% AN INAUGURAL THESIS ON JAUNDICE; V CONTAINING OBSERVATIONS ON THE LIVER, AND SOME OF ITS DISEASES. SUBMITTED TO THE EXAMINATION , or THE j>ff REV*. JOHN EWING, S. T. P. PROVOST, THE TRUSTEES AND MEDICAL FACULTY OF THE UNIVERSITY OF PENNSYLVANIA ; ON THE 6th DAY OF JUNE, 1799, FOR THE DEGREE OF DOCTOR OF MEDICINE, TAMES NORCOM, OF N. CAROLINA, HONORARY MEMBER OF THE PHILADELPHIA MEDICAL AND CHEMICAL SOCIETIES. Phoebe fave, nevus Urr.bla tua ingredltur. Ti a UL. P II II. AD E LP KI A: PRINTED BY J A I.I E S CAREY, FOR MATEIEW CAREY, 11S, MARXE-'■iTll:.LI\ \ TO CASPER WISTAR, M. D. ADJUNCT PROFESSOR OF ANATOMY, SURGERY AND MIDWIFERY, IN THE UNIVERSITY OF PENNSYLVANIA. X HIS differtation is refpectfully infcribed, as a fmall tribute of gratitude and cfteem, for the important and difinterefted fervices, which he has been pleafed to render his Much obliged friend and Very devoted fervant, JAMES NORCOM. INTRODUCTION. XJL PROBATIONARY thefis being necefTary to obtain a degree in medicine j I have ventured in the fubfequent pages to lay before the public a few hafty obfervations on the fubject of jaundice—- This I have done, not from a confcioufnefs of the utility of fuch a practice, not with a view to di- vulge or promulgate any favourite hypothefis of my own, nor yet with an intention to abet, or op- pofe the affeverations of others ; but in obedience only to that law, by which it is exacted. I once indulged myfclf in the agreeable expecta- tion, of inflituting a feries of experiments, on fome indigenous vegetable production ; but have to re- gret, that the want of talents, time, and oppor- tunity, qualifications indifpenfable to the execution of fuch a talk, has rendered it wholly imprac- ticable. In every inaugural eifay, which hath come under my examination, it has been cuftomary to quote the authority of dilllrcnt writers, andtofpecify by par- A 2 (iv) ticular references} the work, or parts of the work, from which fuch quotations have been taken—In the following meets, I fhall not introduce fuch quotations or references at all, except, what I may have occafion to mention in the text or body of the compofition, and hope to be excufed, mould I in any place be found adopting opinions which have not been generally acknowledged, without fpecial reference to the authors of their exiftence. Of this pardon, I fhall be the more confident, if gen- tlemen recollect, that the majority of thefes are mere compilations, and that the more or lefs judi- cious his feieaion, the greater or lefs will be the merit of the author's performance. In thus deviating, from a long efbblilhed cuftom, I do not intend to deny my obliga- tions to authors who haye treated on the fubject about to be confidered-The facts upon which many of the following obfervations are founded, are contained in the writings of Morgagni, Bonetus, Schenkius, Monroe, Boerhaave and Hoff- man—I am not fenfible of having taken any thing for granted, which experiment and the common obfervations of mankind have not amply illuflrated —Without prepofleifion in favour of any parti- cular opinion, and with a predilection to the autho- rity of none, I have read attentively the works of thofe, who have written profeffedly on my fubject, and have been guided in my arrangement, by the dictates of my own undemanding. (v) T am aware that I have to encounter the ordeal of public opinion, though totally unqualified for fuch a trial; and coming forward in a literary world under many difadvantages, more efpecially in a publication like the prefent, executed with fo much precipitation and hurry, no one will expect to find me invulnerable by the fhafts of criticifm—■ I therefore fubmit it with the utmoft diffidence, foiiciting fuch allowances from an indulgent public, as its numerous inaccuracies fo egregioufly require. HISTORY OF THE DISEASE. X HE difeafe which I have feledted from the nosological catalogue, as the fubject of enquiry on the prefent occafion, is one, which has been long known among medical practi- tioners, by the name of Jaundice. It is defcribed in books of antient authority by a variety of appellations, fuch as Morbus Acuatus, Icretus, Aurigo, Icterus, Morbus Regius, and many others equally arbitrary and uninterefting. It is a difeafe, which is probably coeval with fome of the moft an- tiquated of human maladies, and is common in all warm climates—Perfons of every age, fex, and conftitution, are alike fubject to its invafion, it occurs ofteneft in the bilious temperament, or in thofe who are fubje£fc to hepatic and towel complaints, and is faid to appear principally in the feafons in which thofe complaints are mofl prevalent. Such as have once had the difeafe, are liable to frequent returns of it. Jaundice conuftf in too great a quantity of the matter of bile in the blood, exhibiting a yellownefs of different de- grees of intenfity, and more or lefs difFufed, on the exter- nal furface of the body. It is brought on by caufes, which prevent the excretion of bile, after it is feparated from the blood; and poffibly, by fome inexplicable changes in die circulation, effected by caufes to be hereafter enume- ( 8 ) rated. People in common circumflances, often go about with the difeafe upon them, without experiencing any great inconvenience, and tranfact the ordinary bufinefs of life, particularly, where no great mufcular exertion, is required. The duration of Jaundice is extremely uncer- tain: in fome it will difappear in a few days; in others it will continue for many months, nay even years, without producing any confiderable conftitutional injury, SYMPTOMS. Antecedent to the appearance of Jaundice, the patient 13 often heard to complain, of pain fometimes acute, but ct- tener obtufe, in the right hypochondrium, or in the epigaf- tric region juft below the fcrobiculus cordis, at a point cor- refp'onding to the entrance of the biliary and pancreatic ducts, into the dOodenum. It is often preceded by naufea, ficknefs, anxiety, a difpofition to faint, with figns of languor and univerfal debility, which frequently continue fome tiVne before the icteritious colour makes its appearance upon the external fuperficies of the body. But it not unfrcquently happens that the acceflion of the difeafe is fudden, and with- out any premonitory fymptom whatever. There is generally a fenfe of weight, and tenfion^ about the hepatic region, with a pain, which is commonly referred to the ftomach, and which is cither continual and obtufe, or intermitting and very fevere; JafTitudc of body, dejection of mind, drcw- finefs, difinclination to motion, and unrefrefhing fleep, are its conflant attendants. The tunicx albuginesc of the eyes, are the parts where yellownefs, generally, is firft perceptible, after which, the nails, and at length the whole furface of th<* body, acquires an uncommonly yellow colour; this yellow- nefs in fome cafes has been known to pervade every part cf (9) the body, internal, as well as externaj, even the very bones and cartilages themfelves, have been found deeply impreg- nated with bile. The colour of the fkin in Jaundice, correfponds exactly with that, which may be produced, by a mixture of bile