time (in some instances) as a month or six weeks a fresh crop appearing every 2 or 3 days during all that time. 11 Distinguish’d from the small pox by suddeness of the eruption after the first attack of the fever & by the very short time required for maturation of the pustules. The pustules arise all at once & the state of maturation is generally completed in 12 or 14 hours they [rising] at first filled with a thin transparent fluid, which in so short a time, still often change into thick, yellow pus. All the functions of the body go on regularly the patient sleeps well, eats well etc. & it is rare if any bad symptoms arise. This disease will go through its natural course, as well as the small pox or measles. If the pustules continue to break out for a long time, & endanger hectic fever bark is the most efficaceous medicine we can use to carry off this disposition of the habit. This disease never happens but once during life. Miliary Fever a disease whose existence has been much disputed some asserting that it was produced by some matter in the system which was discharged by the eruption others denying that the eruption was any thing more than consequence of sweating during long confinemt in a warm bed. 12 If a healthy man is laid in a warm bed, plenty of watry fluids exhibited with relaxants or stimulants for 48 hours an eruption is produced occasioned by a greater quantity of sweat being secreted through the true than what can pass through the false skin in consequence of which this fluid matter is collected & accumulated betwixt the cutis & cuticula raising the later up into small pimples. although the disease may generally produced as above yet there is a miliary eruption to which lying in women are subject arising [certainly] from another cause The common symptoms of fever first take place & the eruption arises in the first paroxysm of the fever with evident signs of inflamation & the febrile symptoms disappear upon the eruption, but if from any accident the eruption disappears of a sudden the symptoms of fever return with irritability depression of strength etc. which are attended with very great danger. A woman in [childbed] being weak and irritable the slightest accident produces a sinking of the pustules with symptoms of irritability which are attended with great danger & can only be remedied by reproducing the eruption as hereafter specified This fever probably proceeds from the child (of lying in women) not being [illegible] into blood but going to [illegible] & milk which if not properly secreted may occasion this eruption the particular acid [smell] accompanying this [disease] [inductus] [to] believe this to be the case. 13 A miliary eruption happening to women in childbed is distinguished from that occasioned by confinement by being preceded by the febrile paroxysm & its departure upon the eruption. Treatment simple [illegible] most endeavour to support the strength & take off the irritability of the habit by exhibiting nourishing foods, decoctions of the bark together with agreable spice etc. If the pustules shd sink a little volatile alkali, together with a little wine & some quick acting stimulant exhibited to reproduce them, if they often [illegible] (Blisters may be apply’d with success) & this is not unfrequently the case Bark is frequently of very great use also Scarlet fever to be treated as an erysipelatous inflamation, agreeing in every respect with that disease, only occupying an uncommonly large span of the body at times the whole or greatest part of the external surface. This disease is at times accompanied with phlegmonous & symptoms of general inflamation but symptoms of irritability are much more frequent 14 Herpes miliares, or shingles generally arise in spots particularly upon the trunk of the body have a dispositn to spread so as to surround it like a belt. Clusters of small pustules filled with a watry fluid which is seldom attended with any great inconvenience & does not come to maturation. This disease does not proceed from infectious matter The exhibition of the bark almost instantly carries off the disease by diminishing the irritability of the skin & so rendering it insensible to the stimulus of the neutral salts with which the eruptn is filled. Lect: 33d May 19th 1772 The lungs are subject to suppuration not only from inflamation of the part itself but from a variety of other causes ulcers here from the contind motion of the parts are prevented from healing & consequently very fatal. [Exeluratn] may arise in this part, as in any other from a phlegmonous inflamatn peripnuemony may terminate in inflamation & an abscess be produced which generally bursts into the lungs, in preference to the cavity of the thorax. 15 IF the matter be spit up upon its first breaking in large quantity if the matter diminishes gradually ion qy without any fetor we have reason to hope that it will cure. This is the almost only species of [exaleratn] of the lungs that heals the inflamatn of the parts having formed a cyst which keeps great mot. from taking place so as to prevent its healing. If an inflamation of the pleura, or mediestinum take place an abscess may be form’d which will burst into the lungs & thus produce the disease. [The] ulcer may be also formed from inflamatn of the mucous membrane in catarrhs pus is sometimes formed upon the surface of the inflamed membrane, but it is a very difficult mass to distinguish pus as formed from the mucus secreted which in m any cases greatly resembles pus By throwing the matter into water if it be mucus it retains its consistence & by having a little air entangled it swims on the water. pus diffuses itself more through the water & sinks. pus has often a fetid smell mucus never. pus is often of an appearance as if mixt with a [illegible] powders, of a 16 broken texture, greyish colour, and lumpy but we are often liable to be deceived in trusting to this appearance because the mucus frequently hardens into little clots. An ulcer may be also formed in the lungs by [illegible] or excoriation from the acrimony of the watry humours secreted in catarrhs. Venl ulcers are sometimes, but very rarely formed in the lungs if so pulmonary consumption takes place. An exalceration of the lungs may arise & frequently does in scrophula of them in this disease the mucus glands are primarily & chiefly infected with the disease although this is little attended to afterwards. The disease frequently arises also in scorbutic habits when encrea’d [secret.] takes place from the pulmonary [illegible] small masses of mucus adhering to the lungs forming little tubercles, by being forced off & spit up are at times the occasion of exulceration by being violently forced, & turn off from the mucus membrane Extraneous bodies as [illegible] etc. have got into the lungs & by remaining there have occasioned inflamatn suppuration & abscess in the part but such accidents rarely happen & have sometimes produced such a convulsive cough & diffy of breathing as immediately to destroy. 17 Wounds penetrating the thorax do not always produce exalceration, but frequently heal by the first intention, neither are they so fatal as we would expect they do however sometimes occasion suppuration and exalceration Matter absorbed from any other part of the body is evidently secreted by all the glands of the body hence it by fermenting with the substance of the lungs converts it into a matter or similar substance to itself & so at times produce exalceration of the part. The breath of the diseased person has sometimes is affected the attendants with the same disease by carrying off a qy of the [gas] it is [illegible] however [illegible] cough of [illegible] Exalcerations of the lungs are apt to arise from 2 other causes [illegible] haemorrages, & chronic general inflamation. An haemorrage may take place, at least on extravasatn of blood whether the vessels be ruptured, or whole if the blood be thrown into a cavity no opening externally we may call it extravasation, if the blood is [illegible] into a cavity opening [externally] we call it [hemorya]. 18 There are a number of openings from the blood vessels into the cavities which throw out a fluid thinner than the red blood [illegible] serum mixt with water & sometimes coagulable lymph. but they also from disease, as relaxation, as from the blood moving with greater velocity admit the red blood to pass through them. most generally happens from the latter cause as from inflamatn of the part etc. hence the mucus is sometimes streaked with blood when spit up which blood is thrown out by these small orifices of the blood vessels & mixt with it. The most common case of hemorage takes place from encreas’d circulation in the parts forcing the blood through the relaxed exhalants, the evacuatn empties the vessels, it therefore after a time generally stops or also goes on till there be such a quantity of blood evacuated, as to prove fatal, or the trachea is so suddenly filled with blood that respiratn is obstructed & the patient suffocated. 19 Dr Fordyce imagines the menses hemorage from the [illegible] & take place in this way & not from rupture of the vessels. Whilst the haemorage continues the blood is spit up frothy & of a florid colour, but when that which has lain sometime in the lungs is spit up, it is of a dark colour, & sometimes mixt with mucus. the blood is generally perfectly cleared out of the lungs, but at times continue also & by remaining, produces exalceration & abscess. A similar discharge by haemorage takes place from all other parts of the body from the [illegible] of young men particularly the menstrual discharge is probably an evacuation of the [illegible] kind. Lect: 94th May 19th 1772 Haem of [illegible] & haemorage from other parts, may arise from laxaty of the exhalant vessels in which case not only the thinner parts of the blood are suffered to pass through their extremities, but the red particles also, & this may happen without any encreas’d action of the arteries or of the general circulation. 20 Haemorages from raptures frequently take place in the breast from blows or violent injury, these are more generally cured than when any previous disease in the parts take place. The vessels [ruptured] are sometimes extremely small as to suffer a quantity of blood to be emitted only subjet to [illegible] or appear in small globules mixt with the mucus. Hemorage may & frequently does arise from exalceration of the lungs. When an ulcer is spreading it not only destroys the other pats but the sides of the vessels also hence we should expect in such cases very great & very frequent haemorages but the vessels generally have their extremities plugged by lymph from the previous inflamatn Hemorage may arise lastly from gangrene & mortification of the lungs which would generally destroy, if no hemorage was to take place. When menstruatn is obstructed [illegible] habits hemorage takes place from the lungs, or other parts of the body. the discharge from these parts, [supplying] the defect in the menstrual discharge. In obstructions however from weakness no such discharge is substituted. The hooping cough sometimes occasions a rupture of some of the pulmonary vessels and hemorrhage is the consequence. Asthma may have the same effect 21 Remedies used to stop bleeding from every part of the body but more particularly that from the lungs. 1 By emptying the blood vessels we diminish the power with which the blood is thrown out of the ruptured vessel. From whatever cause it is produced, if the system be strong evacuatn may be [cured] Bleeding is the most immediate but the qy must be properly adapted to the circumstance of the case. If the blood be thrown out by the exhalants & the patient strong & plethoric bleeding may be used if the bleeding arises from relaxatn as happens more particularly from the womb in this case we must not bleed but use strengthening medicines as the bark etc. In cases of rupture & erosion of the vessels of the patient be strong etc. Bleeding may be used, but not otherwise. Sedatives diminish the action of the vessels & stops hemorage in same manner as bleeding does. [illegible] by diminishing the velocity of the circulating fluids. 22 Acids are pretty powerfull and may be employ’d with advantage in hemorage from every part, [illegible] & muriatic acids have been preferred, these having probably somewhat more astringency than the others. If acids are unsuccessfull & there be great danger. preparations of lead are the most effectual particularly in [haemopto?] shd never be [cured] but when the others fail as their [illegible] [illegible] If haemorage takes place in strong or phlethoric habit with inflamy symptoms astringents are rather apt to do mischief by encreasing the contracdtile power of the blood vessels more than they diminish the circulatn of their fluids. If hemorage arises from laxity astringents may be used with great propriety. Allum dragons blood & japan earth are most powerfull & their effects most immediate, but of short duration. The vegetable astringents acdt slowly but their effects are more lasting than those that are stronger. Relaxants have been employ’d with success in some haemorages shd not be given in quantities suffict. to produce sickness. They are particularly usefull in internal hemorages by throwing the circulation externally astringents act more particularly upon the internal vessels hence throw [illegible] (papers of Med: may be properly [illegible] 23 Expectorants shd be used as squills, or such as do not encrease the action of the vessels. Mucilaginous & oily medicines shd be employ’d to prevent the bad effects of violent coughing that may arise. The patient shd be kept quiet, and in a reclining posture which takes off the weight of the column of blood; from the ruptured vessel. The patient shd be confined to food that does not stimulate & is easy of digestion. Animal foods then should be avoided. Lect: 95th May 20th 1772 A cause of suppurat. of the lungs as mentiond is chronic general inflamatn or hectic fever. The latter only apply’d to such cases as the lungs are affected with the dis. This disease is an encreased action of the arteries, the heart not acting strongly at the same time, arises from several causes & has been called by difft names is attended at a hard & contracted pulse but not full, and strong. It may take place in consequence of the strength of the habit alone in the spring when the vessels of young [illegible] are strengthen’d by the cold of the weather. the warmth of the returning summer at times stimulates the system is much as to produce an encreasd, habitual action of the vessels & hectic fever. 24 Young women from the age of puberty to 22 are particularly subject to this disease which is accompanied with symptoms of irritability the whole called the chlorosis. The pulse becomes hard, & frequent the symptoms encreased by the natl evening paroxysm. The appetite is [lost] & the organs of digestion impaired the body is emaciated and in women [illegible] gastric symptoms take place In this case the disease is to be carried off in men by evacuations in women by the applicat. of the natural stimulus which is the most infallible remedy yet discovered When the habit has been exhausted by acute general inflamation, chronic general inflammation sometimes continues after any violent phlegmat. as the small pox measles rheumatism etc. this disease is apt to take place, the pulse being hard the blood inflammatory etc. and the patient gradually weakened & at last cut off. From the long use of any powerfull inflamy stimulant as mercury, guaiacum etc. the hardness & quickness of the pulse continue after the use of the stimulus is discontinued.s 25 The remedy employ’d in the last case with the greatest success is sarsaparilla Some stimulating matter such as [illegible] variolous or morbillous matter absorpt into the system, after they can no longer produce a fever, stimulate the system & [fetch] on this disease the measles more apt to produce this disease than the small pox Tumor long continued so as to make a long continued distension on any part stimulates the system & produces the disease Exalceration of the lungs produced by inflamatn and abscess frequently cures the inflamatn surrounding the cyst keeping the part steady & unaffected by the act of the lungs People most subject to pulmonary consumption are such as are of a delicate habit fine white complexion florid cheeks red hair often in small quantity [illegible] etc. The disease is hereditary arising from peculiarity of temperament communicated by the parents. The skin through the day time is dry and contracted but frequently in the morning profuse sweats take place any additional stimulus greatly heats the system, as digestion of food & exercise, the appetite is lost & the powers of digestion impaired. The blood is thrown upon the lungs stimulates & inflames [illegible] haemorage from the lungs frequently take place the muscular strength is greatly diminish’d & the body is [illegible] symptoms of weakness slowly produce other dropsical swellings [illegible] [illegible] dropsy frequently take place 26 The stimulus keeps up the spirits of the patient in a very extraordinary manner, as that they never think they are in such danger as they really are. The same particularly takes place in dropsy from the distension continually kept up, by the water contain’d in the abdomen When an ulcer is formed in the lungs the absorption of the pus continues to stimulate the system & keep up the hectic fever symptoms of the disease are. A paleness of the face, [blueness] of the eyes, & cleanness of the tongue from the red blood not being perfectly formed or its texture destroy’d when formed The pus being secreted upon any particular glands as of the intestines produces purging on the skin colliquative sweats, or upon the kidneys great discharge of urine was to waste the patients strength If the disease remains as a consequence of the measles or other inflamatory disorder bleeding & evacuatn are of great use. If hectic fever arises from the apsorptn of pus from any part [not] the lungs, the bark is employ’d with the best success 27 But bark can never be used properly where the lungs are affected with inflammation or suppuration. Strengthening medicines are hurtfull in every case when hectic fever is produced, from any other cause but the absorption of pus from a wound or ulcer. although the patient seems weak & emaciated we must take off the strong action of the arteries by evacuation bleeding seems the most eligible, but must be made in such cases in small quantity only, and frequently repeated. purging & the evacuations produce partial weakness & are apt to do hurt. Relaxants may be advantageously employ’d they tend immediately to counteract the disease by preventing the blood from being thrown upon the lungs shd be exhibited in small doses only Sedatives are also of use. Acids may be advantageously exhibited. Vegetable foods should only be allowed & a milk diet. the patient should breath a free atmosphere in the vicinity of running water & a dry [soil] at a distance from a [illegible] [illegible] All animal food shd be avoided milks excepted shd those are best that have least coagulable matter in them. 28 The climate should be temperate & regularly so, the situation defended from cold winds high hills these are improper on acct. of the cold the [illegible] wind in this country to be particularly avoided. Riding has been recommended & is particularly usefull in catarrhs, & slight inflamations of the lungs, but if there be ulcers formed in the lungs and hectic fever present, the stimulus from riding is so far from being of use that it is very hurtfull. When exalceratn of the lungs is produced from the bursting of a recent formed abscess into the lungs there is hopes of the patients recovery but most other cases are in the end fatal, no remedies that are of use in other ulcers, can be used. Bark encreases the diffy of respiratn & mercury stimulates too powerfully if there so great difficulty in spitting up the matter, gartle expectorants may be made use of. if the cough be very troublesome opiates may in some instances be safely used as also to procure sleep, when it is wanting naturally [illegible] are in most cases too stimulating to be of service in this disease 29 Lect: 96th May 21st 1772 Rheumatism varies pretty considerably in its appearance more perhaps than inflamtn so that it has been much disposed that the disease [illegible] & that part of the body were capable of being inflected with the disease It commonly occupies the external parts of the body it may also occupy the internal parts as we find metastasis take place from the external to the internal parts, [illegible] the brain & intestines. It may occupy the skin which is much [illegible], & colder in the parts diseased. It may occupy the muscles, hence those of these parts affected with the disease loos their powers in some measure. It may infect the internal membranes as the violence of the pain of the aponeuresis of the thigh testifies. It seems capable then of affecting almost every part of the body. It originally arises always in the external parts, and only from one known cause [illegible] cold 30 The cause however is not in every cause evident. but when it can be traced to any cause cold is always it. as we know that cold is capable of producing it & of no other cause but cold we attribute it always to the effects of cold. The only necessary symptoms to constitute rheumatism are coldness, paleness of the parts and inability of motion in the muscles. Cold produces in general a contract of the small vessels which is sometimes permanent & at other times continues no longer than the cause. The former seem always to be the case in rheumatism the coldness & paleness show if the circulatin is retarded which is the known effect of cold, immobility is a necessy consequence of the contractn of the small vessels These symptoms constitute the disease and always take place at first. sometimes these symptoms remain the same for a very great length of time but they more generally produce other affections as inflamatn which is only the consequence of & not the disease itself 31 The arteries propelling the blood more strongly into the capillaries endeavour to distend them, & occasion pain which however is very difft. from what takes place in those vessels when inflamed. as the endeavour is contin’d of & [illegible] to distend the capillaries the pain is lasting, being a continual gnawing in place of acute, throbbing pain which takes place in inflamatn of these vessels. Rheumatism is divided into 3 kinds if attended with genl inflamation it is called acute if there be no general inflamatn the disease is call’d chronic threumatism or if the inflamat. be not attended with danger. The encreased actn of the arteries at last frequently get the better of the contractn at first inflamatn of the part is produced which in the present case is the cure of the disease, but if the obstruction does not yield to this encreased arterial action general affectn is produced Hardness, fullness, frequency of the pulse etc. which all the symptoms of inflamatn the tongue becomes white, the patient thirsty, appetite lost, and frequently oppression of the breast with (at times) stupor, delirium & affection of the brain. The fullness of the pulse is occasioned by the quantity of the blood thrown out by the heart 32 By evacuations then we can diminish the quantity of blood & so take off the fullness from the [pulse] in this [illegible] although the action of the heart is weakened that of the arteries continues hence the frequency & hardness of the pulse frequently continue after its fullness is removed by evacuatn or continuance of the disease. If the encreased action of the arteries carries of the disease then health is restored, if not it produces an acute fever & genl inflamn The general inflamatn may prove fatal by affecting the brain, or the delirium if the patient survives may be converted into mania The disease sometimes continues perfectly topical without producing any general inflmatn of the habit. The more considerable the topical & general inflamatn are the shorter is the disease likely to be & vice versa. Another appearance in rheumatism [illegible] renders it most troublesome & difft metastases when there is general inflammation are very apt to take place by which the seat of the disease is translated from one part of the body to another and that without any order. Regularly or often evidt cause is that one limb or both, or perhaps almost every part of the body at the same time 33 Metastasis has often been accounted for by saying that the matter is taken up from one part and lodged in another but there appears to be no matter in this disease it cannot be communicated by the applicatn of any infectious matter nor its existence otherwise proved If rheumatic matter was in the system & capable of producing the disease by being mixt in the heart with the whole mas of blood would be spread through the whole body uniformly unless we allow that some part is more fit for the reception of this matter than others, but this does not appear to be the case for no part of the body seems to be exempt from it by metastasis it must then be allowed that of the matter be spread through the whole system there must be some particular disposit. Metastasis serves to prolong the disease when it affects the brain it very suddenly proves fatal or if the intestines it produces spasm flatulency etc. When the disease is cured in one part of the body it by infecting another part retards the cure as the secondary affection is so difficult or often more so than the first or the disease sometimes takes place in 2, 3, or more difft parts of the body whilst the original affection remains [uncured]. 34 in the blood vessels of the part affected to be infected with the disease else the affection would be general as the applicatn of the matter must be this however is not the case and as it never was, nor can be proved, that any such matter does exist in the body this particular disposition (in one part) of the vessels is of itself suffict,. to account for the disease; and should therefore be admitted as the [cause]. Lect: 97th May 22nd 1772. Treatment of the Rheumatism In rheumatism we might suppose it proper to employ the natural method of cure for carrying off the disease [illegible] by the encreased action of the vessels. but in rheumatism the natural cure is the only part of the disease that is [illegible] dangerous & troublesome, we should then endeavour to shock the tending to natural cure & carry off the general inflmatn by the exhibition of remedies If the pulse be hard strong, & frequent & symptoms of general inflamatn prevent copious & repeated bleeding should be used to carry them off not only in qy suffict. to regulate the action of the vessels but to get the better of it so as to carry it entirely off. 35 Relaxants are employed at very considerable efficacy and they are [these] [med:] which tend directly to counteract the disease and remove the obstructions that take place they should be used in an all other cases [illegible] not before the strong action of the vessels is carried off. Blisters & stimulants may be advantageously applied to the part & internal stimulants be exhibited of the antispasmodic kind if the circulatn be languid Relaxants must be employ’d for a length of time often before they are of any use & the most efficaceous as antimony & ipecacuanha shd be exhibited Medicines strengthening & destroying the [illegible] ability of the system are of most use when the disease is apt to return frequently & put on the appearance of a spasmodic affection which it sometimes does. Rheumatism properly not divided according to the difft. part of the body affected, but according as it is attended with more or less general inflamat. if the general inflamatn be very great we call it acute rheumatism or rheumatic fever if the general inflamatn be absent or in considerable it is called chronic Rheumatism as these differ only in degree there can be no boundary properly ascertain’d betwixt the two 36 Acute rheumatism happens more frequently to such as never before had the disease & to people of a disposit. in which inflamatn is apt to take place. frequently arises at first with symptoms that are only slight as with a little cold & immobility of some particular part with out any great pain which upon fresh exposure to cold is encreased to a very considerable degree The tendons & [aponeutosis] of the muscles are more generally affected in this than in [illegible] rheumatism. At other times the very first symptoms of the disease are violent acute pain immobility redness & inflammation of the part are the first symptoms of the disease & genl inflamatn succeeds The affect. spread from the part which it originally affected, violent symptoms of inflamation etc. come on in a very great degree sometimes even to prove fatal. frequent metastasis takes place in this stage. it sometimes but rarely happens that all the external parts are affected at once and the whole joints of the body become immoveable with very great pain & soreness over all the body very soon after the attack the pulse becomes hard, strong & frequent, the tongue becomes white, appetite is lost & all the other symptoms of general inflamation. 37 The inflamatn sometimes arises to such a degree that the brain is affected stupor first, then delirium take place & the patient is cut off or if the patient [illegible] the delirium is sometimes converted into mania Delirium more frequently takes place in this disease from want of sleep which delirium is accompanied with the most violent ravings (symptoms) quick motion of the eyes, raving, snatching every thing out of the attendants hands, jumping out of the bed, requiring 2, or 3 men to hold them, in some instances have leapt out of the window or stabb’d themselves. If the patient recovers from this state the disease gradually intermits, going off during the day tie & returning at night. the strength of the patient being exhausted & the rheumatism carried off by the continuance of the disease. Metastasis to the internal parts seldom takes place whilst the patient continues strong. the more the patient is exhausted the more mobile it is & the greater dispositn for metastasis to take place. when this happens to the brain delirium is produced & the disease cuts off the patient frequently in a few hours. 38 Lect: 98th May 22d 1772 Treatment of acute rheumatism suppose we are called in at the beginning of the disease it is not generally of difft cure as the genl inflamatn may be carried off by copious evacuation The rheumatism is not to be attended to but the general inflamatn to be got rid of as upon that the whole danger of the disease depends. We are to make copious evacuatn if the patient be strong 16 or 18 ounces of blood are to be taken away & the operatn repeated the next day if the genl inflamatn be not removed & so continue till we overcome it & nothing else appears in this stage of the disease to be of any use, if any [illegible] must be given it may be in the [illegible] relaxants as [illegible] If we loose the opportunity of making large evacuatn at first we never after have the disease is much in our power at this period nothing shd be used but barley water and such [illegible] food If the genl inflamatn is entirely carried off by the bleeding but the rheumatism continues with pain in the part affected then relaxant may be used with great advantage to carry off this remaining affection of the disease topical bleeding by cupping leeches etc. are often of use when inflamatn be confin’d to a [illegible] part. 39 Suppose the general inflamation is not so considerable that there is but little hardness & fullness of the pulse, in such cases large evacuations are not so necessary 12 or 14 ounces may be taken away, & there is seldom a necessity of repeating the operatn it is better however always to exceed in too much than too little blood. when the proper evacuatn is made relaxants may be exhibited of which emetic tartar is the most effiacacious, & may be given in as large qy as the patient can bear without being sick at stomach from ¼ to ½ grain may be exhibited every 2 or 3 hours in water. suppose we have not been called till the disease has continued 2 or 3 days during which time general inflamatn has taken place and the proper evacuations have been neglected or made in too small quantity in this case Metastasis has not taken place, the extremities are affected with the disease, sometimes one and sometimes another. that the patient has been for several nights entirely or almost without sleep in this case evacuation is not so efficacious but must be made not withstanding we can weaken the system now tho’ we cannot take off the encreased action of the vessels. 40 We must not take away such large quantities of blood nor repeat it so frequently by such large evacuatn we diminish the strength but not the hardness of the pulse in the present case we must have patience as relaxants cannot be employ’d whilst the hardness of the pulse continues, much less stimulants or antispasmodics we should then desist for a day or two giving medicines and trust to & watch nature the action of the vessels in such cases frequently diminish of themselves & by this means we shall in time fetch the disease so that we can employ relaxants with advantage to carry off the disease. Suppose the disease has continued for 10 days or a fortnight and evacuations have either been made in too small a quantity or not at all that the strength of the heart, and muscular powers and diminished, that the pulse is hard, but neither strong, nor feeble but rather small & contracted the system at the same time considerably weaken’d. Patients are often reduced to the state by bad practise such as bleeding whilst stimulants are exhibited at the same time such 41 as guaiacum, volatile alkali etc. The evacuations by bleeding in this case diminish the strength of the general habit, whilst the stimulants keep [illegible] the encreas’d arterial action and other inflamatory symptoms, this practise [illegible] inconsistent & in every case has [illegible] In this situation we are [difficulted] how to act, if we bleed we diminish the strength without taking off the hard action from the arteries whilst stimulant encrease the action of the arteries without encreasing the strength of the system in general If in such case the rheumatism were fixt to a particular part, we might be of use by freeing the part from pain by the applicatn of leeches, cupping etc. taking off the stimulus from the part, and so free the general system or by blisters we may free the habit from the disease which affect it in general but if frequent metastasis takes place the use of these means are ineffectual on the disease as soon as we cure it in one phase takes place in another in this case do nothing if we be not pretty sure of doing that which is proper. trust to nature keep up the strength as much as possible by the exhbitn of mild & nourishing food of easy digestion and the disease generally terminates better than when medicines are exhibited 42 Accidents that may occur during the treatment of this disease which are attended with very great danger to the patient. If delirium arises from general inflamatn is to be carried off by evacuations as mentioned before. If delirium arises from want of sleep if the hardness of the pulse be gone off & if the delirium so encreasing so as to endanger the patients life opium must in this case be used. A practitioner is tempted in [no] disease, [illegible] than in the present to exhibit opium but if we exhibit opium whist general inflamation takes place no good effects are produced, the patient when he does sleep is not refreshed, nor sensible of it. but [illegible] disturbed & anguish awakes unrefresh’d, & fatigued and denies that he has slept at all. But if the general inflamatn be gone, the pulse soft & the delirium encreasing so as to threaten the destruction of the patient in this case opium must be exhibited if in small quantities so as not to produce a continued sleep for 12 or 14 hours at least it always in such cases is hurtfull instead of being of benefit or requires then a good deal of courage & resolution in the practitioner to exhibit a dose sufficiently large to produce this effect as it otherwise is part [illegible] & restoring the patient in a few hours in some instances after its exhibition 43 When no delirium has taken place the exhibitn of a small quantity of opium is not attended with such danger but may be exhibited to advantage if the inflamatory symptoms be entirely gone. Suppose metastasis has taken place to the brain the only means we know of removing it is by applying a blister to the head or back, so as powerfully to stimulate the neighbouring parts Metastasis to the intestines is more painfull than dangerous by the exhibition of internal stimulants together with relaxants & opiates we have it in our power to remove the seat to the extremities or external parts or perhaps to carry it off entirely Suppose the disease returns in the night only like an intermittent being perfectly free during the day in such cases the bark may be exhibited in quantity of zfs or zvs during the day which very generally carries off the disease When the disease continues seated in a particular part of the body after all symptoms of general inflammation are gone off in such cases topical applications of stimulating kind are blisters volatile alkali mustard seed etc. are often effectual in carrying it off 44 suppose the hardness of the pulse removed but the disease returns at uncertain intervals it them is to be considered as a spasmodic disease and to be treated with stimulants [illegible] antispasmodic kind, apply’d to the part affected. Suppose the genl inflamatn carried off but the disease continues the patient is then in the state of chronic rheumatism When rheumatism is attended with no or very little general inflamatn we then call the disease chronic rheumatism. the great difference between which diseases consist in the absence of the general inflamatn & the symptoms depending thereon. IN every case of rheumatism, where there is hardness of the pulse it is always advisable to bleed unless the disease has greatly reduced the strength of the patient so as to render evacuatn dangerous. Stimulants employ’d should be of the antispasmodic kin ad guaiacum & volatile alkali & other resinous stimulants. spices have a great tendency to encrease or produce symptoms of general inflamation without removing the disease they are therefore not so proper as the others [illegible] in chronic rheumatism where stimulants are necessary 45 If there be no symptoms of general inflamatn relaxants may be used, as emetic tartar, rattlesnake root etc. with other antimonial preperations. When the disease is obstinate by exhibiting opium with ipecacuanha, or other relaxants we can exhibit them in much larger quantities & so, as to act more powerfully. It is not sweating as has been thought by some which carries the disease, because the natural sweats which often take place are never of use but on the contrary tend greatly to weaken the patient’s strength. Stimulants & relaxants may very properly be exhibited together the first acting more powerfully on the internal & the latter upon the external blood vessels. Topical applications may be employed in chronic rheumatism with very good effect, there being little or no disposition to metastasis. The application of blisters, & volatile liniment prepared with the caustic volatile alkali. after chronic rheumatism has been cured & the patient is subject to relapse upon slight exposure to cold in these cases the habit is to be strengthened & its irritability destroyed by the exhibition of the bark bitters [exercise[ cold bath pure air etc. 46 Lect: 99th May 23d 1772 Chronic diseases if a disease terminated in 40 days it was called an acute disease, if it ran out longer it was called a chronic disease, this distinction not a natural one for many diseases as a fever for instance, may terminate sooner or continue longer than the time mentioned, excepting in such cases as apoplexy with either [pill] or go off immediately there is no such thing as determining from the time of their continuance or drawing a line of distinction betwixt acute & chronic disease Most of these diseases treated of have some natural cure ([illegible]) excite some action in the vessels which tends to carry off the disease, those to trat of have no natural cure. this distinction [we choose] to retain betwixt acute & chronic disease. such diseases as have a natl cure are always more complicated & the effects of medicines less certain, those that have no natl cure are more simple & the actn of diseases are better ascertained with their mode of action Weakness being in the diseases to treat of the great or only [illegible] we think proper to begin with its history & treatment as such. Weakness to be divided into two kinds, sometimes in weakness the irritability is diminished but in others & more commonly it is encreased when the system is weak the operations of the body are not carried on with any degree of fever & therefore are more easily disturbed we shd expect the later to be the most common case. 47 When the irritability is diminish’d in weakness of the habit we call the disease paralytic or palsy this we don’t treat of at present The other [illegible] when the weakness is attended with encreased irritability may be distinguished into 2 kinds which may be divided into each as are produced suddenly (e.g.) from great haemorrage as from violent purgings. 