FIRST LINES
OF THE
PRACTICE OF PHYSIC.
BY
WILLIAM CULLEN, M.D.
Professor of the Practice of Physic in the University of Edinburgh;
First Physician to his Britannic Majesty for Scotland;
Fellow of the Royal College of Physicians of Edinburgh;
Or the Royal Societies of London and of Edinburgh,
Of the Royal Society of Medicine of Paris, &c. &c. &c;
A NEW EDITION.
From the Last British Edition,
REVERSED CORRECTED and ENLARGED, by the AUTHOR.
IN THREE VOLUMES
VOL. 1
PRINTER at WORCESTER, MASSACHUSETTS,
by ISAIAH THOMAS.
Sold at his BOOKSTORE in WORCESTER, and by him and
COMPANY in BOSTON.
MDCCXC.



CONTENTS.
PREFACE - Page 19
INTRODUCTION -- 49
PART I.
OF PYREXIA, OR FEBRILE DIS-
EASES --53
BOOK I.
OF FEVERS –54
CHAPTER I.
Of the Phenomena of Fevers –54
CHAP. II.
Of the Proximate Cause of Fever -- 66
CHAP. III.
Of the Difference of Fevers, and its
Causes ---82
CHAP. 

CONTENTS.
Page
CHAP. IV.
Of the remote Causes of FEVERS - 94
CHAP. V.
Of the Prognosis of FEVERS - 109
CHAP. VI.
Of the Method of Cure in FEVERS 124
Sect.  I. Of the Cure in Continued Fe-
vers --124
Sect. II. Of the Cure of Intermittent
Fevers -- 173
BOOK II.
of INFLAMMATIONS, OR PHLEG-
MASIÆ --- 178
CHAP.I.
Of INFLAMMATION in general178
Sect. I. Of the Phenomena of Inflam-
mation ---178
Sect. II. Of the proximate Cause of In-
flammation –180
Sect. III. Of the Terminations of In-
flammation -188
Sect. IV. Of the remote Causes of In-
flammation --197
Sect. V. Of the Cure of Inflammation 198
CHAP. 

CONTENTS,
Page.
CHAP. II.
Of INFLAMMATION, more strictly Cu-
taneous -- 205
CHAP. III.
0f OPHTHALMIA, or Inflammation of the
Eye - - -209
CHAP. IV.
Of PHRENSY, or Phrenitis -217
CHAP. V.
Of the QUINSY,  or Cynanche - 222:
Sect. I. Of the Cynanche Tonsillaris 222
Sect. II. Of the Cynanche Maligna 226
Sect. III. Of the Cynanche Trachealis 231
Sect. IV. Of the Cynanche Pharyn-
gœa ---237
Sect. V. Of the Cynanche Parotidœa 238
CHAP. VI.
Of PNEUMONIC INFLAMMATION 240.
CHAP. VII.
Of PERIPNEUMONIA NOTHA, or Bas-
tard Peripneumony - 265,
CHAP.


CONTENTS.
Page.
CHAP. VIII.
Of the GASTRITIS, or Inflammation of
the Stomach --- 272
CHAP. IX.
Of the ENTERITIS, or Inflammation of
the Intestines -- 283
CHAP. X.
Of the HEPATITIS, or Inflammation of
the Liver -- 286
CHAP. XI.
Of the NEPHRITIT, or Inflammation of
the Kidneys -- 293
CHAP. XII.
Of the RHEUMATISM -- 296
CHAP. XIII.
Of the TOOTHACH, or Odontalgia 314
CHAP. XIV.
Of the GOUT-- 323                              


19
PREFACE.
TO deliver a System of the Doctrines
and Rules proper for directing the Practice of Physic, is
an undertaking that appears to me to be attended with
great difficulty; and, after an experience of more than
forty years in that practice, as well as after much reading
and reflection, it was with great diffidence that I ever en-
tered upon such a work. It was, however, what seemed
to be my duty as a Professor that induced me to make the
attempt; and I was engaged in it by the same sentiments
that the illustrious Dr. Boerhaave has expressed in the
following passage of the Preface to his Institutions: Simul
enim docendo admotus eram sensi, propriorum cogitatorum ex-
plicatione docentem plus prosicere, quam si opus ab alio con-
scriptum interpretari suscipit. Sua quippe optime intelligit,
sua cuique prœ cœteris placent, unde clarhrsere doctrina, at
que animata plerumque fequitur oratio. Qui vero sensa alte-
rius exponit, inselicius sœpenumero eadem assequitur; quum-
que suo quisque sensu abundat, multa resutanda frequenter in-
venit, unde gravemsrustra laborem aggravat, minusque in-
titata diclione utitur. It is well known, that a Text book
is not only extremely useful, but necessary to students
who are to hear Lectures; and from the same considera-
tions

20 PREFACE.
tions that moved Dr. Boerhaave, I also wished to have one
for myself; while at the same time, from some peculiar
circumstances in my situation, I had some additional in-
ducements to undertake such a work.
BEFORE I was established as a Professor of the Practice
of Physic in this University, I had been employed in giving
Clinical Lectures in the Royal Infirmary; and upon that
occasion had delivered, what, in my own opinion, seemed
most just with regard to both the nature and the cure of
the diseases of which I had occasion to treat. But I soon
found, that my doctrines were taken notice of, as new, and
peculiar to myself; and were accordingly severely criticis-
ed by those who, having long before been trained up in the
system of Boerhaave, had continued to think that that sys-
tem neither required any change, nor admitted of any a-
mendment. I found, at the same time, that my doctrines
were frequently criticised by persons who either had not
been informed of them correctly, or who seemed not to
understand them fully; and therefore, as soon as I was
employed to teach a more complete system of the Prac-
tice of Physic, I judged it necessary to publish a Text
book, not only for the benefit of my hearers, but that I
might also have an opportunity of obtaining the opinion
of the public more at large, and thereby be enabled ei-
ther to vindicate my doctrines, or be taught to correct them.
These were the motives for my attempting the Volumes I
formerly published; and now, from many years experi-
ence of their utility to my hearers, as well as from the fa-
vourable reception they have met with from the Public,
I am induced to give a new edition of this Work, not on-
ly 

21 PREFACE.
ly, as I hope, more correct in many parts, but also more
complete and comprehensive in its general extent.
AT the first publication of this Work, it was intended
chiefly for the use of those Gentlemen who attended my
Lectures: Although, even then, for the reasons I have
mentioned, it was rendered more full than Text books
commonly are; and, in the repeated Editions I have since
had occasion to give, I have been constantly endeavour-
ing to render it more full and comprehensive. In these
respects, I hope the present edition will appear to be ren-
dered more fit for general use, and better calculated to af-
ford satisfaction to all those who think they may still re-
ceive any instruction from reading on this subject.
WHILE I thus deliver my Work in its now more im-
proved state, with the hopes that it may be of use to oth-
ers as well as to those who hear my Lectures, I must at
the same time observe, that  it presents a system which is
in many respects new; and therefore I apprehend it to be
not only proper, but necessary, that I should explain here
upon what grounds, and from what confederations, this
has been attempted.
IN the first place, I apprehend, that, in every branch of
science with respect to which new facts are daily acquired,
and these consequently giving occasion to new reflections,
which correct the principles formerly adopted, it is neces-
sary, from time to time, to reform and renew the whole
system, with all the additions and amendments which it
has received and is then capable of. That at present this
is requisite with regard to the Science of Medicine, will, I
believe,          


22 PREFACE.
believe, readily occur to every person who at all thinks
for himself, and is acquainted with the Systems which have
hitherto prevailed. While, therefore, I attempt this, I
think it may be allowable, and upon this occasion even
proper) that I should offer some remarks on the principal
Systems of Medicine which have of late prevailed in Eu-
rope, and that I should take notice of the present state of
Physic as it is influenced by these. Such remarks, I hope,
may be of some use to those who attempt to improve their
knowledge by the reading of books.
WHETHER the Practice of Physic should admit of rea-
soning, or be entirely rested  upon experience, has long
been, and may still be, a matter of dispute. I shall not,
however, at present enter upon the discussion of this; be-
cause I can venture to assert, that, at almost all times, the
practice has been, and still is, with every person, founded,
more or less, upon certain principles established by rea-
soning: And therefore, in attempting to offer some view
of the present state of Physic, I must give an account of
those systems of the principles of the science which have
lately prevailed, or may be supposed still to prevail, in
Europe.
WHEN, after many ages of darkness, which had destroy-
ed almost the whole of ancient literature, learning was a-
gain restored in the fifteenth century; so, from causes.
which are well known, it was-the system of Galen alone
that the Physicians of those days became acquainted with;
and during the course of the sixteenth century, the study
of Physicians was almost solely employed in explaining
and confirming that system. Early, indeed, in the fif-
teenth. 

23 PREFACE.
teenth century, the noted Paracelsus had laid the founda-
tion of a Chemical System which was in direct opposition to
that of Galen; and, by the efficacy of the medicines em-
ployed by Paracelsus and his followers, their system came
to be received by many: But the systematic Physicians
continued to be chiefly Galenists, and kept possession of
the Schools till the middle of the seventeenth century. It
is not, however, necessary here to enter into any further
detail respecting the fate of those two opposite sects; for
the only circumstance concerning them, which I would
wish at present to point out, is, that, in the writings of
both, the explanations they severally attempted to give of
the phænomena of health or sickness turned very entirely
upon the state of the fluids of the body.
SUCH was the state of the science of Physic till about the
middle of the seventeenth century, when the circulation
of the blood came to be generally known and admitted;
and when this, together with the discovery of the recepta-
cle of the chyle, and of the thoracic duct, finally exploded
the Galenic system. About the same period, a considera-
ble revolution had taken place in the system of Natural
Philosophy. In the course of the seventeenth century,
Galileo had introduced mathematical reasoning; and Lord
Bacon having proposed the method of induction, had
thereby excited a disposition to observe facts, and to make
experiments. These new modes of philosophizing, it
might be supposed, would soon have had some influence
on the state of medicine; but the progress of this was slow.
The knowledge of the Circulation did indeed necessarily
lead to the consideration as well as to a clearer view of the
Organic System in animal bodies; which again led to the
application

24 PREFACE.
application of the mechanical philosophy towards explain-
ing the phænomena of the animal economy; and it was
applied accordingly, and continued, till very lately, to be
the fashionable mode of reasoning on the subject. Such
reasoning, indeed, must still in several respects continue to
be applied: But it would be easy to show, that it neither
could, nor ever can be, applied to any great extent in ex-
plaining the animal economy; and we must therefore look
for other circumstances which had a greater share in
modelling the system of Physic.
WITH this view it may be remarked, that, till the pe-
riod just now mentioned, every Physician, whether Ga-
lenist or Chemist, had been so much accustomed to con-
fider the state and condition of the fluids, both as
the cause of disease, and as the foundation for explaining
the operation of medicines, that what we may term an Hu-
moral Pathology still continued to make a great part
of every system. In these circumstances, it was soon per-
ceived, that chemistry promised a much better explana-
tion than the Galenic or Aristotelian philosophy had
done; and, therefore, while the latter was entirely laid a-
side a chemical reasoning was everywhere received. Lord
Bacon, with his usual sagacity, had early observed, that
chemistry promised a great number of facts, and he there-
by gave it credit; whilst the Corpuscularian philosophy, re-
stored by Gaslendi, readily united with the reasonings of the
Chemists; and the philosophy of Des Cartes readily unit-
ed with both. From all these circumstances, an Humoral,
and chiefly a Chemical Pathology, came to prevail very
much till the end of the last century; and has, indeed,
continued 

25 PREFACE.
continued to have a great share in our systems down to the
present time.
IT is proper now, however, to observe, that about the be-
ginning of the present century, when every part of science
came to be on a more improved and correct footing, there
appeared in the writings of STAHL, of HOFFMAN, and of
BOERHAAVE, three new, and considerably different, Sys-
tems of Physic; which have ever since had a great share
in directing the practice of it. In order, therefore, to
give a nearer view of the present state of Physic, I shall of-
fer some remarks upon these different systems; endeavour-
ing to point out the advantages as well as the disadvan-
tages of each, and how far they still prevail; or, ac-
cording to my judgment, deserve to do so.
I SHALL begin with considering that of Dr. Stahl, which
I think appeared first, and for a long time after was the
prevailing system in Germany.
THE chief and leading principle of this system is, that
the rational foul of man governs the whole economy of
his body. At all times, Physicians have observed, that
the animal economy has in itself a power or condition, by
which, in many instances, it resists the injuries which
threaten it; and by which it also, on many occasions, cor-
rects or removes the disorders induced, or arising in it.
This power, Physicians very anciently attributed, under a
vague idea, to an agent in the system, which they called
NATURE; and the language of a vis conservatrix et med-
uatrix nature, has continued in the schools of medicine
from the most ancient times to the present.
B DR.

26 PREFACE.
DR. STAHL has explicitly founded his system on the
supposition, that the power of nature, so much talked of,
is entirely in the rational foul. He supposes, that, upon
many occasions, the foul ads independently of the state of
the body; and that, without any physical necessity arising
from that state, the foul, purely in consequence of its in-
telligence, perceiving the tendency of noxious powers
threatening, or of disorders anywise arising in the system,
immediately excites such motions in the body as are suited
to obviate the hurtful or pernicious consequences which
might otherwise take place. Many of my readers may
think it was hardly necessary for me to take notice of a
system founded upon so fanciful a hypothesis; but there is
often so much seeming appearance of intelligence and de-
sign in the operations of the animal economy, that many
eminent persons, as Perrault in France, Nichols and Mead
in England, Porterfield and Simson in Scotland, and
Gaubius in Holland, have very much countenanced the
same opinion, and it is therefore certainly entitled to some
regard. It is not, however, necessary for me here to en-
ter into any refutation of it. Dr. Hoffman has done this
fully, in his Commentarius de differentia inter Hoffmanni
doctrinam medico-mecbanicam et G.E. Stablii medico organ-
icam; and both Boerhaave and Haller, though no favour-
ers of materialism, have maintained a doctrine very oppa-
site to that of Stahl.
IN my Physiology I have offered some arguments against
the same; and I shall only add now, that whoever consid-
ers what has been said by Dr. Nichols in his Oratio de An-
ima Medica, and by Dr. Gaubius in some parts of his
Pathology, must perceive, that the admitting of such a
capricious government of the animal economy, as these
authors 

27 PREFACE.
authors in some instances suppose, would at once lead us
to reject all the physical and mechanical reasoning we
might employ concerning the human body. Dr. Stahl
himself seems to have been aware of this; and therefore,
in his Preface to Juncker's Conspeclus Therapiœ Specialis,
has acknowledged, that his general principle was not at
all necessary; which is in effect saying that it is not com-
patible with any system of principles that ought to govern
our practice. Upon this footing, I might have at once
rejected the Stahlian principle: But it is even dangerous
to bring any such principle into view; for, after all Dr.
Stahl had said in the passage just now referred to, I find,
that, in the whole of their practice, both he and his fol-
lowers have been very much governed by their general
principle. Trusting much to the constant attention and
wisdom of nature, they have proposed the Art of curing by
expectation; have therefore, for the most part, proposed
only very inert and frivolous remedies; have zealously
opposed the use of some of the most efficacious, such as o-
pium and the Peruvian bark; and are extremely reserved
in the use of general remedies, such as bleeding, vomiting,
&c.
ALTHOUGH these remarks, upon a system which may
now be considered as exploded or neglected, may seem
superfluous; I have been willing to give these strictures
on the Stahlian system, that I might carry my remarks a
little farther, and take this opportunity of observing, that,
in whatever manner we may explain what have been call-
ed the operations of nature, it appears to me, that the gen-
eral doctrine of Nature curing diseases, the so much vaunt-
ed Hippocratic method of curing, has often had a very
baneful influence on the practice of physic; as either lead-
B 2 ing 