with a certain proportion of water, giving a pale yellow fhade, bu': now and then tending to that of a deep yellow, according as the bile is more or lefs diluted, with the watery part of the blood. The urine being faturated with biliary matter affumes a yellowifh red, tinging a piece of paper, or linen, dipt in it, of a durable fafFron colour. The faliva, which in a ftate of health is perfectly infipid, becomes fenfibly bit- ter, which frequently gives the patient an idea, while eating, that his food is bitter. Thefe fymptoms are often accompanied by thirft, want of appetite, great irritability of ftomach, and frequent fits of vomiting; and if the difeafe continues two or three days, the patient becomes confiderably emaciated. Such ?s happen to be afflicted with this complaint, fuffer exquifite torment, from flatulency, dyfpepfia, heart-burn, hiccough, and acid eructations; twitting and rumbling of the bowels, with extreme pain. The fceces are pah-, rough and irregular, and at laft affume an afh or clay colour, nor have they their ufual fseculent odour. The bowels are for the meft part conftipated, and the excrements, when voided, have often an uncommonly putrid fmell. During the whole courfe of the difeafe, more or lefs fever at.ter.J3, with alternate chills and flumes, and fometimesa delirium with partial fpafms, or univerfal convulfion. The fever is often very violent, but feldom comes en until many of the other fymptoms h:-ve cou- B (10) tinueJ fome time. The pulfe is variable, generally quicker and ftronger than natural; fometimes, however, it is pre- ternaturally flow and hard. As the difeafe advances, refpiration becomes more and more difficult, with palpitations of the heart, uneafinefs and anxiety about the prcecordia.—The languor and laflitude go on increafing, with dullnefs and a degree of ftupidity, fome- times bordering on fatuity, until the whole body is tinged of a yellow hue, which, in fome few inftances, has approached fo near to black, as to have given rife to the ridiculous term, Black Jaundice. Objects viewed by perfons in Jaundice, fometimes appear indifcriminately of a yellow colour, except fuch as are blue* which, according to fome authors, are often miftaken for green -An itching, and drynefs of the fkin, often teaze the patient ; while hemorrhages from the nofe, gums and inteftines, affift in aggrandizing the lift of his diftreffes-—a diarrhoea rarely attends, but when it does, although accorr> panied with profufe difcharges by urine and perfpiration, is commonly deemed a falutary fymptom. Obftructlons and dropfy, finally come on; the patient falls into a ftate of extreme debility, and after fome hours of intolerable pain, appears fuddenly relieved, and finks, as it were imperceptibly, from a ftate of celeftial tranquility, into a.i evcrlafting (lumber—The fatal termination is net always thus caff, the patient fometimes feels, in the lad moments of departing life, the mod excruciating mifery—Very differ- ent, ir.deed, is the face of things, when the difeafe is about to end favourably—the patient, in this cafe, is not much re- duc: -■ but continues to go about, h.vj fewer of the fymptom.?, (-II) and thofe lefs violent, his fpirits continue good, and his di- geftion not much impaired, until, by his own cautious ma- nagement, by the uncontrolled exertions of nature, or by the interpofition of proper medical aid, the difeafe is. entirely fubdued, and he reftored to perfect health. Before I proceed to the next divifion of my fubject, it will Rot be amifs, to premife a few remarks, on the nature, fjcre- tion, and ufe, of the BILE. The bile is a fluid of a greenilh yellow colour, an intenfely bitter tafte, of an oleagenous vifcidity, having a peculiar aro- matic odour, a little more thick in its confidence than milk, and rather more vifcid. It has been called an animal foap, but I do not be* Iieve with fufficient accuracy; becaufe, the analogy be- tween them is by no means fo extenfive, as has been fanci- fully imagined—Chemifts, to be fure, have obtained from it an oil, and an alkali, but admitting the formal exiftence of thefe two fubftances in the bile (which I very much doubt), it remains yet to prove, that they exift in fuch a ftate of com- bination, as to conftitute a true foap.—The milk, we are taught by chemiftry, is capable of affording a fixed alkali, ?.vA we are certain, that oil is prefent in it, in great abun- dance, yet, no one will pretend to fay, that it is a foap, oil that account; and we might with as much reafon, and pro- priety, give the epithet to one, as die other—The bile too has, in the hands of the dyer, fucceeded in taking out ftains and blotches, from clothes, but, redified fpirit and the fixed alkalies are, in fuch cafes, equally facccisful—It is Did to B 2 ( " ) have anfwerdd further, the purpofes of the artift, as a me- dium of union, for oil and water, in the art of varnifhing; and the phyfiologift has been content to fuppofe, that it might have fome analogous operation, upon the oily, and aqueous parts of our aliment, in the primae vise; but it fhould be remembered, that there are other fubftances which will do the fame thing, as animal glues, the yolk of an egg, vegetable gums, mucilages, &c. and with what propriety, or judgment, any of thefe fubftances could be called foaps, the intelligent reader will be at no lofs to determine. In order to obtain further information, on this fubject, I made a few fimple experiments; the refults of which, with deference to the high authority of Fourcroy, Cadet, Chapjal, and others equal in celebrity, I will relate for the benefit of my readers—i ft. The bile, unlike the fubftance called foap, is not mifcible with oil, except by the affinity of an interme- dium—2dly. No neutral fait is obtained by treating the bile with acids—3ly. That fubftance feparated from bile by the addition of an acid is foluble in, and mifcible with water— Thefe facts, in my opinion, go very far in proving that the appellation of foap, as applied to the bile, is an unjuft one ; that fuch a conclufion will be warranted or confirmed, by future and more convincing experiments, I fhall not attempt to affert. The bile, from numberlefs experiments which have been inftituted and performed on it, appears to be compofed of a ferous or watery part,—a coagulable putrifiable matter, analogous to the coagulable lymph of the blood, and a fub- tile aromatic principle, in which, befides its peculiar odour, its colouring matter and bitternefs are thought to refi.le- I {hall no: add to the many uninterefting difputes, which luve been agitated about the origin and formation of its C 13 ) conftituent parts; and it would only be making an unneceffary digreflion to ftate the current opinions on the fubject. Subjected to the torture of fire, the bile yields an empy- reumatic refinous oil, the mineral alkali, a fmall quantity of iron, and phofphorated lime—it is alfo faid to contain a large quantity of carbonic acid or fixed air, united to the mineral- alkali which is contained in it, and this has been foufid more efpecially the cafe, with thofe Concretions, which are often derived from it; hence, a