2d any violent disease as fever weaken slowly in several difft ways in as much as during their [illegible] women there is an encreased action which tends to exhaust and weaken, or in violent disease there is considerable irritation which not only produces great [depression] of strength, but permanent weakness. inflamatn of the intestines produces great depression of strength & leaves a weakness behind in the parts affected with the disease. The principal difference is in the manner in which the disease is produced [illegible] either suddenly or slowly & the difft & variety of cure depends upon these circumstances also. Acute diseases weaken by disturbing or destroying the appetite & organs of digestion renders the stomach incapable of receiving food or of connection it into chyle when [illegible] In many cases without any great evacuation the fluids seem to be exhausted as destroyed by the disease. The action of stimuli generally produce weakness of the second species even although this effect should be produced in a short time. sedatives apt to leave a degree of weakness behind them & this of the 2 species. 48 Supposing weakness suddenly produced & no other disease present the muscular strength is diminished, the force of the heart & arteries also, the pulse is weak empty and soft. if there be no stimulus the action of the heart becomes much slower than natural. the pulse beating only perhaps 40 or 50 in a minute, but if there be the least irritation as from digestion, exercise etc. the pulse becomes much quicker than natural The patient is disposed to sleep more than natural, the appetite considerable often greater than the powers of infection, which is however considerable, so as to fill the vessels in a short time with a great quantity of blood. In this case it is generally suffict. to exhibit plenty of nourishing food keep the patient in a free & pure air. Bark may be used which prevents the danger of relapse into the disease which first produced the weakness. These are the symptoms of weakness suddenly produced the disease perfectly gone off is seldom attended with any danger but mostly get rid of as above & in a short time [illegible] the disease producing a weakness when it generally proves fatal. 49 Weakness may be produced slowly [illegible] by any slow evacuatn as purging not violent but long continued or any similar discharge It is not always the qy of the evacuation that produces the weakness. the fluor albus, or involuntary emissions of semen weaken more than any other although the quantity evacuated is but trifling In action is another source of weakness in the habit, want of suffict. exercise producing depression of strength bad digestion Any fever that runs out into a great length, or other disease any long continued action of stimuli as of mercury or guaiacum by stimulating the vessels and encreasing their action for a length of time tend greatly to weakening the system Living in an impure or [illegible] air as putrid vapours or air unfit for respiration renders the habit weak & of that kind of weakness which is slowly produced all impure airs are not equally hurtfull inflamable air may be respired & less hurt than fixable air & both & less danger than putrid vapours Anxiety or weakness produced in the body by any exertion of the mind as study, grief etc. always produce the kind of weakness that takes place slowly. want of sleep & spasmodic affection of the muscles have the same effect of producing weakness of the 2d kind. Disorders of the intestinal canal from frequent & free use of acids, spirits, food of difficult digestion use of spices & other stimuli 50 apply to assist digestion by purging either natural or artificial by application of sedatives. Lead particularly or from any other weakness arising in consequence of another disease. Another cause taking place slowly and peculiar to women. obstructions of the menstrual evacuation At puberty which in this country is about 14 or 15 menstruation takes place. Lect: 100 May 25th 1772 Obstruction, or irregularity of the menstrual flux produces that species of weakness which takes flow slowly & is difficultly removed. An haemorrhage may arise from the womb or vagina before the age of puberty, as from the nostrils or any other part of the body which however is perfectly distinct from and unconnected with the menstrual discharge The age of puberty differs in different climates in warm countries it is from the ages of 11 to 19 years in this country about 14 or 15. at this time the breasts and parts of generation encrease in size and an haemorrage takes place from the uterus preceded by plethoric symptoms as pain & fullness in the lower belly, breasts etc. sometimes also accompanied by hysteria fitts which frequently happens at this time the [illegible] of the other parts of the body [illegible] 51 The haemorrhage continues for 1, 2, 3 or 4 days & for the first 2 or 3 times is generally irregular returning perhaps in a fortnight as perhaps not for 3 or 4 months it afterwards becomes regular 7 returns at the end of 28 days in most women, with some variatn however in point of time with difft women. in young women, there is often a sense of fullness & weight about the abdomen & [illegible] pubis with a swelling & fullness of the breasts which precedes the discharge. the haemorrhage generally continues about 3 days with some variation however in point of duration it sometimes regularly at shorter intervals than time of longer than five weeks. the quantity of blood [illegible] is not very considerable, it has been estimated at 6 or 7 ounces which appears to be a sufficty large estimation. it continues then to return till about the age of 44 or 45 sometimes however it [illegible] so young as at 40 & at others not till 50 sometimes it stops all at once, but it is more generally irregular for some time both in the qy & periods of its returns. it after this time ceases for life excepting that in some instances there seems to be an attempt in nature towards the renewal of the body about the age of y70 years, in which cases there is a return of the menstrual discharge, new teeth are sometimes formed the eye sight & different [senses] renewed. 52 If during this time a woman be impregnated the menstruation stops, sometimes however it returns for once or twice & in some instances has been regular through the whole period of pregnancy. This however is very rare & the haemorrhage in these cases most [illegible] from the vagina The only species of animal that menstruates in any considerable quantity so as to be observable in some species of the monkey kind. in all animals [illegible] quardrupeds there is a similar discharge though inconsiderable at the time they [illegible] male. it however is not regular in any but the human species depending upon the habit of the body more in the quadruped kind as they never are disposed to take the male nor to menstruate but at such times as they are fat & well fed [illegible] [when] [illegible] During the time a woman give suck as well as during pregnancy the menses generally stop & it has been said by some that when the menses return after being stopt by giving suck or disease which they return at the very period they would had no obstruction takes place, but the periods regularly continued. Menstruatn may be stopt by exposure to cold during the [illegible] or by disease as fever, also by anxiety of the mind, or plethora or weakness of the body produced slowly from any cause. when the menses are stopt by any of the causes last mention’d they do not 53 return at the next period, but the body is diseased if plethora takes place all the functions of the body are disturbed & the menses also when obstruction of the menses takes place from this cause hysteric symptoms are often produced The menses are sometimes encreased in quantity so as to produce disease either continue longer or return more frequently etc. and in this case always produce disease [illegible]. weakness irritability of the habit etc. and the diseases depending thereon. The menses are often encreas’d in qy is as to produce disease from injury some to the parts in difft labours abortions etc. Causes assigned for menstruatn very [illegible] has been supposed that by menstruatn that blood was evacuated which should serve for the nourishment of the foetus, but that it does not answer this, appears from this consideration. [illegible] that in all other viviparous animals there is the same [illegible] of fluids & yet no menstruatn or at least the quantity of blood evacuated is inconsiderable & of no account neither has there been any other cause assigned in any way satisfactory The manner in which it was produced has been as much questioned it evidently depends upon encreased action in the vessels of the part 54 this appears from the encrease of size in the parts as also from the swelling of the breasts in young women before this evacuation [illegible] from phlegmonous inflamatn sometimes taking place in difft parts of the body when this evacuation does not take place. It evidently depends in other [illegible] made up of plethora & fullness as they never menstruate [illegible] [illegible] in this habit of body. It has been said that blood was gradually accumulating in the system so as to produce such a plethora in the course of 28 days as to occasion this discharge but that it does not depend merely upon plethora appears from this that a much larger quantity of blood may be taken away without preventing the flux It would seem to arise at first from the particular encrease of [illegible] in the parts of genern & from the plethora that now takes place in the whole system. The growth of the body at this period being generally stopt for a time, a larger quantity of blood is formed by the organs of the digestion, than is necessary for the support of the body. A plethora then takes place, through the whole habit at this period of life, & an eruption from the uterus in consequence of an encreased action in the vessels of these parts, from the particr stimulus occasion’d by their encreas’d growth. why the menses should exactly return at 55 the end of 28 days we know not. this evacuatn has been called the menstrual flux, from the moon changing at the same period. but then there seems to be no power in the moon of producing or regulating the menstrual flux an equal number of women menstruating at the fall new or any in difft day of the moons age so that the moon does not appear in the least to affect the menses. The menses are stopt by any cause that produces a contraction of the small vessels, as weakness, grief, anxiety, fear etc. as also from plethora which prevents the blood vessels from exerting their usual force upon their [illegible] from exposure to cold [illegible] the eruptn the applicat. of astringents [illegible] of the vessels [illegible] produced & from impregnation. Too great flow of the menses may arise from relaxation of the small vessels, as from too great action of the vessels of the system in general. The menses seem to be stopt during pregnancy by the exit of the haemorrhage from the uterus being shut up, by the application of the membranes to the mouth of the womb & by its being stopt up by a coagulum of lymph we may [illegible] them, that whatever evacuatn takes place during the months of pregnancy is not from the uterus, but from the vagina, the os uteri being closely shut up by a coagulum of menses. If the menses are obstructed the disease [illegible] generally takes [illegible] often weakness is produced which is to be considered of the [kind] [illegible] & evenly produced. 56 The menses generally disappear betwixt the ages of 40 & 50 years with very considerable variety however in point of time in different women. The cause of the menses ceasing probably arises from the contraction of the small vessels that takes place in advanced age, as we find a great many of the capillaries entirely obliterated that plumpness is lost the tendons & large blood vessels from this cause become more apparent in old age. If the menses flow in too great quantity at irregular periods or an obstructed from whatever cause, disease is generally produced, & hysteric symptoms appear. when the menses are [illegible] the [illegible] disease are produced [is] [illegible] the stoppage of any other [evacuation] discharge that has become habitual. Lect: 100 May 25th 1772 Remedies employ’d to remove obstructed menses, or to diminish their quantity when they flow in such proportion as to weaken the system by the greatness of the evacuation. If they be obstructed from plethora or do not take place at the usual time & then be symptoms of plethora prevent it is of use to take away a quantity of blood. 57 It has been questioned in this case whether the blood should be taken from a vein in the arm or foot there seems to be very little difference, from whatever part of the body the blood be taken, provided the evacuation be made. If after this evacuatn the menses shd not appear stimulants may at times be used, but they shd never be exhibited whilst there are any symptoms of plethora. such is not particularly upon the intestines & also abdominal viscera [illegible] purgatives are preferable. If the obstruction is occasion’d from weakness produced from any sudden cause then nourishing food exhibited for a short time so as to strengthen the general habit will almost allways render them. supposing the obstruction proceeds from any other cause we employ remedies to reproduce the haemorrhage. Stimulants have been used, those of the antispasmodic kind should be preferr’d other stimulants however have been used as resinous substan. preparations of iron, mercury, spices & of [all] which resins have the preference, they should be employ’d so as to act constantly & uniformly on the system, Preperatn of iron have been used with success in weak habits, as they have also a strengthening quality 58 as well as a power of stimulating and encreasing the circulation they are on this acct preferable to most other stimulants. Myrrh, galbanum, [opoponax] which shd be exhibited alongst the aloes so as to [illegible] Mercurial stimulants have a dispositn to weaken the system, are therefore improper & particularly hurtfull in all cases adhere the obstruction is either produced by or accompanied with general weakness of the system. Of all cathartics, aloes seem the most powerfull in reproducing the menstrual flux, may be properly exhibited with some of the resins, these medicines should be continued to act for some time as they have a particular power of operating at that time the evacuation should not naturally take place they shd be exhibited in quantities suffict to produce an evacuation or two every day from the intestines Relaxants employ’d at the time are particularly usefull, such as exposing the parts to the steams of warm water etc. or impregnated it [illegible] stimulants & antispasmodics as [illegible] [illegible] The natural stimulus adopted to the part affected is the most efficaceous of all applications and often proves effectual when all others fail. In too great flow of the menses we shd have a regard to the cause producing it because the treatment may be very different 59 Too great flow of the menses may proceed, first from plethora or from too strong action of the vessels upon their contents If we wish to check them in such cases, we should rather make evacuations & employ sedatives of the vit. acid & if the symptoms of plethora continue we should bleed, use a slander diet and avoid stimuli of every kind, because all such encrease the disease. When the disease takes place from genl weakness or from injury [illegible] to the parts by abortion etc. in these cases we should employ strengtheners of which the bark is preferable to all others & the most powerfull of the vegetable astringents [illegible] galls may be exhibited internally with advantage. When weakness takes place slowly the stomach & intestines are generally first affected the stomach after eating feels full [flataley] acidity & takes place the intestines are affected with flatulency & spasmodic pains the peristaltic motion is disturbed purging or costiveness is apt to take place. 60 At the same time the muscular strength is gradually lost, the patient becomes restless & uneasy with want of sleep there is added to this a pain in the small of the bark, appearing to be seated in the spine, which is encreased from exercise or fatigue of either body, or kind of the weakness be more considerable dropsical swellings often take place, beginning at the extremities & ascending to the abdomen partial evacuations as sweats, diarrhoea, gonorrhoea [illegible] fluor albus etc. & the place which evacuations exhaust the patient so much as frequently to destroy & in every case is difficulty got rid of. Remedies strengthening the system may be divided into two classes first such as prevent the strength from being further exhausted & such as really do strengthen the system the first class operate by preventing the living power of the body from being exhausted and the latter operate by encreasing the flow of this living power into the body. 61 Anxiety of the mind a great cause of weakness this should ben be avoided by going to places of amusement such as mineral waters travelling to difft climates etc. the vessels should be filled if possible with a quantity of good blood. the first action of the living power being to adopt the vessels to the quantity of blood they contain nourishing foods then become strengthening remedies in order to this the stomach & intestines should be kept in order of the digestion be pretty good, but appetite a wanting we may use [acids] etc. to procure an appetite Stimulants shd be employd in moderate quantity alongst which the food as spices to assist the digestion, wine also if it does not turn sour upon the stomach. If the peristaltic motion be deficient it is to be kept up by purgatives so as to keep the [prima] viae [illegible] of foeculent matter, unless the patient be subject to too great flow of [illegible] or to the haemorrhoids. 62 Neutral salts are apt to weaken the intestines in this case too much, vegetable purgatives are apt to turn [illegible] we may then conveniently [join] a small quantity of [fallop] which is of itself apt to produce spasms & gripes in the intestines with the milder acting purgatives The appetite is often impaired by mucus in the stomach this is to be got rid of by gentle emetics as the exhibitn of the [illegible] We should also attend to the state of the blood vessels themselves taking care that they act sufficiently & not too powerfully upon their contents when evacuations are requisite purging is preferable to bleeding the latter relaxing the vessels [the] suddeness of the evacuation & is rendering them liable to be more filled with blood That taking away a quantity of blood from the vessels disposes them to receive a greater quantity appears from this experiment that nothing tends to fatten more than frequently respected bleeding in small quantities at a time. By exercise we can draw the living power from the blood vessels to the muscles hence moderate exercise in free air is of great use in weakness of the system attended with hectic fever, in which case the whole action of the vis vita seems to be concentrated in the action of the blood vessels upon their content muscular motion & all the other functions being weakened. Exercise also encreases the powers of digestion & strengthens the appetite 63 Lect: 102 May 26th 1772 Emptiness of the large weakens much more than emptiness of the small vessels if the blood then principally circulating in the external parts the system is weakened hence a warm atmosphere or whatever stimulates the skin, so as to draws the circulatn externally weakens the habit, a warm summer has the same effects the [illegible] in these cases is to be restored by the application of cold which has just the contrary effect. we should take care however that the change from hot to cold climate be not sudden, but gradual. also violent or inflamatory diseases will be produced. In order to strengthen the system the cold bath has been used. upon jumping into cold water all the external vessels are suddenly contracted & the blood forced upon the internal ones, when he comes out of the water the cold being removed, the heat restored the external vessels are relax’d & a profuse sweating sometimes takes place & contractn of the external vessels being out at all permanent if then the system is strengthened it is not upon the same principle as conting living in a cold atmosphere Cold air strengthens much more than warm hence men in general are much stronger in the spring than they are in the autumn of the year. The cold bath very doubtfull in its effects sometimes weakening the system in place of strengthening it A warm atmosphere is sometimes the means of strengthening the habit particularly to such habits as are [illegible] from cold air such as asthmatic & those subject [illegible] 64 Astringents used in a large quantity exhaust but in small doses strengthen in the latter case they act particularly upon the large blood vessels, in [illegible] their action is general upon the whole system. If there be any dispositn in the small vessels to contract beyond their natural pitch as hectic fever hypochondria etc. astringents in such cases cannot be used. He now breathes air unfit for respiration there is a great depression of strength produced. all animals as quadrupeds, birds, fishes, and insects of necessity breathe respirable air. Life not being to be supported without it. All vapours excepting inflamable air that we are acquaint with are heavier than respirable air such then always tend towards the earth. A man going out of an air partly unfit for respiration into that which is perfectly pure, feels himself suddenly relieved, as if from an oppressive lead. The air upon high hills is not so dense as in lower situations it is also more changeable in temperature The system may also be strengthened by increasing the flow of living power 1st by habit a man who has lived a sedentary life although he may live in a pure atmosphere, eat good food etc. yet he becomes weak, feeble & incapable of exerting his muscles, this by habitual [illegible] Exercise may be overcome & the strength restored 65 Stimulants may be employ’d to encrease the action of the vessels, but this is seldom of use in strengthening the general habit, from the disposition they have to stimulate the blood vessels solely, or principally to action & so weaken the other powers of the body. Stimulants then can never be used as strengtheners, unless in lax habits, & cases where there seems to be no particular disposition in the blood vessels to strong action. But exercise may be used to the greatest advantage in most cases of weakness, provided it be not to such excess as to fatigue. It is a matter of the greatest importance that the exercise should be agreable & amusing so as to take off the attention of the mind from the diseased state of the body. Exercise should be universal so that every muscle in the body be employ’d have riding on horse back or in a carriage are preferable to walking, the lower extremities in the later being only employ’d. Rowing etc. very beneficial Exercise should be performed in pure air, hence exercise in close rooms weakens, in place of strengthening the body. Remedies strengthening the habit are the bark bitters of the vegetable class preparations of iron etc. when the weakness ahs been suddenly produced our medicines are efficacious & suddenly so, but in cases where weakness has been generally [illegible] & long continued they are not so affected 66 It has ben question’d & seems as yet to be undetermined, whether bitter medicines should be exhibited compounded or not there are reasons pro & con. the strongest argument for exhibiting simple bitters is that they are of a class of medicines that by contn’d use soon loose their effects as medicines, and are avail [illegible] of these qualities by exhibiting [illegible] alone because one bitter acts powerfully after another by use has lost its powers. In weakness where there is a disposition in the blood vessels to great contraction these medicines are not nigh so proper which is probably owing to their astringency When these medicines loose their efficacy by intermitting their use for a few days they may be returned to & recover their effects upon the habit. If weakness be the only disease the patient should not be suffered to lie abed, but kept out as much as possible the warmth of the bed rendering the habit irritable & preventing the increase of strength. Preperations of iron are much more stimulating than the vegetable bitters are therefore more or less proper according to the state of the particular case Containing the lectures from No 91 to 102. Practise of Physick by Dr Fordyce No 1 Practise of Physick Index Page No Treatment of the small pox 1 Treatment after the small pox 6 Measles and treatment 8 Chicken pox 10 Miliary fever 11 Scarlet fever 13 Herpes miliares, or shingles 14 Causes of [exaleratn] of the lungs 14 Symptoms of the disease 15 Causes of pulmonary hemorrhage 17 Treatment of Haem of [illegible] 21 Hectic fever chronic general Inflamatn causes of consumptn 23 Symptoms, treatment etc. 25 Rheumatism 29 Treatment of the rheumatism 34 Chronic diseases 46 Weakness of the system, causes, treatment etc. 47 Menstruation, theory of 50 Treatment of obstructed menses 56 Modes of strengthening the habit 60 1 Lect: 91st May 18th 1772 Treatment of the small pox one general observation is that there is no means of shortening the disease or putting a stop to it when it has once taken place it must be gone through, all to be done then, is to avoid, or prevent and dangerous symptoms that may arise in the course of the disease. 1st When the fever takes place it is usefull to clear the prima viae of any matter they may contain by the exhibition of an emetic & gentle laxative to prevent the [lodgement] of any mucus or harden’d excrements that may be contain’d in the intestines as of any acidity that may be lodged in the stomach [These] remeds cannot be used so properly after the eruption. If the fever be attended with considerable symptoms of general inflamatn if the patient be plethoric or young & every strong it will be of use to take away a quantity of blood & this cannot be done with equal propriety after the eruption has taken place 10, or 12 ounces of blood is generally suffict. and it is very seldom necessary to repeat the operation. this evactn to be made previous to the eruption of the pustules 2 unless in the circumstances mention’d. Bleeding & evacuations are hurtfull. The more violent the fever in general the more violent the eruption and vice versa. we might then suppose, that by the diminishing the fever, by the use of relaxants etc. the eruption should be more mil this however does not appear to be the case altho’ relaxants in general do no mischief & are very usefull if the fever shd not be the small pox. There never can be a case where strengthening remedies can be wasted to support the patient curing the fever, all stimulants then etc. should be avoided. the eruptive fever is almost never fatal, generally going off upon the eruption In children, previous to the eruption convulsions sometimes take place, or disappear upon the eruption very seldom continue after remarks that the pox in this case are almost always of the distinct kind. do nothing for the convulsions, trust to nature they almost always go off themselves. 3 Then the eruption has taken place if the symptoms of inflamation do not run high if no symptoms of irritability take place, if the pustules gradually fill with yellow pus, if the hands, feet are inflamed as the face subsides, if no difficulty of respiratn nor costiveness takes place we must then let nature alone & not disturb her by medicines. [but] suppose the patient to be costive it is apt to encrease all the dangerous symptoms. the intestines should be evacuated by glysters, purgatives should by no means be exhibited before the period of maturation as the pustules are apt to sink by their operation Sleep may be procured by opium if the patient be restless. If the patient has an evacuation in 48 hours we should make no evacuation by medicines as too great discharges that way are very apt to do mischief If symptoms of great inflamation take place, if the pulse be hard & strong, if the face and eyes be inflamed, if delirium, or symptoms of oppress’d brain take place bleeding becomes necessary. Dr. Boerhave has supposed that the variolous fever has been carried off & the patient cured without any eruption taking place, this however we deny. 4 We should not be too rash in making evacuations by bleeding etc. as the pustules have sometimes immediately sank & the patient been cut off unless then the brain be affected we should rather avoid using the lancet. When necessary 10 or 12 ounces is generally sufficient, and we should not repeat the evacuation. The bad effects of evacuations are particularly evident in pregnant women If absorption takes place, as often happens, the evacuation in consequence is almost always fatal If the pustules continue watry, stimulate the skin, with erysipelatous inflamation between them or little blisters arise with great soreness Bark is the best medicine for filling the pustules with good pus but it is very apt at the same time to produce disorder in the breast difficulty of breathing & rendering the mucous secretion of the throat so thick as not to be evacuated. If the brain be affected, or the breast as above we should by no means be induced to exhibit the bark & ought immediately to leave it off it if produces these symptoms 5 Opium tends also to produce good suppuration & is therefore in such cases very properly exhibited, if no symptoms of general inflamation take place If the patient should want sleep for 3 or 4 nights it produces very great mischief & opium should be [illegible] [upon] [even] although general inflamation should take place opium tho is very apt to increase the oppression of the [evacuation] viscidity of the secretions from the trachea & dispositn to suffocation shd never be used then, but when absolutely necessary If the throat should be very sore gargles may be used, if the [illegible] sweet kind, and oily if mucilaginous draughts freely used to defend the parts. at the time of maturation the matter becomes often so thick as entirely to stop up the trachea, the patient has in some instances been saved under the present circumstances by the exhibition of an emetic expectorants [illegible] even to be usefull in this disease The thorax is very apt to be loaded with blood hence diff. of respiration impurity of the air greatly encreases this symptom & shd be avoided, by keeping the windows open, letting the patient walk out etc. (6) The variolous effluvia seem to defray the perspirable air in an extraordinary degree & of course require a greater supply of it fresh. We should remember that the patient is subject as well during this disease as at other times to catarrh, colds, pulmonary consumption etc. by exposure to too great a degree of cold, such exposure then should be avoided as dangerous. If the extremities do not swell when the face subsides about the period of maturation, blisters in such cases are of the greatest use & sinapisms apply’d to the parts which by their stimulus encrease the external circulation & prevent the blood from affecting the brain & chest If the small pox at any time subside we should employ some quick acting stimulus as wine with a little spice, volatile alkali etc. & blisters should be apply’d externally to throw the circulation upon the skin again stimulants however are by no means necessary during the [illegible] of the disease. Lect: 92d May 18th 1772 after the disease is at the hight the absorption of the pus produces general inflamation & the matter being deposited in difft. parts produces inflamation & abscess. this topical inflamation & general inflamation are to be got rid of by evacuations, purging seems much preferable to the bleeding in most habits that shd be freely exhibited& makes the pus [illegible] 7 If the pulse be very hard as is sometimes the case when the pustules have been very numerous, it is necessary to make evacuations by bleeding. this is but seldom necessary. Purging should be always used as well to take off the general inflamatn, as to carry off the matter out of the system by weakening the system in general they produce the first & by hardening the general change of the fluids they produce the [illegible] pus is capable of passing through the urinary vessels & the vessels of the skin also by encreasing any of the secretions then we procure a greater evacuation of the pus than of the thicker parts of the humours proportionally hence evacuation of every kind may be of use If the small pox leave a disposition in the body of producing inflamation, [absorp] etc. periodically at that time of the year in which the small pox happened in this case this particular disposition is best overcome by the exhibition of the bark in considerable quants for about a month before we expect the disease to take place, which by diminishing the irritability [illegible] the inflamatn from taking place or if the inflamatn does take place good pus is formed & the disease carried off. 8 Measles arise from an infection similar to the small pox as there is no matter formed in the disease, it cannot be communicated by inoculat. but is always apply’d in form of vapour never [illegible] to the body, [illegible] always [propagated & [be] [produced] [by] [illegible] The infection is received for some time before the disease is produced & is preceded by greater inflamatory