28 PREFACE.
ing physicians into, or continuing them in, a weak and fee-
ble practice; and at the same time superseding or discour-
aging all the attempts of art. Dr. Huxham has properly
observed, that even in the hands of Sydenham it had this
effect. Although it may sometimes avoid the mischiefs of
bold and rash practitioners, yet it certainly produces that
caution and timidity which have ever opposed the intro-
duction of new and efficacious remedies. The opposition
to chemical medicines in the sixteenth and seventeenth
centuries, and the noted condemnation of Antimony by the
Medical Faculty of Paris, are to be attributed chiefly to
those prejudices, which the physicians of France did not
entirely get the better of for near a hundred years after.
We may take notice of the reserve it produced in Boer-
liaave, with respect to the use of the Peruvian Bark. We
have had lately published, under the title of Constitutiones
Epidemiœ, notes of the particular practice of the late
Baron Van Swieten; upon which the editor very properly
observes, That the use of the bark, in intermitting fevers,
appears very rarely in that practice; and we know very
well where Van Swieten learned that reserve.
I MIGHT go farther, and show how much the attention
to the Autocrateia, allowed of, in one shape or other, by
every sect. has corrupted the practice among all physi-
cians, from Hippocrates to Stahl. It must, however, be
sufficiently obvious, and I shall conclude the subject with
observing, that although the vis medicatrix naturæ must
unavoidably be received as a fact; yet, wherever it is ad-
mitted, it throws an obscurity upon our system; and it is
only where the impotence of our art is very manifest and
considerable, that we ought to admit of it in practice.
TO 

29 PREFACE.
to finish our remarks upon the Stahlian System, I shall
shortly observe, that it did not depend entirely upon the
Autocrateia, but also supposed a state of the body and dis-
eases, that admitted of remedies; which, under the power
and direction of the foul, acted upon the organization and
matter of the body, so as to cure its diseases. Upon this
footing, the Stahlian pathology turned entirely upon Pleth-
ora and Cacochymy. It was with respect to the former
that they especially applied their doctrine of the Autocra.
teia in a very fanatical manner; and, with respect to the
latter, they have been involved in a humoral pathology as-
much as the systematic physicians who had gone before
them, and with a theory so incorrect as not to merit now
the smallest attention. After all, I ought not to dismiss the
consideration of the Stahlian system, without remarking,
that as the followers of this system were very intent upon
observing the method of nature, so they were very atten-
tive in observing the phenomena of diseases, and have giv-
en us in their writings many facts not to be found else-
where
WHILE the doctrines of Stahl were prevailing in the u-
niversity of Halle, Dr. Hoffman, a professor in the same
university, proposed a system that was very different. He
received into his system a great deal of the mechanical,
Cartesian, and chemical doctrines of the systems which
had appeared before: But, with respect to these, it is of
no consequence to observe in what manner he modified
the doctrines of his predecessors, as his improvements in
these respects were no ways considerable, and no part of
them now remain; and the real value of his works, be-
yond what I am just now going to mention, rests entirely
B 3. on 

30 PREFACE.
on the many facts they contain. The merit of Dr. Hoff-
man and of his works is, that he made, or rather suggested,
an addition to the system, which highly deserves our atten-
tion. Of this I cannot give a clearer account than by giving
it in the author's own words. In his Medicina Rationalis
Systematica, Tom. III. § 1. chap. 4. he has given his Gene-
alogia morborum ex turbato solidorum, et fluidorum mechanis-
mo; and in the 47th and last paragraph of this chapter, he
sums up his doctrine in the following words: Ex hisce au-
tem omnibus uberius hactenus excussis, per quam dilucide ap.
Parere arbitror, quod solus SPASMUS et simplex ATONIA, œ-
quabilem, liberum,ac proportionatum sanguinis omnisque gen-
eris fluidorum motum, quibus excretionum successus et integri-
tas functionum animi et corporis proxime nititur, turbando ac
pervertendo, universam vitalem œconomiam subruant ac des-
truant; atque hincuniversa pathologia longe rectius atque sacll-
ins EX VITIO MOTUUM MICRCOS MICORUM IN SOLIDIS,
quam EX VARITS AFFECTIONIBIS VITIOSORUM HUMO-
RUM, deduci atque explkari possit, adeoqne omnis generis a-
gritudines interne, ad PRÆTEENA TUALES GENERIS
NERVOUS AFFECTIONES sint referendœ. Etenim lœsis quo-
cunque modo, vel nervisper corpus discurrentibus, vel mem-
branosis quibusvis nervosis partibus, illico motuum anomaliœ,
modo leviores, modo graviores subsequuntur.  Deinde attenta
observatio doces, motus quosvis morbosos principaliter sedem
figere et tyrannidem exercere in nervosis corporis partibus,
cujus generis prœter omnes canales, qui systaltico et diastalti-
co motu pollentes, contentos succos tradunt, universum nimi-
rum intestinorum et ventriculi ab œsopbago ad anum cana-
lem, totum systema vasorum arteriosorum, dutluum biliarh-
rum, salivalium, urinariorum et subcutaneorum, sunt quoque
membrane nerveo-muscularcs cerebri et medulla spinalis,
prœsertim bœc, quœ dura mater vacatur, organis sensortis
obductœ,                            

31 PREFACE.
obductœ, nec non tunicœ illœ ac ligamenta, que offa cingunt
artusque sirmant. Nam nullus dolor, nulla inflammatio,
nullus spasmus, nulla motus et sensus impotentia, nulla sebris
aut humoris illius excretio, accidit, in qua non bœ partes pa-
tiantur. Porro etiam omnes, que morbos gignunt cause,
operationem suam potissimum persiciunt in partes motu et sen-
su prœditas, et canales ex bis coagmentatos, eorum motum,
et cum hoc sluiddorum cursum, pervertendo; ita tamen, ut
sicuti variœ indolis funt, sie etiam varie in nerveas partes a-
gant, iisdemque noxam affricent. Demunt omnia quoque eximie
virtutis medicamenta, non tam in partis fluidas, carum era-
sin ac intemperiem corrigendo, quam potius in solidas et
nervosas, earundem motus alterando ac moderando, suam
edunt operationem: De quibus tamen omnibus, in vulgari us-
que eo recepta morborum doctrina, altum est silentium.
IT is true that Dr. Willis had laid a foundation for this
doctrine, in his Pathologia Cerebri et Nervorum; and Bag-
livi had proposed a system of this kind in his Specimen de
fibra motrici et morbosa. But, in these writers, it was ei-
ther not extensively applied to diseases, or was still so in-
volved in many physiological errors, that they had at-
tracted little attention; and Dr. Hoffman was the first
who gave any tolerably simple and clear system on the
subject, or pointed out any extensive application of it to
the explanation of diseases.
THERE can be no fort of doubt that the phenomena of
the animal economy in health and in sickness, can only be
explained by considering the state and affections of the
primary moving powers in it. It is to me surprising that
physicians were so long of perceiving this, and I think we
are therefore particularly indebted to Dr. Hoffman for
B 4 putting;

32 PREFACE.
putting us into the proper train of investigation; and it
every day appears that Physicians perceive the necessity
ofentering more and more into this inquiry. It was this,
I think, which engaged Dr. Kaaw Boerhaave to publish
his work intitled lmpetum saciens; as well as Dr. Gaubius
to give the Pathology of the Solidum vivum.  Even the
Baron Van Swieten has upon the same view thought it
necessary, in at least one particular, to make a very con-
siderable change in the doctrine of his matter, as he has
done in his Commentary upon the 755th Aphorism. Dr.
Haller has advanced this part of science very much by his
experiments on irritability and sensibility. In these and in
many other instances, particularly in the writings of Mr.
Barthez of Montpelier, of some progress in the study of
the affections of the Nervous System, we must perceive
how much we are indebted to Dr. Hoffman for his so
properly beginning it. The subject, however, is difficult:
The laws of the Nervous System, in the various circum-
stances of the animal economy, are by no means ascer-
tained; and, from want of attention and observation with
the view so a system on this subject, the business appears
to many as an inexplicable mystery. There is no wonder,
therefore, that, on such a difficult subject, Dr. Hoffman's
system was imperfect and incorrect; and has had less in-
fluence on the writings and practice of Physicians since
his time, than might have been expected. He himself has
not applied his fundamental doctrine so extensively as he
might have done; and he has every where intermixed an
Humoral Pathology as incorrect and hypothetical as any
other. Though he differed from his colleague Dr. Stahl
in the fundamental doctrines of his system, it is but too
evident that he was very much infected with the Stahlian
doctrines 

33 PREFACE.
doctrines of Plethora and Cacochymy, as may be observ-
ed throughout the whole course of his work; and particu--
larly in his chapter De morborum generatiane ex nimia san-
guinis quantitate et humorum impuritate.
BUT it is needless for me to dwell any longer upon the
system of Hoffman; and I am next to offer some remarks
on the system of Dr. Boerhaave the cotemporary of both
the other Systematics, and who, over all Europe, and es-
pecially in this part of the world, gained higher reputa-
tion than either of the others.
DR. BOERHAAVE was a man of general erudition; and,
in applying to medicine, he had carefully studied the aux-
iliary branches of Anatomy, Chemistry, and Botany, so
that he excelled in each. In forming a System of Physic,
he seems to have studied diligently all the several writ-
ings of both ancient and modern physicians; and, without
prejudice in favour of any former systems, he endeavour-
ed to be a candid and genuine ecclectic.  Possessed of an
excellent systematic genius, he gave a system superior to
any that had ever before appeared;  As in the great ex-
tent, and seemingly perfect consistency, of system, he ap-
peared to improve and refine upon everything that had
before been offered; and as in his Lectures he explained
his doctrines with great clearness and elegance; he soon
acquired a very high reputation, and his system was more
generally received than any former had been since the
time of Galen. Whoever will consider the merits of Dr.
Boerhaave, and can compare his system with that of form-
er writers, must acknowledge that he was very justly es-
teemed, and gave a system which was at that time deserv-
edly valued.
B-5, BUT,          

34 PREFACE.
BUT, in the progress of an inquisitive and industrious
age, it was not to be expected that any system should last
so long as Boerhaave's has done. The elaborate Com-
mentary of Van Swieten on Boerhaave's system of prac-
tice, has been only finished a few years ago; and though
this Commentator has added many facts, and made some
corrections, he has not, except in the particular mention-
ed above, made any improvement in the general system.
It is even surprising that Boerhaave himself, though he
lived near forty years after he had first formed his system,
had hardly in all  that time made any corrections of it or
additions to it; the following is the most remarkable. In
Aphorisin 755, the words forte et nervosi, tarn cerebri quam
cerebelli cordi destinati inertia, did not appear in any e-
dition before the fourth; and what a difference of system.
this points at, every physician must perceive.
WHEN I first applied to the study of Physic, I learned
only the system of Boerhaave; and even when I came to
take a Professor's chair in this university, I found that sys-
tem here in its entire and full force; and as I believe it
still subsists in credit elsewhere, and that no other system
of reputation has been yet offered to the world, I think it
necessary for me to point out particularly the imperfec-
tions and deficiencies of the Boerhaavian system, in order
to show the propriety and necessity of attempting a new
one.
TO execute this, however, so fully as I might, would
lead me into a detail that can hardly be admitted of here
and I hope it is not necessary, as I think, that every intel-
ligent person, who has acquired any tolerable knowledge
of the present state of our science, must, in many instances
perceive

35 PREFACE.
perceive its imperfections. I shall therefore touch only
upon the great lines of this system; and from the remarks
Pam to offer, trust that both the mistakes and deficiencies
which run through the whole of his works will appear.
DR. BOERRAAVE’S treatise of the diseases of the simple
solid, has the appearance of being very clear and consid-
ent, and was certainly considered by him as a fundamental
doctrine; but, in my apprehension, it is neither correct
nor extensively applicable. Not to mention the useless,
and perhaps erroneous, notion of the composition of earth
and gluten; nor his mistake  respecting the structure of
compound membranes; nor his inattention to the state of
the cellular texture; all of them circumstances which
render his doctrine imperfect; I shall insist only upon the
whole being very little applicable to the explaining the
phenomena of health or sickness. The laxity or rigidity
of the simple solid, does, indeed, take place at the differ-
ent periods of life, and may perhaps; upon other occasions,,
occur as the cause of disease: But I presume, that the
state of the simple solid is, upon few occasions, either
changeable or actually changed; and that, in ninety nine
cases of an hundred, the phenomena attributed to such a
change, do truly depend on the state of the solidum vivum;
a circumstance which Dr. Boerhaave has hardly taken
notice of in any part of his works. How much this shows
the deficiency and imperfection of his system, I need not
explain. The learned work of Dr. Gaubius, above re-
ferred to, as well as many other treatises of late authors,.
point out sufficiently the defects and imperfections of'
Boerhaave on this subject.
AFTER Dr. Boerhaave has considered the diseases of the
solids, lie in the next place attempts to explain the more
B 6 simple

36 PREFACE.
simple diseases of the fluids; and there, indeed, he deliv-
ers a more correct doctrine of acid and alkali than had
been given before: But, after all, he has done it very im-
perfectly. We have, indeed, since his time, acquired more
knowledge upon the subject of digestion; and so much as
to know, that a great deal more is yet necessary to enable
us to understand in what manner the animal fluids are
formed from the aliments taken in. And although Dr.
Boerhaave has fallen into no considerable error with re-
spect to a morbid acidity in the stomach, he could not pos-
sibly be complete upon that subject; and his notion of the
effects of acidity in the mass of blood seems to have been
entirely mistaken, and is indeed not consistent with what he
himself has delivered elsewhere.
HIS doctrine of alkali is somewhat better founded, but
is probably carried too far; and the state of alkalescency
and putrefaction, as well as all the other changes which
can take place in the condition of animal fluids, are par-
ticulars yet involved in great obscurity, and are therefore
still subjects of dispute.
THERE is another particular, in which Boerhaave's doc-
trine concerning the fluids appears to me imperfect and
unsatisfactory; and that is, in his doctrine de Glutinoso
spontaneo. The causes which he has assigned for it are by
no means probable, and the actual existence of it is seldom
to be proved. Some of the proofs adduced for the exist-
ence of the phlegma calidum, are manifestly founded on a
mistake with respect to what has been called the inflam-
matory cruft, (see Van Swieten's Commentary, page 96);
and the many examples given by Boerhaave of a glutinosum
appearing in the human body, (Apb. 75.) are an of them
nothing 

37 PREFACE.
nothing more than instances of collections or concretions
found out of the course of the circulation.
IF, then, we consider the imperfection of Dr. Boer-
haave's doctrine with respect to the state and various con-
dition of the animal fluids; and if at the same time we re-
flect how frequently he and his followers have employed
the supposition of an acrimony or Ientor of the fluids, as
causes of disease, and for directing the practice; we must,
as I apprehend, be satisfied, that his system is not only de-
ficient and incomplete, but fallacious and apt to mislead.
Although it cannot be denied, that the fluids of the hu-
man body suffer various morbid changes; and that upon
these, diseases may primarily depend; yet I must beg leave
to maintain, that the nature of these changes is seldom un-
derftood, and more seldom still is it known when they
have taken place: That our reasonings concerning them,
have been, for the most part, purely hypothetical; have
therefore contributed nothing to improve, and have often
misled the practice of physic. In this, particularly, they
have been hurtful, that they have withdrawn our attention
from, and prevented our study of, the motions of the ani-
mal system, upon the state of which the phenomena of dis-
eases do more certainly and generally depend. Whoever,
then, shall consider the almost total neglect of the state of
the moving powers of the animal body, and the prevalence
of an hypothetical humoral pathology, so conspicuous in
every part of the Boerhaavian System, must be convinced
of its very great defects, and perceive the necessity of at-
tempting one more correct.
AFFTER giving this general view, it is not requisite to en-
ter into particulars: But, I believe, there are very few
pages         

38 PREFACE.
pages of his aphorisms in which there does not occur some
error or defect; although, perhaps, not to be imputed to
the fault of Boerhave, so much as to this, that since his-
time a great collection of new facts has been acquired by
observation and experiment. This indeed, affords the best
and most solid reason for attempting a new system: For
when many new facts have been acquired, it becomes requi-
fite that these should be incorporated into a system,where-
by not only particular subjects may be improved, but the
whole may be rendered more complete, consistent, and
useful. Every system, indeed, must be valuable in pro-
portion to the number of facts that it embraces and com-
prehends; and Mons. Quesney could not pay a higher
compliment to the System of Boerhaave, than by saying;
that it exhibited La medicine collective.
BUT here it will, perhaps, be suggested to me, that the
only useful work on the subject of Physic, is the making
a collection of all the facts that relate to the art, and
therefore of all that experience has taught us with respect:
to the cure of diseases. I agree entirely in the opinion;
but doubt if it can ever be properly accomplished, with-
out aiming at some system of principles, by a proper in-
duction and generalisation of facts: At least I am per-
suaded that it can be done not only very safely, but most
usefully in this way. This, however, must be determin-
ed by a trial. I know that the late Mr. Lieutaud has at-
tempted a work on the plan of collecting facts without
any reasoning concerning their causes: And while I am
endeavouring to give some account of the present state of
Physic, I cannot dismiss the subject without offering some
remarks upon the promising Synopsis universœ medicine,
composed.