fuf- picion has arifen, that this latent air, might ihcreafe the at- traction or cohefion of the other parts of the bile, and thus con- tribute to the formation of calculi: on the probability of this theory I am totally unprepared even to venture an opinion—The bile appears to be a gelatinous compound, intimately united in its parts, capable of coagulation by acids, and fufceptible of greater fluidity by being combined with alkalies; its coa- gulability is diminifhed by putrefaction, and its coagulum is fo clofely blended with the other parts of it, that it cannot be obtained free from them, except by its own proper folvent. From experiments, which appear to have been faithfully made, and candidly related, it is concluded, that the prin- ciple of bitternefs in the bile (whatever it be) refifts the effects of putrefaaion ; while the vifcid coagulable matter, more readily putrefies than other fubilancss. The bile which is found i.i the gall-bladder, differ* from the newly fecreted bile, in being more vifcid, yellow, and bitter: this does not arife fo much from a difference - of origin, nature, or fecretion, .as from confinement and ftagnation in the gall-bladder, where by the abforption of its more attenuated and limpid parts, it undergoes this remark- f 14 ) able change. The conftituent principles of the cyftic and hepatic bile are the fame, and the only way in which they differ, is in the proportion of their component parts. The apparatus of veffeis, appropriated to the fecretion of bile, is curious and interefting. The vifcus which is princi- pally concerned in this noble operation, is the liver, a gland of the conglomerate kind, of a dufky red colour, deftined to refine and depurate the vital mafs; while it is at the fame time fubfervienr, to one of the moft wonderful and indifpenf- able proceffes in the animal ceconomy : viz. digeftion. The liver, the largeft gland in the body, is fituated in that part of the abdominal cavity, called by anatomifts, the right hypochondrium, which it often completely fills; it frequently occupies a portion of the epigaftric, and is fometimes of fuch fize, as to extend a confiderable diftance into the left hypochondriac region ; it is covered by a proper membrane •f its own, and a common one from the peritoneum ;—it is fixed in its place, with its convex furface correfponuing to the concavity of the diaphragm, by ligaments, derived chiefly from the peritoneum, and attached to various parts of the abdominal parietes, called lateral, coronary, um- bilical, fufpenfbiy, &c. The liver, in a natural and healthy ftate, is entirely vafcular, compofed of the ramifications of the vena portarum, hepatic veins, and hepatic artery, the fecretory and excretory ducts, befides which, enter into its compoution, in common with all other parts of the body, nerves, and lymphatic veffeis. The fecretion of bile is very remarkable, for unlike the ether fecreted fluids of the body, it is not feparated from entire arterial blood, but from that which is collected from the vifjera of the abdpmcn, iu one large vefiU, known by, ( is ) the name of vena portarum, a vein, performing in a greal meafure the office of an artery, which ramifies every where through the fubftance of the liver, and fends off the biliary fluid from its capillary or extreme branches, in a fet of fe- cretory veffels, called pori biliarii, which uniting in their Courfe out of the liver, form larger and larger trunks, until they make up a veffel of confiderable fize, diftinguifhed by the name of hepatic duct, through which and the ductus Communis choledochus, the bile is perpetually diftihing, into the duodenum, except by fome fpafmodic affection or morbid diftenfion of that inteftine, or fome obftruction \n. the com- mon duct, its admiflion is prevented; when, it paffes in a retrograde direction, through the cyftic duct into the gall- bladder, where it is called cyftic, in contradiftinction to tne other, which has acquired the name of hepatic bile. The gall-bladder is a fmall pyriform bag, which lies in a depreffion on the concave furface of the liver, at the an- terior part, and right fide of its great' lobe, with its fundus or large extremity pointing downwards. It is compofed of two principal coats, the internal of which is villous, like the .villous coat of the inteftines; the fecond is fup- pofed to be mufcular; it has alfo, a partial covering from the peritoneum ; it terminates obliquely upwards ?nd inwards, in a fmall twifted neck, continued into a mem- branous dud, called cyftic, which joining with the hep?.tic, forms the ductus communis choledochus. This refervoir does not feem to exift as immediately neceffary to the fecretion of bile, nor as indifpenfable in the procefs of digeftion, but as a receptacle, provided by nature, to contain any fuperfluous quantity of bile, that might accidentally be feparated. This opinion is rendered probable, by diifeaions, which fhew the tfvftic duct to have beer, completely obliterated, and the gdi- bladder full of concretions, when no diforder of the liver, or irregularity in the funaion of digeftion, had been taken notice of before death. That bile, which is depofited in the gall-bladder, by its ftagnation acquires fuch acrimony, as to excite a contraaion of its mufcular coat, which propels it into the duodenum, except by fome mechanical power, as the diftenfion of the ftomach, vomiting, violent its of cough- ng, &c. it be previoufly evacuated. Whether this difcharge is accidental merely, or whether it anfwers any valuable purpofes in the ceconomy, phyfiologifts are not agreed. The fecretion of bile is a fubjea enveloped in much ob- fcurity; the ufe of it, however, is fomewhat better under- ftood—From the effeas of an impeded or prevented fecre- tion of bile on the conftitution, it is fuppofed that the biliary fecretion, is intended to obviate a putrefaaive ten- dency of the blood—And when we confider, that nature ufes venous bleod for it, and that too, which is colleaed from parts where proceffes of a fermentative kind, are often going on ; added to this, the tardy circulation of the blood, from tvhich bile is derived; that whateve* has a tendency to in- creafe putrefaaion out of the body, augments the fecretion of bile; that in the higheft grades of bilious fever, in which the tendency of the fyftem to putrefaaion is fo great, a re- dundance of bile fo often occurs; and that the fecretion is i icreafed from ftarving in which fymptoms of putrefcence are fo conftantly obferved; we cannot help believing, there is fome foundation for this opinion—Whether this increafed biliary fecretion, be owing to fome change produced in the blood, which facilitates its converfion into bile; or an effort of the fyftem to refill the effeas of caufes, inducing putre- faaion, is not clearly afcertained. But we uniformly find ( i? ) it to attend the long continuance of hot weather, fhewing itfelf during the prevalence of thofe fevers, which prevail in the fummer and autumnal months—It is acknowledged by moft writers, that when remittent fevers continue until the commencement of cold weather, they lofe their malignity, and tKeir bilious fymptoms vanifh—This remark feems to fhew, that the redundancy of bile which appears m thofe fevers called bilious, is more the effea of a particular ftate cf the blood in the hot feafon, than of the difeafe which it accompanies—And how often muft it have happened to praaitioners, to obferve fevers of the remittent and inter- mittent type, in every feafon of the year, in which there occurred no one circumftance that would lead them to fuf- .pea a redundance of bile; nor will they deny having feen, profufe and unnatural difcharges of bile, with which little or no general fever appeared, as in cholera morbus, bilious diarrhoea, &c.