symptoms of the mucous membrane, hence there is such an encreas’d secretion from the glands of the eyes, nose, throat etc. as to have the disease mistaken often for a catarrh. The fever is much more frequently attended with symptoms of general inflamation & the breast is more dangerously affected than in the small pox The eruption is not so uniform, but may appear in the 2, 3, or 4 day & the disease be qually mild when the eruption takes place the fever abates, but the symptoms of general inflamation as hardness quickness of the pulse, affection of the brain etc. are apt to continue In eruption is more of the erysipelatous kind than the small pox. The pustules seldom appear above the surface of the skin, and are never filled with pus as the small pox, but vanish without coming to suppuration, contain only a watry fluid 9 There is not the same costiveness symptoms of genl inflamation run much higher & are attended with great danger purgings being more frequent than in the small pox. The eruption does not go off regularly sometimes continues for 24 hours & from that to 5 or 6 days but seldom continues longer and the danger is not over at this time as is the case in the small pox. The great danger arises at the period when the measles disappear. the breast, & lungs are apt at this time to be affected, and pulmonary consumption is at times the consequence. blisters are of use in relieving the complaints of the breast We may bleed with great safety during the eruptive fever, at the time of the eruption, & more particularly at the disappearing of the measles which at this time should not be neglected in short bleeding is the cure for almost every bad symptoms that arises in the disease & should never be neglected at its termination if there remain any symptoms of inflamatn in the general habit Authors have described measles in which symptoms of irritation, and not of general inflamat. took place such cases are never [illegible] 10 The danger in this disease universally arises from general inflamatn so that the removal of almost every bad symptom depends upon bleeding In affections of the breast, blisters are of use, & purgatives may be used without any danger of the pustules sinking, because they never contain any fluid matter we have no danger to apprehend then, from this cause as we have in the small pox. Purgatives should never be omitted at the end of the disease as they are of great [illegible] to carry of the inflamatory symptoms remaining. Chicken pos of still less [illegible] appears to arise from infection certainly in some cases, probably always though not ascertained is always propagated by vapour, tho’ there is great reason to suppose it might be communicated by [???culatn] the pustules being filled with fluid matter which might easily be collected. The eruption generally takes place at the first paroxysm of the fever, but one series of eruptions will continue to succeed another as soon as the foregoing have disappeared, for so long a time (in some instances) as a month or six weeks a fresh crop appearing every 2 or 3 days during all that time. 11 Distinguish’d from the small pox by suddeness of the eruption after the first attack of the fever & by the very short time required for maturation of the pustules. The pustules arise all at once & the state of maturation is generally completed in 12 or 14 hours they [rising] at first filled with a thin transparent fluid, which in so short a time, still often change into thick, yellow pus. All the functions of the body go on regularly the patient sleeps well, eats well etc. & it is rare if any bad symptoms arise. This disease will go through its natural course, as well as the small pox or measles. If the pustules continue to break out for a long time, & endanger hectic fever bark is the most efficaceous medicine we can use to carry off this disposition of the habit. This disease never happens but once during life. Miliary Fever a disease whose existence has been much disputed some asserting that it was produced by some matter in the system which was discharged by the eruption others denying that the eruption was any thing more than consequence of sweating during long confinemt in a warm bed. 12 If a healthy man is laid in a warm bed, plenty of watry fluids exhibited with relaxants or stimulants for 48 hours an eruption is produced occasioned by a greater quantity of sweat being secreted through the true than what can pass through the false skin in consequence of which this fluid matter is collected & accumulated betwixt the cutis & cuticula raising the later up into small pimples. although the disease may generally produced as above yet there is a miliary eruption to which lying in women are subject arising [certainly] from another cause The common symptoms of fever first take place & the eruption arises in the first paroxysm of the fever with evident signs of inflamation & the febrile symptoms disappear upon the eruption, but if from any accident the eruption disappears of a sudden the symptoms of fever return with irritability depression of strength etc. which are attended with very great danger. A woman in [childbed] being weak and irritable the slightest accident produces a sinking of the pustules with symptoms of irritability which are attended with great danger & can only be remedied by reproducing the eruption as hereafter specified This fever probably proceeds from the child (of lying in women) not being [illegible] into blood but going to [illegible] & milk which if not properly secreted may occasion this eruption the particular acid [smell] accompanying this [disease] [inductus] [to] believe this to be the case. 13 A miliary eruption happening to women in childbed is distinguished from that occasioned by confinement by being preceded by the febrile paroxysm & its departure upon the eruption. Treatment simple [illegible] most endeavour to support the strength & take off the irritability of the habit by exhibiting nourishing foods, decoctions of the bark together with agreable spice etc. If the pustules shd sink a little volatile alkali, together with a little wine & some quick acting stimulant exhibited to reproduce them, if they often [illegible] (Blisters may be apply’d with success) & this is not unfrequently the case Bark is frequently of very great use also Scarlet fever to be treated as an erysipelatous inflamation, agreeing in every respect with that disease, only occupying an uncommonly large span of the body at times the whole or greatest part of the external surface. This disease is at times accompanied with phlegmonous & symptoms of general inflamation but symptoms of irritability are much more frequent 14 Herpes miliares, or shingles generally arise in spots particularly upon the trunk of the body have a dispositn to spread so as to surround it like a belt. Clusters of small pustules filled with a watry fluid which is seldom attended with any great inconvenience & does not come to maturation. This disease does not proceed from infectious matter The exhibition of the bark almost instantly carries off the disease by diminishing the irritability of the skin & so rendering it insensible to the stimulus of the neutral salts with which the eruptn is filled. Lect: 33d May 19th 1772 The lungs are subject to suppuration not only from inflamation of the part itself but from a variety of other causes ulcers here from the contind motion of the parts are prevented from healing & consequently very fatal. [Exeluratn] may arise in this part, as in any other from a phlegmonous inflamatn peripnuemony may terminate in inflamation & an abscess be produced which generally bursts into the lungs, in preference to the cavity of the thorax. 15 IF the matter be spit up upon its first breaking in large quantity if the matter diminishes gradually ion qy without any fetor we have reason to hope that it will cure. This is the almost only species of [exaleratn] of the lungs that heals the inflamatn of the parts having formed a cyst which keeps great mot. from taking place so as to prevent its healing. If an inflamation of the pleura, or mediestinum take place an abscess may be form’d which will burst into the lungs & thus produce the disease. [The] ulcer may be also formed from inflamatn of the mucous membrane in catarrhs pus is sometimes formed upon the surface of the inflamed membrane, but it is a very difficult mass to distinguish pus as formed from the mucus secreted which in m any cases greatly resembles pus By throwing the matter into water if it be mucus it retains its consistence & by having a little air entangled it swims on the water. pus diffuses itself more through the water & sinks. pus has often a fetid smell mucus never. pus is often of an appearance as if mixt with a [illegible] powders, of a 16 broken texture, greyish colour, and lumpy but we are often liable to be deceived in trusting to this appearance because the mucus frequently hardens into little clots. An ulcer may be also formed in the lungs by [illegible] or excoriation from the acrimony of the watry humours secreted in catarrhs. Venl ulcers are sometimes, but very rarely formed in the lungs if so pulmonary consumption takes place. An exalceration of the lungs may arise & frequently does in scrophula of them in this disease the mucus glands are primarily & chiefly infected with the disease although this is little attended to afterwards. The disease frequently arises also in scorbutic habits when encrea’d [secret.] takes place from the pulmonary [illegible] small masses of mucus adhering to the lungs forming little tubercles, by being forced off & spit up are at times the occasion of exulceration by being violently forced, & turn off from the mucus membrane Extraneous bodies as [illegible] etc. have got into the lungs & by remaining there have occasioned inflamatn suppuration & abscess in the part but such accidents rarely happen & have sometimes produced such a convulsive cough & diffy of breathing as immediately to destroy. 17 Wounds penetrating the thorax do not always produce exalceration, but frequently heal by the first intention, neither are they so fatal as we would expect they do however sometimes occasion suppuration and exalceration Matter absorbed from any other part of the body is evidently secreted by all the glands of the body hence it by fermenting with the substance of the lungs converts it into a matter or similar substance to itself & so at times produce exalceration of the part. The breath of the diseased person has sometimes is affected the attendants with the same disease by carrying off a qy of the [gas] it is [illegible] however [illegible] cough of [illegible] Exalcerations of the lungs are apt to arise from 2 other causes [illegible] haemorrages, & chronic general inflamation. An haemorrage may take place, at least on extravasatn of blood whether the vessels be ruptured, or whole if the blood be thrown into a cavity no opening externally we may call it extravasation, if the blood is [illegible] into a cavity opening [externally] we call it [hemorya]. 18 There are a number of openings from the blood vessels into the cavities which throw out a fluid thinner than the red blood [illegible] serum mixt with water & sometimes coagulable lymph. but they also from disease, as relaxation, as from the blood moving with greater velocity admit the red blood to pass through them. most generally happens from the latter cause as from inflamatn of the part etc. hence the mucus is sometimes streaked with blood when spit up which blood is thrown out by these small orifices of the blood vessels & mixt with it. The most common case of hemorage takes place from encreas’d circulation in the parts forcing the blood through the relaxed exhalants, the evacuatn empties the vessels, it therefore after a time generally stops or also goes on till there be such a quantity of blood evacuated, as to prove fatal, or the trachea is so suddenly filled with blood that respiratn is obstructed & the patient suffocated. 19 Dr Fordyce imagines the menses hemorage from the [illegible] & take place in this way & not from rupture of the vessels. Whilst the haemorage continues the blood is spit up frothy & of a florid colour, but when that which has lain sometime in the lungs is spit up, it is of a dark colour, & sometimes mixt with mucus. the blood is generally perfectly cleared out of the lungs, but at times continue also & by remaining, produces exalceration & abscess. A similar discharge by haemorage takes place from all other parts of the body from the [illegible] of young men particularly the menstrual discharge is probably an evacuation of the [illegible] kind. Lect: 94th May 19th 1772 Haem of [illegible] & haemorage from other parts, may arise from laxaty of the exhalant vessels in which case not only the thinner parts of the blood are suffered to pass through their extremities, but the red particles also, & this may happen without any encreas’d action of the arteries or of the general circulation. 20 Haemorages from raptures frequently take place in the breast from blows or violent injury, these are more generally cured than when any previous disease in the parts take place. The vessels [ruptured] are sometimes extremely small as to suffer a quantity of blood to be emitted only subjet to [illegible] or appear in small globules mixt with the mucus. Hemorage may & frequently does arise from exalceration of the lungs. When an ulcer is spreading it not only destroys the other pats but the sides of the vessels also hence we should expect in such cases very great & very frequent haemorages but the vessels generally have their extremities plugged by lymph from the previous inflamatn Hemorage may arise lastly from gangrene & mortification of the lungs which would generally destroy, if no hemorage was to take place. When menstruatn is obstructed [illegible] habits hemorage takes place from the lungs, or other parts of the body. the discharge from these parts, [supplying] the defect in the menstrual discharge. In obstructions however from weakness no such discharge is substituted. The hooping cough sometimes occasions a rupture of some of the pulmonary vessels and hemorrhage is the consequence. Asthma may have the same effect 21 Remedies used to stop bleeding from every part of the body but more particularly that from the lungs. 1 By emptying the blood vessels we diminish the power with which the blood is thrown out of the ruptured vessel. From whatever cause it is produced, if the system be strong evacuatn may be [cured] Bleeding is the most immediate but the qy must be properly adapted to the circumstance of the case. If the blood be thrown out by the exhalants & the patient strong & plethoric bleeding may be used if the bleeding arises from relaxatn as happens more particularly from the womb in this case we must not bleed but use strengthening medicines as the bark etc. In cases of rupture & erosion of the vessels of the patient be strong etc. Bleeding may be used, but not otherwise. Sedatives diminish the action of the vessels & stops hemorage in same manner as bleeding does. [illegible] by diminishing the velocity of the circulating fluids. 22 Acids are pretty powerfull and may be employ’d with advantage in hemorage from every part, [illegible] & muriatic acids have been preferred, these having probably somewhat more astringency than the others. If acids are unsuccessfull & there be great danger. preparations of lead are the most effectual particularly in [haemopto?] shd never be [cured] but when the others fail as their [illegible] [illegible] If haemorage takes place in strong or phlethoric habit with inflamy symptoms astringents are rather apt to do mischief by encreasing the contracdtile power of the blood vessels more than they diminish the circulatn of their fluids. If hemorage arises from laxity astringents may be used with great propriety. Allum dragons blood & japan earth are most powerfull & their effects most immediate, but of short duration. The vegetable astringents acdt slowly but their effects are more lasting than those that are stronger. Relaxants have been employ’d with success in some haemorages shd not be given in quantities suffict. to produce sickness. They are particularly usefull in internal hemorages by throwing the circulation externally astringents act more particularly upon the internal vessels hence throw [illegible] (papers of Med: may be properly [illegible] 23 Expectorants shd be used as squills, or such as do not encrease the action of the vessels. Mucilaginous & oily medicines shd be employ’d to prevent the bad effects of violent coughing that may arise. The patient shd be kept quiet, and in a reclining posture which takes off the weight of the column of blood; from the ruptured vessel. The patient shd be confined to food that does not stimulate & is easy of digestion. Animal foods then should be avoided. Lect: 95th May 20th 1772 A cause of suppurat. of the lungs as mentiond is chronic general inflamatn or hectic fever. The latter only apply’d to such cases as the lungs are affected with the dis. This disease is an encreased action of the arteries, the heart not acting strongly at the same time, arises from several causes & has been called by difft names is attended at a hard & contracted pulse but not full, and strong. It may take place in consequence of the strength of the habit alone in the spring when the vessels of young [illegible] are strengthen’d by the cold of the weather. the warmth of the returning summer at times stimulates the system is much as to produce an encreasd, habitual action of the vessels & hectic fever. 24 Young women from the age of puberty to 22 are particularly subject to this disease which is accompanied with symptoms of irritability the whole called the chlorosis. The pulse becomes hard, & frequent the symptoms encreased by the natl evening paroxysm. The appetite is [lost] & the organs of digestion impaired the body is emaciated and in women [illegible] gastric symptoms take place In this case the disease is to be carried off in men by evacuations in women by the applicat. of the natural stimulus which is the most infallible remedy yet discovered When the habit has been exhausted by acute general inflamation, chronic general inflammation sometimes continues after any violent phlegmat. as the small pox measles rheumatism etc. this disease is apt to take place, the pulse being hard the blood inflammatory etc. and the patient gradually weakened & at last cut off. From the long use of any powerfull inflamy stimulant as mercury, guaiacum etc. the hardness & quickness of the pulse continue after the use of the stimulus is discontinued.s 25 The remedy employ’d in the last case with the greatest success is sarsaparilla Some stimulating matter such as [illegible] variolous or morbillous matter absorpt into the system, after they can no longer produce a fever, stimulate the system & [fetch] on this disease the measles more apt to produce this disease than the small pox Tumor long continued so as to make a long continued distension on any part stimulates the system & produces the disease Exalceration of the lungs produced by inflamatn and abscess frequently cures the inflamatn surrounding the cyst keeping the part steady & unaffected by the act of the lungs People most subject to pulmonary consumption are such as are of a delicate habit fine white complexion florid cheeks red hair often in small quantity [illegible] etc. The disease is hereditary arising from peculiarity of temperament communicated by the parents. The skin through the day time is dry and contracted but frequently in the morning profuse sweats take place any additional stimulus greatly heats the system, as digestion of food & exercise, the appetite is lost & the powers of digestion impaired. The blood is thrown upon the lungs stimulates & inflames [illegible] haemorage from the lungs frequently take place the muscular strength is greatly diminish’d & the body is [illegible] symptoms of weakness slowly produce other dropsical swellings [illegible] [illegible] dropsy frequently take place 26 The stimulus keeps up the spirits of the patient in a very extraordinary manner, as that they never think they are in such danger as they really are. The same particularly takes place in dropsy from the distension continually kept up, by the water contain’d in the abdomen When an ulcer is formed in the lungs the absorption of the pus continues to stimulate the system & keep up the hectic fever symptoms of the disease are. A paleness of the face, [blueness] of the eyes, & cleanness of the tongue from the red blood not being perfectly formed or its texture destroy’d when formed The pus being secreted upon any particular glands as of the intestines produces purging on the skin colliquative sweats, or upon the kidneys great discharge of urine was to waste the patients strength If the disease remains as a consequence of the measles or other inflamatory disorder bleeding & evacuatn are of great use. If hectic fever arises from the apsorptn of pus from any part [not] the lungs, the bark is employ’d with the best success 27 But bark can never be used properly where the lungs are affected with inflammation or suppuration. Strengthening medicines are hurtfull in every case when hectic fever is produced, from any other cause but the absorption of pus from a wound or ulcer. although the patient seems weak & emaciated we must take off the strong action of the arteries by evacuation bleeding seems the most eligible, but must be made in such cases in small quantity only, and frequently repeated. purging & the evacuations produce partial weakness & are apt to do hurt. Relaxants may be advantageously employ’d they tend immediately to counteract the disease by preventing the blood from being thrown upon the lungs shd be exhibited in small doses only Sedatives are also of use. Acids may be advantageously exhibited. Vegetable foods should only be allowed & a milk diet. the patient should breath a free atmosphere in the vicinity of running water & a dry [soil] at a distance from a [illegible] [illegible] All animal food shd be avoided milks excepted shd those are best that have least coagulable matter in them. 28 The climate should be temperate & regularly so, the situation defended from cold winds high hills these are improper on acct. of the cold the [illegible] wind in this country to be particularly avoided. Riding has been recommended & is particularly usefull in catarrhs, & slight inflamations of the lungs, but if there be ulcers formed in the lungs and hectic fever present, the stimulus from riding is so far from being of use that it is very hurtfull. When exalceratn of the lungs is produced from the bursting of a recent formed abscess into the lungs there is hopes of the patients recovery but most other cases are in the end fatal, no remedies that are of use in other ulcers, can be used. Bark encreases the diffy of respiratn & mercury stimulates too powerfully if there so great difficulty in spitting up the matter, gartle expectorants may be made use of. if the cough be very troublesome opiates may in some instances be safely used as also to procure sleep, when it is wanting naturally [illegible] are in most cases too stimulating to be of service in this disease 29 Lect: 96th May 21st 1772 Rheumatism varies pretty considerably in its appearance more perhaps than inflamtn so that it has been much disposed that the disease [illegible] & that part of the body were capable of being inflected with the disease It commonly occupies the external parts of the body it may also occupy the internal parts as we find metastasis take place from the external to the internal parts, [illegible] the brain & intestines. It may occupy the skin which is much [illegible], & colder in the parts diseased. It may occupy the muscles, hence those of these parts affected with the disease loos their powers in some measure. It may infect the internal membranes as the violence of the pain of the aponeuresis of the thigh testifies. It seems capable then of affecting almost every part of the body. It originally arises always in the external parts, and only from one known cause [illegible] cold 30 The cause however is not in every cause evident. but when it can be traced to any cause cold is always it. as we know that cold is capable of producing it & of no other cause but cold we attribute it always to the effects of cold. The only necessary symptoms to constitute rheumatism are coldness, paleness of the parts and inability of motion in the muscles. Cold produces in general a contract of the small vessels which is sometimes permanent & at other times continues no longer than the cause. The former seem always to be the case in rheumatism the coldness & paleness show if the circulatin is retarded which is the known effect of cold, immobility is a necessy consequence of the contractn of the small vessels These symptoms constitute the disease and always take place at first. sometimes these symptoms remain the same for a very great length of time but they more generally produce other affections as inflamatn which is only the consequence of & not the disease itself 31 The arteries propelling the blood more strongly into the capillaries endeavour to distend them, & occasion pain which however is very difft. from what takes place in those vessels when inflamed. as the endeavour is contin’d of & [illegible] to distend the capillaries the pain is lasting, being a continual gnawing in place of acute, throbbing pain which takes place in inflamatn of these vessels. Rheumatism is divided into 3 kinds if attended with genl inflamation it is called acute if there be no general inflamatn the disease is call’d chronic threumatism or if the inflamat. be not attended with danger. The encreased actn of the arteries at last frequently get the better of the contractn at first inflamatn of the part is produced which in the present case is the cure of the disease, but if the obstruction does not yield to this encreased arterial action general affectn is produced Hardness, fullness, frequency of the pulse etc. which all the symptoms of inflamatn the tongue becomes white, the patient thirsty, appetite lost, and frequently oppression of the breast with (at times) stupor, delirium & affection of the brain. The fullness of the pulse is occasioned by the quantity of the blood thrown out by the heart 32 By evacuations then we can diminish the quantity of blood & so take off the fullness from the [pulse] in this [illegible] although the action of the heart is weakened that of the arteries continues hence the frequency & hardness of the pulse frequently continue after its fullness is removed by evacuatn or continuance of the disease. If the encreased action of the arteries carries of the disease then health is restored, if not it produces an acute fever & genl inflamn The general inflamatn may prove fatal by affecting the brain, or the delirium if the patient survives may be converted into mania The disease sometimes continues perfectly topical without producing any general inflmatn of the habit. The more considerable the topical & general inflamatn are the shorter is the disease likely to be & vice versa. Another appearance in rheumatism [illegible] renders it most troublesome & difft metastases when there is general inflammation are very apt to take place by which the seat of the disease is translated from one part of the body to another and that without any order. Regularly or often evidt cause is that one limb or both, or perhaps almost every part of the body at the same time 33 Metastasis has often been accounted for by saying that the matter is taken up from one part and lodged in another but there appears to be no matter in this disease it cannot be communicated by the applicatn of any infectious matter nor its existence otherwise proved If rheumatic matter was in the system & capable of producing the disease by being mixt in the heart with the whole mas of blood would be spread through the whole body uniformly unless we allow that some part is more fit for the reception of this matter than others, but this does not appear to be the case for no part of the body seems to be exempt from it by metastasis it must then be allowed that of the matter be spread through the whole system there must be some particular disposit. Metastasis serves to prolong the disease when it affects the brain it very suddenly proves fatal or if the intestines it produces spasm flatulency etc. When the disease is cured in one part of the body it by infecting another part retards the cure as the secondary affection is so difficult or often more so than the first or the disease sometimes takes place in 2, 3, or more difft parts of the body whilst the original affection remains [uncured]. 34 in the blood vessels of the part affected to be infected with the disease else the affection would be general as the applicatn of the matter must be this however is not the case and as it never was, nor can be proved, that any such matter does exist in the body this particular disposition (in one part) of the vessels is of itself suffict,. to account for the disease; and should therefore be admitted as the [cause]. Lect: 97th May 22nd 1772. Treatment of the Rheumatism In rheumatism we might suppose it proper to employ the natural method of cure for carrying off the disease [illegible] by the encreased action of the vessels. but in rheumatism the natural cure is the only part of the disease that is [illegible] dangerous & troublesome, we should then endeavour to shock the tending to natural cure & carry off the general inflmatn by the exhibition of remedies If the pulse be hard strong, & frequent & symptoms of general inflamatn prevent copious & repeated bleeding should be used to carry them off not only in qy suffict. to regulate the action of the vessels but to get the better of it so as to carry it entirely off. 35 Relaxants are employed at very considerable efficacy and they are [these] [med:] which tend directly to counteract the disease and remove the obstructions that take place they should be used in an all other cases [illegible] not before the strong action of the vessels is carried off. Blisters & stimulants may be advantageously applied to the part & internal stimulants be exhibited of the antispasmodic kind if the circulatn be languid Relaxants must be employ’d for a length of time often before they are of any use & the most efficaceous as antimony & ipecacuanha shd be exhibited Medicines strengthening & destroying the [illegible] ability of the system are of most use when the disease is apt to return frequently & put on the appearance of a spasmodic affection which it sometimes does. Rheumatism properly not divided according to the difft. part of the body affected, but according as it is attended with more or less general inflamat. if the general inflamatn be very great we call it acute rheumatism or rheumatic fever if the general inflamatn be absent or in considerable it is called chronic Rheumatism as these differ only in degree there can be no boundary properly ascertain’d betwixt the two 36 Acute rheumatism happens more frequently to such as never before had the disease & to people of a disposit. in which inflamatn is apt to take place. frequently arises at first with symptoms that are only slight as with a little cold & immobility of some particular part with out any great pain which upon fresh exposure to cold is encreased to a very considerable degree The tendons & [aponeutosis] of the muscles are more generally affected in this than in [illegible] rheumatism. At other times the very first symptoms of the disease are violent acute pain immobility redness & inflammation of the part are the first symptoms of the disease & genl inflamatn succeeds The affect. spread from the part which it originally affected, violent symptoms of inflamation etc. come on in a very great degree sometimes even to prove fatal. frequent metastasis takes place in this stage. it sometimes but rarely happens that all the external parts are affected at once and the whole joints of the body become immoveable with very great pain & soreness over all the body very soon after the attack the pulse becomes hard, strong & frequent, the tongue becomes white, appetite is lost & all the other symptoms of general inflamation. 37 The inflamatn sometimes arises to such a degree that the brain is affected stupor first, then delirium take place & the patient is cut off or if the patient [illegible] the delirium is sometimes converted into mania Delirium more frequently takes place in this disease from want of sleep which delirium is accompanied with the most violent ravings (symptoms) quick motion of the eyes, raving, snatching every thing out of the attendants hands, jumping out of the bed, requiring 2, or 3 men to hold them, in some instances have leapt out of the window or stabb’d themselves. If the patient recovers from this state the disease gradually intermits, going off during the day tie & returning at night. the strength of the patient being exhausted & the rheumatism carried off by the continuance of the disease. Metastasis to the internal parts seldom takes place whilst the patient continues strong. the more the patient is exhausted the more mobile it is & the greater dispositn for metastasis to take place. when this happens to the brain delirium is produced & the disease cuts off the patient frequently in a few hours. 38 Lect: 98th May 22d 1772 Treatment of acute rheumatism suppose we are called in at the beginning of the disease it is not generally of difft cure as the genl inflamatn may be carried off by copious evacuation The rheumatism is not to be attended to but the general inflamatn to be got rid of as upon that the whole danger of the disease depends. We are to make copious evacuatn if the patient be strong 16 or 18 ounces of blood are to be taken away & the operatn repeated the next day if the genl inflamatn be not removed & so continue till we overcome it & nothing else appears in this stage of the disease to be of any use, if any [illegible] must be given it may be in the [illegible] relaxants as [illegible] If we loose the opportunity of making large evacuatn at first we never after have the disease is much in our power at this period nothing shd be used but barley water and such [illegible] food If the genl inflamatn is entirely carried off by the bleeding but the rheumatism continues with pain in the part affected then relaxant may be used with great advantage to carry off this remaining affection of the disease topical bleeding by cupping leeches etc. are often of use when inflamatn be confin’d to a [illegible] part. 39 Suppose the general inflamation is not so considerable that there is but little hardness & fullness of the pulse, in such cases large evacuations are not so necessary 12 or 14 ounces may be taken away, & there is seldom a necessity of repeating the operatn it is better however always to exceed in too much than too little blood. when the proper evacuatn is made relaxants may be exhibited of which emetic tartar is the most effiacacious, & may be given in as large qy as the patient can bear without being sick at stomach from ¼ to ½ grain may be exhibited every 2 or 3 hours in water. suppose we have not been called till the disease has continued 2 or 3 days during which time general inflamatn has taken place and the proper evacuations have been neglected or made in too small quantity in this case Metastasis has not taken place, the extremities are affected with the disease, sometimes one and sometimes another. that the patient has been for several nights entirely or almost without sleep in this case evacuation is not so efficacious but must be made not withstanding we can weaken the system now tho’ we cannot take off the encreased action of the vessels. 