39 PREFACE.
composed by the first physician of a learned and ingenious
nation.
IN this work there are many facts and much observa-
tion from the Author's own experience, which may be
usetul to those who have otherwise acquired some knowl-
edge and discernment; but, throughout the whole work,
there is such total want of method, arrangement, system,
or decifion, that, in my humble opinion, it can be of little
use, and may prove very perplexing to those who are yet
to learn. The distinction of the genera of diseases, the
distinction of the species of each, and often even that of
the varieties, I hold to be a necessary foundation of every
plan of Physic, whether Dogmatical or Empirical. But
very little of this distinction is to be found in the work of
Mr. Lieutaud; and in his preface he tells us, that he
meant to neglect such arguta sedulitas. And indeed his
method of managing his subject must certainly interrupt
and retard all methodical nosology. His arrangement of
diseases is according to no affinity, but that of the slightest
and uninstructive kind, the place of the body which they
happen to affect. His Generalia et incertœ sedis, have
hardly any connexion at all; the titles Rheumatisms, Hy-
pocbondriasis, Hydrops, follow one another. When he does
attempt any general doctrine, it is not till long after he
has treated of the widely scattered particulars. Under
each particular title which he assumes, he has endeavour-
ed to enumerate the whole of the symptoms that ever ap-
peared in a disease under that title; and this without
aiming at any distinction between the essential and acci-
dental symptoms, or marking the several combinations
Under which these symptoms do for the most part steadily
appear. 

40 PREFACE.
appear. From the concurrence of accidental symptoms,
the variety of the same disease is frequently considerable,
a circumstance necessarily perplexing and distracting to
young practitioners; but it seems strange to me, that an
experience of thirty years, in considerable practice, could
do nothing to relieve them.
MR. LIEUTEAD has at the same time increased the con-
fusion that must arise from this want of distinction, by
his considering as primary diseases, what appear to me to
be the symptoms, effects, and sequels, of other diseases
only. Of this I think the Æstus morbosus, Virum exolutio,
Dolores, Stagnatio sanguinis, Purulentia, Tremor, Pervigili-
um, Raucedo, Suffocatio, Vomica, Empyema, Singultus, Vom-
hus Dolor Stomachi, Tenesmus, all treated of under sepa-
rate titles, are examples. A general symptomatologia may
be a very useful work, with a view to a System of Patholo-
gy; but, with a view to practice without any System, it
must have bad effects, as leading only to a palliative
practice, and diverting from the proper efforts towards
obtaining a radical cure. Mr. Lieutaud, indeed, has en-
deavoured to exhibit the symptoms above mentioned as
so many primary diseases: But he has seldom succeeded in
this; and, in delivering the practice, he commonly finds .
it necessary to consider them as symptoms, and that not
without some theory, implied or expressed, with respect?
to their proximate causes. His title of Dolores may be tak-
en as an example of this; and from which it may be
readily perceived how far such treatises can be really.
useful.
IN establishing a proper pathology, there is nothing that
has been of more service than the Dissection of morbid
bodies.          

41 PREFACE.
bodies. Mr. Lieutaud has been much and most com-
mendably employed in this way, and in this Synopsis he
has endeavoured to communicate his knowledge on the
subject; but, in my humble opinion, he has seldom done
it in a manner that can be useful. In the same way that
he has delivered the symptoms of diseases without any
instructive arrangement; so, on the subject of the appear-
ances after death, he has mentioned every morbid appear-
ance that had ever been observed after the disease of
which he is then treating; but these appearances are
strangely huddled together, without any notice taken of
those which belong to one set of symptoms or to another;
and, with regard to the whole, without any attempt to
distinguish between the causes of diseases and the causes
of death; although the want of such distinction is the
well known ground of fallacy upon this subject. I take
for an example, the appearances mentioned as having been
observed after dropsy. Here morbid appearances, found
in every part of the body, in every cavity of it, and in ev-
ery viscus contained in these cavities, are enumerated;
but which of these morbid states are more frequent or
more rare, and which had been more particularly con-
nected with the different causes, or with the different state
of symptoms previously recited, we are not informed, nor
has he enabled us to discover. In short, the dissection of
morbid bodies has been, and may be, highly useful; but
in order to be so, it must be under a different management
from what we find, either in this Synopsis, or even in the
Historia Anatomico-medica.
I CANNOT dismiss this subject without remarking, that
the dissection of morbid bodies, is chiefly valuable upon
account

42 PREFACE.
account of its leading us to discover the proximate causes-
of diseases; and the great and valuable work of the illus-
trious Morgagni, is properly intitled De sedibus et CAUSIS.
It may well seem surprising, then, that Lieutaud should
find the whole of proximate causes atra caligine mersas
and that he should never have thought of applying his
diffection towards the ascertaining at least some of these.
BUT let me now proceed to consider the important part
of every practical work, and of this Synopsis universe medi-
cinœ; that is, the method of curing diseases.
HERE, again, upon the same plan as in giving the histories
of difeafe, the method of cure is delivered by enumerating
the whole of the remedies that have ever been employed
in a disease under the title prefixed; without assigning the
species, or the circumstances to which the remedies,
though of a very different and sometimes opposite nature,
are peculiarly adapted. On the subject of Asthma, he very
justly observes that physicians have been to blame in con-
founding under this title, almost all the species of Dys-
pnœa; and he himself very properly considers Asthma as
a disease distinct  from all the other cases of Dyspnœa. Still,
however, he considers Asthma as of many different species,
arising from many different causes, which, till we under-
stand better, we cannot attempt to remove. Notwithstand-
ing all this, he proceeds to deliver a very general cure.
Parum abest, says he, quin specifict titulo gaudeant pefloralia,
vulneraria, et incidentia! But from such language I receive
no clear idea; nor can I obtain any clear direction from
the enumeration of his medicines. Baccœ juniperi, gummi
tragacantbum vel ammoniacum, sapo, aqua picea, terebinthi-
na, &c. quœ tamen baud indifcritninatim sunt usurpanda, fed
pro-

43 PREFACE.
pro re nata, delectu opus est. Very justly indeed, delectu
opus est; but here, as in many other instances, he gives us
no fort of assistance,
FROM his endeavours, though not always successful, to
neglect all system, his practice is generally delivered in a
very indecisive manner; or, what has the same effect, in a
way so conditional as will render it always difficult, and
often impossible, for a young practitioner to follow him.
Let us take, for example, his cure of Dropsy. " The cure
" may be begun by bloodletting in certain conditions;
“ but, in others, it cannot be employed without danger. It
" gives relief in difficult breathing; but, after it is practis-
" ed, the symptoms are aggravated, and rendered more obsti-
" nate. It is not to he concealed that some persons have
" been cured by repeated bloodlettings, or spontaneous
“ hæmorrhagies; but it is at the same time known, that such
“ a remedy inopportunely employed, has in many instances has-
" tenedon the fatal event."
IN the same manner he treats of vomiting, purging,
sweating, and the use of mineral waters; but I must con-
sess, that he has no where removed any of my doubts or
difficulties, and indeed he has sometimes increased them.
He says, that hepatics, or aperients, such as the lingua cer-
vina, berbe capillares, &c. deserve commendation; but
that, when the disease has arisen to a certain degree, they
have been, or the most part, found to be useless. He observes,
that the powder of toads given in wine, to the quantity of a
scruple or more, has succeeded with severals.
SUCH are, commonly, the methods of enre delivered
by Mr. Lieutaud, longiori et forte selicissima praxi edoctus.
IT

44 PREFACE.
IT would be tedious to enter further into that detail
which a criticism of this irnmethodical and uninstructive
work might lead  me into ;  but, if the bounds proper for
this preface did not prevent me, I would particularly
show that the work is far from being free from those rea-
sonings which the author pretends to avoid, and would af-
fect even to despise. He still holds the doctrines of the
concoction and critical evacuation of morbis-
ic matter; doctrines depending upon subtile theories,
and which, in my opinion, can in nowise be ascertained
as matters of fact. Mr. Lieutaud likewise is still very
much upon the old plan of following nature, and there-
fore gives often what I consider as a feeble and inert prac-
tice. The humectantia, diluentia, demulcentia, et temperan-
tia, are with him very universal remedies, and often those
which alone are to be employed.
THE mention of these medicines might lead me to take
notice of Mr. Lieutaud's second volume, in which, ab in-
sula remediorum sarragine alienus, he promises a great res-
ormation upon the subject; but this falls so far short of
the idea of British physicians, that I need not make any
remarks upon it. With respect to his lift of simples, or
Emporetica, as he is pleased to term them, an English apoth-
ecary would smile at it; and with respect to his officinalia,
I believe they are to be found no where but in the Codex
Medicamentarius of Paris; and in his Magistralia his doses
are generally such as the most timid practitioner of this
country would hardly descend to, and such as none of our
practitioners of experience would depend upon. In short,
the whole of the work, both with respect to the theories
with which it abounds, and to the facts which it gives,
will

45 PREFACE.
will not, in my apprehension, bear any serious criticism.
But I must conclude; and shall only say further, that such
as I have represented it, is this work, executed by a man
of the first rank in the profession. It is indeed for that
reason I have chosen it as the example of a work, upon
the plan of giving facts only, and of avoiding the study or
even the notice of the proximate causes of diseases; and
with what advantage such a plan is pursued, I shall leave
my readers to consider.
IN the following treatise I have followed a different
course. I have endeavoured to collect the facts relative
to the diseases of the human body, as fully as the nature of
the work and the bounds necessarily prescribed to it would
admit: But I have not been satisfied with giving the facts,
without endeavouring to apply  them to the investigation
of proximate causes, and upon these to establish a more
scientific and decided method of cure. In aiming at this,
I flatter myself that I have avoided hypothesis, and what
have been called theories. I have, indeed, endeavoured
to establish many general doctrines, both physiological;
and pathological; but I trust that these are only a general-
isation of facts, or conclusions from a cautious and full
induction; and if any one shall refute to admit, or directiy
shall oppose, my general doctrines, he must do it by show-
ing that I have been deficient or mistaken in assuming and
applying facts. I have, myself, been jealous of my being
sometimes imperfect in these respects; but I have gener-
ally endeavoured to obviate the consequences of this, by
proving, that the proximate causes which I have assigned,
are true in fact, as well as deductions from any reasoning
that I may seem to have employed. Further, to obviate
any dangerous fallacy in proposing a method of cure, I
have

46 PREFACE.
have always been anxious to suggest that which, to the
best of my judgment, appeared to be the method approved
of by experience, as much as it was the consequence of
system.
UPON this general plan I have endeavoured to form a
system of physic that should comprehend the whole of the
facts relating to the science, and that will, I hope, collect
and arrange them in better order than has been done be-
fore, as well as point out in particular those which are still
wanting to establish general principles. This which I
have attempted, may, like other systems, hereafter suffer
a change; but I am confident that we are at present in a
better train of investigation than physicians were in before
the time of Dr. Hoffman. The affections of the motions
and moving powers of the animal economy, must certainly
be the leading inquiry in considering the diseases of the hu-
man body. The inquiry may be difficult; but it must be
attempted, or the subject must be deserted altogether. I
have, therefore, assumed the general principles of Hoff-
man, as laid down in the passage which I have quoted a-
Love; and if I have rendered them more correct, and more
extensive in their application; and, more particularly, if
I have avoided introducing the many hypothetical doc-
trines of the Humoral Pathology which disfigured both
his and all the other systems which have hitherto prevail-
ed; I hope I shall be excused for attempting a system,
which upon the whole may appear new.
Edinburgh, Nov. 1783.

PART I.
OF PYREXIÆ
OR
FEBRILE DISEASES. 



FIRST LINES
OF THE
PRACTICE OF PHYSIC.
Introduction.
I.
IN teaching the Practice
of Physic, we endeavour
to give instruction for
discerning, distinguishing,
preventing, and curing dis-
eases, as they occur in par-
ticular persons.
II.
The art of DISCERNING and DISTINGUSH
ING diseases, may be best attained by an ac-
C curate

50 PRACTICE
curate and complete observation of their phe-
nomena, as these occur in concourse and in
succession, and by constantly endeavouring to
distinguish the peculiar and inseparable con-
currence of symptoms, to establish a METHOD-
ICAL NOSOLOGY, or an arrangement of dis-
eases according to their genera and species,
founded upon observation alone, abstracted
from all reasoning. Such an arrangement I
have attempted in another work, to which in
the course of the present I shall frequently
refer.
III.
THE PREVENTION of diseases depends
upon the knowledge of their remote causes;
which is partly delivered in the general Pa-
thology, and partly to be delivered in this
treatise.
IV.
THE CURE of diseases is chiefly, and al-
most unavoidably, founded in the knowledge
of their proximate causes. This requires an
acquaintance with the Institutions of Medi-
cine; that is, the knowledge of the structure,
a&ion, and functions of the human body;
of the several changes which it may undergo;
and of the several powers by which it can
be changed. Our knowledge of these par-
ticulars,

51 OF PHYSIC.
ticulars, however, is still incomplete, is in
many respect doubtful, and has been often
involved in mistake and error. The doc-
trine, therefore, of proximate causes, founded
upon that knowledge, must be frequently pre-
carious and uncertain. It is, however, possi-
ble for a judicious physician to avoid what is
vulgarly called theory, that is, all reasoning
founded upon hypothesis, and thereby many
of the errors which have formerly taken
place in the Institutions of Medicine. It is
possible also for a person who has an extensive
knowledge of the facts relative to the animal
economy in health and in sickness, by a cau-
tious and complete induction, to establish
many general principles which may guide his
reasoning with safety; and while, at the same
time, a physician admits as a foundation of
practice those reasonings only which are sim-
ple, obvious and certain, and for the most part
admits as proximate causes those alone that
are established as matters of fact rather than
as deductions of reasoning, he may with great
advantage establish a system of practice chiefly
founded on the doctrine of proximate causes.
But when this cannot be done with sufficient
certainty, the judicious and prudent physician
will have recourse to Experience alone;
always, however, aware of the hitherto in-
complete and fallacious state of Empiricism.
C 2 V.