—But to return. The bile is a fubftance admirably adapted to the affimUa- tlon of the many heterogeneous compounds with which it meets in the firft paffages—The glutinous part of it, ferves as a medium of union, for the aqueous and oily parts of our aliments—By its bitter and antifeptic qualities, it obviates or correas their afcefcent, and putrefaaive tendency—And by its gentle ftimulus, it imparts vigour to the inteftines, keeps up their periftaltic aaion, and thus promotes and facilitates the expulfion of the faeces—That thefe are the effeas of bile in the inteftinal canal, is evinced, by what happens from an excefs, or total privation of it. CAUSES. J.-.imdice, rr•.•rb commonly ari'cs from st: oc':r:lt: ;*i to t:-e nn-.i-'c- Oi bi.e i:"s-o t..c v..i'r~v—• -•> -'-«■-«•• ., ( i8 ) either in the hepatic dua, fome of its branches, or in the cluaus communis choledochus; in both cafes, the liver be- comes difeafed from congeftion, and the bile, if it continues to be fecreted, is either taken* up by the patulous mouths of the abforbents, or regurgitates direaly through the branches of the hepatic veins—An impeded or depraved fecretion of bile, I believe, feldom, if ever, gives rife to Jaundice—on the contrary, it is generally owing to an obftruaion, to its excretion, after it has been duely and naturally fecerned by the liver; by which means, it is admitted into the circulation, and communicates to the fluids fecreted from the blood, its colour, bitternefs, and other fenfible qualities. The bile, I faid, might return into the circulation after its fecretion in the liver, by abforption and regurgitation. Under the head of abforption, I prefume, little need be faid : for it is univerfally allowed, that there exift numerous lymphatic veffels, in the liver, gall-bladder and biliary duas, which, in a natural and found ftate of the parts, only take away, the pure watery part of the bile, and perhaps, a fluid which is continually exhaling into their cavities, to lubricate and defend them from its acrimony—But when the excretion is prohibited, either in confequence of die ftimulus of diflenfion, or from fome quality in the bile, ic is abforbed by the lymphatics, and unlefs its efflux into the inteftincs be fpeedily promoted, the whole volume of blood \s impregnated with it. A great deal has been faid to prove, that a regurgitation of bile never takes place, and from the experiments and ob- fervations cf doctor Monroe of Edinburgh, it would fecm, ( 19 ) that it rarely dees ; but that it fometimes happens, I am pcr- fuaded by the following reafons: i. A common injeaion paffes readily, and eafily, from the hepatic dua into the hepatic veins, and vena cava. 2. Having proved the paf- fage pervious, by injeaion, it is plain, that when the gall- bladder is much diftended, and an infuperable obftruakm exifts in the duaus communis choledochus, the bile by the immenfe preffure to which it is fubjeaed from the contrac- tion of the diaphragm and abdominal mufcles, in the aa of vomiting, or during any other violent exertion of the body, will pafs again through the fecretory duas, to the fountain from which it originally fprang—nor is there any difficulty in uuderftanding the facility, with which this may happen; for, as the blood is continually moving forward in the vena portarum and hepatic veins, towards the heart, the refiftance muft be greater at the obftruaion in the dua, than it can be at the veins where the biliary pores take their rife. Ana, laftly, how can we account, for the fudden relief whicn violent fits of vomiting give, when no calculus is voided, and no bile evacuated, but by recurring to the doctrine of regur- gitation. Inflammation, fuppuration, and fchirrous tumors of tin liver, have been ranked among the caufes which produce Jaundice ; but as there are upon record fo many cafes of in- flamed, and obftrua*1. liver, in which the difeafe has never appeared, it may be juftly doubted whether fuch affcc^u^o, exclufive of fjme irregularity or obftruaion in the biliary duas, are capable of producing it at :ftT Monroe fuppofes m.i;, (■■ e-) * L*. U to «tum, it certain* «», but * no «hcr nj. ( 3* ) Tt has been doubted too, that obftruaion in the hepatU dua, could produce the difeafe, but, there have been cafet ef Jaundice, from indurated and fchirrous liver where the larger duas could not have been affeaed, which will force us to admit it: and is it not probable that partial affeaions o£ the liver, by preffing on the branches of the hepatic dua, inay fometimes induce thofe evanefcent fymptoms of Jaun- dice which are fo often taken notice of—Yet, I believe, by far the moft common feat of the obftruaion, is juft at the termination of the dua in the duodenum : this is incontro- frertibly proven by diffeaions, and by the acute pain, atten- dant on the prefence of gall-ftones, which could arife only from the irritation at the interline; for, from the experi- ments of doaor Monroe and others it feems, that the duas themfelves poffefs no mufcular coat, and but little fenfibility or contraaile power. Thirdly—Spafm—aaing fo as to diminifh, or cut off the communication, from the liver to the inteftines—whether the biliary duas have pofitively mufcular fibres, and are capa- ble of afluming an aaion of the fpafmodic kind, I fhall not take upon me, to aflert * although, I am difpofed to think, that what happens in cafes of fpafmodic Jaundice, may be well enough comprehended, by an acquaintance with the "mufcular ftruaure of the duodenum, without adverting to the controverfy about the mufcularity of thefe duas. This caufe of the difeafe is always to be fufpeaed, when it occurs fuddenly, without any preceding fign of indifpofi- tion; when it affeas perfons fubjea to hyfteria, hypochon- driafis, and other fpafmodic difeafes; or fuch as are under the influence of violent commotions of mind, and when the difeafe difappears, foon after the intermiffion of the fpafm. <3* ) The effea of violent paflions of the mind in giving orlgia to Jaundice, is demonftrated by frequent and repeated ex- perience in the praaice of medicine : nor will this furprife anyone, in the leaft acquainted with the conneaion which fubfifts between the mind and body, and how powers af- feaing the brain and nerves, communicate their effeas to every part of the fyftem—Although thefe effeas from the nature of their caufes, elude the obfervation of our fenfes, ftill, they are fo confentaneous to reafon and analogy, that we are compelled to acknowledge them. Fourthly—Infpiffated