40 We must not take away such large quantities of blood nor repeat it so frequently by such large evacuatn we diminish the strength but not the hardness of the pulse in the present case we must have patience as relaxants cannot be employ’d whilst the hardness of the pulse continues, much less stimulants or antispasmodics we should then desist for a day or two giving medicines and trust to & watch nature the action of the vessels in such cases frequently diminish of themselves & by this means we shall in time fetch the disease so that we can employ relaxants with advantage to carry off the disease. Suppose the disease has continued for 10 days or a fortnight and evacuations have either been made in too small a quantity or not at all that the strength of the heart, and muscular powers and diminished, that the pulse is hard, but neither strong, nor feeble but rather small & contracted the system at the same time considerably weaken’d. Patients are often reduced to the state by bad practise such as bleeding whilst stimulants are exhibited at the same time such 41 as guaiacum, volatile alkali etc. The evacuations by bleeding in this case diminish the strength of the general habit, whilst the stimulants keep [illegible] the encreas’d arterial action and other inflamatory symptoms, this practise [illegible] inconsistent & in every case has [illegible] In this situation we are [difficulted] how to act, if we bleed we diminish the strength without taking off the hard action from the arteries whilst stimulant encrease the action of the arteries without encreasing the strength of the system in general If in such case the rheumatism were fixt to a particular part, we might be of use by freeing the part from pain by the applicatn of leeches, cupping etc. taking off the stimulus from the part, and so free the general system or by blisters we may free the habit from the disease which affect it in general but if frequent metastasis takes place the use of these means are ineffectual on the disease as soon as we cure it in one phase takes place in another in this case do nothing if we be not pretty sure of doing that which is proper. trust to nature keep up the strength as much as possible by the exhbitn of mild & nourishing food of easy digestion and the disease generally terminates better than when medicines are exhibited 42 Accidents that may occur during the treatment of this disease which are attended with very great danger to the patient. If delirium arises from general inflamatn is to be carried off by evacuations as mentioned before. If delirium arises from want of sleep if the hardness of the pulse be gone off & if the delirium so encreasing so as to endanger the patients life opium must in this case be used. A practitioner is tempted in [no] disease, [illegible] than in the present to exhibit opium but if we exhibit opium whist general inflamation takes place no good effects are produced, the patient when he does sleep is not refreshed, nor sensible of it. but [illegible] disturbed & anguish awakes unrefresh’d, & fatigued and denies that he has slept at all. But if the general inflamatn be gone, the pulse soft & the delirium encreasing so as to threaten the destruction of the patient in this case opium must be exhibited if in small quantities so as not to produce a continued sleep for 12 or 14 hours at least it always in such cases is hurtfull instead of being of benefit or requires then a good deal of courage & resolution in the practitioner to exhibit a dose sufficiently large to produce this effect as it otherwise is part [illegible] & restoring the patient in a few hours in some instances after its exhibition 43 When no delirium has taken place the exhibitn of a small quantity of opium is not attended with such danger but may be exhibited to advantage if the inflamatory symptoms be entirely gone. Suppose metastasis has taken place to the brain the only means we know of removing it is by applying a blister to the head or back, so as powerfully to stimulate the neighbouring parts Metastasis to the intestines is more painfull than dangerous by the exhibition of internal stimulants together with relaxants & opiates we have it in our power to remove the seat to the extremities or external parts or perhaps to carry it off entirely Suppose the disease returns in the night only like an intermittent being perfectly free during the day in such cases the bark may be exhibited in quantity of zfs or zvs during the day which very generally carries off the disease When the disease continues seated in a particular part of the body after all symptoms of general inflammation are gone off in such cases topical applications of stimulating kind are blisters volatile alkali mustard seed etc. are often effectual in carrying it off 44 suppose the hardness of the pulse removed but the disease returns at uncertain intervals it them is to be considered as a spasmodic disease and to be treated with stimulants [illegible] antispasmodic kind, apply’d to the part affected. Suppose the genl inflamatn carried off but the disease continues the patient is then in the state of chronic rheumatism When rheumatism is attended with no or very little general inflamatn we then call the disease chronic rheumatism. the great difference between which diseases consist in the absence of the general inflamatn & the symptoms depending thereon. IN every case of rheumatism, where there is hardness of the pulse it is always advisable to bleed unless the disease has greatly reduced the strength of the patient so as to render evacuatn dangerous. Stimulants employ’d should be of the antispasmodic kin ad guaiacum & volatile alkali & other resinous stimulants. spices have a great tendency to encrease or produce symptoms of general inflamation without removing the disease they are therefore not so proper as the others [illegible] in chronic rheumatism where stimulants are necessary 45 If there be no symptoms of general inflamatn relaxants may be used, as emetic tartar, rattlesnake root etc. with other antimonial preperations. When the disease is obstinate by exhibiting opium with ipecacuanha, or other relaxants we can exhibit them in much larger quantities & so, as to act more powerfully. It is not sweating as has been thought by some which carries the disease, because the natural sweats which often take place are never of use but on the contrary tend greatly to weaken the patient’s strength. Stimulants & relaxants may very properly be exhibited together the first acting more powerfully on the internal & the latter upon the external blood vessels. Topical applications may be employed in chronic rheumatism with very good effect, there being little or no disposition to metastasis. The application of blisters, & volatile liniment prepared with the caustic volatile alkali. after chronic rheumatism has been cured & the patient is subject to relapse upon slight exposure to cold in these cases the habit is to be strengthened & its irritability destroyed by the exhibition of the bark bitters [exercise[ cold bath pure air etc. 46 Lect: 99th May 23d 1772 Chronic diseases if a disease terminated in 40 days it was called an acute disease, if it ran out longer it was called a chronic disease, this distinction not a natural one for many diseases as a fever for instance, may terminate sooner or continue longer than the time mentioned, excepting in such cases as apoplexy with either [pill] or go off immediately there is no such thing as determining from the time of their continuance or drawing a line of distinction betwixt acute & chronic disease Most of these diseases treated of have some natural cure ([illegible]) excite some action in the vessels which tends to carry off the disease, those to trat of have no natural cure. this distinction [we choose] to retain betwixt acute & chronic disease. such diseases as have a natl cure are always more complicated & the effects of medicines less certain, those that have no natl cure are more simple & the actn of diseases are better ascertained with their mode of action Weakness being in the diseases to treat of the great or only [illegible] we think proper to begin with its history & treatment as such. Weakness to be divided into two kinds, sometimes in weakness the irritability is diminished but in others & more commonly it is encreased when the system is weak the operations of the body are not carried on with any degree of fever & therefore are more easily disturbed we shd expect the later to be the most common case. 47 When the irritability is diminish’d in weakness of the habit we call the disease paralytic or palsy this we don’t treat of at present The other [illegible] when the weakness is attended with encreased irritability may be distinguished into 2 kinds which may be divided into each as are produced suddenly (e.g.) from great haemorrage as from violent purgings. 2d any violent disease as fever weaken slowly in several difft ways in as much as during their [illegible] women there is an encreased action which tends to exhaust and weaken, or in violent disease there is considerable irritation which not only produces great [depression] of strength, but permanent weakness. inflamatn of the intestines produces great depression of strength & leaves a weakness behind in the parts affected with the disease. The principal difference is in the manner in which the disease is produced [illegible] either suddenly or slowly & the difft & variety of cure depends upon these circumstances also. Acute diseases weaken by disturbing or destroying the appetite & organs of digestion renders the stomach incapable of receiving food or of connection it into chyle when [illegible] In many cases without any great evacuation the fluids seem to be exhausted as destroyed by the disease. The action of stimuli generally produce weakness of the second species even although this effect should be produced in a short time. sedatives apt to leave a degree of weakness behind them & this of the 2 species. 48 Supposing weakness suddenly produced & no other disease present the muscular strength is diminished, the force of the heart & arteries also, the pulse is weak empty and soft. if there be no stimulus the action of the heart becomes much slower than natural. the pulse beating only perhaps 40 or 50 in a minute, but if there be the least irritation as from digestion, exercise etc. the pulse becomes much quicker than natural The patient is disposed to sleep more than natural, the appetite considerable often greater than the powers of infection, which is however considerable, so as to fill the vessels in a short time with a great quantity of blood. In this case it is generally suffict. to exhibit plenty of nourishing food keep the patient in a free & pure air. Bark may be used which prevents the danger of relapse into the disease which first produced the weakness. These are the symptoms of weakness suddenly produced the disease perfectly gone off is seldom attended with any danger but mostly get rid of as above & in a short time [illegible] the disease producing a weakness when it generally proves fatal. 49 Weakness may be produced slowly [illegible] by any slow evacuatn as purging not violent but long continued or any similar discharge It is not always the qy of the evacuation that produces the weakness. the fluor albus, or involuntary emissions of semen weaken more than any other although the quantity evacuated is but trifling In action is another source of weakness in the habit, want of suffict. exercise producing depression of strength bad digestion Any fever that runs out into a great length, or other disease any long continued action of stimuli as of mercury or guaiacum by stimulating the vessels and encreasing their action for a length of time tend greatly to weakening the system Living in an impure or [illegible] air as putrid vapours or air unfit for respiration renders the habit weak & of that kind of weakness which is slowly produced all impure airs are not equally hurtfull inflamable air may be respired & less hurt than fixable air & both & less danger than putrid vapours Anxiety or weakness produced in the body by any exertion of the mind as study, grief etc. always produce the kind of weakness that takes place slowly. want of sleep & spasmodic affection of the muscles have the same effect of producing weakness of the 2d kind. Disorders of the intestinal canal from frequent & free use of acids, spirits, food of difficult digestion use of spices & other stimuli 50 apply to assist digestion by purging either natural or artificial by application of sedatives. Lead particularly or from any other weakness arising in consequence of another disease. Another cause taking place slowly and peculiar to women. obstructions of the menstrual evacuation At puberty which in this country is about 14 or 15 menstruation takes place. Lect: 100 May 25th 1772 Obstruction, or irregularity of the menstrual flux produces that species of weakness which takes flow slowly & is difficultly removed. An haemorrhage may arise from the womb or vagina before the age of puberty, as from the nostrils or any other part of the body which however is perfectly distinct from and unconnected with the menstrual discharge The age of puberty differs in different climates in warm countries it is from the ages of 11 to 19 years in this country about 14 or 15. at this time the breasts and parts of generation encrease in size and an haemorrage takes place from the uterus preceded by plethoric symptoms as pain & fullness in the lower belly, breasts etc. sometimes also accompanied by hysteria fitts which frequently happens at this time the [illegible] of the other parts of the body [illegible] 51 The haemorrhage continues for 1, 2, 3 or 4 days & for the first 2 or 3 times is generally irregular returning perhaps in a fortnight as perhaps not for 3 or 4 months it afterwards becomes regular 7 returns at the end of 28 days in most women, with some variatn however in point of time with difft women. in young women, there is often a sense of fullness & weight about the abdomen & [illegible] pubis with a swelling & fullness of the breasts which precedes the discharge. the haemorrhage generally continues about 3 days with some variation however in point of duration it sometimes regularly at shorter intervals than time of longer than five weeks. the quantity of blood [illegible] is not very considerable, it has been estimated at 6 or 7 ounces which appears to be a sufficty large estimation. it continues then to return till about the age of 44 or 45 sometimes however it [illegible] so young as at 40 & at others not till 50 sometimes it stops all at once, but it is more generally irregular for some time both in the qy & periods of its returns. it after this time ceases for life excepting that in some instances there seems to be an attempt in nature towards the renewal of the body about the age of y70 years, in which cases there is a return of the menstrual discharge, new teeth are sometimes formed the eye sight & different [senses] renewed. 52 If during this time a woman be impregnated the menstruation stops, sometimes however it returns for once or twice & in some instances has been regular through the whole period of pregnancy. This however is very rare & the haemorrhage in these cases most [illegible] from the vagina The only species of animal that menstruates in any considerable quantity so as to be observable in some species of the monkey kind. in all animals [illegible] quardrupeds there is a similar discharge though inconsiderable at the time they [illegible] male. it however is not regular in any but the human species depending upon the habit of the body more in the quadruped kind as they never are disposed to take the male nor to menstruate but at such times as they are fat & well fed [illegible] [when] [illegible] During the time a woman give suck as well as during pregnancy the menses generally stop & it has been said by some that when the menses return after being stopt by giving suck or disease which they return at the very period they would had no obstruction takes place, but the periods regularly continued. Menstruatn may be stopt by exposure to cold during the [illegible] or by disease as fever, also by anxiety of the mind, or plethora or weakness of the body produced slowly from any cause. when the menses are stopt by any of the causes last mention’d they do not 53 return at the next period, but the body is diseased if plethora takes place all the functions of the body are disturbed & the menses also when obstruction of the menses takes place from this cause hysteric symptoms are often produced The menses are sometimes encreased in quantity so as to produce disease either continue longer or return more frequently etc. and in this case always produce disease [illegible]. weakness irritability of the habit etc. and the diseases depending thereon. The menses are often encreas’d in qy is as to produce disease from injury some to the parts in difft labours abortions etc. Causes assigned for menstruatn very [illegible] has been supposed that by menstruatn that blood was evacuated which should serve for the nourishment of the foetus, but that it does not answer this, appears from this consideration. [illegible] that in all other viviparous animals there is the same [illegible] of fluids & yet no menstruatn or at least the quantity of blood evacuated is inconsiderable & of no account neither has there been any other cause assigned in any way satisfactory The manner in which it was produced has been as much questioned it evidently depends upon encreased action in the vessels of the part 54 this appears from the encrease of size in the parts as also from the swelling of the breasts in young women before this evacuation [illegible] from phlegmonous inflamatn sometimes taking place in difft parts of the body when this evacuation does not take place. It evidently depends in other [illegible] made up of plethora & fullness as they never menstruate [illegible] [illegible] in this habit of body. It has been said that blood was gradually accumulating in the system so as to produce such a plethora in the course of 28 days as to occasion this discharge but that it does not depend merely upon plethora appears from this that a much larger quantity of blood may be taken away without preventing the flux It would seem to arise at first from the particular encrease of [illegible] in the parts of genern & from the plethora that now takes place in the whole system. The growth of the body at this period being generally stopt for a time, a larger quantity of blood is formed by the organs of the digestion, than is necessary for the support of the body. A plethora then takes place, through the whole habit at this period of life, & an eruption from the uterus in consequence of an encreased action in the vessels of these parts, from the particr stimulus occasion’d by their encreas’d growth. why the menses should exactly return at 55 the end of 28 days we know not. this evacuatn has been called the menstrual flux, from the moon changing at the same period. but then there seems to be no power in the moon of producing or regulating the menstrual flux an equal number of women menstruating at the fall new or any in difft day of the moons age so that the moon does not appear in the least to affect the menses. The menses are stopt by any cause that produces a contraction of the small vessels, as weakness, grief, anxiety, fear etc. as also from plethora which prevents the blood vessels from exerting their usual force upon their [illegible] from exposure to cold [illegible] the eruptn the applicat. of astringents [illegible] of the vessels [illegible] produced & from impregnation. Too great flow of the menses may arise from relaxation of the small vessels, as from too great action of the vessels of the system in general. The menses seem to be stopt during pregnancy by the exit of the haemorrhage from the uterus being shut up, by the application of the membranes to the mouth of the womb & by its being stopt up by a coagulum of lymph we may [illegible] them, that whatever evacuatn takes place during the months of pregnancy is not from the uterus, but from the vagina, the os uteri being closely shut up by a coagulum of menses. If the menses are obstructed the disease [illegible] generally takes [illegible] often weakness is produced which is to be considered of the [kind] [illegible] & evenly produced. 56 The menses generally disappear betwixt the ages of 40 & 50 years with very considerable variety however in point of time in different women. The cause of the menses ceasing probably arises from the contraction of the small vessels that takes place in advanced age, as we find a great many of the capillaries entirely obliterated that plumpness is lost the tendons & large blood vessels from this cause become more apparent in old age. If the menses flow in too great quantity at irregular periods or an obstructed from whatever cause, disease is generally produced, & hysteric symptoms appear. when the menses are [illegible] the [illegible] disease are produced [is] [illegible] the stoppage of any other [evacuation] discharge that has become habitual. Lect: 100 May 25th 1772 Remedies employ’d to remove obstructed menses, or to diminish their quantity when they flow in such proportion as to weaken the system by the greatness of the evacuation. If they be obstructed from plethora or do not take place at the usual time & then be symptoms of plethora prevent it is of use to take away a quantity of blood. 57 It has been questioned in this case whether the blood should be taken from a vein in the arm or foot there seems to be very little difference, from whatever part of the body the blood be taken, provided the evacuation be made. If after this evacuatn the menses shd not appear stimulants may at times be used, but they shd never be exhibited whilst there are any symptoms of plethora. such is not particularly upon the intestines & also abdominal viscera [illegible] purgatives are preferable. If the obstruction is occasion’d from weakness produced from any sudden cause then nourishing food exhibited for a short time so as to strengthen the general habit will almost allways render them. supposing the obstruction proceeds from any other cause we employ remedies to reproduce the haemorrhage. Stimulants have been used, those of the antispasmodic kind should be preferr’d other stimulants however have been used as resinous substan. preparations of iron, mercury, spices & of [all] which resins have the preference, they should be employ’d so as to act constantly & uniformly on the system, Preperatn of iron have been used with success in weak habits, as they have also a strengthening quality 58 as well as a power of stimulating and encreasing the circulation they are on this acct preferable to most other stimulants. Myrrh, galbanum, [opoponax] which shd be exhibited alongst the aloes so as to [illegible] Mercurial stimulants have a dispositn to weaken the system, are therefore improper & particularly hurtfull in all cases adhere the obstruction is either produced by or accompanied with general weakness of the system. Of all cathartics, aloes seem the most powerfull in reproducing the menstrual flux, may be properly exhibited with some of the resins, these medicines should be continued to act for some time as they have a particular power of operating at that time the evacuation should not naturally take place they shd be exhibited in quantities suffict to produce an evacuation or two every day from the intestines Relaxants employ’d at the time are particularly usefull, such as exposing the parts to the steams of warm water etc. or impregnated it [illegible] stimulants & antispasmodics as [illegible] [illegible] The natural stimulus adopted to the part affected is the most efficaceous of all applications and often proves effectual when all others fail. In too great flow of the menses we shd have a regard to the cause producing it because the treatment may be very different 59 Too great flow of the menses may proceed, first from plethora or from too strong action of the vessels upon their contents If we wish to check them in such cases, we should rather make evacuations & employ sedatives of the vit. acid & if the symptoms of plethora continue we should bleed, use a slander diet and avoid stimuli of every kind, because all such encrease the disease. When the disease takes place from genl weakness or from injury [illegible] to the parts by abortion etc. in these cases we should employ strengtheners of which the bark is preferable to all others & the most powerfull of the vegetable astringents [illegible] galls may be exhibited internally with advantage. When weakness takes place slowly the stomach & intestines are generally first affected the stomach after eating feels full [flataley] acidity & takes place the intestines are affected with flatulency & spasmodic pains the peristaltic motion is disturbed purging or costiveness is apt to take place. 60 At the same time the muscular strength is gradually lost, the patient becomes restless & uneasy with want of sleep there is added to this a pain in the small of the bark, appearing to be seated in the spine, which is encreased from exercise or fatigue of either body, or kind of the weakness be more considerable dropsical swellings often take place, beginning at the extremities & ascending to the abdomen partial evacuations as sweats, diarrhoea, gonorrhoea [illegible] fluor albus etc. & the place which evacuations exhaust the patient so much as frequently to destroy & in every case is difficulty got rid of. Remedies strengthening the system may be divided into two classes first such as prevent the strength from being further exhausted & such as really do strengthen the system the first class operate by preventing the living power of the body from being exhausted and the latter operate by encreasing the flow of this living power into the body. 61 Anxiety of the mind a great cause of weakness this should ben be avoided by going to places of amusement such as mineral waters travelling to difft climates etc. the vessels should be filled if possible with a quantity of good blood. the first action of the living power being to adopt the vessels to the quantity of blood they contain nourishing foods then become strengthening remedies in order to this the stomach & intestines should be kept in order of the digestion be pretty good, but appetite a wanting we may use [acids] etc. to procure an appetite Stimulants shd be employd in moderate quantity alongst which the food as spices to assist the digestion, wine also if it does not turn sour upon the stomach. If the peristaltic motion be deficient it is to be kept up by purgatives so as to keep the [prima] viae [illegible] of foeculent matter, unless the patient be subject to too great flow of [illegible] or to the haemorrhoids. 62 Neutral salts are apt to weaken the intestines in this case too much, vegetable purgatives are apt to turn [illegible] we may then conveniently [join] a small quantity of [fallop] which is of itself apt to produce spasms & gripes in the intestines with the milder acting purgatives The appetite is often impaired by mucus in the stomach this is to be got rid of by gentle emetics as the exhibitn of the [illegible] We should also attend to the state of the blood vessels themselves taking care that they act sufficiently & not too powerfully upon their contents when evacuations are requisite purging is preferable to bleeding the latter relaxing the vessels [the] suddeness of the evacuation & is rendering them liable to be more filled with blood That taking away a quantity of blood from the vessels disposes them to receive a greater quantity appears from this experiment that nothing tends to fatten more than frequently respected bleeding in small quantities at a time. By exercise we can draw the living power from the blood vessels to the muscles hence moderate exercise in free air is of great use in weakness of the system attended with hectic fever, in which case the whole action of the vis vita seems to be concentrated in the action of the blood vessels upon their content muscular motion & all the other functions being weakened. Exercise also encreases the powers of digestion & strengthens the appetite 63 Lect: 102 May 26th 1772 Emptiness of the large weakens much more than emptiness of the small vessels if the blood then principally circulating in the external parts the system is weakened hence a warm atmosphere or whatever stimulates the skin, so as to draws the circulatn externally weakens the habit, a warm summer has the same effects the [illegible] in these cases is to be restored by the application of cold which has just the contrary effect. we should take care however that the change from hot to cold climate be not sudden, but gradual. also violent or inflamatory diseases will be produced. In order to strengthen the system the cold bath has been used. upon jumping into cold water all the external vessels are suddenly contracted & the blood forced upon the internal ones, when he comes out of the water the cold being removed, the heat restored the external vessels are relax’d & a profuse sweating sometimes takes place & contractn of the external vessels being out at all permanent if then the system is strengthened it is not upon the same principle as conting living in a cold atmosphere Cold air strengthens much more than warm hence men in general are much stronger in the spring than they are in the autumn of the year. The cold bath very doubtfull in its effects sometimes weakening the system in place of strengthening it A warm atmosphere is sometimes the means of strengthening the habit particularly to such habits as are [illegible] from cold air such as asthmatic & those subject [illegible] 64 Astringents used in a large quantity exhaust but in small doses strengthen in the latter case they act particularly upon the large blood vessels, in [illegible] their action is general upon the whole system. If there be any dispositn in the small vessels to contract beyond their natural pitch as hectic fever hypochondria etc. astringents in such cases cannot be used. He now breathes air unfit for respiration there is a great depression of strength produced. all animals as quadrupeds, birds, fishes, and insects of necessity breathe respirable air. Life not being to be supported without it. All vapours excepting inflamable air that we are acquaint with are heavier than respirable air such then always tend towards the earth. A man going out of an air partly unfit for respiration into that which is perfectly pure, feels himself suddenly relieved, as if from an oppressive lead. The air upon high hills is not so dense as in lower situations it is also more changeable in temperature The system may also be strengthened by increasing the flow of living power 1st by habit a man who has lived a sedentary life although he may live in a pure atmosphere, eat good food etc. yet he becomes weak, feeble & incapable of exerting his muscles, this by habitual [illegible] Exercise may be overcome & the strength restored 65 Stimulants may be employ’d to encrease the action of the vessels, but this is seldom of use in strengthening the general habit, from the disposition they have to stimulate the blood vessels solely, or principally to action & so weaken the other powers of the body. Stimulants then can never be used as strengtheners, unless in lax habits, & cases where there seems to be no particular disposition in the blood vessels to strong action. But exercise may be used to the greatest advantage in most cases of weakness, provided it be not to such excess as to fatigue. It is a matter of the greatest importance that the exercise should be agreable & amusing so as to take off the attention of the mind from the diseased state of the body. Exercise should be universal so that every muscle in the body be employ’d have riding on horse back or in a carriage are preferable to walking, the lower extremities in the later being only employ’d. Rowing etc. very beneficial Exercise should be performed in pure air, hence exercise in close rooms weakens, in place of strengthening the body. Remedies strengthening the habit are the bark bitters of the vegetable class preparations of iron etc. when the weakness ahs been suddenly produced our medicines are efficacious & suddenly so, but in cases where weakness has been generally [illegible] & long continued they are not so affected 66 It has ben question’d & seems as yet to be undetermined, whether bitter medicines should be exhibited compounded or not there are reasons pro & con. the strongest argument for exhibiting simple bitters is that they are of a class of medicines that by contn’d use soon loose their effects as medicines, and are avail [illegible] of these qualities by exhibiting [illegible] alone because one bitter acts powerfully after another by use has lost its powers. In weakness where there is a disposition in the blood vessels to great contraction these medicines are not nigh so proper which is probably owing to their astringency When these medicines loose their efficacy by intermitting their use for a few days they may be returned to & recover their effects upon the habit. If weakness be the only disease the patient should not be suffered to lie abed, but kept out as much as possible the warmth of the bed rendering the habit irritable & preventing the increase of strength. Preperations of iron are much more stimulating than the vegetable bitters are therefore more or less proper according to the state of the particular case Containing the lectures from No 91 to 102. Practise of Physick by Dr Fordyce No 1 Practise of Physick Index Page No Treatment of the small pox 1 Treatment after the small pox 6 Measles and treatment 8 Chicken pox 10 Miliary fever 11 Scarlet fever 13 Herpes miliares, or shingles 14 Causes of [exaleratn] of the lungs 14 Symptoms of the disease 15 Causes of pulmonary hemorrhage 17 Treatment of Haem of [illegible] 21 Hectic fever chronic general Inflamatn causes of consumptn 23 Symptoms, treatment etc. 25 Rheumatism 29 Treatment of the rheumatism 34 Chronic diseases 46 Weakness of the system, causes, treatment etc. 47 Menstruation, theory of 50 Treatment of obstructed menses 56 Modes of strengthening the habit 60 1 Lect: 91st May 18th 1772 Treatment of the small pox one general observation is that there is no means of shortening the disease or putting a stop to it when it has once taken place it must be gone through, all to be done then, is to avoid, or prevent and dangerous symptoms that may arise in the course of the disease. 1st When the fever takes place it is usefull to clear the prima viae of any matter they may contain by the exhibition of an emetic & gentle laxative to prevent the [lodgement] of any mucus or harden’d excrements that may be contain’d in the intestines as of any acidity that may be lodged in the stomach [These] remeds cannot be used so properly after the eruption. If the fever be attended with considerable symptoms of general inflamatn if the patient be plethoric or young & every strong it will be of use to take away a quantity of blood & this cannot be done with equal propriety after the eruption has taken place 10, or 12 ounces of blood is generally suffict. and it is very seldom necessary to repeat the operation. this evactn to be made previous to the eruption of the pustules 2 unless in the circumstances mention’d. Bleeding & evacuations are hurtfull. The more violent the fever in general the more violent the eruption and vice versa. we might then suppose, that by the diminishing the fever, by the use of relaxants etc. the eruption should be more mil this however does not appear to be the case altho’ relaxants in general do no mischief & are very usefull if the fever shd not be the small pox. There never can be a case where strengthening remedies can be wasted to support the patient curing the fever, all stimulants then etc. should be avoided. the eruptive fever is almost never fatal, generally going off upon the eruption In children, previous to the eruption convulsions sometimes take place, or disappear upon the eruption very seldom continue after remarks that the pox in this case are almost always of the distinct kind. do nothing for the convulsions, trust to nature they almost always go off themselves. 