52 PRACTICE, &c.
V.
With a strict: attention to these considera-
tions in the whole of the following Treatise,
I proceed to treat of particular diseases in the
order of my Methodical Nosology.
PART

PART I.
Of Pyrexiae, or Jebrile Diseases
VI.
PYREXIÆ, or febrile diSeaSes,
are distinguished by the fol-
lowing appearances. After
beginning with some degree
of cold shivering, they show
some increase of heat, and
an increased frequency of pulse, with the in-
terruption and disorder of several functions,
particularly some diminution of strength in
the animal functions.
VII.
OF the Pyrexiæ I have formed a class,
and have subdivided it into the five orders of
FEVERS, INFLAMMATIONS, ERUPTIONS,
HEMORRHAGIES, and FLUXES. See Synop-
sis Nosologiæ Methodicæ, Edit. 3. 1780.
C 3 BOOK

BOOK I.
OF FEVERS.
CHAP. I.
OF THE PHENOMENA OF FEVERS.
VIII.
THOSE diseases are more
strictly called Fevers, which have the gen-
eral symptoms of pyrexia, without having
alongst with them any topical affection that is
essential and primary, such as the other orders
of the Pyrexiæ always have.
IX.
Fevers, as differing in the number and va-
riety of their symptoms, have been very prop-
erly considered as of distinct genera and spe-
cies. But we suppose, that there are certain
circumstances in common to all the diseases
comprehended under this order, which are
therefore those essentially necessary to, and
properly 

55 OF PHYSIC.
properly constituting the nature of fever. It
is our business especially, and in the first place,
to investigate these; and I expect to find them
as they occur in the paroxysm, or fit, of an in-
termittent fever, as this is most commonly
formed,
X.
The phenomena to be observed in such a
paroxysm are the following. The person is
affected, first, with a languor or sense of debil-
ity, a sluggishness in motion, and some uneasi-
ness in exerting it, with frequent yawning and
stretching. At the same time, the face and
extremities become pale; the features shrink;
the bulk of every external part is diminished;
and the skin, over the whole body, appears
constricted, as if cold had been applied to it.
At the coming on of these symptoms, some
coldness of the extremities, though little taken
notice of by the patient, may be perceived by
another person. At length, the patient him-
self feels a sensation of cold, commonly first in
his back, but, from thence, passing over the
whole body; and now his skin feels warm to
another person. The patient's sense of cold
increasing, produces a tremor in all his limbs
with frequent successions or rigors of the
trunk of the body. When this sense of cold,
and its effects, have continued for some time,
they become less violent, and are alternated
with warm flushings. By degrees, the cold
C 4 goes 

56 PRACTICE
goes off entirely; and a heat, greater than
natural, prevails, and continues over the
whole body. With this heat, the colour of
the skin returns, and a preternatural redness
appears, especially in the face. Whilst the
heat and redness come on, the skin is relaxed
and smoothed, but, for some time, continues
dry. The features of the face, and other
parts of the body, recover their usual size, and
become even more turgid. When the heat,
redness, and turgescence have increased and
continued for some time, a moisture appears
upon the forehead, and by degrees becomes a
sweat, which gradually extends downwards
over the whole body. As this sweat contin-
ues to flow, the heat of the body abates; the
sweat, after continuing some time, gradually
ceases; the body returns to its usual tempera-
ture; and most of the functions are restored to
their ordinary state.
XI.
This series of appearances gives occasion
to divide the paroxysm into three different
stages; which are called the COLD, the HOT,
and the SWEATING STAGES or Fits.
In-the course of these, considerable changes
happen in the state of several other functions,
which are now to be mentioned.
XII.
Upon the first approach of languor, the
pulse becomes sometimes flower, and always
weaker          

57 OF PHYSIC.
weaker than before. As the sense of cold
comes on, the pulse becomes smaller, very
frequent, and often irregular. As the cold
abates, and the heat comes on, the pulse be-
comes more regular, hard, and full; and in
these respects, increases till the sweat breaks
out. As the sweat flows, the pulse becomes
softer, and less frequent, till the sweat ceasing
altogether, it returns to its usual state.
XIII.
The respiration also suffers some changes,,
During the cold stage, the respiration is small,
frequent, and anxious, and is sometimes at-
tended with a cough; as the hot stage comes
on, the respiration becomes fuller and more
free. but continues still frequent and anxious,
till the flowing of the sweat relieves the anxi-
ety, and renders the breathing less frequent and
more free. With the ceasing of the sweat, the
breathing returns to its ordinary state.
XIV.
The natural functions also suffer a change.
Upon the approach of the cold stage, the ap-
petite for food ceases, and does not return till
the paroxysm be over, or the sweat has flowed
for some time. Generally, during the whole
of the paroxysm, there is not only a want of
appetite, but an aversion from all solid, and
especially animal food. As the cold stage ad-
C 5 vances,

58 PRACTICE
vances, there frequently comes on a sickness and
nausea, which often increase to a vomiting of
a matter that is for the most part bilious. This
vomiting commonly puts an end to the cold
stage, and brings on the hot. As the hot stage
advances, the nausea and vomiting abate; and
when the sweat breaks out, they generally cease
altogether.
XV.
A considerable degree of thirst is common-
ly felt during the whole course of the parox-
ysm. During the cold stage, the thirst seems
to arise from the dryness and clamminess of the
mouth and sauces; but, during the hot stage,
from the heat which then prevails over the
whole body; and, as the sweat flows, the
mouth becomes moister, and the thirst, togeth-
er with the heat, gradually abates.
XVI.
In the course of a paroxysm, there is often
a considerable change in the state of the se-
cretions. The circumstances just now men-
tioned show it in the secretion of the saliva
and mucus of the mouth; and it is still more
remarkable with respect to the urine. Dur-
ing the cold stage, the urine is almost colour-
less, and without cloud or sediment. In the
hot stage, it becomes high coloured, but is
still without sediment. After the sweat has
slowed 

59 OF PHYSIC.
slowed freely, the urine deposites a sediment,
commonly lateritious, and continues to do so
for some time after the paroxysm is over.
XVII.
Excepting in certain uncommon cases which
are attended throughout with a diarrhœa,
stools seldom occur till towards the end of a
paroxysm, when commonly a stool happens,
and which is generally of a loose kind.
XVIII.
Analogous to these changes in the state of
the secretions, it frequently happens, that tu-
mours subsisting on the surface of the body,
suffer, during the cold stage of fevers, a hid-
den and considerable detumescence; but gen-
erally, though not always, the tumours return
to their former size during the sweating stage.
In like manner, ulcers are sometimes dried
up during the cold stage; and return again to
discharge matter during the sweating stage, or
after the paroxysm is over.
XIX.
Certain changes appear also in sensation
and thought. During the cold stage, the
sensibility is often greatly impaired; but when
the hot stage is formed, the sensibility is re-
covered, and often considerably increased.
C 6 XX          

60 PRACTICE
XX.
With respect to the intellectual functions,
when the cold stage comes on, attention and
recollection become difficult, and continue
more or less so during the whole paroxysm.
Hence some confusion of thought takes place,
and often arises to a delirium, which sometimes
comes on at the beginning of the cold stage,
but more frequently not till the hot stage be
formed.
XXI.
It belongs also to this place to remark that
the cold stage sometimes comes on with a drow-
siness and stupor, which often increase to a
degree that may be called comatose, or apo-
plectic.
XXII.
We have still to add, that sometimes, early
in the cold stage, a headach comes on; but
which, more commonly, is not felt till the hot
stage be formed, and then is usually attended
with a throbbing of the temples. The head-
ach continues till the sweat breaks out; but
as this flows more freely, that gradually goes
off. At the same time with the headach,
there are commonly pains of the back, and
of some of the great joints; and these pains
have the same course with the headach.
XXIII. 

61 OF PHYSIC.
XXIII.
These are nearly the whole, and are at least
the chief of the phenomena which more con-
stantly appear in the paroxysm of an intermit-
tent fever; and we have pointed out their or-
dinary concourse and succession. With re-
spect to the whole of them, however, it is to
be observed, that, in different cases, the seve-
ral phenomena are in different degrees; that
the series of them is more or less complete;
and that the several parts or stages in the time
they occupy, are in a different proportion to
one another.
XXIV.
It is very seldom that a fever consists of a
single paroxysm, such as we have now de-
scribed; and it more generally happens, after
a certain length of time has elapsed from the
ceasing of the paroxysm, that the same series
of phenomena again arises, and observes the
same course as before; and these states of FE-
VER and APYREXIA often continue to alter-
nate with one another for many times. In
such cases, the length of time from the end of
one paroxysm to the beginning of another, is
called an INTERMISSION; and the length of
time from the beginning of one paroxysm to
the beginning of another next succeeding, is
called an INTERVAL.
XXV.         

62 PRACTICE
XXV.
When the disease consists of a number of
paroxysms, it is generally to be observed;
that the intervals between them are nearly
equal; but these intervals are of different
lengths in different cases. The most usual
interval is that of forty eight hours, which is
named the TERTIAN period. The next most
common is that of seventy two hours, and is
named the QUARTAN period. Some other
intervals also are observed, particularly one of
twenty four hours, named therefore the QUO-
TIDIAN; and the appearace of this is pretty
frequent. But all other intervals longer than
that of the quartan are extremely rare, and
probably are only irregularities of the tertian
or quartan periods.
XXVI.
The paroxysms of pure intermittent fevers
are always finished in less than twenty four
hours; and though it happens that there are
fevers which consist of repeated paroxysms,
without any entire intermission between them;
yet in such cases it is observed, that, though
the hot and sweating stages of the paroxysm
do not entirely cease before the twenty four
hours from their beginning have expired, they
suffer, however, before that time, a consider-
able abatement or REMISSION of their vio-
lence;

63 OF PHYSIC.
lence; and, at the return of the quotidian pe-
riod, a paroxysm is in some shape renewed,
which runs the same course as before. This
constitutes what is called a REMITTENT
FEVER.
XXVII.
When in theSe remittents the remission is
considerable, and the return of a new parox-
ysm is distinctly marked by the symptoms of
a cold stage at the beginning of it; such fe-
vers retain strictly the appellation of Re-
mittents. But when it happens, as it does
in certain cases, that the remission is not con-
siderable, is perhaps without sweat, and that
the returning paroxysm is not marked by the
most usual symptoms of a cold stage, but
chiefly by the aggravation or EXACERBA-
TION of a hot stage, the disease is called a
CONTINUED FEVER.
XXVIII.
In some cases of continued fever, the re-
missions and exacerbations are so inconsider-
able as not to be easily observed or distin-
guished; and this has led physicians to imag-
ine, that there is a species of fever subsisting
for several days together, and seemingly con-
sisting of one paroxysm only. This they
have called a Continent Fever; but, in
a long course of practice, I have not had an
opportunity of observing such a fever.
XXIX.

64 PRACTICE
XXIX.
It is, however, to be observed here, that
the fevers of a continued form are to be dis-
tinguished from one another; and that, while
some of a very continued form do still belong
to the section of intermittents, there are oth-
ers which, though still consisting of separate
and repeated paroxysms, yet, as different by
their causes and circumstances from intermit-
tents, are to be distinguished from the whole
of these, and are more strictly to be called and
considered as CONTINUED. Such are most
of those which have been commonly supposed
to be CONTINENT; and those which by most
writers have been simply named CONTINU-
ED; and which term I have employed as the
title of a section, to be distinguished from that
of INTERMITTENT.
I shall here add the marks by which, in
practice, these different continued fevers may
be distinguished from one another.
Those fevers of a continued form, which,
however, still belong to the section of Inter-
mittents, may be distinguished by their hav-
ing passed from an intermittent or remittent
form, to that of a continued; by their show-
ing some tendency to become intermittent, or
at least remittent; by their being known to
have been occasioned by marsh miasmata;
and, for the most part, by their having but
one paroxysm, or one exacerbation and re-
mission, in the course of twenty four hours.
On 

65 OF PHYSIC.
On the other hand, Continued Fevers, to
be more strictly so called, may be distinguish-
ed by their showing little tendency to become
intermittent or remittent in any part of their
course, and especially after the first week of their
continuance; by their being occasioned by hu-
man contagion, at least by other causes than
the marsh miasmata; and by their having pret-
ty constantly an exacerbation and remission
twice in the course of every twenty four hours.
In both cases, the knowledge of the nature of
the epidemic for the time prevailing, may have
a great share in determining the nature of the
particular fever.
XXX.
With respect: to the form, or Type, of fe-
vers, this further may be observed, That the
quartan, while it has the longest interval, has,
at the same time, the longest and most violent
cold stage; but, upon the whole, the shortest
paroxysm: That the tertian, having a shorter
interval than the quartan, has, at the same time,
a shorter and less violent cold stage; but a
longer paroxysm: And, lastly, that the quo-
tidian, with the shortest interval, has the least
of a cold stage, but the longest paroxysm.
XXXI.
The type of fevers is sometimes changed in
their course. When this happens, it is gener-
ally           

66 PRACTICE
ally in the following manner: Both tertians
and quartans change into quotidians, quotid-
ians into remittents, and these last become oft-
en of the most continued kind. In all these
cases, the fever has its paroxysms protracted
longer than usual, before it changes into a
type of more frequent repetition.
XXXII.
From all this a presumption arises, that
every fever consists of repeated paroxysms;
differing from others chiefly in the circum-
stances and repetition of the paroxysms; and,
therefore, that it was allowable for us to take
the paroxysm of a pure intermittent as an ex-
ample and model of the whole
CHAP II.
OF THE PROXIMATE CAUSE OF FEVER.
XXXIII.
THE proximate  cause of fe-
ver seems hitherto to have eluded the research
of physicians; and I shall not pretend to as-
certain it in a manner that may remove every
difficulty; but I shall endeavour to make an
approach towards it, and such as, I hope, may
be of use in conducting the practice in this
disease;

67 OF PHYSIC.
disease; while at the same time I hope to a-
void several errors which have formerly pre-
vailed on this subject.
XXXIV.
As the hot stage of fever is so constantly
preceded by a cold stage, we presume that
the latter is the cause of the former; and,
therefore, that the cause of the cold stage is
the cause of all that follows in the course of
the paroxysm. See Boerh. Aph. 756.
XXXV.
To discover the cause of the cold stage of
fevers, we may observe, that it is always pre-
ceded by strong marks of a general debility
prevailing in the system. The smallness and
weakness of the pulse, the paleness and cold-
ness of the extreme parts, with the shrinking
of the whole body, sufficiently show that the
action of the heart and larger arteries is, for
the time, extremely weakened.Together
with this, the languor, inactivity, and debility
of the animal motions, the imperfect sensa-
tions, the feeling of cold, while the body is
truly warm, and some other symptoms, all
show that the energy of the brain is, on this
occasion, greatly weakened; and I presume,
that, as the weakness of the action of the heart
can hardly be imputed to any other cause,
this weakness also is a proof of the diminish-
ed energy of the brain.
XXXVI.

68 PRACTICE
XXXVI.
I shall hereafter endeavour to show, that
the most noted of the remote causes of fever,
as contagion, miasmata, cold, and fear, are
of a sedative nature; and therefore render it
probable that a debility is induced. Like-
wise, when the paroxysms of a fever have
ceased to be repeated, they may again be re-
newed, and are most commonly renewed by
the application of debilitating powers. And,
further, the debility which subsists in the ani-
mal motions and other functions through the
whole of fever, renders it pretty certain that
sedative or debilitating powers have been ap-
plied to the body.
XXXVII.
It is therefore evident, that there are three
states which always take place in fever; a state
of debility, a state of cold, and a state of heat;
and as these three states regularly and con-
stantly succeed each other in the order we
have mentioned them, it is presumed that they
 are in the series of cause and effect with re-
spect to one another. This we hold as a
matter of fact, even although we should not
be able to explain in what manner or by what
mechanical means these states severally pro-
duce each other.
XXXVIII. 