mucus, or any vifcid matter whatever, fluffing up or clogging the orifices of the excretory duas in fuch a manner, as to prohibit the free and eafy paffage of bile into the duodenum— We fhall not be furprifed to hear of fuch a thing happen* ing in the biliary paflages, when we remember, that, like the inteftines, the gall-bladder and biliary duas, have innume- rable villous projeaions on their internal furfaces: nor fhall we be more at a lofs to underftand, how the quantity and confiftence of their mucus difcharge may be fo augmented,; or changed, as to retard or hinder the egrefs of bile into tha inteftines^-We fhall be led to fufpea this caufe of Jaundice? from the remedies which prove moft beneficial towards it» removal; from the relaxed and debilitated habit of body, which is its ufual companion, and from a predominance of tenacious phlegm, in the throat, ftomach and bowels: hence the origin of the difeafe in infants, called by nurfes the Yel- low Gum, which almoft always difappears, as foon as the mucus, with which their primx viae were engorged, is ex- pelled from their bodies. (32 ) • A retention of the meconium in infants gives rife to Jaun- dice, by mechanically fhutting the entrance of the biliary4 dua into the duodenum, or inducing, by its quantity or acri- mony, fpafm in the inteftines, and thereby preventing the admiffion of bile into them. This yellownefs in infants, is afcribed by fome, to an ab- forption of the meconium itfelf—This may fometimes be the eafe, but that it does not uniformly happen, is evinced, by its frequently occurring with bilious diarrhoea. It has been remarked, with great apparent confidence, that an increafed craffitude or vifcidity of the bile, cannot pro- duce Jaundice, becaufe (fay the advocates of this opinion) if its confiftence be fuch, as to prevent its paffing through the1 excretory duas, it is hard to conceive, how it fhould get through the inconceivably fmall orifices of .the fecretory or lymphatic veffels—I grant, that after the bile has become fo infpiffated in the gall-bladder and excretory duas, as to ren- der its exit into the duodenum difficult or impoflible, it is not to be fuppofed, that it will return to the blood through the minute fecretory tubes, which are probably as paffive as the excretory duas themfelves. But whoever will allow himfplf time to recollea the facility, with which the abfor- oents take up the moft firm and folid parts of the body, can find no difficulty in admitting, that a preternatural fpiffitude of the bile, may once in a while, give rife to the complaint; and it is in the higheft degree probable, that the abforbents have fome inherent aaion of their own, which enables them to perform their offices more completely, while excre- tory veffels are all paffive in their operation—It has been urged, like wife, that circumftances in the hiftory of the dif- eafe are repugnant to this opinion—The one upon which ( 33 ) moft ftrefs is laid, is, that the gall-bladder has been frequently found, after death, in a ftate of great diftenfion from a col- leaion of thick vifcid bile, yet Jaundice had not been the confequence. To this objeaion, it is anfwer enough to fay, that tHe gall-bladder has often been found diftended, with more fluid bile, in which the difeafe did not precede death. Fifthly—Tumours—efpecially of a fchirrous nature, in the - liver, pancreas and parts circumjacent, by their fize or fituation co.mpreffing the biliary duas—Examples of Jaun- dice from this caufe are taken notice of by all anatomical writers—In cafes of fwollen and indurated liver, the difeafe is not occafioned by a want of fecretion, (for we are informed by very refpeaable authority, that the liver will continue to fecern bile in a very difordered ftate) but, by the difeafed part, preffing upon the hepatic dua or fome of its ramifica- tions, while the reft of it is performing the bufinefs of fecre- tion. This will be the cafe when the induration is feated m the concave part, or when the conglobate glands, inclofcd in the capfula Gliffonii, become enlarged. Under this head may be confidered, cafes of >undice which occur during pregnancy, from the preffure of^ the uterus, or colon diftended with indurated feces; in which the difeafe goes off after delivery as foon as the parts are reftored to their original and healthy ftate. The difeafe is alfo likely to occur in coftive habits, in which cafe, it muft be produced by fome of the large in- teftines preffing on the biliary duas, or, (which is more pro- bable) by an unufual quantity of bile being confined in the inteftines and abforbed by jhe Ucbal veflels. «.«,1 r"."> That all the caufes which have been en jmewttu «- ,- -« ( 34) duce Jaundice, will appear evident to every one in the leaft converfant with anatomy ; and that they have produced it, the diffeaions of Bonetus, Morgagni, and other equally diftinguifhed anatomifts, abundantly prove. But what fhall we fay of that yellownefs or Jaundice (if I am permitted to call it fuch) which is occafionally feen in the bilious fever of our country, and efpecially in that malignant form of it denominated yellow fever?—I acknow- ledge that, in my mind, there exifts not a doubt on the fub- jea—I am decidedly of opinion that it is owing to bile pre- fent in the blood. This opinion I the more readily embrace, i. Becaufe it occurs in thofe difeafes in which a redundance of bile is fo common; 2. and during the feafons principally in which thofe difeafes prevail; 3. becaufe, we do not know, for certain, of any other way, by which this phenomenon could be produced— but any how, it is very certain, that thefe icteric phenomena prefent themfelves, with copious difcharges of bile from the ftomach and inteftines, a manifeft proof, that the biliary duas are pervious and clear of obftruaions. It is by no means an uncommon thing, to find perfons during the hot feafon, with high coloured urine and a fenfiblc yellownefs in the whites of the eyes, without general fever, but accom- panied with bilious vomiting, or diarrhoea ; and perfons con- valescing from an attack of ordinary intermitting, or remitt- ing fever, fometimes meet us with unequivocal fymptoms of Jaundice-—It alfo occurs in a fmall degree in thofe complaints fo common among us, called inward fevers, and particularly in perfons much addiaed to the u(e of ardent fpirits. How it comes to pafs, that the caufes producing bilious fever, and the intemperate ufc of fpirituous liquors, fhould aa in fuch ( 35 ) a manner as to produce this immoderate fecretion of bile, I fhall not attempt to explain ; but that they have fome fpeci- fic operation upon the liver, we have the moft unexception- able teftimony to prove, or whence happens it that fhe liver is fo uniformly affeaed in both cafes ?