3 Then the eruption has taken place if the symptoms of inflamation do not run high if no symptoms of irritability take place, if the pustules gradually fill with yellow pus, if the hands, feet are inflamed as the face subsides, if no difficulty of respiratn nor costiveness takes place we must then let nature alone & not disturb her by medicines. [but] suppose the patient to be costive it is apt to encrease all the dangerous symptoms. the intestines should be evacuated by glysters, purgatives should by no means be exhibited before the period of maturation as the pustules are apt to sink by their operation Sleep may be procured by opium if the patient be restless. If the patient has an evacuation in 48 hours we should make no evacuation by medicines as too great discharges that way are very apt to do mischief If symptoms of great inflamation take place, if the pulse be hard & strong, if the face and eyes be inflamed, if delirium, or symptoms of oppress’d brain take place bleeding becomes necessary. Dr. Boerhave has supposed that the variolous fever has been carried off & the patient cured without any eruption taking place, this however we deny. 4 We should not be too rash in making evacuations by bleeding etc. as the pustules have sometimes immediately sank & the patient been cut off unless then the brain be affected we should rather avoid using the lancet. When necessary 10 or 12 ounces is generally sufficient, and we should not repeat the evacuation. The bad effects of evacuations are particularly evident in pregnant women If absorption takes place, as often happens, the evacuation in consequence is almost always fatal If the pustules continue watry, stimulate the skin, with erysipelatous inflamation between them or little blisters arise with great soreness Bark is the best medicine for filling the pustules with good pus but it is very apt at the same time to produce disorder in the breast difficulty of breathing & rendering the mucous secretion of the throat so thick as not to be evacuated. If the brain be affected, or the breast as above we should by no means be induced to exhibit the bark & ought immediately to leave it off it if produces these symptoms 5 Opium tends also to produce good suppuration & is therefore in such cases very properly exhibited, if no symptoms of general inflamation take place If the patient should want sleep for 3 or 4 nights it produces very great mischief & opium should be [illegible] [upon] [even] although general inflamation should take place opium tho is very apt to increase the oppression of the [evacuation] viscidity of the secretions from the trachea & dispositn to suffocation shd never be used then, but when absolutely necessary If the throat should be very sore gargles may be used, if the [illegible] sweet kind, and oily if mucilaginous draughts freely used to defend the parts. at the time of maturation the matter becomes often so thick as entirely to stop up the trachea, the patient has in some instances been saved under the present circumstances by the exhibition of an emetic expectorants [illegible] even to be usefull in this disease The thorax is very apt to be loaded with blood hence diff. of respiration impurity of the air greatly encreases this symptom & shd be avoided, by keeping the windows open, letting the patient walk out etc. (6) The variolous effluvia seem to defray the perspirable air in an extraordinary degree & of course require a greater supply of it fresh. We should remember that the patient is subject as well during this disease as at other times to catarrh, colds, pulmonary consumption etc. by exposure to too great a degree of cold, such exposure then should be avoided as dangerous. If the extremities do not swell when the face subsides about the period of maturation, blisters in such cases are of the greatest use & sinapisms apply’d to the parts which by their stimulus encrease the external circulation & prevent the blood from affecting the brain & chest If the small pox at any time subside we should employ some quick acting stimulus as wine with a little spice, volatile alkali etc. & blisters should be apply’d externally to throw the circulation upon the skin again stimulants however are by no means necessary during the [illegible] of the disease. Lect: 92d May 18th 1772 after the disease is at the hight the absorption of the pus produces general inflamation & the matter being deposited in difft. parts produces inflamation & abscess. this topical inflamation & general inflamation are to be got rid of by evacuations, purging seems much preferable to the bleeding in most habits that shd be freely exhibited& makes the pus [illegible] 7 If the pulse be very hard as is sometimes the case when the pustules have been very numerous, it is necessary to make evacuations by bleeding. this is but seldom necessary. Purging should be always used as well to take off the general inflamatn, as to carry off the matter out of the system by weakening the system in general they produce the first & by hardening the general change of the fluids they produce the [illegible] pus is capable of passing through the urinary vessels & the vessels of the skin also by encreasing any of the secretions then we procure a greater evacuation of the pus than of the thicker parts of the humours proportionally hence evacuation of every kind may be of use If the small pox leave a disposition in the body of producing inflamation, [absorp] etc. periodically at that time of the year in which the small pox happened in this case this particular disposition is best overcome by the exhibition of the bark in considerable quants for about a month before we expect the disease to take place, which by diminishing the irritability [illegible] the inflamatn from taking place or if the inflamatn does take place good pus is formed & the disease carried off. 8 Measles arise from an infection similar to the small pox as there is no matter formed in the disease, it cannot be communicated by inoculat. but is always apply’d in form of vapour never [illegible] to the body, [illegible] always [propagated & [be] [produced] [by] [illegible] The infection is received for some time before the disease is produced & is preceded by greater inflamatory symptoms of the mucous membrane, hence there is such an encreas’d secretion from the glands of the eyes, nose, throat etc. as to have the disease mistaken often for a catarrh. The fever is much more frequently attended with symptoms of general inflamation & the breast is more dangerously affected than in the small pox The eruption is not so uniform, but may appear in the 2, 3, or 4 day & the disease be qually mild when the eruption takes place the fever abates, but the symptoms of general inflamation as hardness quickness of the pulse, affection of the brain etc. are apt to continue In eruption is more of the erysipelatous kind than the small pox. The pustules seldom appear above the surface of the skin, and are never filled with pus as the small pox, but vanish without coming to suppuration, contain only a watry fluid 9 There is not the same costiveness symptoms of genl inflamation run much higher & are attended with great danger purgings being more frequent than in the small pox. The eruption does not go off regularly sometimes continues for 24 hours & from that to 5 or 6 days but seldom continues longer and the danger is not over at this time as is the case in the small pox. The great danger arises at the period when the measles disappear. the breast, & lungs are apt at this time to be affected, and pulmonary consumption is at times the consequence. blisters are of use in relieving the complaints of the breast We may bleed with great safety during the eruptive fever, at the time of the eruption, & more particularly at the disappearing of the measles which at this time should not be neglected in short bleeding is the cure for almost every bad symptoms that arises in the disease & should never be neglected at its termination if there remain any symptoms of inflamatn in the general habit Authors have described measles in which symptoms of irritation, and not of general inflamat. took place such cases are never [illegible] 10 The danger in this disease universally arises from general inflamatn so that the removal of almost every bad symptom depends upon bleeding In affections of the breast, blisters are of use, & purgatives may be used without any danger of the pustules sinking, because they never contain any fluid matter we have no danger to apprehend then, from this cause as we have in the small pox. Purgatives should never be omitted at the end of the disease as they are of great [illegible] to carry of the inflamatory symptoms remaining. Chicken pos of still less [illegible] appears to arise from infection certainly in some cases, probably always though not ascertained is always propagated by vapour, tho’ there is great reason to suppose it might be communicated by [???culatn] the pustules being filled with fluid matter which might easily be collected. The eruption generally takes place at the first paroxysm of the fever, but one series of eruptions will continue to succeed another as soon as the foregoing have disappeared, for so long a time (in some instances) as a month or six weeks a fresh crop appearing every 2 or 3 days during all that time. 11 Distinguish’d from the small pox by suddeness of the eruption after the first attack of the fever & by the very short time required for maturation of the pustules. The pustules arise all at once & the state of maturation is generally completed in 12 or 14 hours they [rising] at first filled with a thin transparent fluid, which in so short a time, still often change into thick, yellow pus. All the functions of the body go on regularly the patient sleeps well, eats well etc. & it is rare if any bad symptoms arise. This disease will go through its natural course, as well as the small pox or measles. If the pustules continue to break out for a long time, & endanger hectic fever bark is the most efficaceous medicine we can use to carry off this disposition of the habit. This disease never happens but once during life. Miliary Fever a disease whose existence has been much disputed some asserting that it was produced by some matter in the system which was discharged by the eruption others denying that the eruption was any thing more than consequence of sweating during long confinemt in a warm bed. 12 If a healthy man is laid in a warm bed, plenty of watry fluids exhibited with relaxants or stimulants for 48 hours an eruption is produced occasioned by a greater quantity of sweat being secreted through the true than what can pass through the false skin in consequence of which this fluid matter is collected & accumulated betwixt the cutis & cuticula raising the later up into small pimples. although the disease may generally produced as above yet there is a miliary eruption to which lying in women are subject arising [certainly] from another cause The common symptoms of fever first take place & the eruption arises in the first paroxysm of the fever with evident signs of inflamation & the febrile symptoms disappear upon the eruption, but if from any accident the eruption disappears of a sudden the symptoms of fever return with irritability depression of strength etc. which are attended with very great danger. A woman in [childbed] being weak and irritable the slightest accident produces a sinking of the pustules with symptoms of irritability which are attended with great danger & can only be remedied by reproducing the eruption as hereafter specified This fever probably proceeds from the child (of lying in women) not being [illegible] into blood but going to [illegible] & milk which if not properly secreted may occasion this eruption the particular acid [smell] accompanying this [disease] [inductus] [to] believe this to be the case. 13 A miliary eruption happening to women in childbed is distinguished from that occasioned by confinement by being preceded by the febrile paroxysm & its departure upon the eruption. Treatment simple [illegible] most endeavour to support the strength & take off the irritability of the habit by exhibiting nourishing foods, decoctions of the bark together with agreable spice etc. If the pustules shd sink a little volatile alkali, together with a little wine & some quick acting stimulant exhibited to reproduce them, if they often [illegible] (Blisters may be apply’d with success) & this is not unfrequently the case Bark is frequently of very great use also Scarlet fever to be treated as an erysipelatous inflamation, agreeing in every respect with that disease, only occupying an uncommonly large span of the body at times the whole or greatest part of the external surface. This disease is at times accompanied with phlegmonous & symptoms of general inflamation but symptoms of irritability are much more frequent 14 Herpes miliares, or shingles generally arise in spots particularly upon the trunk of the body have a dispositn to spread so as to surround it like a belt. Clusters of small pustules filled with a watry fluid which is seldom attended with any great inconvenience & does not come to maturation. This disease does not proceed from infectious matter The exhibition of the bark almost instantly carries off the disease by diminishing the irritability of the skin & so rendering it insensible to the stimulus of the neutral salts with which the eruptn is filled. Lect: 33d May 19th 1772 The lungs are subject to suppuration not only from inflamation of the part itself but from a variety of other causes ulcers here from the contind motion of the parts are prevented from healing & consequently very fatal. [Exeluratn] may arise in this part, as in any other from a phlegmonous inflamatn peripnuemony may terminate in inflamation & an abscess be produced which generally bursts into the lungs, in preference to the cavity of the thorax. 15 IF the matter be spit up upon its first breaking in large quantity if the matter diminishes gradually ion qy without any fetor we have reason to hope that it will cure. This is the almost only species of [exaleratn] of the lungs that heals the inflamatn of the parts having formed a cyst which keeps great mot. from taking place so as to prevent its healing. If an inflamation of the pleura, or mediestinum take place an abscess may be form’d which will burst into the lungs & thus produce the disease. [The] ulcer may be also formed from inflamatn of the mucous membrane in catarrhs pus is sometimes formed upon the surface of the inflamed membrane, but it is a very difficult mass to distinguish pus as formed from the mucus secreted which in m any cases greatly resembles pus By throwing the matter into water if it be mucus it retains its consistence & by having a little air entangled it swims on the water. pus diffuses itself more through the water & sinks. pus has often a fetid smell mucus never. pus is often of an appearance as if mixt with a [illegible] powders, of a 16 broken texture, greyish colour, and lumpy but we are often liable to be deceived in trusting to this appearance because the mucus frequently hardens into little clots. An ulcer may be also formed in the lungs by [illegible] or excoriation from the acrimony of the watry humours secreted in catarrhs. Venl ulcers are sometimes, but very rarely formed in the lungs if so pulmonary consumption takes place. An exalceration of the lungs may arise & frequently does in scrophula of them in this disease the mucus glands are primarily & chiefly infected with the disease although this is little attended to afterwards. The disease frequently arises also in scorbutic habits when encrea’d [secret.] takes place from the pulmonary [illegible] small masses of mucus adhering to the lungs forming little tubercles, by being forced off & spit up are at times the occasion of exulceration by being violently forced, & turn off from the mucus membrane Extraneous bodies as [illegible] etc. have got into the lungs & by remaining there have occasioned inflamatn suppuration & abscess in the part but such accidents rarely happen & have sometimes produced such a convulsive cough & diffy of breathing as immediately to destroy. 17 Wounds penetrating the thorax do not always produce exalceration, but frequently heal by the first intention, neither are they so fatal as we would expect they do however sometimes occasion suppuration and exalceration Matter absorbed from any other part of the body is evidently secreted by all the glands of the body hence it by fermenting with the substance of the lungs converts it into a matter or similar substance to itself & so at times produce exalceration of the part. The breath of the diseased person has sometimes is affected the attendants with the same disease by carrying off a qy of the [gas] it is [illegible] however [illegible] cough of [illegible] Exalcerations of the lungs are apt to arise from 2 other causes [illegible] haemorrages, & chronic general inflamation. An haemorrage may take place, at least on extravasatn of blood whether the vessels be ruptured, or whole if the blood be thrown into a cavity no opening externally we may call it extravasation, if the blood is [illegible] into a cavity opening [externally] we call it [hemorya]. 18 There are a number of openings from the blood vessels into the cavities which throw out a fluid thinner than the red blood [illegible] serum mixt with water & sometimes coagulable lymph. but they also from disease, as relaxation, as from the blood moving with greater velocity admit the red blood to pass through them. most generally happens from the latter cause as from inflamatn of the part etc. hence the mucus is sometimes streaked with blood when spit up which blood is thrown out by these small orifices of the blood vessels & mixt with it. The most common case of hemorage takes place from encreas’d circulation in the parts forcing the blood through the relaxed exhalants, the evacuatn empties the vessels, it therefore after a time generally stops or also goes on till there be such a quantity of blood evacuated, as to prove fatal, or the trachea is so suddenly filled with blood that respiratn is obstructed & the patient suffocated. 19 Dr Fordyce imagines the menses hemorage from the [illegible] & take place in this way & not from rupture of the vessels. Whilst the haemorage continues the blood is spit up frothy & of a florid colour, but when that which has lain sometime in the lungs is spit up, it is of a dark colour, & sometimes mixt with mucus. the blood is generally perfectly cleared out of the lungs, but at times continue also & by remaining, produces exalceration & abscess. A similar discharge by haemorage takes place from all other parts of the body from the [illegible] of young men particularly the menstrual discharge is probably an evacuation of the [illegible] kind. Lect: 94th May 19th 1772 Haem of [illegible] & haemorage from other parts, may arise from laxaty of the exhalant vessels in which case not only the thinner parts of the blood are suffered to pass through their extremities, but the red particles also, & this may happen without any encreas’d action of the arteries or of the general circulation. 20 Haemorages from raptures frequently take place in the breast from blows or violent injury, these are more generally cured than when any previous disease in the parts take place. The vessels [ruptured] are sometimes extremely small as to suffer a quantity of blood to be emitted only subjet to [illegible] or appear in small globules mixt with the mucus. Hemorage may & frequently does arise from exalceration of the lungs. When an ulcer is spreading it not only destroys the other pats but the sides of the vessels also hence we should expect in such cases very great & very frequent haemorages but the vessels generally have their extremities plugged by lymph from the previous inflamatn Hemorage may arise lastly from gangrene & mortification of the lungs which would generally destroy, if no hemorage was to take place. When menstruatn is obstructed [illegible] habits hemorage takes place from the lungs, or other parts of the body. the discharge from these parts, [supplying] the defect in the menstrual discharge. In obstructions however from weakness no such discharge is substituted. The hooping cough sometimes occasions a rupture of some of the pulmonary vessels and hemorrhage is the consequence. Asthma may have the same effect 21 Remedies used to stop bleeding from every part of the body but more particularly that from the lungs. 1 By emptying the blood vessels we diminish the power with which the blood is thrown out of the ruptured vessel. From whatever cause it is produced, if the system be strong evacuatn may be [cured] Bleeding is the most immediate but the qy must be properly adapted to the circumstance of the case. If the blood be thrown out by the exhalants & the patient strong & plethoric bleeding may be used if the bleeding arises from relaxatn as happens more particularly from the womb in this case we must not bleed but use strengthening medicines as the bark etc. In cases of rupture & erosion of the vessels of the patient be strong etc. Bleeding may be used, but not otherwise. Sedatives diminish the action of the vessels & stops hemorage in same manner as bleeding does. [illegible] by diminishing the velocity of the circulating fluids. 22 Acids are pretty powerfull and may be employ’d with advantage in hemorage from every part, [illegible] & muriatic acids have been preferred, these having probably somewhat more astringency than the others. If acids are unsuccessfull & there be great danger. preparations of lead are the most effectual particularly in [haemopto?] shd never be [cured] but when the others fail as their [illegible] [illegible] If haemorage takes place in strong or phlethoric habit with inflamy symptoms astringents are rather apt to do mischief by encreasing the contracdtile power of the blood vessels more than they diminish the circulatn of their fluids. If hemorage arises from laxity astringents may be used with great propriety. Allum dragons blood & japan earth are most powerfull & their effects most immediate, but of short duration. The vegetable astringents acdt slowly but their effects are more lasting than those that are stronger. Relaxants have been employ’d with success in some haemorages shd not be given in quantities suffict. to produce sickness. They are particularly usefull in internal hemorages by throwing the circulation externally astringents act more particularly upon the internal vessels hence throw [illegible] (papers of Med: may be properly [illegible] 23 Expectorants shd be used as squills, or such as do not encrease the action of the vessels. Mucilaginous & oily medicines shd be employ’d to prevent the bad effects of violent coughing that may arise. The patient shd be kept quiet, and in a reclining posture which takes off the weight of the column of blood; from the ruptured vessel. The patient shd be confined to food that does not stimulate & is easy of digestion. Animal foods then should be avoided. Lect: 95th May 20th 1772 A cause of suppurat. of the lungs as mentiond is chronic general inflamatn or hectic fever. The latter only apply’d to such cases as the lungs are affected with the dis. This disease is an encreased action of the arteries, the heart not acting strongly at the same time, arises from several causes & has been called by difft names is attended at a hard & contracted pulse but not full, and strong. It may take place in consequence of the strength of the habit alone in the spring when the vessels of young [illegible] are strengthen’d by the cold of the weather. the warmth of the returning summer at times stimulates the system is much as to produce an encreasd, habitual action of the vessels & hectic fever. 24 Young women from the age of puberty to 22 are particularly subject to this disease which is accompanied with symptoms of irritability the whole called the chlorosis. The pulse becomes hard, & frequent the symptoms encreased by the natl evening paroxysm. The appetite is [lost] & the organs of digestion impaired the body is emaciated and in women [illegible] gastric symptoms take place In this case the disease is to be carried off in men by evacuations in women by the applicat. of the natural stimulus which is the most infallible remedy yet discovered When the habit has been exhausted by acute general inflamation, chronic general inflammation sometimes continues after any violent phlegmat. as the small pox measles rheumatism etc. this disease is apt to take place, the pulse being hard the blood inflammatory etc. and the patient gradually weakened & at last cut off. From the long use of any powerfull inflamy stimulant as mercury, guaiacum etc. the hardness & quickness of the pulse continue after the use of the stimulus is discontinued.s 25 The remedy employ’d in the last case with the greatest success is sarsaparilla Some stimulating matter such as [illegible] variolous or morbillous matter absorpt into the system, after they can no longer produce a fever, stimulate the system & [fetch] on this disease the measles more apt to produce this disease than the small pox Tumor long continued so as to make a long continued distension on any part stimulates the system & produces the disease Exalceration of the lungs produced by inflamatn and abscess frequently cures the inflamatn surrounding the cyst keeping the part steady & unaffected by the act of the lungs People most subject to pulmonary consumption are such as are of a delicate habit fine white complexion florid cheeks red hair often in small quantity [illegible] etc. The disease is hereditary arising from peculiarity of temperament communicated by the parents. The skin through the day time is dry and contracted but frequently in the morning profuse sweats take place any additional stimulus greatly heats the system, as digestion of food & exercise, the appetite is lost & the powers of digestion impaired. The blood is thrown upon the lungs stimulates & inflames [illegible] haemorage from the lungs frequently take place the muscular strength is greatly diminish’d & the body is [illegible] symptoms of weakness slowly produce other dropsical swellings [illegible] [illegible] dropsy frequently take place 26 The stimulus keeps up the spirits of the patient in a very extraordinary manner, as that they never think they are in such danger as they really are. The same particularly takes place in dropsy from the distension continually kept up, by the water contain’d in the abdomen When an ulcer is formed in the lungs the absorption of the pus continues to stimulate the system & keep up the hectic fever symptoms of the disease are. A paleness of the face, [blueness] of the eyes, & cleanness of the tongue from the red blood not being perfectly formed or its texture destroy’d when formed The pus being secreted upon any particular glands as of the intestines produces purging on the skin colliquative sweats, or upon the kidneys great discharge of urine was to waste the patients strength If the disease remains as a consequence of the measles or other inflamatory disorder bleeding & evacuatn are of great use. If hectic fever arises from the apsorptn of pus from any part [not] the lungs, the bark is employ’d with the best success 27 But bark can never be used properly where the lungs are affected with inflammation or suppuration. Strengthening medicines are hurtfull in every case when hectic fever is produced, from any other cause but the absorption of pus from a wound or ulcer. although the patient seems weak & emaciated we must take off the strong action of the arteries by evacuation bleeding seems the most eligible, but must be made in such cases in small quantity only, and frequently repeated. purging & the evacuations produce partial weakness & are apt to do hurt. Relaxants may be advantageously employ’d they tend immediately to counteract the disease by preventing the blood from being thrown upon the lungs shd be exhibited in small doses only Sedatives are also of use. Acids may be advantageously exhibited. Vegetable foods should only be allowed & a milk diet. the patient should breath a free atmosphere in the vicinity of running water & a dry [soil] at a distance from a [illegible] [illegible] All animal food shd be avoided milks excepted shd those are best that have least coagulable matter in them. 28 The climate should be temperate & regularly so, the situation defended from cold winds high hills these are improper on acct. of the cold the [illegible] wind in this country to be particularly avoided. Riding has been recommended & is particularly usefull in catarrhs, & slight inflamations of the lungs, but if there be ulcers formed in the lungs and hectic fever present, the stimulus from riding is so far from being of use that it is very hurtfull. When exalceratn of the lungs is produced from the bursting of a recent formed abscess into the lungs there is hopes of the patients recovery but most other cases are in the end fatal, no remedies that are of use in other ulcers, can be used. Bark encreases the diffy of respiratn & mercury stimulates too powerfully if there so great difficulty in spitting up the matter, gartle expectorants may be made use of. if the cough be very troublesome opiates may in some instances be safely used as also to procure sleep, when it is wanting naturally [illegible] are in most cases too stimulating to be of service in this disease 29 Lect: 96th May 21st 1772 Rheumatism varies pretty considerably in its appearance more perhaps than inflamtn so that it has been much disposed that the disease [illegible] & that part of the body were capable of being inflected with the disease It commonly occupies the external parts of the body it may also occupy the internal parts as we find metastasis take place from the external to the internal parts, [illegible] the brain & intestines. It may occupy the skin which is much [illegible], & colder in the parts diseased. It may occupy the muscles, hence those of these parts affected with the disease loos their powers in some measure. It may infect the internal membranes as the violence of the pain of the aponeuresis of the thigh testifies. It seems capable then of affecting almost every part of the body. It originally arises always in the external parts, and only from one known cause [illegible] cold 30 The cause however is not in every cause evident. but when it can be traced to any cause cold is always it. as we know that cold is capable of producing it & of no other cause but cold we attribute it always to the effects of cold. The only necessary symptoms to constitute rheumatism are coldness, paleness of the parts and inability of motion in the muscles. Cold produces in general a contract of the small vessels which is sometimes permanent & at other times continues no longer than the cause. The former seem always to be the case in rheumatism the coldness & paleness show if the circulatin is retarded which is the known effect of cold, immobility is a necessy consequence of the contractn of the small vessels These symptoms constitute the disease and always take place at first. sometimes these symptoms remain the same for a very great length of time but they more generally produce other affections as inflamatn which is only the consequence of & not the disease itself 31 The arteries propelling the blood more strongly into the capillaries endeavour to distend them, & occasion pain which however is very difft. from what takes place in those vessels when inflamed. as the endeavour is contin’d of & [illegible] to distend the capillaries the pain is lasting, being a continual gnawing in place of acute, throbbing pain which takes place in inflamatn of these vessels. Rheumatism is divided into 3 kinds if attended with genl inflamation it is called acute if there be no general inflamatn the disease is call’d chronic threumatism or if the inflamat. be not attended with danger. The encreased actn of the arteries at last frequently get the better of the contractn at first inflamatn of the part is produced which in the present case is the cure of the disease, but if the obstruction does not yield to this encreased arterial action general affectn is produced Hardness, fullness, frequency of the pulse etc. which all the symptoms of inflamatn the tongue becomes white, the patient thirsty, appetite lost, and frequently oppression of the breast with (at times) stupor, delirium & affection of the brain. The fullness of the pulse is occasioned by the quantity of the blood thrown out by the heart 32 By evacuations then we can diminish the quantity of blood & so take off the fullness from the [pulse] in this [illegible] although the action of the heart is weakened that of the arteries continues hence the frequency & hardness of the pulse frequently continue after its fullness is removed by evacuatn or continuance of the disease. If the encreased action of the arteries carries of the disease then health is restored, if not it produces an acute fever & genl inflamn The general inflamatn may prove fatal by affecting the brain, or the delirium if the patient survives may be converted into mania The disease sometimes continues perfectly topical without producing any general inflmatn of the habit. The more considerable the topical & general inflamatn are the shorter is the disease likely to be & vice versa. Another appearance in rheumatism [illegible] renders it most troublesome & difft metastases when there is general inflammation are very apt to take place by which the seat of the disease is translated from one part of the body to another and that without any order. Regularly or often evidt cause is that one limb or both, or perhaps almost every part of the body at the same time 33 Metastasis has often been accounted for by saying that the matter is taken up from one part and lodged in another but there appears to be no matter in this disease it cannot be communicated by the applicatn of any infectious matter nor its existence otherwise proved If rheumatic matter was in the system & capable of producing the disease by being mixt in the heart with the whole mas of blood would be spread through the whole body uniformly unless we allow that some part is more fit for the reception of this matter than others, but this does not appear to be the case for no part of the body seems to be exempt from it by metastasis it must then be allowed that of the matter be spread through the whole system there must be some particular disposit. Metastasis serves to prolong the disease when it affects the brain it very suddenly proves fatal or if the intestines it produces spasm flatulency etc. When the disease is cured in one part of the body it by infecting another part retards the cure as the secondary affection is so difficult or often more so than the first or the disease sometimes takes place in 2, 3, or more difft parts of the body whilst the original affection remains [uncured]. 34 in the blood vessels of the part affected to be infected with the disease else the affection would be general as the applicatn of the matter must be this however is not the case and as it never was, nor can be proved, that any such matter does exist in the body this particular disposition (in one part) of the vessels is of itself suffict,. to account for the disease; and should therefore be admitted as the [cause]. Lect: 97th May 22nd 1772. Treatment of the Rheumatism In rheumatism we might suppose it proper to employ the natural method of cure for carrying off the disease [illegible] by the encreased action of the vessels. but in rheumatism the natural cure is the only part of the disease that is [illegible] dangerous & troublesome, we should then endeavour to shock the tending to natural cure & carry off the general inflmatn by the exhibition of remedies If the pulse be hard strong, & frequent & symptoms of general inflamatn prevent copious & repeated bleeding should be used to carry them off not only in qy suffict. to regulate the action of the vessels but to get the better of it so as to carry it entirely off. 35 Relaxants are employed at very considerable efficacy and they are [these] [med:] which tend directly to counteract the disease and remove the obstructions that take place they should be used in an all other cases [illegible] not before the strong action of the vessels is carried off. Blisters & stimulants may be advantageously applied to the part & internal stimulants be exhibited of the antispasmodic kind if the circulatn be languid Relaxants must be employ’d for a length of time often before they are of any use & the most efficaceous as antimony & ipecacuanha shd be exhibited Medicines strengthening & destroying the [illegible] ability of the system are of most use when the disease is apt to return frequently & put on the appearance of a spasmodic affection which it sometimes does. Rheumatism properly not divided according to the difft. part of the body affected, but according as it is attended with more or less general inflamat. if the general inflamatn be very great we call it acute rheumatism or rheumatic fever if the general inflamatn be absent or in considerable it is called chronic Rheumatism as these differ only in degree there can be no boundary properly ascertain’d betwixt the two 36 Acute rheumatism happens more frequently to such as never before had the disease & to people of a disposit. in which inflamatn is apt to take place. frequently arises at first with symptoms that are only slight as with a little cold & immobility of some particular part with out any great pain which upon fresh exposure to cold is encreased to a very considerable degree The tendons & [aponeutosis] of the muscles are more generally affected in this than in [illegible] rheumatism. At other times the very first symptoms of the disease are violent acute pain immobility redness & inflammation of the part are the first symptoms of the disease & genl inflamatn succeeds The affect. spread from the part which it originally affected, violent symptoms of inflamation etc. come on in a very great degree sometimes even to prove fatal. frequent metastasis takes place in this stage. it sometimes but rarely happens that all the external parts are affected at once and the whole joints of the body become immoveable with very great pain & soreness over all the body very soon after the attack the pulse becomes hard, strong & frequent, the tongue becomes white, appetite is lost & all the other symptoms of general inflamation. 37 The inflamatn sometimes arises to such a degree that the brain is affected stupor first, then delirium take place & the patient is cut off or if the patient [illegible] the delirium is sometimes converted into mania Delirium more frequently takes place in this disease from want of sleep which delirium is accompanied with the most violent ravings (symptoms) quick motion of the eyes, raving, snatching every thing out of the attendants hands, jumping out of the bed, requiring 2, or 3 men to hold them, in some instances have leapt out of the window or stabb’d themselves. If the patient recovers from this state the disease gradually intermits, going off during the day tie & returning at night. the strength of the patient being exhausted & the rheumatism carried off by the continuance of the disease. Metastasis to the internal parts seldom takes place whilst the patient continues strong. the more the patient is exhausted the more mobile it is & the greater dispositn for metastasis to take place. when this happens to the brain delirium is produced & the disease cuts off the patient frequently in a few hours. 38 Lect: 98th May 22d 1772 Treatment of acute rheumatism suppose we are called in at the beginning of the disease it is not generally of difft cure as the genl inflamatn may be carried off by copious evacuation The rheumatism is not to be attended to but the general inflamatn to be got rid of as upon that the whole danger of the disease depends. We are to make copious evacuatn if the patient be strong 16 or 18 ounces of blood are to be taken away & the operatn repeated the next day if the genl inflamatn be not removed & so continue till we overcome it & nothing else appears in this stage of the disease to be of any use, if any [illegible] must be given it may be in the [illegible] relaxants as [illegible] If we loose the opportunity of making large evacuatn at first we never after have the disease is much in our power at this period nothing shd be used but barley water and such [illegible] food If the genl inflamatn is entirely carried off by the bleeding but the rheumatism continues with pain in the part affected then relaxant may be used with great advantage to carry off this remaining affection of the disease topical bleeding by cupping leeches etc. are often of use when inflamatn be confin’d to a [illegible] part. 39 Suppose the general inflamation is not so considerable that there is but little hardness & fullness of the pulse, in such cases large evacuations are not so necessary 12 or 14 ounces may be taken away, & there is seldom a necessity of repeating the operatn it is better however always to exceed in too much than too little blood. when the proper evacuatn is made relaxants may be exhibited of which emetic tartar is the most effiacacious, & may be given in as large qy as the patient can bear without being sick at stomach from ¼ to ½ grain may be exhibited every 2 or 3 hours in water. suppose we have not been called till the disease has continued 2 or 3 days during which time general inflamatn has taken place and the proper evacuations have been neglected or made in too small quantity in this case Metastasis has not taken place, the extremities are affected with the disease, sometimes one and sometimes another. that the patient has been for several nights entirely or almost without sleep in this case evacuation is not so efficacious but must be made not withstanding we can weaken the system now tho’ we cannot take off the encreased action of the vessels. 