69 OF PHYSIC.
XXXVIII.
How the state of debility produces some of
the symptoms of the cold stage, may perhaps
be readily explained; but how it produces
all of them, I cannot explain otherwise than
by referring the matter to a general law of the
animal economy, whereby it happens, that
powers which have a tendency to hurt and
destroy the system, often excite such motions
as are suited to obviate the effects of the nox-
ious power. This is the vis MEDICATRIX
nature, so famous in the schools of physic;
and it seems probable, that many of the mo-
tions excited in fever are the effects of this
power.
XXXIX.
That the increased action of the heart and
arteries, which takes place in the hot stage of
fevers, is to be considered as an effort of the
vis medicatrix naturveœ has been long a com-
mon opinion among physicians; and I am
disposed to assert, that some part of the cold
stage may be imputed to the same power. I
judge so, because the cold stage appears to be
universally a means of producing the hot ;
because cold, externally applied, has very
often similar effects; and more certainly still,
because it seems to be in proportion to the
degree of tremor in the cold stage, that the
hot stage proceeds more or less quickly to a
termination          

70 PRACTICE
termination of the paroxysm, and to a more
complete solution and longer intermission.
See XXX.
XL.
It is to be particularly observed, that, dur-
ing the cold stage of fever, there seems to be a
spasm induced every where on the extremi-
ties of the arteries, and more especially of
those upon the surface of the body. This ap-
pears from the suppression of all excretions,
and from the shrinking of the external parts;
and although this may perhaps be imputed,
in part, to the weaker action of the heart in
propelling the blood into the extreme vessels;
yet, as these symptoms often continue after
the action of the heart is restored, there is
reason to believe, that a spasmodic constric-
tion has taken place; that it subsists for some
time, and supports the hot stage; for this stage
ceases with they flowing of the sweat, and the
return of other excretions, which are marks
of the relaxation of vessels formerly constrist-
ed. Hoffman. Med. rat. System. Tom. IV,
P. I. Sect. I. Cap. I. art. 4.
XLI.
The idea of fever, then, may be, that a
spasm of the extreme vessels, however induc-
ed, proves an irritation to the heart and ar-
teries; and that this continues till the spasm
is relaxed or overcome. There are many
appearances which support this opinion; and
there

71 OF PHYSIC.
there is little doubt that a spasm does take
place, which proves an irritation to the heart,
and therefore may be considered as a princi-
pal part in the proximate cause of fever. It
will still, however remain a question, what is
the cause of this spasm; whether it be direct-
ly produced by the remote cause of fever, or
if it be only a part of the operation of the
vis medicatrix naturæ.
XLII
I am disposed to be of the latter opinion,
because, in the flrst place, while it remains
still certain that a debility lays the foundation
of fever, it is not obvious in what manner the
debility produces the spasm, and, what seems
to be its effect, the increased action of the
heart and arteries; and, secondly, because, in
almost all the cases in which an effort is made
by the vis medicatrix naturæ, a cold fit and a
spasm of the extreme vessels are almost always
the beginnings of such an effort. See Gaub.
Pathol. Medicin. art. 750.
XLIII.
It is therefore presumed, that such  a cold
fit and spasm at the beginning of fever, is a
part of the operation of the vis medicatrix .
but, at the same time, it seems to me proba-
ble, that, during the whole course of the fe
ver, there is an atony subsisting in the ex-
treme vessels, and that the relaxation of the
spasm

72 PRACTICE
spasm requires the restoring of the tone and
action of these.
XLIV.
This it may be difficult to explain; but
I think it may be ascertained as a fact, by the
consideration of the symptoms which take
place with respect to the functions of the
stomach in fevers, such as the anorexia, nau-
sea, and vomiting. (XIV.)
From many circumstances it is sufficiently
certain, that there is a consent between the
stomach and surface of the body; and in all
cases of the consent of distant parts, it is pre-
sumed to be by the connexion of the nervous
system, and that the consent which appears is
between the sentient and moving fibres of the
one part with those of the other; is such, that
a certain condition prevailing in the one part
occasions a similar condition in the other.
In the case of the stomach and surface of
the body, the consent particularly appears by
the connexion which is observed between the
state of the perspiration and the state of the ap-
petite in healthy persons; and if it may be
presumed that the appetite depends upon the
state of tone in the muscular fibres of the
stomach, it will follow, that the connexion
of appetite and perspiration depends upon a
consent between the muscular fibres of the
stomach and the muscular fibres of the extreme
vessels, or of the organ of perspiration, on the
the surface of the body.

73 OF PHYSIC.
It is further in proof of the connexion be-
tween the appetite and perspiration, and at the
same time of the circumstances on which it
depends, that cold applied to the surface of
the body, when it does not stop perspiration,
but proves a stimulus to it, is always a power-
ful means of exciting appetite.
Having thus established the connexion or
consent mentioned, we argue, that as the
symptoms of anorexia, nausea, and vomiting,
in many cases, manifestly depend upon a state
of debility or loss of tone in the muscular fibres
of the stomach; so it may be presumed, that
these symptoms, in the beginning of fever, de-
pend upon an atony communicated to the
muscular fibres of the stomach from the mus-
cular fibres of the extreme vessels on the
surface of the body.
That the debility of the stomach which
produces vomiting in the beginning of fe-
vers actually depends upon an atony of the
extreme vessels on the surface of the body,
appears particularly from a fact observed by
Dr. Sydenham. In the attack of the plague,
a vomiting happens, which prevents any med-
icine from remaining on the stomach; and
Dr. Sydenham tells us, that in such cases he
could not overcome this vomiting but by ex-
ternal means applied to produce a sweat; that
is, to excite the action of the vessels on the
surface of the body.
The same connexion between the state of
the stomach and that of the extreme vessels
D on

74 PRACTICE
on the surface of the body, appears from this
also, that the vomiting, which so frequently
happens in the cold stage of fevers, commonly
ceases upon the coming on of the hot, and very
certainly upon any sweat's coming out (XIV.)
It is indeed probable, that the vomiting in
the cold stage of fevers, is one of the means
employed by nature for restoring the deter-
mination to the surface of the body; and it is
a circumstance affording proof, both of this,
and of the general connexion between the
stomach and surface of the body, that emetics
thrown into the stomach, and operating there,
in the time of the cold stage, commonly put
an end to it, and bring on the hot stage.
It also affords a proof of the same connex-
ion, that cold water taken into the stomach
produces an increase of heat on the surface
of the body, and is very often a convenient
and effectual means of producing sweat.
From the whole we have now laid on this
subject, I think it is sufficiently probable, that
the symptoms of anorexia, nausea, and vomit-
ing, depend upon, and are a proof of, an atony
subsisting in the extreme vessels on the surface
of the body; and that this atony therefore,
now ascertained as a matter of fact, may be
considered as a principal circumstance in the
proximate cause of fever.
XLV.
This atony we suppose to depend upon a
diminution of the energy of the brain; and
that 

75 OF PHYSIC.
that this diminution takes place in fevers, we
conclude, not only from the debility prevail-
ing in so many of the functions of the body,
mentioned above (XXXV.) but particularly
from symptoms which are peculiar to the brain
itself. Delirium is a frequent symptom of
fever; and as from the physiology and pathol-
ogy we learn that this symptom commonly
depends upon some inequality in the excite-
ment of the brain or intellectual organ; we
hence conclude, that, in fever, it denotes some
diminution in the energy of the brain. De-
lirium, indeed, seems often to depend upon
an increased impetus of the blood in the ves-
sels of the brain, and therefore attends phren-
itis. It frequently appears also in the hot
stage of fevers, accompanied with a headach
and throbbing of the temples. But as the
impetus of the blood in the vessels of the head
is often considerably increased by exercise, ex-
ternal heat, passions, and other causes, without
occasioning any delirium; so, supposing that
the same impetus, in the case of fever, produces
delirium, the reason must be, that, at the same
time, there is some cause which diminishes the
energy of the brain, and prevents a free com-
munication between the parts concerned in
the intellectual functions. Upon the same
principles also, I suppose there is another spe-
cies of delirium, depending more entirely on
the diminished energy of the brain, and which
may therefore arise when there is no unusual
increase of the impetus of the blood in the
D 2 vessels 

76 PRACTICE
vessels of the brain. Such seems to be the de-
lirium occurring at the beginning of the cold
stage of fevers, or in the hot stage of such fe-
vers as show strong marks of debility in the
whole system.
XLVI.
Upon the whole, our doctrine of fever is
explicitly this. The remote causes (XXXVI.)
are certain sedative powers applied to the
nervous system, which diminishing the energy
of the brain, thereby produce a debility in
the whole of the functions (XXXV.) and par-
ricularly in the action of the extreme vessels
(XLIII.) (XLIV.) Such, however, is, at
the same time, the nature of the animal econ-
omy (XXXVIII.) that this debility proves an
indirect stimulus to the sanguiferous system;
whence, by the intervention of the cold stage,
and spasm connected with it (XXXIX. XL.)
the action of the heart and larger arteries is in-
creased (XL.) and continues so (XLI.) till it
his had the effect of restoring the energy of
the brain, of extending this energy to the ex-
treme vessels, of restoring therefore their action,
and thereby especially overcoming the spasm
affecting them; upon the removing of which,
the exertion of sweat, and other marks of the
relaxation of excretories, take place.
XLVII.
This doctrine will, as I suppose, serve to
explain not only the nature of fever in gen-
eral,                     

77 OF PHYSIC. 
eral, but also the various cases of it which oc-
cur. Before proceeding, however, to this, it
may be proper to point out the opinions, and,
as I apprehend, the mistakes, which have
formerly prevailed on this subject.
XLVIII.
It has been supposed that a lentor or viscid-
ity prevailing in the mass of blood, and stag-
nating in the extreme vessels, is the cause of
the cold stage of fevers and its consequences.
But there is no evidence of any such viscidity
previously subsisting in the fluids; and as it
is very improbable that such a state of them
can be very quickly produced, so the sudden-
ness with which paroxysms come on, renders
it more likely that the phenomena depend up-
on some cause acting upon the nervous system,
or the primary moving powers of the animal
economy. See Van Swieten apud Boerh.
Aph. 755.
XLIX.
Another opinion, which has been almost
universally received, is, that a noxious mat-
ter introduced into or generated in the body,
is the proximate cause of fever; and that the
increased action of the heart and arteries,
which forms so great a part of the disease, is an
effort of the vis medicatrix naturæ to expel this
morbific matter; and particularly to change
D 3 or

78 PRACTICE
or concoct it, so as to render it either alto-
gether innocent, or, at least, fit for being more
easily thrown out of the body. This doc-
trine, however, although of as great antiquity
as any of the records of physic now remain-
ing, and although it has been received by al-
most every school of medicine, yet appears to
me to rest upon a very uncertain foundation.
There are fevers produced by cold, fear, and
other causes, accompanied with all the essen-
tial circumstances of fever, and terminating
by sweat; but, at the same time, without any
evidence or suspicion of morbific matter.
There have been fevers suddenly cured by
a hemorrhagy, so moderate as could not car-
ry out any considerable portion of a matter
diffused over the whole mass of blood; nor
can we conceive how the morbific matter
could be collected or determined to pass off
by such an outlet as in that case is opened.
Even supposing a morbific matter were
present, there is no explanation given in what
manner the concoction of it is performed;
nor is it shown that any such change does in
fact take place. In certain cases, it is indeed
evident, that a noxious matter is introduced
into the body, and proves the cause of fever;
but, even in these cases, it appears that the
noxious matter is thrown out again, without
having suffered any change; that the fever
often terminates before the matter is expelled;
and that, upon many occasions, without wait-
ing the supposed time of concoction, the fe-
ver

79 OF PHYSIC.
ver can be cured, and that by remedies which
do not seem to operate upon the fluids, or to
produce any evacuation.
L.
While we thus reason against the notion of
fever being an effort of nature, for concoct-
ing and expelling a morbific matter; I by no
means intend to deny that the cause of fever
frequently operates upon the fluids, and par-
ticularly produces a putrescent state of them.
I acknowledge that this is frequently the case;
but, at the same time, I maintain, that such
a change of the fluids is not commonly the
cause of fever; that very often it is an effect
only; and that there is no reason to believe
the termination of the fever to depend upon
the expulsion of the putrid matter.
LI.
Another opinion which has prevailed, re-
mains still to be mentioned. In intermittent
fevers, a great quantity of bile is commonly
thrown out by vomiting; and this is so fre-
quently the case, that many have supposed an
unusual quantity of bile, and perhaps a pecu-
liar quality of it, to be the cause of intermit-
tent fevers. This, however, does not appear
to be well founded. Vomiting, by whatever
means excited, if often repeated with violent
straining, seems to be powerful in emulging
D 4 the

80 PRACTICE
the biliary ducts, and commonly throws out
a great deal of bile. This will happen espe-
cially in the case of intermittent fevers. For
as, in the state of debility and cold stage of
these fevers, the blood is not propelled in the
usual quantity into the extreme vessels, and
particularly into those on the surface of the
body, but is accumulated in the vessels of the
internal parts, and particularly in the vena
portarum; so this may occasion a more copi-
ous secretion of bile.
These considerations will, in some measure,
account for the appearance of an unusual
quantity of bile in intermittent fevers; but
the circumstance which chiefly occasions the
appearance of bile in these cases, is the influ-
ence of warm climates and seasons. These
seldom fail to produce a state of the human
body, in which the bile is disposed to pass off,
by its secretories, in greater quantity than
usual; and perhaps also changed in its quality,
as appears from the disease of cholera, which
so frequently occurs in warm seasons. At the
same time, this disease occurs often without
fever; and we shall hereafter render it suf-
ficiently probable, that intermittent fevers,
for the most part, arise from another cause,
that is, from marsh effluvia; while, on the
other hand, there is no evidence of their
arising from the state of the bile only. The
marsh effluvia, however, commonly operate
most powerfully in the same season that
produces the change and redundance of the
bile;

81 OF PHYSIC.
bile; and therefore, considering the vomit-
ing, and other circumstances of the intermit-
tent fevers which here concur, it is not sur-
prising that autumnal intermittents are so oft-
en attended with effusions of bile.
This view of the subject does not lead us
to consider the state of the bile as the cause
of intermittents, but merely as a circumstance
accidentally concurring with them, from the
state of the season in which they arise. What
attention this requires in the conduct of the
disease, I shall consider hereafter.
LII.
From this view of the principal hypotheses
which have hitherto been maintained with
respect to the proximate cause of fever, it
will appear, that fevers do not arise from
changes in the state of the fluids; but that,
on the contrary, almost the whole of the phe-
nomena of fevers lead us to believe that they
chiefly depend upon changes in the state of
the moving powers of the animal system.
Though we should not be able to explain all
the circumstances of the disease, it is at least;
of some advantage to be led into the proper
train of investigation. I have attempted so
pursue it; and shall now endeavour to apply
the doctrine already delivered, towards ex-
plaining the diversity of fevers.
D 5 CHAP.

82 PRACTICE
CHAP. III.
OF THE DIFFERENCE OF FEVERS,
AND ITS CAUSES.
LIII.
TO ascertain the difference of
fevers, I think it necessary to observe, in the
first place, that every fever of more than one
day's duration consists of repeated, and in some
measure separate, paroxysms; and that the
difference of fevers taken notice of above
(from XXV. to XXX.) appears to consist in
the different state of paroxysms, and in the
different circumstances of their repetition.
LIV.
That fevers generally consist of distinct,
and in some measure separately repeated, par-
oxysms, I have alleged above to be a mat-
ter of fact; but I shall here endeavour to
confirm it, by assigning the cause.
LV.
In every fever, in which we can distinctly
observe any number of separate parox-
ysms, we constantly find that each parox-
ysm is finished in less than twenty four hours;
but as cannot perceive any thing in
the 

83 OF PHYSIC.
the cause of fevers determining to this, I
must presume it to depend on some general
law of the animal economy. Such a law
seems to be that which subjects the economy,
in many respects, to a diurnal revolution.
Whether this depends upon the original con-
formation of the body, or upon certain pow-
ers constantly applied to it, and inducing a
habit, I cannot positively determine; but the
returns of sleep and watching, of appetites
and excretions, and the changes which regu-
larly occur in the state of the pulse, show suf-
ficiently, that in the human body a diurnal
revolution takes place.
LVI.
It is this diurnal revolution which, I sup-
pose, determines the duration of the parox-
ysms of fevers; and the constant and uni-
versal limitation of these paroxysms (as ob-
served in LV.) while no other cause of it can
be assigned, renders it sufficiently probable
that their duration depends upon, and is de-
termined by, the revolution mentioned. And
that these paroxysms are connected with that
diurnal revolution, appears further from this,
that though the intervals of paroxysms are dif-
ferent in different cases, yet the times of the ac-
cession of paroxysms are generally fixed to one
time of the day; so that Quotidians come on
in the morning, Tertians at noon, and Quar-
tans in the afternoon.
D 6 LVII.         