----1 may here remark, that ftarving has produced Jaundice ; it is explained thus ; after the abftraaion of nutrition, the blood continuing to move on by the powers of the circulation, is loft principally in the fecretions and excretions; among the reft the biliary fecretion continues, and by fome provident effort of the confti- tution is often augmented ; by which means the bile, pafilng. in its ufual courfe into the inteftines, is taken up by the laaeal abforbents, and conveyed into the circulation, where, in con- fequence of the diminiihed quantity of blood, it becomes perceptible to the fenfes. In addition to the more common caufes which produce Jaundice, I muft not forget to mention others which are more ambiguous in their operation. They are the bites of poi- fonous and rabid animals-Contagion—fuppreffion of fome cuftomary evacuation—:Repelled eruptions, wounds and frac- tures of the cranium , inftances of all which are mentioned by medical writers—they may produce the difeafe by induc- ing fViifm which is itfelf the caufe of obftruaion, or by fern.; convulfive effort which takes place during the accident, forcing infpiffited mucus or calculi from the gall-bladder, into the duaus communis choledochus—but, that neither of thefe caufes could have induced it, in fome inftances, would ap- pear; from the fuddennefs with which it cam: on, from hi having occurred in perfons not fubject to fpafmodic dika^s and who had not been expofird to any of the caufes which arc generally thought to produce fpafm; and admitting a fpaf- siodic affection of the inteftin,s had occurred,, the quantity £ 2 (3 parts, fimibr to that ob- ( 39 ) ferved, in afFeaions of the kidnies and bladder, which it not well underftood—Vomiting is always a troublefome fymptom, but is a falutary effort of the ceconomy, to relieve the liver and its excretories, of their unwelcome and oppref- five load—The yellownefs which appears in fome one or. every part of the body, as in the eyes, urine, fkin, faliva, nails, occ. is owing to the limpid or ferous part of the blood being tinged by the colouring matter of the bile—When the. fkin takes on that extraordinary dark yellow appearance, which in fome cafes tends to a livid colour, the dif- eafe is abfurdly denominated black Jaundice. The proxi- mity of the colour of the fkin to that of a black in a few cafes, has led fome to fuppofe that there is fomething peculiar in its nature. Among the antients there were fome, who believed that it. was owing, to fome affeaion or alteration in the fpleen —Others were fatisfied with an idea, that it was'owing to an abforption of black bile, fecerned by the capfube atrabi- liariae : but thefe opinions totter, upon the moft fuperficial examination ; for, firft of all, this black colour has frequently been obferved to occur when the fpleen has been in perfea health, and, on the other hand, it is now allowed, that no fuch fluid as that called by the antients atrabilis, is prepared in the body. Others again there are, who fuppofe it owing to an organical confumption of the biliary fyftem; but this fuppofi- tion appears to be equally void of foundation : for it undoubt- edly very often occurs, where the liver and excretory duas have not been more affeaed than in ordinary cafes of the difeafe-----It is now generally believed, that there is no- thin^ extraordinary in the difeafe called black Jaundice, as to its nature or with a view to its medical treatment; and that it depends entirely on a change in the colour of the bile, before or after abforption, from an inveterate duration of the difeafe ; perhaps it may be influenced by fome conftU tutional difference iu the perfon affeaed. ( 4* ) The imperfea or depraved vifion, muft depend upon an alteration in the humours of the eye, from effufions of bile, diminifhing their tranfparency and altering their confiftence; of courfe, objeas being viewed through a yellow or not perfeaiy tranfparent medium, have a yellow tinge, or arc ken. indiftinaiy—This depraved vifion feldom occurs, but that it fometimes does, is unqueftionably true; and when it does happen, can be owing to nothing but an extravafation of biliary matter in the humours, or between the coats of, the eye; which, although invifible to the eye of a beholder, may be fo confiderable, as to colour the rays of light in their courfe to the retina. The green appearance of blue objeas in iaeric people, is in all probability occafioned by fome accidental combination of colours in the eye which I do ^ not thoroughly comprehend—The bile prefent in the faliva imparts a bitter tafte to it, and in confequence of this, every thing taken into the mouths of jaundiced perfons, is fup- pofed by them, to have a bitter tafte ; while, communicating its acrimony to the perfpirable matter, it excites a prurient or itching fenfation on the fkin, which is more or lefs fevere according to the greater or lefs acrimony of the bile ; but whence it happens, that fome are fo much perplexed by this fymptom, whilft others are perfeaiy exempt from it, is not eafily conjeaured. The rough, hard and irregular faeces, depend upon the abfence of the mucilaginous qualities of the bile, which in a natural ftate of things, lubricates their fur- face, and diminifhes their tendency to cohefion : their more putrid odour and white appearance, are brought about by the want of the colouring and antifeptic part of the bile. Coftivenefs arifes from a defea of bile, without which the inteftines do not perform their ordinary periftaltic contrac- tion; hence alfo arifes, want of appetite, and loathing of food, <4i ) for without the bile the aliment continues longer than or- dinary in the alimentary canal and digeflion is impeded: hence arife heart-burn, hiccough, acid eructations and fla- tulency, all, from an abfence of the antifeptic and other prin. ciples cf the bile, which are the proper correaors of acef- cency. Whenby vomitingorany other caufe, a calculusorother obftruaing matter is expelled, a large quantity of bile rufhe,s into the inteftines, and is immediately fucceeded by a bi- lious diarrhoea, which is always efteemed a harbinger of approaching health. The fever which accompanies the other fymptoms and often proves fatal to the patient, is either fymptomatic of the inflammation in the liver and biliary duas, or is occa- fioned by the flimulus of the bile upon the heart and arte- ries, which it excites into ftronger and more frequent con- traaions. If Jaundice continues long (fay fome) the blood, from the great proportion of bile in it, degenerates into a thin watery fluid, which, by reafon of its tenuity, tranfudes with eafe through the exhalents into the cells of the cellular membrane, colkas in the greater cavities of the body and gives origin to dropfies of the moft incurable kind.