40 We must not take away such large quantities of blood nor repeat it so frequently by such large evacuatn we diminish the strength but not the hardness of the pulse in the present case we must have patience as relaxants cannot be employ’d whilst the hardness of the pulse continues, much less stimulants or antispasmodics we should then desist for a day or two giving medicines and trust to & watch nature the action of the vessels in such cases frequently diminish of themselves & by this means we shall in time fetch the disease so that we can employ relaxants with advantage to carry off the disease. Suppose the disease has continued for 10 days or a fortnight and evacuations have either been made in too small a quantity or not at all that the strength of the heart, and muscular powers and diminished, that the pulse is hard, but neither strong, nor feeble but rather small & contracted the system at the same time considerably weaken’d. Patients are often reduced to the state by bad practise such as bleeding whilst stimulants are exhibited at the same time such 41 as guaiacum, volatile alkali etc. The evacuations by bleeding in this case diminish the strength of the general habit, whilst the stimulants keep [illegible] the encreas’d arterial action and other inflamatory symptoms, this practise [illegible] inconsistent & in every case has [illegible] In this situation we are [difficulted] how to act, if we bleed we diminish the strength without taking off the hard action from the arteries whilst stimulant encrease the action of the arteries without encreasing the strength of the system in general If in such case the rheumatism were fixt to a particular part, we might be of use by freeing the part from pain by the applicatn of leeches, cupping etc. taking off the stimulus from the part, and so free the general system or by blisters we may free the habit from the disease which affect it in general but if frequent metastasis takes place the use of these means are ineffectual on the disease as soon as we cure it in one phase takes place in another in this case do nothing if we be not pretty sure of doing that which is proper. trust to nature keep up the strength as much as possible by the exhbitn of mild & nourishing food of easy digestion and the disease generally terminates better than when medicines are exhibited 42 Accidents that may occur during the treatment of this disease which are attended with very great danger to the patient. If delirium arises from general inflamatn is to be carried off by evacuations as mentioned before. If delirium arises from want of sleep if the hardness of the pulse be gone off & if the delirium so encreasing so as to endanger the patients life opium must in this case be used. A practitioner is tempted in [no] disease, [illegible] than in the present to exhibit opium but if we exhibit opium whist general inflamation takes place no good effects are produced, the patient when he does sleep is not refreshed, nor sensible of it. but [illegible] disturbed & anguish awakes unrefresh’d, & fatigued and denies that he has slept at all. But if the general inflamatn be gone, the pulse soft & the delirium encreasing so as to threaten the destruction of the patient in this case opium must be exhibited if in small quantities so as not to produce a continued sleep for 12 or 14 hours at least it always in such cases is hurtfull instead of being of benefit or requires then a good deal of courage & resolution in the practitioner to exhibit a dose sufficiently large to produce this effect as it otherwise is part [illegible] & restoring the patient in a few hours in some instances after its exhibition 43 When no delirium has taken place the exhibitn of a small quantity of opium is not attended with such danger but may be exhibited to advantage if the inflamatory symptoms be entirely gone. Suppose metastasis has taken place to the brain the only means we know of removing it is by applying a blister to the head or back, so as powerfully to stimulate the neighbouring parts Metastasis to the intestines is more painfull than dangerous by the exhibition of internal stimulants together with relaxants & opiates we have it in our power to remove the seat to the extremities or external parts or perhaps to carry it off entirely Suppose the disease returns in the night only like an intermittent being perfectly free during the day in such cases the bark may be exhibited in quantity of zfs or zvs during the day which very generally carries off the disease When the disease continues seated in a particular part of the body after all symptoms of general inflammation are gone off in such cases topical applications of stimulating kind are blisters volatile alkali mustard seed etc. are often effectual in carrying it off 44 suppose the hardness of the pulse removed but the disease returns at uncertain intervals it them is to be considered as a spasmodic disease and to be treated with stimulants [illegible] antispasmodic kind, apply’d to the part affected. Suppose the genl inflamatn carried off but the disease continues the patient is then in the state of chronic rheumatism When rheumatism is attended with no or very little general inflamatn we then call the disease chronic rheumatism. the great difference between which diseases consist in the absence of the general inflamatn & the symptoms depending thereon. IN every case of rheumatism, where there is hardness of the pulse it is always advisable to bleed unless the disease has greatly reduced the strength of the patient so as to render evacuatn dangerous. Stimulants employ’d should be of the antispasmodic kin ad guaiacum & volatile alkali & other resinous stimulants. spices have a great tendency to encrease or produce symptoms of general inflamation without removing the disease they are therefore not so proper as the others [illegible] in chronic rheumatism where stimulants are necessary 45 If there be no symptoms of general inflamatn relaxants may be used, as emetic tartar, rattlesnake root etc. with other antimonial preperations. When the disease is obstinate by exhibiting opium with ipecacuanha, or other relaxants we can exhibit them in much larger quantities & so, as to act more powerfully. It is not sweating as has been thought by some which carries the disease, because the natural sweats which often take place are never of use but on the contrary tend greatly to weaken the patient’s strength. Stimulants & relaxants may very properly be exhibited together the first acting more powerfully on the internal & the latter upon the external blood vessels. Topical applications may be employed in chronic rheumatism with very good effect, there being little or no disposition to metastasis. The application of blisters, & volatile liniment prepared with the caustic volatile alkali. after chronic rheumatism has been cured & the patient is subject to relapse upon slight exposure to cold in these cases the habit is to be strengthened & its irritability destroyed by the exhibition of the bark bitters [exercise[ cold bath pure air etc. 46 Lect: 99th May 23d 1772 Chronic diseases if a disease terminated in 40 days it was called an acute disease, if it ran out longer it was called a chronic disease, this distinction not a natural one for many diseases as a fever for instance, may terminate sooner or continue longer than the time mentioned, excepting in such cases as apoplexy with either [pill] or go off immediately there is no such thing as determining from the time of their continuance or drawing a line of distinction betwixt acute & chronic disease Most of these diseases treated of have some natural cure ([illegible]) excite some action in the vessels which tends to carry off the disease, those to trat of have no natural cure. this distinction [we choose] to retain betwixt acute & chronic disease. such diseases as have a natl cure are always more complicated & the effects of medicines less certain, those that have no natl cure are more simple & the actn of diseases are better ascertained with their mode of action Weakness being in the diseases to treat of the great or only [illegible] we think proper to begin with its history & treatment as such. Weakness to be divided into two kinds, sometimes in weakness the irritability is diminished but in others & more commonly it is encreased when the system is weak the operations of the body are not carried on with any degree of fever & therefore are more easily disturbed we shd expect the later to be the most common case. 47 When the irritability is diminish’d in weakness of the habit we call the disease paralytic or palsy this we don’t treat of at present The other [illegible] when the weakness is attended with encreased irritability may be distinguished into 2 kinds which may be divided into each as are produced suddenly (e.g.) from great haemorrage as from violent purgings. 2d any violent disease as fever weaken slowly in several difft ways in as much as during their [illegible] women there is an encreased action which tends to exhaust and weaken, or in violent disease there is considerable irritation which not only produces great [depression] of strength, but permanent weakness. inflamatn of the intestines produces great depression of strength & leaves a weakness behind in the parts affected with the disease. The principal difference is in the manner in which the disease is produced [illegible] either suddenly or slowly & the difft & variety of cure depends upon these circumstances also. Acute diseases weaken by disturbing or destroying the appetite & organs of digestion renders the stomach incapable of receiving food or of connection it into chyle when [illegible] In many cases without any great evacuation the fluids seem to be exhausted as destroyed by the disease. The action of stimuli generally produce weakness of the second species even although this effect should be produced in a short time. sedatives apt to leave a degree of weakness behind them & this of the 2 species. 48 Supposing weakness suddenly produced & no other disease present the muscular strength is diminished, the force of the heart & arteries also, the pulse is weak empty and soft. if there be no stimulus the action of the heart becomes much slower than natural. the pulse beating only perhaps 40 or 50 in a minute, but if there be the least irritation as from digestion, exercise etc. the pulse becomes much quicker than natural The patient is disposed to sleep more than natural, the appetite considerable often greater than the powers of infection, which is however considerable, so as to fill the vessels in a short time with a great quantity of blood. In this case it is generally suffict. to exhibit plenty of nourishing food keep the patient in a free & pure air. Bark may be used which prevents the danger of relapse into the disease which first produced the weakness. These are the symptoms of weakness suddenly produced the disease perfectly gone off is seldom attended with any danger but mostly get rid of as above & in a short time [illegible] the disease producing a weakness when it generally proves fatal. 49 Weakness may be produced slowly [illegible] by any slow evacuatn as purging not violent but long continued or any similar discharge It is not always the qy of the evacuation that produces the weakness. the fluor albus, or involuntary emissions of semen weaken more than any other although the quantity evacuated is but trifling In action is another source of weakness in the habit, want of suffict. exercise producing depression of strength bad digestion Any fever that runs out into a great length, or other disease any long continued action of stimuli as of mercury or guaiacum by stimulating the vessels and encreasing their action for a length of time tend greatly to weakening the system Living in an impure or [illegible] air as putrid vapours or air unfit for respiration renders the habit weak & of that kind of weakness which is slowly produced all impure airs are not equally hurtfull inflamable air may be respired & less hurt than fixable air & both & less danger than putrid vapours Anxiety or weakness produced in the body by any exertion of the mind as study, grief etc. always produce the kind of weakness that takes place slowly. want of sleep & spasmodic affection of the muscles have the same effect of producing weakness of the 2d kind. Disorders of the intestinal canal from frequent & free use of acids, spirits, food of difficult digestion use of spices & other stimuli 50 apply to assist digestion by purging either natural or artificial by application of sedatives. Lead particularly or from any other weakness arising in consequence of another disease. Another cause taking place slowly and peculiar to women. obstructions of the menstrual evacuation At puberty which in this country is about 14 or 15 menstruation takes place. Lect: 100 May 25th 1772 Obstruction, or irregularity of the menstrual flux produces that species of weakness which takes flow slowly & is difficultly removed. An haemorrhage may arise from the womb or vagina before the age of puberty, as from the nostrils or any other part of the body which however is perfectly distinct from and unconnected with the menstrual discharge The age of puberty differs in different climates in warm countries it is from the ages of 11 to 19 years in this country about 14 or 15. at this time the breasts and parts of generation encrease in size and an haemorrage takes place from the uterus preceded by plethoric symptoms as pain & fullness in the lower belly, breasts etc. sometimes also accompanied by hysteria fitts which frequently happens at this time the [illegible] of the other parts of the body [illegible] 51 The haemorrhage continues for 1, 2, 3 or 4 days & for the first 2 or 3 times is generally irregular returning perhaps in a fortnight as perhaps not for 3 or 4 months it afterwards becomes regular 7 returns at the end of 28 days in most women, with some variatn however in point of time with difft women. in young women, there is often a sense of fullness & weight about the abdomen & [illegible] pubis with a swelling & fullness of the breasts which precedes the discharge. the haemorrhage generally continues about 3 days with some variation however in point of duration it sometimes regularly at shorter intervals than time of longer than five weeks. the quantity of blood [illegible] is not very considerable, it has been estimated at 6 or 7 ounces which appears to be a sufficty large estimation. it continues then to return till about the age of 44 or 45 sometimes however it [illegible] so young as at 40 & at others not till 50 sometimes it stops all at once, but it is more generally irregular for some time both in the qy & periods of its returns. it after this time ceases for life excepting that in some instances there seems to be an attempt in nature towards the renewal of the body about the age of y70 years, in which cases there is a return of the menstrual discharge, new teeth are sometimes formed the eye sight & different [senses] renewed. 52 If during this time a woman be impregnated the menstruation stops, sometimes however it returns for once or twice & in some instances has been regular through the whole period of pregnancy. This however is very rare & the haemorrhage in these cases most [illegible] from the vagina The only species of animal that menstruates in any considerable quantity so as to be observable in some species of the monkey kind. in all animals [illegible] quardrupeds there is a similar discharge though inconsiderable at the time they [illegible] male. it however is not regular in any but the human species depending upon the habit of the body more in the quadruped kind as they never are disposed to take the male nor to menstruate but at such times as they are fat & well fed [illegible] [when] [illegible] During the time a woman give suck as well as during pregnancy the menses generally stop & it has been said by some that when the menses return after being stopt by giving suck or disease which they return at the very period they would had no obstruction takes place, but the periods regularly continued. Menstruatn may be stopt by exposure to cold during the [illegible] or by disease as fever, also by anxiety of the mind, or plethora or weakness of the body produced slowly from any cause. when the menses are stopt by any of the causes last mention’d they do not 53 return at the next period, but the body is diseased if plethora takes place all the functions of the body are disturbed & the menses also when obstruction of the menses takes place from this cause hysteric symptoms are often produced The menses are sometimes encreased in quantity so as to produce disease either continue longer or return more frequently etc. and in this case always produce disease [illegible]. weakness irritability of the habit etc. and the diseases depending thereon. The menses are often encreas’d in qy is as to produce disease from injury some to the parts in difft labours abortions etc. Causes assigned for menstruatn very [illegible] has been supposed that by menstruatn that blood was evacuated which should serve for the nourishment of the foetus, but that it does not answer this, appears from this consideration. [illegible] that in all other viviparous animals there is the same [illegible] of fluids & yet no menstruatn or at least the quantity of blood evacuated is inconsiderable & of no account neither has there been any other cause assigned in any way satisfactory The manner in which it was produced has been as much questioned it evidently depends upon encreased action in the vessels of the part 54 this appears from the encrease of size in the parts as also from the swelling of the breasts in young women before this evacuation [illegible] from phlegmonous inflamatn sometimes taking place in difft parts of the body when this evacuation does not take place. It evidently depends in other [illegible] made up of plethora & fullness as they never menstruate [illegible] [illegible] in this habit of body. It has been said that blood was gradually accumulating in the system so as to produce such a plethora in the course of 28 days as to occasion this discharge but that it does not depend merely upon plethora appears from this that a much larger quantity of blood may be taken away without preventing the flux It would seem to arise at first from the particular encrease of [illegible] in the parts of genern & from the plethora that now takes place in the whole system. The growth of the body at this period being generally stopt for a time, a larger quantity of blood is formed by the organs of the digestion, than is necessary for the support of the body. A plethora then takes place, through the whole habit at this period of life, & an eruption from the uterus in consequence of an encreased action in the vessels of these parts, from the particr stimulus occasion’d by their encreas’d growth. why the menses should exactly return at 55 the end of 28 days we know not. this evacuatn has been called the menstrual flux, from the moon changing at the same period. but then there seems to be no power in the moon of producing or regulating the menstrual flux an equal number of women menstruating at the fall new or any in difft day of the moons age so that the moon does not appear in the least to affect the menses. The menses are stopt by any cause that produces a contraction of the small vessels, as weakness, grief, anxiety, fear etc. as also from plethora which prevents the blood vessels from exerting their usual force upon their [illegible] from exposure to cold [illegible] the eruptn the applicat. of astringents [illegible] of the vessels [illegible] produced & from impregnation. Too great flow of the menses may arise from relaxation of the small vessels, as from too great action of the vessels of the system in general. The menses seem to be stopt during pregnancy by the exit of the haemorrhage from the uterus being shut up, by the application of the membranes to the mouth of the womb & by its being stopt up by a coagulum of lymph we may [illegible] them, that whatever evacuatn takes place during the months of pregnancy is not from the uterus, but from the vagina, the os uteri being closely shut up by a coagulum of menses. If the menses are obstructed the disease [illegible] generally takes [illegible] often weakness is produced which is to be considered of the [kind] [illegible] & evenly produced. 56 The menses generally disappear betwixt the ages of 40 & 50 years with very considerable variety however in point of time in different women. The cause of the menses ceasing probably arises from the contraction of the small vessels that takes place in advanced age, as we find a great many of the capillaries entirely obliterated that plumpness is lost the tendons & large blood vessels from this cause become more apparent in old age. If the menses flow in too great quantity at irregular periods or an obstructed from whatever cause, disease is generally produced, & hysteric symptoms appear. when the menses are [illegible] the [illegible] disease are produced [is] [illegible] the stoppage of any other [evacuation] discharge that has become habitual. Lect: 100 May 25th 1772 Remedies employ’d to remove obstructed menses, or to diminish their quantity when they flow in such proportion as to weaken the system by the greatness of the evacuation. If they be obstructed from plethora or do not take place at the usual time & then be symptoms of plethora prevent it is of use to take away a quantity of blood. 57 It has been questioned in this case whether the blood should be taken from a vein in the arm or foot there seems to be very little difference, from whatever part of the body the blood be taken, provided the evacuation be made. If after this evacuatn the menses shd not appear stimulants may at times be used, but they shd never be exhibited whilst there are any symptoms of plethora. such is not particularly upon the intestines & also abdominal viscera [illegible] purgatives are preferable. If the obstruction is occasion’d from weakness produced from any sudden cause then nourishing food exhibited for a short time so as to strengthen the general habit will almost allways render them. supposing the obstruction proceeds from any other cause we employ remedies to reproduce the haemorrhage. Stimulants have been used, those of the antispasmodic kind should be preferr’d other stimulants however have been used as resinous substan. preparations of iron, mercury, spices & of [all] which resins have the preference, they should be employ’d so as to act constantly & uniformly on the system, Preperatn of iron have been used with success in weak habits, as they have also a strengthening quality 58 as well as a power of stimulating and encreasing the circulation they are on this acct preferable to most other stimulants. Myrrh, galbanum, [opoponax] which shd be exhibited alongst the aloes so as to [illegible] Mercurial stimulants have a dispositn to weaken the system, are therefore improper & particularly hurtfull in all cases adhere the obstruction is either produced by or accompanied with general weakness of the system. Of all cathartics, aloes seem the most powerfull in reproducing the menstrual flux, may be properly exhibited with some of the resins, these medicines should be continued to act for some time as they have a particular power of operating at that time the evacuation should not naturally take place they shd be exhibited in quantities suffict to produce an evacuation or two every day from the intestines Relaxants employ’d at the time are particularly usefull, such as exposing the parts to the steams of warm water etc. or impregnated it [illegible] stimulants & antispasmodics as [illegible] [illegible] The natural stimulus adopted to the part affected is the most efficaceous of all applications and often proves effectual when all others fail. In too great flow of the menses we shd have a regard to the cause producing it because the treatment may be very different 59 Too great flow of the menses may proceed, first from plethora or from too strong action of the vessels upon their contents If we wish to check them in such cases, we should rather make evacuations & employ sedatives of the vit. acid & if the symptoms of plethora continue we should bleed, use a slander diet and avoid stimuli of every kind, because all such encrease the disease. When the disease takes place from genl weakness or from injury [illegible] to the parts by abortion etc. in these cases we should employ strengtheners of which the bark is preferable to all others & the most powerfull of the vegetable astringents [illegible] galls may be exhibited internally with advantage. When weakness takes place slowly the stomach & intestines are generally first affected the stomach after eating feels full [flataley] acidity & takes place the intestines are affected with flatulency & spasmodic pains the peristaltic motion is disturbed purging or costiveness is apt to take place. 60 At the same time the muscular strength is gradually lost, the patient becomes restless & uneasy with want of sleep there is added to this a pain in the small of the bark, appearing to be seated in the spine, which is encreased from exercise or fatigue of either body, or kind of the weakness be more considerable dropsical swellings often take place, beginning at the extremities & ascending to the abdomen partial evacuations as sweats, diarrhoea, gonorrhoea [illegible] fluor albus etc. & the place which evacuations exhaust the patient so much as frequently to destroy & in every case is difficulty got rid of. Remedies strengthening the system may be divided into two classes first such as prevent the strength from being further exhausted & such as really do strengthen the system the first class operate by preventing the living power of the body from being exhausted and the latter operate by encreasing the flow of this living power into the body. 61 Anxiety of the mind a great cause of weakness this should ben be avoided by going to places of amusement such as mineral waters travelling to difft climates etc. the vessels should be filled if possible with a quantity of good blood. the first action of the living power being to adopt the vessels to the quantity of blood they contain nourishing foods then become strengthening remedies in order to this the stomach & intestines should be kept in order of the digestion be pretty good, but appetite a wanting we may use [acids] etc. to procure an appetite Stimulants shd be employd in moderate quantity alongst which the food as spices to assist the digestion, wine also if it does not turn sour upon the stomach. If the peristaltic motion be deficient it is to be kept up by purgatives so as to keep the [prima] viae [illegible] of foeculent matter, unless the patient be subject to too great flow of [illegible] or to the haemorrhoids. 62 Neutral salts are apt to weaken the intestines in this case too much, vegetable purgatives are apt to turn [illegible] we may then conveniently [join] a small quantity of [fallop] which is of itself apt to produce spasms & gripes in the intestines with the milder acting purgatives The appetite is often impaired by mucus in the stomach this is to be got rid of by gentle emetics as the exhibitn of the [illegible] We should also attend to the state of the blood vessels themselves taking care that they act sufficiently & not too powerfully upon their contents when evacuations are requisite purging is preferable to bleeding the latter relaxing the vessels [the] suddeness of the evacuation & is rendering them liable to be more filled with blood That taking away a quantity of blood from the vessels disposes them to receive a greater quantity appears from this experiment that nothing tends to fatten more than frequently respected bleeding in small quantities at a time. By exercise we can draw the living power from the blood vessels to the muscles hence moderate exercise in free air is of great use in weakness of the system attended with hectic fever, in which case the whole action of the vis vita seems to be concentrated in the action of the blood vessels upon their content muscular motion & all the other functions being weakened. Exercise also encreases the powers of digestion & strengthens the appetite 63 Lect: 102 May 26th 1772 Emptiness of the large weakens much more than emptiness of the small vessels if the blood then principally circulating in the external parts the system is weakened hence a warm atmosphere or whatever stimulates the skin, so as to draws the circulatn externally weakens the habit, a warm summer has the same effects the [illegible] in these cases is to be restored by the application of cold which has just the contrary effect. we should take care however that the change from hot to cold climate be not sudden, but gradual. also violent or inflamatory diseases will be produced. In order to strengthen the system the cold bath has been used. upon jumping into cold water all the external vessels are suddenly contracted & the blood forced upon the internal ones, when he comes out of the water the cold being removed, the heat restored the external vessels are relax’d & a profuse sweating sometimes takes place & contractn of the external vessels being out at all permanent if then the system is strengthened it is not upon the same principle as conting living in a cold atmosphere Cold air strengthens much more than warm hence men in general are much stronger in the spring than they are in the autumn of the year. The cold bath very doubtfull in its effects sometimes weakening the system in place of strengthening it A warm atmosphere is sometimes the means of strengthening the habit particularly to such habits as are [illegible] from cold air such as asthmatic & those subject [illegible] 64 Astringents used in a large quantity exhaust but in small doses strengthen in the latter case they act particularly upon the large blood vessels, in [illegible] their action is general upon the whole system. If there be any dispositn in the small vessels to contract beyond their natural pitch as hectic fever hypochondria etc. astringents in such cases cannot be used. He now breathes air unfit for respiration there is a great depression of strength produced. all animals as quadrupeds, birds, fishes, and insects of necessity breathe respirable air. Life not being to be supported without it. All vapours excepting inflamable air that we are acquaint with are heavier than respirable air such then always tend towards the earth. A man going out of an air partly unfit for respiration into that which is perfectly pure, feels himself suddenly relieved, as if from an oppressive lead. The air upon high hills is not so dense as in lower situations it is also more changeable in temperature The system may also be strengthened by increasing the flow of living power 1st by habit a man who has lived a sedentary life although he may live in a pure atmosphere, eat good food etc. yet he becomes weak, feeble & incapable of exerting his muscles, this by habitual [illegible] Exercise may be overcome & the strength restored 65 Stimulants may be employ’d to encrease the action of the vessels, but this is seldom of use in strengthening the general habit, from the disposition they have to stimulate the blood vessels solely, or principally to action & so weaken the other powers of the body. Stimulants then can never be used as strengtheners, unless in lax habits, & cases where there seems to be no particular disposition in the blood vessels to strong action. But exercise may be used to the greatest advantage in most cases of weakness, provided it be not to such excess as to fatigue. It is a matter of the greatest importance that the exercise should be agreable & amusing so as to take off the attention of the mind from the diseased state of the body. Exercise should be universal so that every muscle in the body be employ’d have riding on horse back or in a carriage are preferable to walking, the lower extremities in the later being only employ’d. Rowing etc. very beneficial Exercise should be performed in pure air, hence exercise in close rooms weakens, in place of strengthening the body. Remedies strengthening the habit are the bark bitters of the vegetable class preparations of iron etc. when the weakness ahs been suddenly produced our medicines are efficacious & suddenly so, but in cases where weakness has been generally [illegible] & long continued they are not so affected 66 It has ben question’d & seems as yet to be undetermined, whether bitter medicines should be exhibited compounded or not there are reasons pro & con. the strongest argument for exhibiting simple bitters is that they are of a class of medicines that by contn’d use soon loose their effects as medicines, and are avail [illegible] of these qualities by exhibiting [illegible] alone because one bitter acts powerfully after another by use has lost its powers. In weakness where there is a disposition in the blood vessels to great contraction these medicines are not nigh so proper which is probably owing to their astringency When these medicines loose their efficacy by intermitting their use for a few days they may be returned to & recover their effects upon the habit. If weakness be the only disease the patient should not be suffered to lie abed, but kept out as much as possible the warmth of the bed rendering the habit irritable & preventing the increase of strength. Preperations of iron are much more stimulating than the vegetable bitters are therefore more or less proper according to the state of the particular case Containing the lectures from No 91 to 102. Practise of Physick by Dr Fordyce No 1 Practise of Physick Index Page No Treatment of the small pox 1 Treatment after the small pox 6 Measles and treatment 8 Chicken pox 10 Miliary fever 11 Scarlet fever 13 Herpes miliares, or shingles 14 Causes of [exaleratn] of the lungs 14 Symptoms of the disease 15 Causes of pulmonary hemorrhage 17 Treatment of Haem of [illegible] 21 Hectic fever chronic general Inflamatn causes of consumptn 23 Symptoms, treatment etc. 25 Rheumatism 29 Treatment of the rheumatism 34 Chronic diseases 46 Weakness of the system, causes, treatment etc. 47 Menstruation, theory of 50 Treatment of obstructed menses 56 Modes of strengthening the habit 60 1 Lect: 91st May 18th 1772 Treatment of the small pox one general observation is that there is no means of shortening the disease or putting a stop to it when it has once taken place it must be gone through, all to be done then, is to avoid, or prevent and dangerous symptoms that may arise in the course of the disease. 1st When the fever takes place it is usefull to clear the prima viae of any matter they may contain by the exhibition of an emetic & gentle laxative to prevent the [lodgement] of any mucus or harden’d excrements that may be contain’d in the intestines as of any acidity that may be lodged in the stomach [These] remeds cannot be used so properly after the eruption. If the fever be attended with considerable symptoms of general inflamatn if the patient be plethoric or young & every strong it will be of use to take away a quantity of blood & this cannot be done with equal propriety after the eruption has taken place 10, or 12 ounces of blood is generally suffict. and it is very seldom necessary to repeat the operation. this evactn to be made previous to the eruption of the pustules 2 unless in the circumstances mention’d. Bleeding & evacuations are hurtfull. The more violent the fever in general the more violent the eruption and vice versa. we might then suppose, that by the diminishing the fever, by the use of relaxants etc. the eruption should be more mil this however does not appear to be the case altho’ relaxants in general do no mischief & are very usefull if the fever shd not be the small pox. There never can be a case where strengthening remedies can be wasted to support the patient curing the fever, all stimulants then etc. should be avoided. the eruptive fever is almost never fatal, generally going off upon the eruption In children, previous to the eruption convulsions sometimes take place, or disappear upon the eruption very seldom continue after remarks that the pox in this case are almost always of the distinct kind. do nothing for the convulsions, trust to nature they almost always go off themselves. 