84 PRACTICE
LVII.
It remains to be remarked, that as Quar-
tans and Tertians are apt to become Quo-
tidians, these to pass into the state of Remit-
tents, and these last to become Continued;
and that, even in the Continued form, daily
exacerbations and remissions are generally to
be observed; so all this shows so much the
power of diurnal revolution, that when, in
certain cases, the daily exacerbations and re-
missions are with difficulty distinguished, we
may still presume, that the general tendency
of the economy prevails, that the disease still
consists of repeated paroxysms, and, upon the
whole, that there is no such disease as that
which the schools have called a Continent Fe-
ver. I expect that this doctrine will be con-
firmed by what I shall say hereafter concern-
ing the periodical movements observed in
continued fevers.
LVIII.
It being thus proved, that every fever, of
more than one day's duration, consists of re-
peated paroxysms; we in the next place, re-
mark, that the repetition of paroxysms de-
pends upon the circumstances of the parox-
ysms which have already taken place. From
what was observed in XXX. and XXXI. it
appears, that the longer paroxysms are pro-
tracted, 

85 OF PHYSIC.
tracted, they are the sooner repeated; and,
therefore, that the cause of the frequent rep-
etition is to be fought for in the cause of the
protraction of paroxysms.
LIX.
Agreeably to what is laid down in XLVI.
and to the opinion of most part of physi-
cians, I suppose, that, in every fever, there is a
power applied to the body, which has a tenden-
cy to hurt and destroy it, and produces in it
certain motions which deviate from the natural
state; and, at the same time, in every fever
which has its full course, I suppose, that, in
consequence of the constitution of the animal
economy, there are certain motions excited,
which have a tendency to obviate the effects of
the noxious power, or to correct and remove
them. Both these kinds of motion are con-
sidered as constituting the disease.
But the former is perhaps strictly the mor-
bid state, while the latter is to be considered
as the operation of the vis medicatrix naturæ
of salutary tendency, and which I shall here-
after call the reaction of the system.
LX.
Upon the supposition that these two states
take place in every paroxysm of fever, it
will appear to be chiefly in the time of the
hot stage that the reaction operates in remov-
ing

86 PRACTICE
ing the morbid state; and therefore, as this
operation succeeds more or less quickly, the
hot stage of paroxysms will be shorter or
longer. But as the length of paroxysm depends
chiefly upon the duration of the hot stage, so
the longer duration of this and of paroxysms,
must be owing either to the obstinacy of re-
sistance in the morbid state, or to the weak-
ness of the salutary reaction; and it is prob-
able that sometimes the one and sometimes
the other of these circumstances takes place.
LXI.
It seems to be only by the state of the
spasm, that we can judge of the resistance of
the morbid state of fever: And with respect
to this spasm I observe, that either the cause
exciting it may be different in different cas-
es; or, though the cause should be the same in
different persons, the different degree of
irritability in each may give occasion to a
greater or lesser degree of spasm; and there-
fore, the reaction in fever being given, the con-
tinuance of the hot stage, and of the whole
paroxysm, may be longer or shorter, according
to the degree of spasm that has been formed.
LXII.
One cause of the obstinacy of spasm in fe-
vers may be clearly perceived. In inflam-
matory diseases there is a diathesis phlogistica
prevailing 

87 OF PHYSIC.
prevailing in the body and this diathsis we
suppose to consist in an increased tone of the
whole arterial system. When, therefore,
this diathesis accompanies fever, as it some-
times does, it may be supposed to give oc-
casion to the febrile spasm's being formed
more strongly, and thereby to produce more
protracted paroxysms. Accordingly we find,
that all inflammatory fevers are of the con-
tinued kind; and that all the causes of the
diathesis phlogistica have a tendency to change
intermittent into continued fevers. Contin-
ued fevers, then, being often attended with
the diathesis phlogistica, we conclude, that in
many cases, this is the cause of their, continued
form.
LXIII.
In many fevers, however, there is no evi-
dence of any diathesis phlogistica being pre-
sent, nor of any other cause of more consider-
able spasm; and, in such cases, therefore, we
must impute the protraction of paroxysms,
and the continued form of the fever, to the
weakness of reaction. That this cause takes
place, we conclude from hence, that, in many
cases of fever, wherein the separate paroxysms
are the longest protracted, and the most diffi-
cultly observed, we find the most considerable
symptoms of a general debility: And there-
fore we infer, that, in such cases, the protract-
ed paroxysms, and continued form, depend
upon a weaker reaction; owing either to the
causes          

88 PRACTICE
causes of debility applied having been of a more-
powerful kind, or from circumstances of the
patient's constitution favouring their opera-
tion.
LXIV.
Upon these principles we make a slep to-
wards explaining in general, with some prob-
ability, the difference of fevers; but must
own, that there is much doubt and difficulty
in applying the doctrine  to particular cafes.
It applies tolerably well to explain the different
states of intermittents, as they are more pure-
ly such, or as they approach more and more
to the continued form: But several difficul-
ties still remain with respect to many circum-
stances of intermittents; and more still with
respect to the difference of those continued
fevers, which we have distinguished in our
Nosology as different from intermittents, and
as more especially intitled to the appellation
of Continued, (see Syn. Nos. Meth. P.V.
Ch. I. Sea. II.) and explained more fully
above.
LXV.
From the view given (LXIII. and LXIV.)
of the causes of the protraction of paroxysms,
and therefore of the form of Continued fevers,
strictly so called, it seems probable, that the
remote causes of these operate by occasioning
either 

89 OF PHYSIC.
either a phlogistic diathesis, or a weaker re-
action; for we can observe, that the most obvi-
ous difference of continued fevers depends up-
on the prevalence of one or other of these states.
LXVI.
Continued fevers have been accounted of
great diversity; but physicians have not been
successful in marking these differences, or in
reducing them to any general heads. The
distinaions made by the ancients are not well
understood; and, so far as either they or the
modern nosologists have distinguished contin-
ued fevers by a difference of duration, their
distinctions are not well founded, and do not
apply in such a manner as to be of any use.
We think it agreeable to observation, and to
the principles above laid down (LXIII.
LXIV.) to distinguish continued fevers ac-
cording as they show either an inflammatory
irritation, or a weaker reaction.
LXVII.
This distinction is the same with that of
fevers into the Inflammatory and Ner-
vous; the distinction at present most gen-
erally received in Britain. To the first, as a
genus, I have given the name of Synocha;
to the second, that of Typhus; and, little flu-
dious whether these names be authorized by the
ancient use of the same terms, I depend upon
their           

90 PRACTICE
their being understood by the characters an-
nexed to them in our Nosology, which I ap-
prehend to be founded on observation.
LXVIII.
By these characters I think continued fe-
vers may in practice be distinguished; and if
that be the case, the principles above laid
down will be confirmed.
LXIX.
Beside these differences of continued fever,
now mentioned, I am not certain of having
observed any other that can be considered as
sundamental. But the most common form
of continued fevers, in this climate, seems to
be a combination of these two genera; and
I have therefore given such a genus a place
in our Nosology, under the title of Synochus.
At the same time, I think that the limits be-
tween the Synochus and Typhus will be with
difficulty assigned; and I am disposed to be-
lieve, that the Synochus arises from the same
causes as the Typhus, and is therefore only a
variety of it.
LXX.
The Typhus seems to be a genus compre-
hending several species. These, however, are
not yet well ascertained by observation; and
in

91 OF PHYSIC.
in the mean time we can perceive that many
of the different cases observed do not imply any
specific difference, but seem to be merely va-
rieties, arising from a different degree of power
in the cause, from different circumstances of
the climate or season in which they happen,
or from different circumstances in the consti-
tution of the persons affected.
LXXI.
Some of the effects arising from these cir-
cumstances require to be particularly explain-
ed.
One is, an unusual quantity of bile appear-
ing in the course of the disease. This abun-
dance of bile may possibly attend some con-
tinued fevers, strictly so called; but, for the
reasons above explained, it more commonly
attends intermittents, and, we believe, it might
have been enumerated (XXIX.) among the
marks distinguishing the latter kind of fevers
from the former. But, though an unusual
quantity of bile should appear with continued
fevers, it is considered in this case, as in that
of intermittents, to be a coincidence only, ow-
ing to the state of the season, and producing
no different species or fundamental distinc-
tion, but merely a variety of the disease. I
think it proper to observe here, that it is
probable that the most part of the continued
fevers named Bilious have been truly such as
belong to the season of Intermittents.
LXXII. 

92 PRACTICE
LXXII.
Another effect of the circumstances occa-
sionally varying the appearance of typhus, is
a putrescent state of the fluids. The an-
cients, and likewise the moderns, who are in
general much disposed to follow the former,
have distinguished fevers, as putrid and non-
putrid: But the notions of the ancients, on
this subject, were not sufficiently correct to
deserve much notice; and it is only of late that
the matter has been more accurately observ-
ed, and better explained.
From the dissolved state of the blood, as it
presents itself when drawn out of the veins,
or as it appears from the red blood's being
disposed to be effused and run off by various
outlets, and from several other symptoms to
be hereafter mentioned, I have now no doubt,
how much soever it has been disputed by-
some ingenious men, that a putrescency of the
fluids to a certain degree does really take place
in many cases of fever. This putrescency,.
however, often attends intermittent, as well as
continued fevers, and, of the continued kind,
both the synochus and typhus, and all of them
in very different degrees; so that, whatever at-
tention it may deserve in practice, there is no
fixing such limits to it as to admit of establish-
ing a species under the title of Putrid.
LXXIII.
Beside differing by the circumstances al-
ready mentioned, fevers differ also by their
being 

98 OF PHYSIC.
being accompanied with symptoms which be-
long to diseases of the other orders of pyrex-
iæ. This sometimes happens in such a man-
ner, as to render it difficult to determine which
of the two is the primary disease. Common-
ly, however, it may be ascertained by the
knowledge of the remote cause, and of the
prevailing epidemic, or by observing the se-
ries and succession of symptoms.
LXXIV.
Most of our systems of physic have marked,
as a primary one, a species of fever under the
title of Hectic; but, as it is described, I
have never seen it as a primary disease. I
have constantly found it as a symptom of some
topical affection, most commonly of an inter-
nal suppuration; and as such it shall be con-
sidered in another place.
LXXV.
The distinction of the several cases of inter-
mittent fever I have not prosecuted here;
both because we cannot assign the causes of
the differences which appear; and because I
apprehend that the differences which in fact
occur may be readily understood from what is
said above (XXV. XXVI. and XXVII.)
and more fully from our Methodical Nosolo-
gy, CI. I. Sect. I.
CHAP.           

94 PRACTICE
CHAP. IV.
OF THE REMOTE CAUSES OF FEVER.
LXXVI.
AS fever has been held to
consist chiefly in an increased action of the
heart and arteries, physicians have sup-
posed its remote causes to be certain direct
stimulants fitted to produce this increased ac-
tion. In many cases, however, there is no
evidence of such stimulants being applied;
and, in those in which they are applied, they
either produce only a temporary frequency
of the pulse, which cannot be considered
as a disease; or, if they do produce a
permanent febrile state, it is by the inter-
vention of a topical inflammation, which pro-
duces a disease different from what is strictly
called fever. (VIII.)
LXXVII.
That direct stimulants are the remote caus-
es of fever, seems farther improbable; be-
cause the supposition does not account for
the phenomena attending the accession of fe-
vers, and because other remote causes can with
greater certainty be assigned.
LXXVIII. 

95 OF PHYSIC.
LXXVIII.
As fevers are so generally epidemic, it is
probable, that some matter floating in the at-
mosphere, and applied to the bodies of men,
ought to be considered as the remote cause of
fevers: And these matters present in the at-
mosphere, and thus acting upon men, may be
considered, either as Contagions, that is,
effluvia arising directly or originally from the
body of a man under a particular disease, and
exciting the same kind of disease in the body
of the person to whom they are applied; or
MIASMATA, that is effluvia arising from oth-
er substances than the bodies of men, pro-
ducing a disease in the person to whom they
are applied.
LXXIX.
Contagions have been supposed to be of
great variety; and it is possible this may be
the case; but that they truly are so, does not
appear clearly from any thing we know at
present. The genera and species of contagi-
ous diseases, of the class of Pyrexiæ, at pres-
ent known, are in number not very great.
They chiefly belong to the order of Fevers, to
that of Exanthemata, or that of Profluvia.
Whether there be any belonging to the order
of Phlegmasiæ, is doubtful; and though there
should, it will not much increase the number
of          

96 PRACTICE
of contagious pyrexiæ. Of the contagious
exanthemata and profluvia, the number of
species is nearly ascertained; and each of
them is so far of a determined nature, that
though they have now been observed and dis-
tinguished for many ages, and in many differ-
ent parts of the world, they have been always
found to retain the same general character,
and to differ only in circumstances, that may
be imputed to season, climate, and other ex-
ternal causes, or to the peculiar constitutions
of the several persons affected. It seems,
therefore, probable, that, in each of these spe-
cies, the contagion is of one specific nature;
and that the number of contagious exanthe-
mata or profluvia is hardly-greater than the
number of species enumerated in the systems
of nosology.
LXXX.
If, while the contagious exanthemata and
profluvia are thus limited, we should suppose
the contagious pyrexiæ to be still of great
and unlimited variety, it must be with re-
spect to the genera and species of continued
fevers. But if I be right in limiting, as I have
done, the genera of these fevers (LXVII.—
LXX.) it will appear likely that the conta-
gions which produce them are not of great va-
riety; and this will be much confirmed, if we
can render it probable that there is one prin-
cipal, perhaps one common, source of such
contagion.
LXXXI.

97 OF PHYSIC.
LXXXI.
To this purpose, it is now well known, that
the effluvia constantly arising from the living
human body, if long retained in the same
place, without being diffused in the atmos-
phere, acquire a singular virulence; and, in
that state, being applied to the bodies of men,
become the cause of a fever which is highly
contagious.
The existence of such a cause is fully prov-
ed by the late observations on jail and hos-
pital fevers; and that the same virulent mat-
ter may be produced in many other places,
must be sufficiently obvious: And it is prob-
able that the contagion arising in this manner
is not, like many other contagions, perma-
nent and constantly existing; but that, in the
circumstances mentioned, it is occasionally
generated. At the same time, the nature of
the fevers from thence, upon different occa-
sions, arising, renders it probable that the
virulent state of human effluvia is the com-
mon cause of them, as they differ only in a
state of their symptoms; which may be im-
puted to the circumstances of season, climate,
&c. concurring with the contagion, and mod-
ifying its force.
LXXXII.
With respect to these contagions, though
we have spoken of them as of a matter float-
ing in the atmosphere, it is proper to observe,
E that 

98 PRACTICE
that they are never found to act but when
they are near to the sources from whence
they arise; that is, either near to the bodies
of men, from which they immediately issue;
or near to some substances which, as having
been near to the bodies of men, are imbued
with their effluvia, and in which substances
these effluvia are sometimes retained in an
active state for a very long time.
The substances thus imbued with an active
and infectious matter, may be called Fomites;
and it appears to me probable, that contagi-
ons, as they arise from fomites, are more pow-
erful than as they arise immediately from the
human body.
LXXXIII.
Miasmata are next to be considered. These
may arise from various sources, and be of dif-
ferent kinds; but we know little of their va-
riety, or of their several effects. We know
with certainty only one species of miasma,
which can be considered as the cause of fe-
ver; and, from the universality of this, it
may be doubted if there be any other.
LXXXIV.
The miasma, so universally the cause of fe-
ver, is that which arises from marshes or moist
ground, acted upon by heat. So many ob-
servations have now been made with respect to
this, 

99 OF PHYSIC.
this, in so many different regions of the earth,
that there is neither any doubt of its being in
general a cause of fevers, nor of its being very
universally the cause of intermittent fevers,
in all their different forms. The similarity
of the climate, season, and foil, in the differ-
ent countries in which intermittents arise, and
the similarity of the diseases, though arising
in different regions, concur in proving that
there is one common cause of these diseases,
and that this is the marsh miasma.
What is the particular nature of this mias-
ma, we know not; nor do we certainly know
whether or not it differs in kind: But it is
probable that, it does not; and that it varies
only in the degree of its power, or perhaps as
to its quantity, in a given space.
LXXXV.
It has been now rendered probable, that
the remote causes of fevers (VIII.) are chief-
ly Contagions or Miasmata, and neither of
them of great variety. We have supposed
that miasmata are the cause of intermittents,
and contagions the cause of continued fevers,
strictly so named; but we cannot with pro-
priety employ these general terms. For, as
the cause of continued fevers  may arise from
somites, and may, in such cases, be called a
Miasma; and as other miasmata also may pro-
duce contagious diseases; it will be proper to
distinguish the causes of fevers, by using the
E 2 terms          

100 PRACTICE.
terms Human or Marsh Effluvia, rather than
the general ones of Contagion or Miasma.
LXXXVI.
To render our doctrine of fever consistent
and complete, it is necessary to add here, that
those remote causes of fever, human and marsti
effluvia, seen: to be of a debilitating or seda-
tive quality. They arise from a putrescent
matter. Their production is favoured and
their power increased, by circumstances which
favour putrefaction; and they often prove
putrefactive ferments with respect to the ani-
mal fluids. As putrid matter, therefore, is
always, with respect to animal bodies, a pow-
erful sedative, so it can hardly be doubted
that human and marsh effluvia are of the
same quality; and it is confirmed by this, that
the debility which is always induced, seems to
be in proportion to the other marks that ap-
pear of the power of those causes.
LXXXVII.
Though we have endeavoured to show
that fevers generally arise from marsh or hu-
man effluvia, we cannot, with any certainty,
exclude some other remote causes, which are
commonly supposed to have at least a share in
producing those diseases. And I proceed,
therefore, to inquire concerning these causes;
the first of which that merits attention is, the
power of cold applied to the human body.
LXXXVIII.