—But although the blood has in a few inftances been found dif- folved and uncommonly thin, I think it more probable, that the hydropic effufions which occur in obftinate cafes of Jaun- dice, are either the confequences of an impediment to the return of blood through the afcending cava, or cf the fymp- icmatic fever which accompanies the difeafe. The dyfpncea, ftriaure acrofs the breaft, palpitation of the heart, irre- gular or intermitting pulfe and uneafinefs or ftarting in fleep, are occafioned by a colleaion of water in the thorax dmit- nifhing its cavity and confequently comprsfSng ths h-:A;t and> lungs. ( 42 ) PROGNOSIS. The termination of Jaundice is precarious, and the event will always be different, according to the nature of its caufe» the violence of the fymptoms, the age, conftitution and other circumftances of the patient. If the difeafe hath come on fuddenly in ftrong and vigorous conftitutions, is recent and its fymptoms mild, it is feldom of extenfive duration, and the probability is generally in favour of a recovery. In cafes, where the difeafe is imagined to originate from fpafm, or from mucus plugging up the biliaty paffages, as indicated by the age, difpofition or temperament of our patient, the prognofis is for the moft part favourable. The lighter or paler the yellow colour of the fkin, the more favourable in general will be the iffue of the difeafe : the nearer it is approximated to black the greater is the danger to be apprehended. Should bile be ejeaed by vomiting, and the ftools con- tinue nearly of their natural colour, if digeftion goes on tole- rably well, and the patient lofes ftrength but flowly, we need not fear a fatal termination. A bilious diarrhoea is always favourable. A Jaundice fucceeding or accompanying a fever is an eouivocal fymptom ; the fooner it occurs in the difeafe the more favourable ; and the longer the duration of the fever which it fucceeds, the more dangerous—When many and violent fymptoms appear; the faeces are white and dry without indications of the prefence of bile in the inteftines ; digeftion flow and imperfect; the paroxyfms of the difeafe frequent and painful; the alvine difcharge copious or coIII- ouative ; the abdomen hard and tumified with great lofs pi it.:nTth ;;nd emaciation, the difeafe i» in a fair way to en J ( 43 ) mortally. If dropfy intervenes with dyfpncea, palpitation, vermicular and intermitting pulfe, heaic fever, with thirft and anxiety, particularly when the patient is advanced" in life or of an infirm conftitution, the cafe is ftill more alarming.— When the fymptoms are complicated and not well marked, we fhould give our prediaion in ambiguous or evafive terms; for it will often happen that fome of the moft mild, and pro- mifing fymptoms, will be combined with others, the moft malignant and fatal; nevertheless, I believe, we may give our- fcfes a greater latitude than is generally allowed; for a long continued obftruaion to the outlet of bile, has not fuch per- manent ill effeas, nor do they prevent the recovery of the patient after the obftruaion is done away, fo long as is generally imagined : and there are not wanting inftances, where Jaundice has returned frequently for many years, in which the perfon enjoyed good health all the time, in the intervals of the attacks. CURE". In this, unlike moft other difeafes, it is impoflible to lay down any one general plan of treatment, which will bz found to hold good indifcriminately. The nature and power of the remedies to be ufed, will de- pend much upon the ftate of the fymptoms, the caufe of the difeafe, and the condition of the fyftem. If inflammation has given rife to it or there exifts a full, hard or tenfe pulfe, pain, heat, thirft and other fymp- toms of general fever—Blood-letting, and the antiphlogiftic regimen, are to be had recourfe to without hefitation or re- ferve. The times when it will be neceffary to repeat the F 2 ( 44 3 operation, are only to be ascertained by an attention to the violence of the fymptoms, and particularly, to the ftate of the pulfe—Cathartics, emetics, and fudorifics fhould be ufed as auxiliaries to the lancet—Acidulated, diluent and demulcent drinks are of confiderable utility and ought not to be omitted. The languor and debility accompanying Jaundice would feem to point out that evacutions were improper, but experience happily convinces us that the reverie of this is true ; and it is by evacuations alone that we have an op- portunity of fubduing the fymptoms; nor is the patient fo much reduced by the effeas of depletion, as by the continuance of the difeafe--Should the pain continue obftinately fevere, af- ter the judicious adminiftration of the remedies juft recom- mended, tepid emollient fomentations to the epigaftrium, and the warm bath, with occafional opiate anodynes are ad- miffible and proper. In fome inftances it may even be pro- per to ufe opium and the lancet in conjunaicn, as will be the cafe when, from a calculus or any other caufe, inflammation exifts in the duas with a fpafmodic conftriaion of parts in their vicinity. When Jaundice arifes from fpafm, in perfons fubjea to fpafmodic difeafes or in fuch as have been expefed to ac- - cidents, which have been known to produce in them fymp- toms of convulfion; opium, amber, vitriolic a;thcr, afa- fcetida and other medicines defignatedby the epithet an- tifpafmedic, will often give inftantaneous relief—perhaps dafiiing cold water in large quantities upon the patient might have fome good effea. When the difeafe is fufpeaed to depend on a Overabun- dance of vifcid mucus, or any other tenacious matter infaict- ing the excretory duas. occurring in the phlegmatic tempera- (45 ) mcnt or during the period of infancy, faponacecus and di- luent medicines with the occafional exhibition of purgatives and .emetics and afterwards tonics," are all that will in general be neceffary—But If the Obftruaion depends upon gall-ftones in the biliary duas, the cure is much more difficult; though their expul- Oon is fometimes effeaed by the unaffifted efforts of nature. It has been afcertained by melancholy experience, that bi- liary calculi yield much lefs to the articles denominated lithontriptics, than thofe which are generated in the urinary organs; it would however be right to give fome of them a trial in every inveterate cafe. The chief and moft celebrated among the folvents for bi- liary calculi, are, the cauftic alkali, foaps, faline folutions, ftrong mineral acids, oil of turpentine, decoaions of com- mon grafs, the juices of fucculent plants and fpirit of wine. Dr. Heberden pcfitively declares, that in many experiments, inftituted to difcover folvents for biliary concretions, he was not fo fortunate as to find any thing that would diffolve them. But admitting they were foluhle in any of thefe fub- ftances out of the body, (which is afferted by fome) it is plain that a direa application of them to calculi in the biliary paffages is wholly impraaicable, if in the inteftines, they are foon voided by ftool and render the interpofition of medical afiiftance unneceffary; and when we reflect on the courfe fuch articles muft take in the circulation, before arriving at the liver, in crder to mix with and medicate the bile in fuch a manner, that it may aa as a fojvent on thefe calculi, the difficulty of introducing a fufficient quantity of them, is felf evident. It is therefore extremely .doubtful whether any re.d benefit lm ever refuited from their exhi- (4*) lition, except what mightmorejuftlybejattrihuted'to their deolr- ftruent effeas; by which, they, to a certain degree, compenfate, for the abfence of the bile, which they refemble in promoting digeftion, and in preferving order and regularity in the bowels* As it is not likely that any thing taken into the body, will in the leaft facilitate the folution of gall-ftones while they are in a fituation to do harm to the conftitution, our princi- pal exertions ought to be direaed to their expulfion. With this intention, the firft indication fhould be, to induce, as far as with fafety may be done, relaxation: In the next place having rendered the dua pervious by. the ftone, we. ihould caufe the patient to make fome violent exertion of his own with a view to expel it. In order to bring on a pro- per degree of relaxation, no remedy feems better calculated, than vensfeaion; the quantity of blood to be taken, muft be regulated by the age, conftitution and fituation of the pa- tient, above all, by the exigencies of the cafe, and the ftate of the fyftem ; after bleeding, the patient may take mucila- ginous and diluent drinks, have emollient and laxative cne- mata occafionally injeaed ; and fomentations applied to the abdominal region. Afier thefe remedies have been ufed fom.etimc, wc fhouki attempt the evacuation of the ftone, by the repeated ufe of emetics and purgatives.