3 Then the eruption has taken place if the symptoms of inflamation do not run high if no symptoms of irritability take place, if the pustules gradually fill with yellow pus, if the hands, feet are inflamed as the face subsides, if no difficulty of respiratn nor costiveness takes place we must then let nature alone & not disturb her by medicines. [but] suppose the patient to be costive it is apt to encrease all the dangerous symptoms. the intestines should be evacuated by glysters, purgatives should by no means be exhibited before the period of maturation as the pustules are apt to sink by their operation Sleep may be procured by opium if the patient be restless. If the patient has an evacuation in 48 hours we should make no evacuation by medicines as too great discharges that way are very apt to do mischief If symptoms of great inflamation take place, if the pulse be hard & strong, if the face and eyes be inflamed, if delirium, or symptoms of oppress’d brain take place bleeding becomes necessary. Dr. Boerhave has supposed that the variolous fever has been carried off & the patient cured without any eruption taking place, this however we deny. 4 We should not be too rash in making evacuations by bleeding etc. as the pustules have sometimes immediately sank & the patient been cut off unless then the brain be affected we should rather avoid using the lancet. When necessary 10 or 12 ounces is generally sufficient, and we should not repeat the evacuation. The bad effects of evacuations are particularly evident in pregnant women If absorption takes place, as often happens, the evacuation in consequence is almost always fatal If the pustules continue watry, stimulate the skin, with erysipelatous inflamation between them or little blisters arise with great soreness Bark is the best medicine for filling the pustules with good pus but it is very apt at the same time to produce disorder in the breast difficulty of breathing & rendering the mucous secretion of the throat so thick as not to be evacuated. If the brain be affected, or the breast as above we should by no means be induced to exhibit the bark & ought immediately to leave it off it if produces these symptoms 5 Opium tends also to produce good suppuration & is therefore in such cases very properly exhibited, if no symptoms of general inflamation take place If the patient should want sleep for 3 or 4 nights it produces very great mischief & opium should be [illegible] [upon] [even] although general inflamation should take place opium tho is very apt to increase the oppression of the [evacuation] viscidity of the secretions from the trachea & dispositn to suffocation shd never be used then, but when absolutely necessary If the throat should be very sore gargles may be used, if the [illegible] sweet kind, and oily if mucilaginous draughts freely used to defend the parts. at the time of maturation the matter becomes often so thick as entirely to stop up the trachea, the patient has in some instances been saved under the present circumstances by the exhibition of an emetic expectorants [illegible] even to be usefull in this disease The thorax is very apt to be loaded with blood hence diff. of respiration impurity of the air greatly encreases this symptom & shd be avoided, by keeping the windows open, letting the patient walk out etc. (6) The variolous effluvia seem to defray the perspirable air in an extraordinary degree & of course require a greater supply of it fresh. We should remember that the patient is subject as well during this disease as at other times to catarrh, colds, pulmonary consumption etc. by exposure to too great a degree of cold, such exposure then should be avoided as dangerous. If the extremities do not swell when the face subsides about the period of maturation, blisters in such cases are of the greatest use & sinapisms apply’d to the parts which by their stimulus encrease the external circulation & prevent the blood from affecting the brain & chest If the small pox at any time subside we should employ some quick acting stimulus as wine with a little spice, volatile alkali etc. & blisters should be apply’d externally to throw the circulation upon the skin again stimulants however are by no means necessary during the [illegible] of the disease. Lect: 92d May 18th 1772 after the disease is at the hight the absorption of the pus produces general inflamation & the matter being deposited in difft. parts produces inflamation & abscess. this topical inflamation & general inflamation are to be got rid of by evacuations, purging seems much preferable to the bleeding in most habits that shd be freely exhibited& makes the pus [illegible] 7 If the pulse be very hard as is sometimes the case when the pustules have been very numerous, it is necessary to make evacuations by bleeding. this is but seldom necessary. Purging should be always used as well to take off the general inflamatn, as to carry off the matter out of the system by weakening the system in general they produce the first & by hardening the general change of the fluids they produce the [illegible] pus is capable of passing through the urinary vessels & the vessels of the skin also by encreasing any of the secretions then we procure a greater evacuation of the pus than of the thicker parts of the humours proportionally hence evacuation of every kind may be of use If the small pox leave a disposition in the body of producing inflamation, [absorp] etc. periodically at that time of the year in which the small pox happened in this case this particular disposition is best overcome by the exhibition of the bark in considerable quants for about a month before we expect the disease to take place, which by diminishing the irritability [illegible] the inflamatn from taking place or if the inflamatn does take place good pus is formed & the disease carried off. 8 Measles arise from an infection similar to the small pox as there is no matter formed in the disease, it cannot be communicated by inoculat. but is always apply’d in form of vapour never [illegible] to the body, [illegible] always [propagated & [be] [produced] [by] [illegible] The infection is received for some time before the disease is produced & is preceded by greater inflamatory symptoms of the mucous membrane, hence there is such an encreas’d secretion from the glands of the eyes, nose, throat etc. as to have the disease mistaken often for a catarrh. The fever is much more frequently attended with symptoms of general inflamation & the breast is more dangerously affected than in the small pox The eruption is not so uniform, but may appear in the 2, 3, or 4 day & the disease be qually mild when the eruption takes place the fever abates, but the symptoms of general inflamation as hardness quickness of the pulse, affection of the brain etc. are apt to continue In eruption is more of the erysipelatous kind than the small pox. The pustules seldom appear above the surface of the skin, and are never filled with pus as the small pox, but vanish without coming to suppuration, contain only a watry fluid 9 There is not the same costiveness symptoms of genl inflamation run much higher & are attended with great danger purgings being more frequent than in the small pox. The eruption does not go off regularly sometimes continues for 24 hours & from that to 5 or 6 days but seldom continues longer and the danger is not over at this time as is the case in the small pox. The great danger arises at the period when the measles disappear. the breast, & lungs are apt at this time to be affected, and pulmonary consumption is at times the consequence. blisters are of use in relieving the complaints of the breast We may bleed with great safety during the eruptive fever, at the time of the eruption, & more particularly at the disappearing of the measles which at this time should not be neglected in short bleeding is the cure for almost every bad symptoms that arises in the disease & should never be neglected at its termination if there remain any symptoms of inflamatn in the general habit Authors have described measles in which symptoms of irritation, and not of general inflamat. took place such cases are never [illegible] 10 The danger in this disease universally arises from general inflamatn so that the removal of almost every bad symptom depends upon bleeding In affections of the breast, blisters are of use, & purgatives may be used without any danger of the pustules sinking, because they never contain any fluid matter we have no danger to apprehend then, from this cause as we have in the small pox. Purgatives should never be omitted at the end of the disease as they are of great [illegible] to carry of the inflamatory symptoms remaining. Chicken pos of still less [illegible] appears to arise from infection certainly in some cases, probably always though not ascertained is always propagated by vapour, tho’ there is great reason to suppose it might be communicated by [???culatn] the pustules being filled with fluid matter which might easily be collected. The eruption generally takes place at the first paroxysm of the fever, but one series of eruptions will continue to succeed another as soon as the foregoing have disappeared, for so long a time (in some instances) as a month or six weeks a fresh crop appearing every 2 or 3 days during all that time. 11 Distinguish’d from the small pox by suddeness of the eruption after the first attack of the fever & by the very short time required for maturation of the pustules. The pustules arise all at once & the state of maturation is generally completed in 12 or 14 hours they [rising] at first filled with a thin transparent fluid, which in so short a time, still often change into thick, yellow pus. All the functions of the body go on regularly the patient sleeps well, eats well etc. & it is rare if any bad symptoms arise. This disease will go through its natural course, as well as the small pox or measles. If the pustules continue to break out for a long time, & endanger hectic fever bark is the most efficaceous medicine we can use to carry off this disposition of the habit. This disease never happens but once during life. Miliary Fever a disease whose existence has been much disputed some asserting that it was produced by some matter in the system which was discharged by the eruption others denying that the eruption was any thing more than consequence of sweating during long confinemt in a warm bed. 12 If a healthy man is laid in a warm bed, plenty of watry fluids exhibited with relaxants or stimulants for 48 hours an eruption is produced occasioned by a greater quantity of sweat being secreted through the true than what can pass through the false skin in consequence of which this fluid matter is collected & accumulated betwixt the cutis & cuticula raising the later up into small pimples. although the disease may generally produced as above yet there is a miliary eruption to which lying in women are subject arising [certainly] from another cause The common symptoms of fever first take place & the eruption arises in the first paroxysm of the fever with evident signs of inflamation & the febrile symptoms disappear upon the eruption, but if from any accident the eruption disappears of a sudden the symptoms of fever return with irritability depression of strength etc. which are attended with very great danger. A woman in [childbed] being weak and irritable the slightest accident produces a sinking of the pustules with symptoms of irritability which are attended with great danger & can only be remedied by reproducing the eruption as hereafter specified This fever probably proceeds from the child (of lying in women) not being [illegible] into blood but going to [illegible] & milk which if not properly secreted may occasion this eruption the particular acid [smell] accompanying this [disease] [inductus] [to] believe this to be the case. 13 A miliary eruption happening to women in childbed is distinguished from that occasioned by confinement by being preceded by the febrile paroxysm & its departure upon the eruption. Treatment simple [illegible] most endeavour to support the strength & take off the irritability of the habit by exhibiting nourishing foods, decoctions of the bark together with agreable spice etc. If the pustules shd sink a little volatile alkali, together with a little wine & some quick acting stimulant exhibited to reproduce them, if they often [illegible] (Blisters may be apply’d with success) & this is not unfrequently the case Bark is frequently of very great use also Scarlet fever to be treated as an erysipelatous inflamation, agreeing in every respect with that disease, only occupying an uncommonly large span of the body at times the whole or greatest part of the external surface. This disease is at times accompanied with phlegmonous & symptoms of general inflamation but symptoms of irritability are much more frequent 14 Herpes miliares, or shingles generally arise in spots particularly upon the trunk of the body have a dispositn to spread so as to surround it like a belt. Clusters of small pustules filled with a watry fluid which is seldom attended with any great inconvenience & does not come to maturation. This disease does not proceed from infectious matter The exhibition of the bark almost instantly carries off the disease by diminishing the irritability of the skin & so rendering it insensible to the stimulus of the neutral salts with which the eruptn is filled. Lect: 33d May 19th 1772 The lungs are subject to suppuration not only from inflamation of the part itself but from a variety of other causes ulcers here from the contind motion of the parts are prevented from healing & consequently very fatal. [Exeluratn] may arise in this part, as in any other from a phlegmonous inflamatn peripnuemony may terminate in inflamation & an abscess be produced which generally bursts into the lungs, in preference to the cavity of the thorax. 15 IF the matter be spit up upon its first breaking in large quantity if the matter diminishes gradually ion qy without any fetor we have reason to hope that it will cure. This is the almost only species of [exaleratn] of the lungs that heals the inflamatn of the parts having formed a cyst which keeps great mot. from taking place so as to prevent its healing. If an inflamation of the pleura, or mediestinum take place an abscess may be form’d which will burst into the lungs & thus produce the disease. [The] ulcer may be also formed from inflamatn of the mucous membrane in catarrhs pus is sometimes formed upon the surface of the inflamed membrane, but it is a very difficult mass to distinguish pus as formed from the mucus secreted which in m any cases greatly resembles pus By throwing the matter into water if it be mucus it retains its consistence & by having a little air entangled it swims on the water. pus diffuses itself more through the water & sinks. pus has often a fetid smell mucus never. pus is often of an appearance as if mixt with a [illegible] powders, of a 16 broken texture, greyish colour, and lumpy but we are often liable to be deceived in trusting to this appearance because the mucus frequently hardens into little clots. An ulcer may be also formed in the lungs by [illegible] or excoriation from the acrimony of the watry humours secreted in catarrhs. Venl ulcers are sometimes, but very rarely formed in the lungs if so pulmonary consumption takes place. An exalceration of the lungs may arise & frequently does in scrophula of them in this disease the mucus glands are primarily & chiefly infected with the disease although this is little attended to afterwards. The disease frequently arises also in scorbutic habits when encrea’d [secret.] takes place from the pulmonary [illegible] small masses of mucus adhering to the lungs forming little tubercles, by being forced off & spit up are at times the occasion of exulceration by being violently forced, & turn off from the mucus membrane Extraneous bodies as [illegible] etc. have got into the lungs & by remaining there have occasioned inflamatn suppuration & abscess in the part but such accidents rarely happen & have sometimes produced such a convulsive cough & diffy of breathing as immediately to destroy. 17 Wounds penetrating the thorax do not always produce exalceration, but frequently heal by the first intention, neither are they so fatal as we would expect they do however sometimes occasion suppuration and exalceration Matter absorbed from any other part of the body is evidently secreted by all the glands of the body hence it by fermenting with the substance of the lungs converts it into a matter or similar substance to itself & so at times produce exalceration of the part. The breath of the diseased person has sometimes is affected the attendants with the same disease by carrying off a qy of the [gas] it is [illegible] however [illegible] cough of [illegible] Exalcerations of the lungs are apt to arise from 2 other causes [illegible] haemorrages, & chronic general inflamation. An haemorrage may take place, at least on extravasatn of blood whether the vessels be ruptured, or whole if the blood be thrown into a cavity no opening externally we may call it extravasation, if the blood is [illegible] into a cavity opening [externally] we call it [hemorya]. 18 There are a number of openings from the blood vessels into the cavities which throw out a fluid thinner than the red blood [illegible] serum mixt with water & sometimes coagulable lymph. but they also from disease, as relaxation, as from the blood moving with greater velocity admit the red blood to pass through them. most generally happens from the latter cause as from inflamatn of the part etc. hence the mucus is sometimes streaked with blood when spit up which blood is thrown out by these small orifices of the blood vessels & mixt with it. The most common case of hemorage takes place from encreas’d circulation in the parts forcing the blood through the relaxed exhalants, the evacuatn empties the vessels, it therefore after a time generally stops or also goes on till there be such a quantity of blood evacuated, as to prove fatal, or the trachea is so suddenly filled with blood that respiratn is obstructed & the patient suffocated. 19 Dr Fordyce imagines the menses hemorage from the [illegible] & take place in this way & not from rupture of the vessels. Whilst the haemorage continues the blood is spit up frothy & of a florid colour, but when that which has lain sometime in the lungs is spit up, it is of a dark colour, & sometimes mixt with mucus. the blood is generally perfectly cleared out of the lungs, but at times continue also & by remaining, produces exalceration & abscess. A similar discharge by haemorage takes place from all other parts of the body from the [illegible] of young men particularly the menstrual discharge is probably an evacuation of the [illegible] kind. Lect: 94th May 19th 1772 Haem of [illegible] & haemorage from other parts, may arise from laxaty of the exhalant vessels in which case not only the thinner parts of the blood are suffered to pass through their extremities, but the red particles also, & this may happen without any encreas’d action of the arteries or of the general circulation. 20 Haemorages from raptures frequently take place in the breast from blows or violent injury, these are more generally cured than when any previous disease in the parts take place. The vessels [ruptured] are sometimes extremely small as to suffer a quantity of blood to be emitted only subjet to [illegible] or appear in small globules mixt with the mucus. Hemorage may & frequently does arise from exalceration of the lungs. When an ulcer is spreading it not only destroys the other pats but the sides of the vessels also hence we should expect in such cases very great & very frequent haemorages but the vessels generally have their extremities plugged by lymph from the previous inflamatn Hemorage may arise lastly from gangrene & mortification of the lungs which would generally destroy, if no hemorage was to take place. When menstruatn is obstructed [illegible] habits hemorage takes place from the lungs, or other parts of the body. the discharge from these parts, [supplying] the defect in the menstrual discharge. In obstructions however from weakness no such discharge is substituted. The hooping cough sometimes occasions a rupture of some of the pulmonary vessels and hemorrhage is the consequence. Asthma may have the same effect 21 Remedies used to stop bleeding from every part of the body but more particularly that from the lungs. 1 By emptying the blood vessels we diminish the power with which the blood is thrown out of the ruptured vessel. From whatever cause it is produced, if the system be strong evacuatn may be [cured] Bleeding is the most immediate but the qy must be properly adapted to the circumstance of the case. If the blood be thrown out by the exhalants & the patient strong & plethoric bleeding may be used if the bleeding arises from relaxatn as happens more particularly from the womb in this case we must not bleed but use strengthening medicines as the bark etc. In cases of rupture & erosion of the vessels of the patient be strong etc. Bleeding may be used, but not otherwise. Sedatives diminish the action of the vessels & stops hemorage in same manner as bleeding does. [illegible] by diminishing the velocity of the circulating fluids. 22 Acids are pretty powerfull and may be employ’d with advantage in hemorage from every part, [illegible] & muriatic acids have been preferred, these having probably somewhat more astringency than the others. If acids are unsuccessfull & there be great danger. preparations of lead are the most effectual particularly in [haemopto?] shd never be [cured] but when the others fail as their [illegible] [illegible] If haemorage takes place in strong or phlethoric habit with inflamy symptoms astringents are rather apt to do mischief by encreasing the contracdtile power of the blood vessels more than they diminish the circulatn of their fluids. If hemorage arises from laxity astringents may be used with great propriety. Allum dragons blood & japan earth are most powerfull & their effects most immediate, but of short duration. The vegetable astringents acdt slowly but their effects are more lasting than those that are stronger. Relaxants have been employ’d with success in some haemorages shd not be given in quantities suffict. to produce sickness. They are particularly usefull in internal hemorages by throwing the circulation externally astringents act more particularly upon the internal vessels hence throw [illegible] (papers of Med: may be properly [illegible] 23 Expectorants shd be used as squills, or such as do not encrease the action of the vessels. Mucilaginous & oily medicines shd be employ’d to prevent the bad effects of violent coughing that may arise. The patient shd be kept quiet, and in a reclining posture which takes off the weight of the column of blood; from the ruptured vessel. The patient shd be confined to food that does not stimulate & is easy of digestion. Animal foods then should be avoided. Lect: 95th May 20th 1772 A cause of suppurat. of the lungs as mentiond is chronic general inflamatn or hectic fever. The latter only apply’d to such cases as the lungs are affected with the dis. This disease is an encreased action of the arteries, the heart not acting strongly at the same time, arises from several causes & has been called by difft names is attended at a hard & contracted pulse but not full, and strong. It may take place in consequence of the strength of the habit alone in the spring when the vessels of young [illegible] are strengthen’d by the cold of the weather. the warmth of the returning summer at times stimulates the system is much as to produce an encreasd, habitual action of the vessels & hectic fever. 24 Young women from the age of puberty to 22 are particularly subject to this disease which is accompanied with symptoms of irritability the whole called the chlorosis. The pulse becomes hard, & frequent the symptoms encreased by the natl evening paroxysm. The appetite is [lost] & the organs of digestion impaired the body is emaciated and in women [illegible] gastric symptoms take place In this case the disease is to be carried off in men by evacuations in women by the applicat. of the natural stimulus which is the most infallible remedy yet discovered When the habit has been exhausted by acute general inflamation, chronic general inflammation sometimes continues after any violent phlegmat. as the small pox measles rheumatism etc. this disease is apt to take place, the pulse being hard the blood inflammatory etc. and the patient gradually weakened & at last cut off. From the long use of any powerfull inflamy stimulant as mercury, guaiacum etc. the hardness & quickness of the pulse continue after the use of the stimulus is discontinued.s 25 The remedy employ’d in the last case with the greatest success is sarsaparilla Some stimulating matter such as [illegible] variolous or morbillous matter absorpt into the system, after they can no longer produce a fever, stimulate the system & [fetch] on this disease the measles more apt to produce this disease than the small pox Tumor long continued so as to make a long continued distension on any part stimulates the system & produces the disease Exalceration of the lungs produced by inflamatn and abscess frequently cures the inflamatn surrounding the cyst keeping the part steady & unaffected by the act of the lungs People most subject to pulmonary consumption are such as are of a delicate habit fine white complexion florid cheeks red hair often in small quantity [illegible] etc. The disease is hereditary arising from peculiarity of temperament communicated by the parents. The skin through the day time is dry and contracted but frequently in the morning profuse sweats take place any additional stimulus greatly heats the system, as digestion of food & exercise, the appetite is lost & the powers of digestion impaired. The blood is thrown upon the lungs stimulates & inflames [illegible] haemorage from the lungs frequently take place the muscular strength is greatly diminish’d & the body is [illegible] symptoms of weakness slowly produce other dropsical swellings [illegible] [illegible] dropsy frequently take place 26 The stimulus keeps up the spirits of the patient in a very extraordinary manner, as that they never think they are in such danger as they really are. The same particularly takes place in dropsy from the distension continually kept up, by the water contain’d in the abdomen When an ulcer is formed in the lungs the absorption of the pus continues to stimulate the system & keep up the hectic fever symptoms of the disease are. A paleness of the face, [blueness] of the eyes, & cleanness of the tongue from the red blood not being perfectly formed or its texture destroy’d when formed The pus being secreted upon any particular glands as of the intestines produces purging on the skin colliquative sweats, or upon the kidneys great discharge of urine was to waste the patients strength If the disease remains as a consequence of the measles or other inflamatory disorder bleeding & evacuatn are of great use. If hectic fever arises from the apsorptn of pus from any part [not] the lungs, the bark is employ’d with the best success 27 But bark can never be used properly where the lungs are affected with inflammation or suppuration. Strengthening medicines are hurtfull in every case when hectic fever is produced, from any other cause but the absorption of pus from a wound or ulcer. although the patient seems weak & emaciated we must take off the strong action of the arteries by evacuation bleeding seems the most eligible, but must be made in such cases in small quantity only, and frequently repeated. purging & the evacuations produce partial weakness & are apt to do hurt. Relaxants may be advantageously employ’d they tend immediately to counteract the disease by preventing the blood from being thrown upon the lungs shd be exhibited in small doses only Sedatives are also of use. Acids may be advantageously exhibited. Vegetable foods should only be allowed & a milk diet. the patient should breath a free atmosphere in the vicinity of running water & a dry [soil] at a distance from a [illegible] [illegible] All animal food shd be avoided milks excepted shd those are best that have least coagulable matter in them. 28 The climate should be temperate & regularly so, the situation defended from cold winds high hills these are improper on acct. of the cold the [illegible] wind in this country to be particularly avoided. Riding has been recommended & is particularly usefull in catarrhs, & slight inflamations of the lungs, but if there be ulcers formed in the lungs and hectic fever present, the stimulus from riding is so far from being of use that it is very hurtfull. When exalceratn of the lungs is produced from the bursting of a recent formed abscess into the lungs there is hopes of the patients recovery but most other cases are in the end fatal, no remedies that are of use in other ulcers, can be used. Bark encreases the diffy of respiratn & mercury stimulates too powerfully if there so great difficulty in spitting up the matter, gartle expectorants may be made use of. if the cough be very troublesome opiates may in some instances be safely used as also to procure sleep, when it is wanting naturally [illegible] are in most cases too stimulating to be of service in this disease 29 Lect: 96th May 21st 1772 Rheumatism varies pretty considerably in its appearance more perhaps than inflamtn so that it has been much disposed that the disease [illegible] & that part of the body were capable of being inflected with the disease It commonly occupies the external parts of the body it may also occupy the internal parts as we find metastasis take place from the external to the internal parts, [illegible] the brain & intestines. It may occupy the skin which is much [illegible], & colder in the parts diseased. It may occupy the muscles, hence those of these parts affected with the disease loos their powers in some measure. It may infect the internal membranes as the violence of the pain of the aponeuresis of the thigh testifies. It seems capable then of affecting almost every part of the body. It originally arises always in the external parts, and only from one known cause [illegible] cold 30 The cause however is not in every cause evident. but when it can be traced to any cause cold is always it. as we know that cold is capable of producing it & of no other cause but cold we attribute it always to the effects of cold. The only necessary symptoms to constitute rheumatism are coldness, paleness of the parts and inability of motion in the muscles. Cold produces in general a contract of the small vessels which is sometimes permanent & at other times continues no longer than the cause. The former seem always to be the case in rheumatism the coldness & paleness show if the circulatin is retarded which is the known effect of cold, immobility is a necessy consequence of the contractn of the small vessels These symptoms constitute the disease and always take place at first. sometimes these symptoms remain the same for a very great length of time but they more generally produce other affections as inflamatn which is only the consequence of & not the disease itself 31 The arteries propelling the blood more strongly into the capillaries endeavour to distend them, & occasion pain which however is very difft. from what takes place in those vessels when inflamed. as the endeavour is contin’d of & [illegible] to distend the capillaries the pain is lasting, being a continual gnawing in place of acute, throbbing pain which takes place in inflamatn of these vessels. Rheumatism is divided into 3 kinds if attended with genl inflamation it is called acute if there be no general inflamatn the disease is call’d chronic threumatism or if the inflamat. be not attended with danger. The encreased actn of the arteries at last frequently get the better of the contractn at first inflamatn of the part is produced which in the present case is the cure of the disease, but if the obstruction does not yield to this encreased arterial action general affectn is produced Hardness, fullness, frequency of the pulse etc. which all the symptoms of inflamatn the tongue becomes white, the patient thirsty, appetite lost, and frequently oppression of the breast with (at times) stupor, delirium & affection of the brain. The fullness of the pulse is occasioned by the quantity of the blood thrown out by the heart 32 By evacuations then we can diminish the quantity of blood & so take off the fullness from the [pulse] in this [illegible] although the action of the heart is weakened that of the arteries continues hence the frequency & hardness of the pulse frequently continue after its fullness is removed by evacuatn or continuance of the disease. If the encreased action of the arteries carries of the disease then health is restored, if not it produces an acute fever & genl inflamn The general inflamatn may prove fatal by affecting the brain, or the delirium if the patient survives may be converted into mania The disease sometimes continues perfectly topical without producing any general inflmatn of the habit. The more considerable the topical & general inflamatn are the shorter is the disease likely to be & vice versa. Another appearance in rheumatism [illegible] renders it most troublesome & difft metastases when there is general inflammation are very apt to take place by which the seat of the disease is translated from one part of the body to another and that without any order. Regularly or often evidt cause is that one limb or both, or perhaps almost every part of the body at the same time 33 Metastasis has often been accounted for by saying that the matter is taken up from one part and lodged in another but there appears to be no matter in this disease it cannot be communicated by the applicatn of any infectious matter nor its existence otherwise proved If rheumatic matter was in the system & capable of producing the disease by being mixt in the heart with the whole mas of blood would be spread through the whole body uniformly unless we allow that some part is more fit for the reception of this matter than others, but this does not appear to be the case for no part of the body seems to be exempt from it by metastasis it must then be allowed that of the matter be spread through the whole system there must be some particular disposit. Metastasis serves to prolong the disease when it affects the brain it very suddenly proves fatal or if the intestines it produces spasm flatulency etc. When the disease is cured in one part of the body it by infecting another part retards the cure as the secondary affection is so difficult or often more so than the first or the disease sometimes takes place in 2, 3, or more difft parts of the body whilst the original affection remains [uncured]. 34 in the blood vessels of the part affected to be infected with the disease else the affection would be general as the applicatn of the matter must be this however is not the case and as it never was, nor can be proved, that any such matter does exist in the body this particular disposition (in one part) of the vessels is of itself suffict,. to account for the disease; and should therefore be admitted as the [cause]. Lect: 97th May 22nd 1772. Treatment of the Rheumatism In rheumatism we might suppose it proper to employ the natural method of cure for carrying off the disease [illegible] by the encreased action of the vessels. but in rheumatism the natural cure is the only part of the disease that is [illegible] dangerous & troublesome, we should then endeavour to shock the tending to natural cure & carry off the general inflmatn by the exhibition of remedies If the pulse be hard strong, & frequent & symptoms of general inflamatn prevent copious & repeated bleeding should be used to carry them off not only in qy suffict. to regulate the action of the vessels but to get the better of it so as to carry it entirely off. 35 Relaxants are employed at very considerable efficacy and they are [these] [med:] which tend directly to counteract the disease and remove the obstructions that take place they should be used in an all other cases [illegible] not before the strong action of the vessels is carried off. Blisters & stimulants may be advantageously applied to the part & internal stimulants be exhibited of the antispasmodic kind if the circulatn be languid Relaxants must be employ’d for a length of time often before they are of any use & the most efficaceous as antimony & ipecacuanha shd be exhibited Medicines strengthening & destroying the [illegible] ability of the system are of most use when the disease is apt to return frequently & put on the appearance of a spasmodic affection which it sometimes does. Rheumatism properly not divided according to the difft. part of the body affected, but according as it is attended with more or less general inflamat. if the general inflamatn be very great we call it acute rheumatism or rheumatic fever if the general inflamatn be absent or in considerable it is called chronic Rheumatism as these differ only in degree there can be no boundary properly ascertain’d betwixt the two 36 Acute rheumatism happens more frequently to such as never before had the disease & to people of a disposit. in which inflamatn is apt to take place. frequently arises at first with symptoms that are only slight as with a little cold & immobility of some particular part with out any great pain which upon fresh exposure to cold is encreased to a very considerable degree The tendons & [aponeutosis] of the muscles are more generally affected in this than in [illegible] rheumatism. At other times the very first symptoms of the disease are violent acute pain immobility redness & inflammation of the part are the first symptoms of the disease & genl inflamatn succeeds The affect. spread from the part which it originally affected, violent symptoms of inflamation etc. come on in a very great degree sometimes even to prove fatal. frequent metastasis takes place in this stage. it sometimes but rarely happens that all the external parts are affected at once and the whole joints of the body become immoveable with very great pain & soreness over all the body very soon after the attack the pulse becomes hard, strong & frequent, the tongue becomes white, appetite is lost & all the other symptoms of general inflamation. 