101 OF PHYSIC.
LXXXVIII.
The operation of cold on a living body is
so different in different circumstances, as to
be of difficult explanation; it is here, there-
fore, attempted with some diffidence.
The power of cold may be considered as
absolute or relative.
The absolute power is that by which it can
diminish the temperature of the body to which
it is applied. And thus, if the natural tem-
perature of the human body is, as we suppose
it to be, that of 98 degrees of Farenheit's ther-
mometer *; every degree of temperature less
than that, may be considered as cold with re-
spect to the human body; and, in proportion
to its degree, will have a tendency to diminish
the temperature of the body. But as the liv-
ing human body has in itself a power of gen-
erating heat, so it can sustain its own proper
heat to the degree above mentioned, though
surrounded by air or other bodies of a lower
temperature than itself; and it appears from
observation, that, in this climate, air, or other
bodies, applied to the living man, do not di-
minish the temperature of his body, unless the
temperature of the bodies applied be below 62
degrees. From hence it appears, that the ab-
solute power of cold in this climate, does not
E 3 act
* In every instance of our mentioning degrees of heat
or cold, we shall mention them by the degrees in Faren-
heit's scale; and the expression of higher or lower shall-
always be according to that scale. 

102 PRACTICE
act upon the living human body, unless the
cold applied be below the degree just now
mentioned.
It appears also, that the human body's be-
ing surrounded by air of a lower temperature
than itself, is necessary to its being retained in
its proper temperature of 98 degrees; for, in
this climate, every temperature of the air
above 62 degrees, applied to the human body,
though still of a lower temperature than itself,
is found to increase the heat of it. And from
all this it appears, that the absolute power of
cold with respect to the human body, is very
different from what it is with respect to inan-
imate bodies.
LXXXIX.
The relative power of cold with respect to
the living human body, is that power by which
it produces a sensation of cold in it; and with
respect to this, it is agreeable to the general
principle of sensation, that the sensation pro-
duced, is not in proportion to the absolute
force of impression, but according as the new
impression is stronger or weaker than that
which had been applied immediately before.
Accordingly, with respect to temperature, the
sensation produced by any degree of this, de-
pends upon the temperature to which the
body had been immediately before exposed;
so that whatever is higher than this feels warm,
and whatever is lower than it feels cold; and
it

103 OF PHYSIC.
it will therefore happen that the opposite sen-
sations of heat and cold may on different oc-
casions arise from the same temperature, as
marked by the thermometer.
With respect to this, however, it is to be
observed, that though every change of tem-
perature gives a sensation of cold or heat as it
is lower or higher than the temperature ap-
plied immediately before, the sensation pro-
duced is, in different cases, of different dura-
tion. If the temperature at any time applied
is under 62 degrees, every increase of temper-
ature applied will give a sensation of heat; but
if the increase of temperature does not arise to
62 degrees, the sensation produced will not
continue long, but be soon changed to a sen-
sation of cold. In like manner, any temper-
ature, applied to the human body, lower than
that of the body itself, gives a sensation of
cold; but if the temperature applied does not
go below 62 degrees, the sensation of cold will
not continue long, but be soon changed to a
sensation of heat.
It will appear hereafter, that the effects of
the sensation of cold will be very different, ac-
cording as it is more permanent or transitory.
XC.
Having thus explained the operation of cold
as absolute or relative with respect to the hu-
man body, I proceed to mention the general
effects of cold upon it.
E 4 1. Cold,

104 PRACTICE
1. Cold, in certain circumstances, has man-
ifestly a sedative power. It can extinguish
the vital principle entirely, either in particu-
lar parts, or in the whole body; and consider-
ing how much the vital principle of animals
depends upon heat, it cannot be doubted that
the power of cold is always more or less di-
rectly sedative.
This effect may be said to take place from
every degree of absolute cold; and, when the
heat of the body has upon any occasion been
preternaturally increased, every lower temper-
ature may be useful in diminishing the activi-
ty of the system; but it cannot diminish the
natural vigour of the vital principle, till the
cold applied is under 62 degrees; nor even
then will it have this effect, unless the cold
applied be of an intense degree, or be applied
for some length of time to a large portion of
the body.
2. It is equally manifest, that, in certain
circumstances, cold proves a stimulus to the
living body, and particularly to the sanguiser-
ous system.
It is probable, that this effect takes place
in every case in which the temperature appli-
ed produces a sensation of cold; and this,
therefore, as depending entirely on the relative
power of cold, will be in proportion to the
change of temperature that takes place.
It appears to me probable, that every change
of temperature from a higher to a lower de-
gree, will prove more or less stimulant; ex-
cepting

105 OF PHYSIC.
cepting when the cold applied is so intense,
as immediately to extinguish the vital princi-
ple in the part.
3. Beside the sedative and stimulant pow-
ers of cold, it is manifestly also a powerful
astringent, causing a contraction of the vessels
on the surface of the body, and thereby pro-
ducing a paleness of the skin and a suppression
of perspiration; and it seems to have similar
effects when-applied to internal parts. It is
likewise probable, that this constriction, as it
takes place especially  in consequence of the
sensibility of the parts to which the cold is
applied, will in some  measure be communi-
cated to other parts of the body; and that
thereby the application of cold proves a tonic
power with respect to the whole system.
These effects of tonic and astringent power
seem to take place both from the absolute and
relative power of cold; and therefore every
application of it which gives a sensation of
cold, is, in its first effect, both astringent and
stimulant, though the former may be oft-
en prevented from being either considerable or
permanent when the latter immediately takes-
place.
XCI.
It will be obvious, that these several effects
of cold cannot all take place at the same time,.
but may in succession be variously combined..
The stimulant power taking place obviates the
E 5 effects,

106 PRACTICE
effects, at least the permanency of the effects,
that might otherwise have arisen from the fe-
dative power. That the same stimulant pow-
er prevents these from the astringent, I have
said above; but the stimulant and tonic pow-
ers of cold are commonly, perhaps always,
conjoined.
XCII.
These general effects of cold now pointed
out are sometimes salutary, frequently mor-
bid; but it is the latter only I am to consider
here, and they seem to be chiefly the follow-
ing.
1. A general inflammatory disposition of
the system, which is commonly accompanied
with Rheumatism or other Phlegmasiæ.
2. The same inflammatory disposition ac-
companied with Catarrh.
3. A Gangrene of particular parts.
4. A Palsy of a single member.
5. A Fever, or Fever strictly so called
(VIII.) which it often produces by its own
power alone, but more commonly it is only
an exciting cause of fever by concurring with
the operation of human or marsh effluvia.
XCIII.
Cold is often applied to the human body
without producing any of these morbid ef-
fects, and it is difficult to determine in what
circumstances 

107 OF PHYSIC.       
circumstances it especially operates in produc-
ing them. It appears to me, that the morbid
effects of cold depend partly upon certain
circumstances of the cold itself, and partly on
certain circumstances of the person to whom
it is applied.
XCIV.
The circumstances of the cold applied,.
which seem to give it effect, are, 1. The in-
tensity or degree of the cold; 2. The length
of time during which it is applied; 3. The
degree of moisture at the same time accom-
panying it; 4. Its being applied by a wind
or current of air; 5. Its being a vicissitude, or
sudden and considerable change of tempera-
ture, from heat to cold..
XCV.
The circumstances of persons renderings
them more liable to be affected by cold, seem
to be, 1. The weakness of the system, and
particularly the lessened vigour of the circula-
tion, occasioned by fasting, by evacuations,
by fatigue, by a last night's, debauch, by ex-
cess in venery, by long watching, by much
study, by rest immediately after great exer-
cise, by sleep, and by preceding disease.
2. The body, or its parts, being deprived of
their accustomed coverings. 3. One part
E 6 of           

108 PRACTICE
of the body being exposed to cold, while the
rest is kept in its usual or a greater warmth-
XCVI.
The power of these circumstances (XCV.)
is demonstrated by the circumstances enabling
persons to refill cold. These are a certain
vigour of constitution, exercise of the body,
the presence of active passions, and the use of
cordials.
Beside these, there are other circumstances
which, by a different operation, enable per-
sons to refill cold acting as a sensation; such
as, passions engaging a close attention to one
object, the use of narcotics, and that state of
the body in which sensibility is greatly dimin-
ished, as in maniacs. To all which is to be
added, the power of habit with respect to those
parts of the body to which cold is more con-
stantly applied, which both diminishes sensi-
bility and increases the power of the activity
generating heat.
XCVII.
Befide cold, there are other powers that
seem to be remote causes of fever; such as,
fear, intemperance in drinking, excess in ven-
ery, and other circumstances, which evidently
weaken the system. But whether any of these
sedative powers be alone the remote cause of
fever, or if they only operate either as concur-
ring

109 OF PHYSIC.
ring with the operation of marsh or human ef-
fluvia, or as giving an opportunity to the ope-
ration of cold, are questions not to be positive-
ly answered; they may possibly of themselves
produce fever; but most frequently they ope-
rate as concurring in one or other of the ways
above mentioned.
XCVIII.
Having now mentioned the chief of the re-
mote causes of fevers, it may be further ob-
served, that these will arise more or less readi-
ly, according as miasmata- and contagions are
more or less prevailing and powerful, or as
these are more or less favoured by the con-
currence of cold and other sedative powers.
CHAP. V.
OF THE PROGNOSIS OF FEVERS.
XCIX.
AS fevers (by LX.) consist
of both morbid and salutary motions and
symptoms, the tendency of the disease to a
happy or fatal issue, or the prognostic in fe-
vers, has been established by marking the
prevalence of the morbid or of the salutary
symptoms; and it might be properly so estab-
lished,

110 PRACTICE
lished, if we could certainly distinguish between
the one and the other of these kinds of symp-
toms; but the operation of the reaction, or
salutary efforts of nature in curing fevers, is
still involved in so much obscurity, that I
cannot explain the several symptoms of it so
clearly as to apply them to the establishing
prognostics; and this, I think, may be done
better, by marking the morbid symptoms
which show the tendency to death in fevers.
C.
This plan of the prognostics in fevers must
proceed upon our knowledge of the causes of
death in general, and in fevers more particu-
larly.
The causes of death, in general, are either
direct or indirect.
The first are those which directly attack and
destroy the vital principle, as lodged in the
nervous system; or destroy the organization
of the brain immediately necessary to the ac-
tion of that principle.
The second, or the indirect causes of death,
are those which interrupt such functions as
are necessary to the circulation of the blood,
and thereby necessary to the due continuance
and support of the vital principle.
CI.
Of these general causes, those which ope-
rate more particularly in fevers seem to be,
first, 

111 OF PHYSIC.
First, The violence of reaction; which either, by
repeated violent excitements, destroys the vital
power itself; or, by its violence, destroys the
organization of the brain necessary to the ac-
tion of that power; or, by the same violence,
destroys the organization of the parts more
immediately necessary to the circulation of
the blood.
Secondly The cause of death in fevers may
be a poison, that is, a power capable of de-
stroying the vital principle; and this poison
may be either the miasma or contagion which
was the remote cause of the fever, or it may be
a putrid matter generated in the course of the
fever. In both cases, the operation of such a
power appears either as acting chiefly on the
nervous system, inducing the symptoms of de-
bility; or as acting upon the fluids of the body,
inducing a putrescent state in them.
CII.
From all this it appears, that the symptoms
showing the tendency to death in fevers, may
be discovered by their being either the symp-
toms
Of violent reaction;
Of great debility;
Or, of a strong tendency to putrefaction in
the fluids.
And to mark those symptoms more particularly.
CIII.           

112 PRACTICE
CIII.
The symptoms which denote the violence of
Reaction, are, 1. The increased force, hardness,.
and frequency of the pulse. 2. The increased
heat of the body. 3. The symptoms which
are the marks of a general inflammatory dia-
thesis, and more especially of a particular de-
termination to the brain, lungs, or other im-
portant viscera. 4. The symptoms which are
the marks of the cause of violent reaction; that
is, of a strong stimulus applied, or of a strong
spasm formed, the latter appearing in a con-
siderable suppression of the excretions.
CIV.
The symptoms which denote a great degree
of debility, are,
In the ANIMAL FUNCTION: I. The
weakness of the voluntary motions; II. The
irregularity of the voluntary motions, de-
pending on their debility; III. The weakness
of sensation; IV. The weakness and irregu-
larity of the intellectual operations.
In the VITUAL FUNCTIONS: I. The weak-
ness of the pulse; II. The coldness or shrink-
ing of the extremities; III. The tendency to
a deliquium animi in an erect posture; IV.
The weakness of respiration.
In the NATURAL FUNCTIONS: I. The
weakness of the stomach, as appearing in an-
orexia, 

113 OF PHYSIC.
orexia, nausea, and vomiting; II. Invol-
untary excretions depending upon a palsy
of the sphincters; III. Difficult deglutition,
depending upon a palsy of the muscles of the
sauces.
CV.
Lastly, The symptoms denoting the putres-
cent slate of the fluids, are,
I. With respect to the stomach; the loath-
ing of animal food, nausea and vomiting, great
thirst, and a desire of acids.
II. With respect to the fluids; 1. The
blood drawn out of the veins not coagulating
as usual 2. Hemorrhagy from different
parts, without marks of increased impetus;
3. Effusions under the skin or cuticle, forming
petechiæ, maculæ, and vibices; 4. Effusions
of a yellow serum under the cuticle.
III. With respect to the state of the excre-
tions; fetid breath, frequent loose and fetid
stools, high coloured turbid urine, fetid sweats,
and the fetor and livid colour of blistered
places.
IV. The cadaverous smell of the whole
body.
CVI.
These several symptoms have very often,
each of them singly, a share in determining the
prognostic; but more especially by their
concurrence          

114 PRACTICE
concurrence and combination with one anoth-
er; particularly those of debility with those
of putrescency.
CVII.
On the subject of the prognostic, it is prop-
er to observe, that many physicians have been
of opinion there is something in the nature of
fevers which generally determines them to be
of a certain duration; and therefore that their
terminations, whether salutary or fatal, hap-
pen at certain periods of the disease, rather
than at others. These periods are called the
Critical Days; carefully marked by Hip-
pocrates and other ancient physicians, as well
as by many moderns of the greatest eminence
in practice; whilst at the same time many oth-
er moderns, of no inconsiderable authority,
deny their taking place in the severs of these
northern regions which we inhabit.
CVIII.
I am of opinion that the doctrine of the an-
cients, and particularly that of Hippocrates,
on this subject, was well founded; and that it
is applicable to the fevers of our climate.
CIX.
I am of this opinion, first, Because I ob-
serve that the animal economy, both from its
own

115 OF PHYSIC.
own constitution, and from habits which are
easily produced in it, is readily subjected to
periodical movements. Secondly, Because, in
the diseases of the human body, I observe pe-
riodical movements to take place with great
constancy and exactness; as in the case of in-
termittent fevers, and many other diseases.
CX.
These confederations render it probable,
that exact periodical movements may take
place in continued fevers; and I think there
is evidence of such movements actually taking
place.
CXI.
The critical days, or those on which we
suppose the termination of continued fevers
especially to happen, are, the third, fifth, sev-
enth, ninth, eleventh, fourteenth, seventeenth,
and twentieth. We mark none beyond this
last; because, though fevers are sometimes
protracted beyond this period, it is, however,
more rarely; so that there are not a sufficient
number of observations to ascertain the course
of them; and further, because it is probable
that, in fevers long protracted, the movements
become less exact and regular, and therefore
less easily observed.
CXII.