—It is obferved by fe- vera! refpeaable praaitioners, that after the operation of vo- mits in this difeafe, biliary concretions have often been found in the ftools of their patients, and they may do ciTcntial fer- vice by difloging from the biliary paffages a large quantity of vifcid humour. If vomiting gives great pain it ought not to be. repeated, but purges fubftituted in its place with the occa- fional ufe of anodynes—what would be the effea cf fub- jcaing the patient to the relaxing influence of a warm bath, while under the operation of an emetic ? from its efficacy in the rcduaicn cf ftrangulated hernia, and in removing obfti- (47 ) nate conftipation, might we not expea advantage from fuch a praaice ? If fchirrous induration of the liver, or any part in the vif- cinity of the biliary duas, hath given origin to the difeafe, danger ;s to be apprehended, and unlefs a long continued and fv^ular courfe of mercury have an effea in relieving th. fymptoms, we may defpair of effcaing a cure; for the difcuffionof indolent fchirrous tumors is always difficult, and too often impoffible— In the worft of cafes, however, medi- cine is capable of affording relief, and it would be un- grateful in the extreme, to abandon our patients over to the arms of death, while there remains the fmalleft hope of a recovery—Palliatives muft therefore be reforted to; fuch as cordials and anodynes,—the mineral waters, fomen- tations and laxatives; by the feafonable and judicious ad- miniftration of which, we may often allay, or obviate fome of the moft diftreffing fymptoms of the difeafe—The volatile alkali, cicuta, and sether, are faid to have been inftrumental in the cure of Jaundice from this caufe; and I think it not improbable that blood-letting, in particular conftitutions or flares of the fyftem, might be praaifed with advantage. If the retention of the meconium in children fhould at any time be the caufe, by creating obftruaion at the orifice of the common dua, the exhibition of fome gently laxative medicine, will very foon check its prcgrefs, but Jauudics will fometimes continue in children, after the ftomach and inteftines are perfeaiy cleanfed, perhaps owing to the vifci- dity which the unabforbed bile acquires by ilagnating in the biliary duas. On the cure of thofe iaeritlous fymptoms. occafioned by ( 48 ) the bites of venomous animals, fraauresof the cranium, &c» I have nothing to fay ; the remedies here, as in all other cafes, fhould be accommodated to the nature of the caufe, and the ftate of the fyftem. In all cafes it will be of the utmoft confequence, to keep the bowels lax and regular; mercury though fometimes ufeful, fhould in ordinary cafes be abftained from, unlefs it be given as a cathartic; and unripe fruits, as having a ten- dency to augment the fecretion of bile, fhould be avoided: The diet of the patient fhould be nutritious, eafy of digeftion and fuch as is leaft difpofed to become acefcent; his repafts fhould be frequent, and in fmall quantities, wi:h diluent and demulcent drinks; moderate exercife wiilbe ferviceable when he is in a ftate to bear it without fatigue or inconvenience— If, in the courfe of the difeafe, he fhould become much re- duced and debilitated, the ufe of ftimulating, tonic, or corro- borative medicines, muft be fled to without delay to fupport and invigorate the patient. It is of importance, to give fome cathartic medicine with opium, to obviate its aftringent ef- feas upon the inteftines. Elifters are fometimes ufed in the difeafe, but they rarely give permanent relief. Specifics upon fpecifics for Jaundice, have a long time degraded the writings of medical praaitioners: to name them only would be offering indignity and difgrace to the leience which I profefs—But in our times, fince days of founder phiiofophy have illuminated the world, and phyficians have learned to take more expanded views of the human conftitution, we have with pleafure beheld thofe children of ampofture rapidly depreciating ; and the time, I know, will yet arrive, when thefe impious boafts of ignorance and fupcr- ftition, will be as much ridiculed and dcteftcd, as they were tonce venerated and adored. (49) Perfons convalefcing from Jaundice, or fuch as are liable io frequent returns of it, fhould be extremely vigilant, and religioufly refrain from every fpecies of intemperance—Ex- pofure to the unwholefome exhalations of a polluted atmof- phere, and the ufe of ardent fpirits, ought to be ftudioufly and abftemioufly avoided—Many, from the nature of their employments and fituations, are unavoidably expofed to va- rious irregularities; others voluntarily plunge themfelves into the moft unnatural exceffes: thefe gentlemen would do well to reflea, what foes they have to encounter, and the •difficulty attending the re-eftablifhment of health after once having loft it; indeed, from the combined effeas of climate, fituation and their own deleterious condua, too much can- riot be apprehended : and how wretched muft be the exift- ence of that being, who is conftantly tortured by the pains of difeafe, and whofe only moments of eafe, are procured by the reiterated application of medicine. Health is doubtlefs the firft and beft of all temporal bleffings, without it our choiceft pleafures become odious and tirefome—the animal machine dwindles into puerile and enervated effeminacy— Honour and opulence become vague and infignificant titles, and life itfelf an unremitting fwue «f »lf«y ««d diitrefs. Thefe are confiderations, which ought to teach mankind the value of health, and make thofe who poffefs it, (edulouily ftrive to chcrifh and preferve it. « The firft phyficians by debauch were made, « Excefs began, and floth fuftains the trade : « By chace our long-liv'd fathers earn'd their food, « Toil ftrunr; their nerves, and purified their blood, * €c The reader is requefted to Corrtbl the following ERRATA. In pzge 4, line 11, for thefe, read thefes. 7, 17, for confift, read confifts. 8, 14, for deodenum, read duodenum^ zr, 23, for froms, read from. 18, 5, for direaty, read direaiy. 21, 25, for inftrumentarily, read inftrumentality: Idem, 1, for feperation, read feparation. 2Q> i, for truly, read truely.