37 The inflamatn sometimes arises to such a degree that the brain is affected stupor first, then delirium take place & the patient is cut off or if the patient [illegible] the delirium is sometimes converted into mania Delirium more frequently takes place in this disease from want of sleep which delirium is accompanied with the most violent ravings (symptoms) quick motion of the eyes, raving, snatching every thing out of the attendants hands, jumping out of the bed, requiring 2, or 3 men to hold them, in some instances have leapt out of the window or stabb’d themselves. If the patient recovers from this state the disease gradually intermits, going off during the day tie & returning at night. the strength of the patient being exhausted & the rheumatism carried off by the continuance of the disease. Metastasis to the internal parts seldom takes place whilst the patient continues strong. the more the patient is exhausted the more mobile it is & the greater dispositn for metastasis to take place. when this happens to the brain delirium is produced & the disease cuts off the patient frequently in a few hours. 38 Lect: 98th May 22d 1772 Treatment of acute rheumatism suppose we are called in at the beginning of the disease it is not generally of difft cure as the genl inflamatn may be carried off by copious evacuation The rheumatism is not to be attended to but the general inflamatn to be got rid of as upon that the whole danger of the disease depends. We are to make copious evacuatn if the patient be strong 16 or 18 ounces of blood are to be taken away & the operatn repeated the next day if the genl inflamatn be not removed & so continue till we overcome it & nothing else appears in this stage of the disease to be of any use, if any [illegible] must be given it may be in the [illegible] relaxants as [illegible] If we loose the opportunity of making large evacuatn at first we never after have the disease is much in our power at this period nothing shd be used but barley water and such [illegible] food If the genl inflamatn is entirely carried off by the bleeding but the rheumatism continues with pain in the part affected then relaxant may be used with great advantage to carry off this remaining affection of the disease topical bleeding by cupping leeches etc. are often of use when inflamatn be confin’d to a [illegible] part. 39 Suppose the general inflamation is not so considerable that there is but little hardness & fullness of the pulse, in such cases large evacuations are not so necessary 12 or 14 ounces may be taken away, & there is seldom a necessity of repeating the operatn it is better however always to exceed in too much than too little blood. when the proper evacuatn is made relaxants may be exhibited of which emetic tartar is the most effiacacious, & may be given in as large qy as the patient can bear without being sick at stomach from ¼ to ½ grain may be exhibited every 2 or 3 hours in water. suppose we have not been called till the disease has continued 2 or 3 days during which time general inflamatn has taken place and the proper evacuations have been neglected or made in too small quantity in this case Metastasis has not taken place, the extremities are affected with the disease, sometimes one and sometimes another. that the patient has been for several nights entirely or almost without sleep in this case evacuation is not so efficacious but must be made not withstanding we can weaken the system now tho’ we cannot take off the encreased action of the vessels. 40 We must not take away such large quantities of blood nor repeat it so frequently by such large evacuatn we diminish the strength but not the hardness of the pulse in the present case we must have patience as relaxants cannot be employ’d whilst the hardness of the pulse continues, much less stimulants or antispasmodics we should then desist for a day or two giving medicines and trust to & watch nature the action of the vessels in such cases frequently diminish of themselves & by this means we shall in time fetch the disease so that we can employ relaxants with advantage to carry off the disease. Suppose the disease has continued for 10 days or a fortnight and evacuations have either been made in too small a quantity or not at all that the strength of the heart, and muscular powers and diminished, that the pulse is hard, but neither strong, nor feeble but rather small & contracted the system at the same time considerably weaken’d. Patients are often reduced to the state by bad practise such as bleeding whilst stimulants are exhibited at the same time such 41 as guaiacum, volatile alkali etc. The evacuations by bleeding in this case diminish the strength of the general habit, whilst the stimulants keep [illegible] the encreas’d arterial action and other inflamatory symptoms, this practise [illegible] inconsistent & in every case has [illegible] In this situation we are [difficulted] how to act, if we bleed we diminish the strength without taking off the hard action from the arteries whilst stimulant encrease the action of the arteries without encreasing the strength of the system in general If in such case the rheumatism were fixt to a particular part, we might be of use by freeing the part from pain by the applicatn of leeches, cupping etc. taking off the stimulus from the part, and so free the general system or by blisters we may free the habit from the disease which affect it in general but if frequent metastasis takes place the use of these means are ineffectual on the disease as soon as we cure it in one phase takes place in another in this case do nothing if we be not pretty sure of doing that which is proper. trust to nature keep up the strength as much as possible by the exhbitn of mild & nourishing food of easy digestion and the disease generally terminates better than when medicines are exhibited 42 Accidents that may occur during the treatment of this disease which are attended with very great danger to the patient. If delirium arises from general inflamatn is to be carried off by evacuations as mentioned before. If delirium arises from want of sleep if the hardness of the pulse be gone off & if the delirium so encreasing so as to endanger the patients life opium must in this case be used. A practitioner is tempted in [no] disease, [illegible] than in the present to exhibit opium but if we exhibit opium whist general inflamation takes place no good effects are produced, the patient when he does sleep is not refreshed, nor sensible of it. but [illegible] disturbed & anguish awakes unrefresh’d, & fatigued and denies that he has slept at all. But if the general inflamatn be gone, the pulse soft & the delirium encreasing so as to threaten the destruction of the patient in this case opium must be exhibited if in small quantities so as not to produce a continued sleep for 12 or 14 hours at least it always in such cases is hurtfull instead of being of benefit or requires then a good deal of courage & resolution in the practitioner to exhibit a dose sufficiently large to produce this effect as it otherwise is part [illegible] & restoring the patient in a few hours in some instances after its exhibition 43 When no delirium has taken place the exhibitn of a small quantity of opium is not attended with such danger but may be exhibited to advantage if the inflamatory symptoms be entirely gone. Suppose metastasis has taken place to the brain the only means we know of removing it is by applying a blister to the head or back, so as powerfully to stimulate the neighbouring parts Metastasis to the intestines is more painfull than dangerous by the exhibition of internal stimulants together with relaxants & opiates we have it in our power to remove the seat to the extremities or external parts or perhaps to carry it off entirely Suppose the disease returns in the night only like an intermittent being perfectly free during the day in such cases the bark may be exhibited in quantity of zfs or zvs during the day which very generally carries off the disease When the disease continues seated in a particular part of the body after all symptoms of general inflammation are gone off in such cases topical applications of stimulating kind are blisters volatile alkali mustard seed etc. are often effectual in carrying it off 44 suppose the hardness of the pulse removed but the disease returns at uncertain intervals it them is to be considered as a spasmodic disease and to be treated with stimulants [illegible] antispasmodic kind, apply’d to the part affected. Suppose the genl inflamatn carried off but the disease continues the patient is then in the state of chronic rheumatism When rheumatism is attended with no or very little general inflamatn we then call the disease chronic rheumatism. the great difference between which diseases consist in the absence of the general inflamatn & the symptoms depending thereon. IN every case of rheumatism, where there is hardness of the pulse it is always advisable to bleed unless the disease has greatly reduced the strength of the patient so as to render evacuatn dangerous. Stimulants employ’d should be of the antispasmodic kin ad guaiacum & volatile alkali & other resinous stimulants. spices have a great tendency to encrease or produce symptoms of general inflamation without removing the disease they are therefore not so proper as the others [illegible] in chronic rheumatism where stimulants are necessary 45 If there be no symptoms of general inflamatn relaxants may be used, as emetic tartar, rattlesnake root etc. with other antimonial preperations. When the disease is obstinate by exhibiting opium with ipecacuanha, or other relaxants we can exhibit them in much larger quantities & so, as to act more powerfully. It is not sweating as has been thought by some which carries the disease, because the natural sweats which often take place are never of use but on the contrary tend greatly to weaken the patient’s strength. Stimulants & relaxants may very properly be exhibited together the first acting more powerfully on the internal & the latter upon the external blood vessels. Topical applications may be employed in chronic rheumatism with very good effect, there being little or no disposition to metastasis. The application of blisters, & volatile liniment prepared with the caustic volatile alkali. after chronic rheumatism has been cured & the patient is subject to relapse upon slight exposure to cold in these cases the habit is to be strengthened & its irritability destroyed by the exhibition of the bark bitters [exercise[ cold bath pure air etc. 46 Lect: 99th May 23d 1772 Chronic diseases if a disease terminated in 40 days it was called an acute disease, if it ran out longer it was called a chronic disease, this distinction not a natural one for many diseases as a fever for instance, may terminate sooner or continue longer than the time mentioned, excepting in such cases as apoplexy with either [pill] or go off immediately there is no such thing as determining from the time of their continuance or drawing a line of distinction betwixt acute & chronic disease Most of these diseases treated of have some natural cure ([illegible]) excite some action in the vessels which tends to carry off the disease, those to trat of have no natural cure. this distinction [we choose] to retain betwixt acute & chronic disease. such diseases as have a natl cure are always more complicated & the effects of medicines less certain, those that have no natl cure are more simple & the actn of diseases are better ascertained with their mode of action Weakness being in the diseases to treat of the great or only [illegible] we think proper to begin with its history & treatment as such. Weakness to be divided into two kinds, sometimes in weakness the irritability is diminished but in others & more commonly it is encreased when the system is weak the operations of the body are not carried on with any degree of fever & therefore are more easily disturbed we shd expect the later to be the most common case. 47 When the irritability is diminish’d in weakness of the habit we call the disease paralytic or palsy this we don’t treat of at present The other [illegible] when the weakness is attended with encreased irritability may be distinguished into 2 kinds which may be divided into each as are produced suddenly (e.g.) from great haemorrage as from violent purgings. 2d any violent disease as fever weaken slowly in several difft ways in as much as during their [illegible] women there is an encreased action which tends to exhaust and weaken, or in violent disease there is considerable irritation which not only produces great [depression] of strength, but permanent weakness. inflamatn of the intestines produces great depression of strength & leaves a weakness behind in the parts affected with the disease. The principal difference is in the manner in which the disease is produced [illegible] either suddenly or slowly & the difft & variety of cure depends upon these circumstances also. Acute diseases weaken by disturbing or destroying the appetite & organs of digestion renders the stomach incapable of receiving food or of connection it into chyle when [illegible] In many cases without any great evacuation the fluids seem to be exhausted as destroyed by the disease. The action of stimuli generally produce weakness of the second species even although this effect should be produced in a short time. sedatives apt to leave a degree of weakness behind them & this of the 2 species. 48 Supposing weakness suddenly produced & no other disease present the muscular strength is diminished, the force of the heart & arteries also, the pulse is weak empty and soft. if there be no stimulus the action of the heart becomes much slower than natural. the pulse beating only perhaps 40 or 50 in a minute, but if there be the least irritation as from digestion, exercise etc. the pulse becomes much quicker than natural The patient is disposed to sleep more than natural, the appetite considerable often greater than the powers of infection, which is however considerable, so as to fill the vessels in a short time with a great quantity of blood. In this case it is generally suffict. to exhibit plenty of nourishing food keep the patient in a free & pure air. Bark may be used which prevents the danger of relapse into the disease which first produced the weakness. These are the symptoms of weakness suddenly produced the disease perfectly gone off is seldom attended with any danger but mostly get rid of as above & in a short time [illegible] the disease producing a weakness when it generally proves fatal. 49 Weakness may be produced slowly [illegible] by any slow evacuatn as purging not violent but long continued or any similar discharge It is not always the qy of the evacuation that produces the weakness. the fluor albus, or involuntary emissions of semen weaken more than any other although the quantity evacuated is but trifling In action is another source of weakness in the habit, want of suffict. exercise producing depression of strength bad digestion Any fever that runs out into a great length, or other disease any long continued action of stimuli as of mercury or guaiacum by stimulating the vessels and encreasing their action for a length of time tend greatly to weakening the system Living in an impure or [illegible] air as putrid vapours or air unfit for respiration renders the habit weak & of that kind of weakness which is slowly produced all impure airs are not equally hurtfull inflamable air may be respired & less hurt than fixable air & both & less danger than putrid vapours Anxiety or weakness produced in the body by any exertion of the mind as study, grief etc. always produce the kind of weakness that takes place slowly. want of sleep & spasmodic affection of the muscles have the same effect of producing weakness of the 2d kind. Disorders of the intestinal canal from frequent & free use of acids, spirits, food of difficult digestion use of spices & other stimuli 50 apply to assist digestion by purging either natural or artificial by application of sedatives. Lead particularly or from any other weakness arising in consequence of another disease. Another cause taking place slowly and peculiar to women. obstructions of the menstrual evacuation At puberty which in this country is about 14 or 15 menstruation takes place. Lect: 100 May 25th 1772 Obstruction, or irregularity of the menstrual flux produces that species of weakness which takes flow slowly & is difficultly removed. An haemorrhage may arise from the womb or vagina before the age of puberty, as from the nostrils or any other part of the body which however is perfectly distinct from and unconnected with the menstrual discharge The age of puberty differs in different climates in warm countries it is from the ages of 11 to 19 years in this country about 14 or 15. at this time the breasts and parts of generation encrease in size and an haemorrage takes place from the uterus preceded by plethoric symptoms as pain & fullness in the lower belly, breasts etc. sometimes also accompanied by hysteria fitts which frequently happens at this time the [illegible] of the other parts of the body [illegible] 51 The haemorrhage continues for 1, 2, 3 or 4 days & for the first 2 or 3 times is generally irregular returning perhaps in a fortnight as perhaps not for 3 or 4 months it afterwards becomes regular 7 returns at the end of 28 days in most women, with some variatn however in point of time with difft women. in young women, there is often a sense of fullness & weight about the abdomen & [illegible] pubis with a swelling & fullness of the breasts which precedes the discharge. the haemorrhage generally continues about 3 days with some variation however in point of duration it sometimes regularly at shorter intervals than time of longer than five weeks. the quantity of blood [illegible] is not very considerable, it has been estimated at 6 or 7 ounces which appears to be a sufficty large estimation. it continues then to return till about the age of 44 or 45 sometimes however it [illegible] so young as at 40 & at others not till 50 sometimes it stops all at once, but it is more generally irregular for some time both in the qy & periods of its returns. it after this time ceases for life excepting that in some instances there seems to be an attempt in nature towards the renewal of the body about the age of y70 years, in which cases there is a return of the menstrual discharge, new teeth are sometimes formed the eye sight & different [senses] renewed. 52 If during this time a woman be impregnated the menstruation stops, sometimes however it returns for once or twice & in some instances has been regular through the whole period of pregnancy. This however is very rare & the haemorrhage in these cases most [illegible] from the vagina The only species of animal that menstruates in any considerable quantity so as to be observable in some species of the monkey kind. in all animals [illegible] quardrupeds there is a similar discharge though inconsiderable at the time they [illegible] male. it however is not regular in any but the human species depending upon the habit of the body more in the quadruped kind as they never are disposed to take the male nor to menstruate but at such times as they are fat & well fed [illegible] [when] [illegible] During the time a woman give suck as well as during pregnancy the menses generally stop & it has been said by some that when the menses return after being stopt by giving suck or disease which they return at the very period they would had no obstruction takes place, but the periods regularly continued. Menstruatn may be stopt by exposure to cold during the [illegible] or by disease as fever, also by anxiety of the mind, or plethora or weakness of the body produced slowly from any cause. when the menses are stopt by any of the causes last mention’d they do not 53 return at the next period, but the body is diseased if plethora takes place all the functions of the body are disturbed & the menses also when obstruction of the menses takes place from this cause hysteric symptoms are often produced The menses are sometimes encreased in quantity so as to produce disease either continue longer or return more frequently etc. and in this case always produce disease [illegible]. weakness irritability of the habit etc. and the diseases depending thereon. The menses are often encreas’d in qy is as to produce disease from injury some to the parts in difft labours abortions etc. Causes assigned for menstruatn very [illegible] has been supposed that by menstruatn that blood was evacuated which should serve for the nourishment of the foetus, but that it does not answer this, appears from this consideration. [illegible] that in all other viviparous animals there is the same [illegible] of fluids & yet no menstruatn or at least the quantity of blood evacuated is inconsiderable & of no account neither has there been any other cause assigned in any way satisfactory The manner in which it was produced has been as much questioned it evidently depends upon encreased action in the vessels of the part 54 this appears from the encrease of size in the parts as also from the swelling of the breasts in young women before this evacuation [illegible] from phlegmonous inflamatn sometimes taking place in difft parts of the body when this evacuation does not take place. It evidently depends in other [illegible] made up of plethora & fullness as they never menstruate [illegible] [illegible] in this habit of body. It has been said that blood was gradually accumulating in the system so as to produce such a plethora in the course of 28 days as to occasion this discharge but that it does not depend merely upon plethora appears from this that a much larger quantity of blood may be taken away without preventing the flux It would seem to arise at first from the particular encrease of [illegible] in the parts of genern & from the plethora that now takes place in the whole system. The growth of the body at this period being generally stopt for a time, a larger quantity of blood is formed by the organs of the digestion, than is necessary for the support of the body. A plethora then takes place, through the whole habit at this period of life, & an eruption from the uterus in consequence of an encreased action in the vessels of these parts, from the particr stimulus occasion’d by their encreas’d growth. why the menses should exactly return at 55 the end of 28 days we know not. this evacuatn has been called the menstrual flux, from the moon changing at the same period. but then there seems to be no power in the moon of producing or regulating the menstrual flux an equal number of women menstruating at the fall new or any in difft day of the moons age so that the moon does not appear in the least to affect the menses. The menses are stopt by any cause that produces a contraction of the small vessels, as weakness, grief, anxiety, fear etc. as also from plethora which prevents the blood vessels from exerting their usual force upon their [illegible] from exposure to cold [illegible] the eruptn the applicat. of astringents [illegible] of the vessels [illegible] produced & from impregnation. Too great flow of the menses may arise from relaxation of the small vessels, as from too great action of the vessels of the system in general. The menses seem to be stopt during pregnancy by the exit of the haemorrhage from the uterus being shut up, by the application of the membranes to the mouth of the womb & by its being stopt up by a coagulum of lymph we may [illegible] them, that whatever evacuatn takes place during the months of pregnancy is not from the uterus, but from the vagina, the os uteri being closely shut up by a coagulum of menses. If the menses are obstructed the disease [illegible] generally takes [illegible] often weakness is produced which is to be considered of the [kind] [illegible] & evenly produced. 56 The menses generally disappear betwixt the ages of 40 & 50 years with very considerable variety however in point of time in different women. The cause of the menses ceasing probably arises from the contraction of the small vessels that takes place in advanced age, as we find a great many of the capillaries entirely obliterated that plumpness is lost the tendons & large blood vessels from this cause become more apparent in old age. If the menses flow in too great quantity at irregular periods or an obstructed from whatever cause, disease is generally produced, & hysteric symptoms appear. when the menses are [illegible] the [illegible] disease are produced [is] [illegible] the stoppage of any other [evacuation] discharge that has become habitual. Lect: 100 May 25th 1772 Remedies employ’d to remove obstructed menses, or to diminish their quantity when they flow in such proportion as to weaken the system by the greatness of the evacuation. If they be obstructed from plethora or do not take place at the usual time & then be symptoms of plethora prevent it is of use to take away a quantity of blood. 57 It has been questioned in this case whether the blood should be taken from a vein in the arm or foot there seems to be very little difference, from whatever part of the body the blood be taken, provided the evacuation be made. If after this evacuatn the menses shd not appear stimulants may at times be used, but they shd never be exhibited whilst there are any symptoms of plethora. such is not particularly upon the intestines & also abdominal viscera [illegible] purgatives are preferable. If the obstruction is occasion’d from weakness produced from any sudden cause then nourishing food exhibited for a short time so as to strengthen the general habit will almost allways render them. supposing the obstruction proceeds from any other cause we employ remedies to reproduce the haemorrhage. Stimulants have been used, those of the antispasmodic kind should be preferr’d other stimulants however have been used as resinous substan. preparations of iron, mercury, spices & of [all] which resins have the preference, they should be employ’d so as to act constantly & uniformly on the system, Preperatn of iron have been used with success in weak habits, as they have also a strengthening quality 58 as well as a power of stimulating and encreasing the circulation they are on this acct preferable to most other stimulants. Myrrh, galbanum, [opoponax] which shd be exhibited alongst the aloes so as to [illegible] Mercurial stimulants have a dispositn to weaken the system, are therefore improper & particularly hurtfull in all cases adhere the obstruction is either produced by or accompanied with general weakness of the system. Of all cathartics, aloes seem the most powerfull in reproducing the menstrual flux, may be properly exhibited with some of the resins, these medicines should be continued to act for some time as they have a particular power of operating at that time the evacuation should not naturally take place they shd be exhibited in quantities suffict to produce an evacuation or two every day from the intestines Relaxants employ’d at the time are particularly usefull, such as exposing the parts to the steams of warm water etc. or impregnated it [illegible] stimulants & antispasmodics as [illegible] [illegible] The natural stimulus adopted to the part affected is the most efficaceous of all applications and often proves effectual when all others fail. In too great flow of the menses we shd have a regard to the cause producing it because the treatment may be very different 59 Too great flow of the menses may proceed, first from plethora or from too strong action of the vessels upon their contents If we wish to check them in such cases, we should rather make evacuations & employ sedatives of the vit. acid & if the symptoms of plethora continue we should bleed, use a slander diet and avoid stimuli of every kind, because all such encrease the disease. When the disease takes place from genl weakness or from injury [illegible] to the parts by abortion etc. in these cases we should employ strengtheners of which the bark is preferable to all others & the most powerfull of the vegetable astringents [illegible] galls may be exhibited internally with advantage. When weakness takes place slowly the stomach & intestines are generally first affected the stomach after eating feels full [flataley] acidity & takes place the intestines are affected with flatulency & spasmodic pains the peristaltic motion is disturbed purging or costiveness is apt to take place. 60 At the same time the muscular strength is gradually lost, the patient becomes restless & uneasy with want of sleep there is added to this a pain in the small of the bark, appearing to be seated in the spine, which is encreased from exercise or fatigue of either body, or kind of the weakness be more considerable dropsical swellings often take place, beginning at the extremities & ascending to the abdomen partial evacuations as sweats, diarrhoea, gonorrhoea [illegible] fluor albus etc. & the place which evacuations exhaust the patient so much as frequently to destroy & in every case is difficulty got rid of. Remedies strengthening the system may be divided into two classes first such as prevent the strength from being further exhausted & such as really do strengthen the system the first class operate by preventing the living power of the body from being exhausted and the latter operate by encreasing the flow of this living power into the body. 61 Anxiety of the mind a great cause of weakness this should ben be avoided by going to places of amusement such as mineral waters travelling to difft climates etc. the vessels should be filled if possible with a quantity of good blood. the first action of the living power being to adopt the vessels to the quantity of blood they contain nourishing foods then become strengthening remedies in order to this the stomach & intestines should be kept in order of the digestion be pretty good, but appetite a wanting we may use [acids] etc. to procure an appetite Stimulants shd be employd in moderate quantity alongst which the food as spices to assist the digestion, wine also if it does not turn sour upon the stomach. If the peristaltic motion be deficient it is to be kept up by purgatives so as to keep the [prima] viae [illegible] of foeculent matter, unless the patient be subject to too great flow of [illegible] or to the haemorrhoids. 62 Neutral salts are apt to weaken the intestines in this case too much, vegetable purgatives are apt to turn [illegible] we may then conveniently [join] a small quantity of [fallop] which is of itself apt to produce spasms & gripes in the intestines with the milder acting purgatives The appetite is often impaired by mucus in the stomach this is to be got rid of by gentle emetics as the exhibitn of the [illegible] We should also attend to the state of the blood vessels themselves taking care that they act sufficiently & not too powerfully upon their contents when evacuations are requisite purging is preferable to bleeding the latter relaxing the vessels [the] suddeness of the evacuation & is rendering them liable to be more filled with blood That taking away a quantity of blood from the vessels disposes them to receive a greater quantity appears from this experiment that nothing tends to fatten more than frequently respected bleeding in small quantities at a time. By exercise we can draw the living power from the blood vessels to the muscles hence moderate exercise in free air is of great use in weakness of the system attended with hectic fever, in which case the whole action of the vis vita seems to be concentrated in the action of the blood vessels upon their content muscular motion & all the other functions being weakened. Exercise also encreases the powers of digestion & strengthens the appetite 63 Lect: 102 May 26th 1772 Emptiness of the large weakens much more than emptiness of the small vessels if the blood then principally circulating in the external parts the system is weakened hence a warm atmosphere or whatever stimulates the skin, so as to draws the circulatn externally weakens the habit, a warm summer has the same effects the [illegible] in these cases is to be restored by the application of cold which has just the contrary effect. we should take care however that the change from hot to cold climate be not sudden, but gradual. also violent or inflamatory diseases will be produced. In order to strengthen the system the cold bath has been used. upon jumping into cold water all the external vessels are suddenly contracted & the blood forced upon the internal ones, when he comes out of the water the cold being removed, the heat restored the external vessels are relax’d & a profuse sweating sometimes takes place & contractn of the external vessels being out at all permanent if then the system is strengthened it is not upon the same principle as conting living in a cold atmosphere Cold air strengthens much more than warm hence men in general are much stronger in the spring than they are in the autumn of the year. The cold bath very doubtfull in its effects sometimes weakening the system in place of strengthening it A warm atmosphere is sometimes the means of strengthening the habit particularly to such habits as are [illegible] from cold air such as asthmatic & those subject [illegible] 64 Astringents used in a large quantity exhaust but in small doses strengthen in the latter case they act particularly upon the large blood vessels, in [illegible] their action is general upon the whole system. If there be any dispositn in the small vessels to contract beyond their natural pitch as hectic fever hypochondria etc. astringents in such cases cannot be used. He now breathes air unfit for respiration there is a great depression of strength produced. all animals as quadrupeds, birds, fishes, and insects of necessity breathe respirable air. Life not being to be supported without it. All vapours excepting inflamable air that we are acquaint with are heavier than respirable air such then always tend towards the earth. A man going out of an air partly unfit for respiration into that which is perfectly pure, feels himself suddenly relieved, as if from an oppressive lead. The air upon high hills is not so dense as in lower situations it is also more changeable in temperature The system may also be strengthened by increasing the flow of living power 1st by habit a man who has lived a sedentary life although he may live in a pure atmosphere, eat good food etc. yet he becomes weak, feeble & incapable of exerting his muscles, this by habitual [illegible] Exercise may be overcome & the strength restored 65 Stimulants may be employ’d to encrease the action of the vessels, but this is seldom of use in strengthening the general habit, from the disposition they have to stimulate the blood vessels solely, or principally to action & so weaken the other powers of the body. Stimulants then can never be used as strengtheners, unless in lax habits, & cases where there seems to be no particular disposition in the blood vessels to strong action. But exercise may be used to the greatest advantage in most cases of weakness, provided it be not to such excess as to fatigue. It is a matter of the greatest importance that the exercise should be agreable & amusing so as to take off the attention of the mind from the diseased state of the body. Exercise should be universal so that every muscle in the body be employ’d have riding on horse back or in a carriage are preferable to walking, the lower extremities in the later being only employ’d. Rowing etc. very beneficial Exercise should be performed in pure air, hence exercise in close rooms weakens, in place of strengthening the body. Remedies strengthening the habit are the bark bitters of the vegetable class preparations of iron etc. when the weakness ahs been suddenly produced our medicines are efficacious & suddenly so, but in cases where weakness has been generally [illegible] & long continued they are not so affected 66 It has ben question’d & seems as yet to be undetermined, whether bitter medicines should be exhibited compounded or not there are reasons pro & con. the strongest argument for exhibiting simple bitters is that they are of a class of medicines that by contn’d use soon loose their effects as medicines, and are avail [illegible] of these qualities by exhibiting [illegible] alone because one bitter acts powerfully after another by use has lost its powers. In weakness where there is a disposition in the blood vessels to great contraction these medicines are not nigh so proper which is probably owing to their astringency When these medicines loose their efficacy by intermitting their use for a few days they may be returned to & recover their effects upon the habit. If weakness be the only disease the patient should not be suffered to lie abed, but kept out as much as possible the warmth of the bed rendering the habit irritable & preventing the increase of strength. Preperations of iron are much more stimulating than the vegetable bitters are therefore more or less proper according to the state of the particular case Containing the lectures from No 91 to 102.