116 PRACTICE
CXII.
That the days now mentioned are the crit-
ical days, seems to be proved by the particu-
lar facts which are found in the writings of
Hippocrates. From these facts, as collected
from the several writings of that author by
M. de Haen, it appears, that of one hundred
and sixty three instances of the termination of
fevers, which happened on one or other of the
first twenty days of the disease, there are one
hundred and seven, or more than two thirds
of the whole number, which happened on one
or other of the eight days above mentioned;
that none happened on the second or thir-
teenth day; and upon the eighth, tenth,
twelfth, fifteenth, sixteenth, eighteenth, and
nineteenth, there are but eighteen instances of
termination, or one ninth of the whole.
CXIII.
As the terminations which happen on the
seven days last mentioned, are, upon the
whole, few; and, upon any one of them, few-
er than those which happen on any of our
supposed critical days; so there are therefore
nine days which may be called NONCRITI-
CAL; while, on the other hand, the many ter-
minations which happened on the seventh,
fourteenth, and twentieth days, afford a proof
both of critical days in general, and that these
are

117 OF PHYSIC.
are the chief of them. Hereafter I shall men-
tion an analogy that renders the power of the
other critical days sufficiently probable.
CXIV.
It appears further, that as, of the termina-
tions which were final and salutary, not a
tenth part happened on the noncritical days;
and of the terminations which were final and
fatal, though the greater number happened
on the critical days, yet above a third of them
happened on the noncritical; so it would ap-
pear, that the tendency of the animal, economy
is to observe the critical days, and that it is
by the operation of some violent and irregular
cause that the course of things is sometimes
turned to the noncritical.
CXV.
What has been said gives sufficient ground
for presuming, that it is the general tendency
of the animal economy to determine the pe-
riodical movements in fevers to be chiefly on
the critical clays. At the same time, we must
acknowledge it to be a general tendency only;
and that, in particular cases, many circum-
stances may occur to disturb the regular course
of it. Thus, though the chief and more re-
markable exacerbations in continued fevers
happen on the critical days, there are truly
exacerbations happening every day; and
these,

118 PRACTICE
these, from certain causes, may become con-
siderable and critical. Further, though in-
termittent fevers are certainly very strongly
determined to observe a tertian or quartan
period, we know there are circumstances which
prevent them from observing these periods
exactly, and which render them either antici-
pating or postponing so much, that the days
of paroxysms come to be quite changed; and
it is allowable to suppose, that the like may
happen with respect to the exacerbations of
continued fevers, so as thereby to disturb the
regular appearance of critical days.
A particular instance of this occurs with re-
spect to the sixth day of fevers. In the writ-
ings of Hippocrates, there are many instances
of terminations happening on the sixth day;
but it is not therefore reckoned among the
critical days; for, of the terminations happen-
ing on that day, there is not one which proves
finally of a salutary kind; the greater number
are fatal; and all the rest are imperfect, and
followed with a relapse. All this shows, that
some violent cause had, in these cases, produc-
ed a deviation from the ordinary course of
nature; that the terminations on the sixth day
are nothing more than anticipations of the
seventh, and therefore a proof of the power
of this last.
CXVI.
The doctrine of critical days has been much
embarrassed by some dissonant accounts of it,
which 

119 OF PHYSIC.
which appear in the writings imputed to Hip-
pocrates. But this may be justly accounted
for from these writings being truly the works
of different persons, and from the most genu-
ine of them having suffered many corruptions;
so that, in short, every thing which is incon-
sistent with the facts above laid down, may
be ascribed to one or other of these causes.
CXVII.
This, further, has especially disturbed the
doctrine of critical days, that Hippocrates
himself attempted, perhaps too hastily, to es-
tablish general rules, and to bring the doctrine
to a general theory, drawn from Pythagorean
opinions concerning the power of numbers.
It is this which seems to have produced the
idea of odd days, and of a quaternary and sep-
tenary period, doctrines which appear so oft-
en in the writings of Hippocrates. These,
however, are inconsistent with the facts above
laid down; and indeed, as Asclepiades and
Celsus have observed, are inconsistent with
one another.
CXVIII.
Upon the whole, therefore, it is apprehend-
ed, that the critical days above assigned are
truly the critical days of Hippocrates, and
may be consistently explained in the following
manner.
CXIX.           

120 PRACTICE
CXIX.
From the universality of tertian or quartan
periods in intermittent fevers, we cannot doubt
of there being, in the animal economy, a ten-
dency to observe such periods; and the critical
days above mentioned are consistent with this
tendency of the economy, as all of them mark
either tertian or quartan periods. These pe-
riods, however, are not promiscuously mixed,
but occupy constantly their several portions
in the progress of the disease; so that, from
the beginning to the eleventh day, a tertian
period takes place; and, from the eleventh to
the twentieth, and perhaps longer, a quartan
period is as steadily observed.
CXX.
What determines the periods to be changed
about the eleventh day, we have not clearly
perceived; but the fact is certain; for there
is no instance of any termination on the thir-
teenth, that is, the tertian period next follow-
ing the eleventh; whereas, upon the four-
teenth, seventeenth, and twentieth, which
mark quartan periods, there are forty three
instances of terminations, and fix only on all
the intermediate days between these.
This prevalence of a quartan period leave?
no room for doubting that the twentieth, and
not the twenty first, is the critical day marked
by

121 OF PHYSIC.
by Hippocrates, though the last is mentioned
as such in the common edition of the Aphor-
isms, taken from  an erroneous manuscript,
which Celsus also seems to have copied.
CXXI.
A consistency with the general tendency of
the system, renders the series of critical days
we have mentioned, probably the true one;
and the only remaining difficulty in finding
what we have delivered to be the same with
the genuine doctrine of Hippocrates, is the
frequent mention of the fourth as  a critical
day.
It is true there are more instances of termi-
nations happening on this day than on some
of those days we have asserted to be truly
critical; but its inconsistency with the more
general tendency, and some other considera-
tions, lead us to deny its being naturally a
critical day; and to think, that the instances
of terminations, which have really occurred
on the fourth day, are to be reckoned among
the other irregularities that happen in this
matter.
CXXII.
I have thus endeavoured to support th-
doctrine of critical days, chiefly upon the
particular facts to be found in the writings of
Hippocrates: And although I might also
F produce           

122 PRACTICE
produce many other testimonies of both an-
cient and modern times; yet it must be own-
ed, that some of these testimonies may be sus-
pected to have arisen rather from a veneration
of Hippocrates, than from accurate observa-
tion.
CXXIII.
With respect to the opinions of many mod-
erns who deny the prevalence of critical days,
they are to be little regarded; for the observa-
tion of the course of continued fevers is known
to be difficult and fallacious; and therefore
the regularity of that course may have often
escaped inattentive and prejudiced observers.
CXXIV.
Our own observations amount to this, that
fevers with moderate symptoms, generally
cases of the synocha, frequently terminate in
nine days, or sooner, and very constantly up-
on one or other of the critical days which fall
within that period; but it is very rare, in this
climate, that cases of either the typhus or
synochus terminate before the eleventh day;
and, when they do terminate on this day, it is
for the most part fatally. When they are
protracted beyond this time, I have very con-
stantly found, that their terminations were up-
on the fourteenth, seventeenth, or twentieth
day.
In

123 OF PHYSIC.
In such cases, the salutary terminations are
seldom attended with any considerable evacu-
ation. A sweating frequently appears, but is
seldom considerable; and I have hardly ever
observed critical and decisive terminations at-
tended with vomiting, evacuations by stool, or
remarkable changes in the urine. The solution
of the disease is chiefly to be discerned from
some return of sleep and appetite, the ceasing
of delirium, and an abatement of the frequen-
cy of the pulse. By these symptoms we can
often mark a crisis of the disease; but it sel-
dom happens suddenly and entirely; and it is
most commonly from some favourable symp-
toms occurring upon one critical day, that we
can announce a more entire solution upon the
next following.
Upon the whole, I am persuaded, that, if
observations shall be made with attention, and
without prejudice, I shall be allowed to con-
clude with the words of the learned and saga-
cious  Gaubius, " Fallor, ni sua constiterit
" HIPPOCRATI auctoritas, GALENO sides,
“ NATURE virtus et ordo."
F2 CHAP.

124 PRACTICE
CHAP. VI.
OF THE METHOD OF CURE IN FEVER..
SECT. I.
Of the CURE of CONTINUED FEVERS.
CXXV.
As it is allowed, that, in ev-
ery fever which has its full course, there is an
effort of nature of a salutary tendency, it might
be supposed that the cure of fevers should be
left to the operations of nature, or that our art
should be only directed to support and regu-
late these operations, and that we should form
our indications accordingly. This plan, how-
ever, I cannot adopt, because the operations
of nature are very precarious, and not so well
understood as to enable us to regulate them
properly. It appears to me, that trusting to
these operations has often given occasion to a
negligent and inert practice; and there is rea-
son to believe, that an attention to the opera-
tions of nature may be often superseded by
art.
CXXVI.

125 OF PHYSIC.
CXXVI.
The plan which to me appears to be
most suitable, is that which forms the indica-
tions of cure upon the view of obviating the
tendency to death; while, at the same time,
the means of executing these indications are
directed by a proper attention to the proxi-
mate cause of fevers.
Upon this plan, in consequence of what has
been laid down above on the subject of the
prognostic, we form three general indications
in the cure of continued fevers; and the one
or other of these is to be employed according
as the circumstances of the fever (CII.) shall
direct.
The first therefore is, To moderate the vio-
lence of reaction.
The second is, To remove the causes or ob-
viate the effects of debility. And,
The third is, To obviate or correct the ten-
dency of the fluids to putrefaction.
CXXVII.
The first indication may be answered, that
is, the violence of reaction may be moderated,
1. By all those means which diminish the
action of the heart and arteries.
2. By those means which take off the spasm
of the extreme vessels, which we suppose to
be the chief cause of violent reaction.
F 3 CXXVIII.

126 PRACTICE
CXXVIII.
The action of the heart and arteries may
be diminished,
1. By avoiding or moderating those irrita-
tions, which, in one degree or other, are al-
most constantly applied to the body.
2. By the use of certain sedative powers.
3. By diminishing the tension and tone of
the arterial system.
CXXIX.
The irritations (CXXVIII. 1.) almost
constantly applied, are the impressions made
upon our senses; the exercise of the body and
mind; and the taking in of aliments. The
avoiding these as much as possible, or the mod-
erating their force, constitute what is rightly
called the ANTIPHLOGISTIC REGIMEN,
proper to be employed in almost every con-
tinued fever.
CXXX.
The conduct of this regimen is to be direct-
ed by the following rules and considerations.
1. Impressions on the external senses, as be-
ing stimulant to the system, and a chief sup-
port of its activity, should be avoided as much
as possible; those especially of more constant
application, those of a stronger kind, and those
which give pain and uneasiness.
No 

127 OF PHYSIC.
No impression is to be more carefully guard-
ed against than that of external heat; while, at
the same time, every other means of increas-
ing the heat of the body is to be shunned.
Both these precautions are to be observed as
soon as a hot stage is fully formed, and to be
attended to during its continuance; excepting
in certain cases, where a determination to
sweating is necessary, or where the stimulant
effects of heat may be compensated by circum-
stances which determine it to produce a relax-
ation and revulsion.
2. All motion of the body is to be avoided,
especially that which requires the exercise of
its own muscles; and that posture of the body
is to be chosen which employs the fewest mus-
cles, and which keeps none of them long in a
state of contraction. Speaking, as it accelerates
respiration, is particularly to be refrained from.
It is to be observed, that every motion of
the body is the more stimulant in proportion
as the body is weaker.
3. The exercise of the mind also is a stim-
ulus to the body; so that all impressions which
lead to thought, and those especially which
may excite emotion or passion, are to be care-
fully shunned.
With respect to avoiding impressions of
all kinds, an exception is to be made in the
case of a delirium coming on, when the pre-
senting of accustomed objects may have the
effect of interrupting and diverting the irreg-
ular train of ideas then arising in the mind.
F 4 4- The       

128 PRACTICE
4. The presence of recent aliment in the
stomach proves always a stimulus to the system,
and ought therefore to be as moderate as pos-
sible. A total abstinence for some time may
be of service; but as this cannot be long con-
tinued with safety, we must avoid the stimulus
of aliment, by choosing that kind which gives
the least. We suppose that alimentary mat-
ters are more stimulant, according as they are
more alkalescent; and this leads to avoid all
animal, and to use vegetable food only.
As our drinks also may prove stimulant, so
all aromatic and spirituous liquors are to be
avoided; and, in answering the present indi-
cation, all fermented liquors, excepting those
of the lowest quality, are to be abstained from.
CXXXI.
Besides these stimulant powers more con-
stantly applied, there are others which, al-
though occasional only, yet, as commonly
accompanying fevers, must be attended to and
removed.
One is, the sense of thirst, which, as a pow-
erful stimulus, ought always, in one way or
other, to be removed.
Another stimulus frequently arises from
crudities, or corrupted humours, in the stom-
ach; and it is to be removed by vomiting, by
dilution, or by the use of acids.
A third stimulus often arises from the pre-
ternatural retention of fæces in the intes-
tines; and ought to be removed by frequent
laxative glysters. A

129 OF PHYSIC.
A fourth stimulus to be constantly suspect-
ed in fevers, is a general acrimony of the flu-
ids, as produced by the increase of motion
and heat, joined with an interruption of the
excretions. This acrimony is to be obviated
or removed by the taking in of large quantities
of mild antiseptic liquors.
CXXXII.
The avoiding of irritation in all these par-
ticulars, (CXXX. and CXXXI.) constitutes
the anti-phlogistic regimen absolutely necessa-
ry for moderating the violence of reaction;
and, if I mistake not, is proper in almost
every circumstance of continued fevers; be-
cause the propriety and safety of employing
stimulants is often uncertain; and because
several of those above mentioned, beside their
stimulant powers, have other qualities by
which they may be hurtful.
It appears to me, that the supposed utility
of stimulants, in certain cases of fever, has oft-
en arisen from a mistake in having ascribed to
their stimulant what really depended upon
their antispasmodic power.
CXXXIII.
A second head of the means (CXXVIIL
2.) for moderating the violence of reaction,
comprehends certain sedative powers, which
may
F 5

130 PRACTICE
may be employed to diminish the activity of
the whole body, and particularly that of the
sanguiferous system.
The first of these to be mentioned is the
application of cold.
Heat is the chief support of the activity of
the animal system; which is therefore provid-
ed in itself with a power of generating heat.
But, at the same time, we observe, that this
would go to excess, were it not constantly
moderated by a cooler temperature in the sur-
rounding atmosphere. When, therefore,
that power of the system generating heat is in-
creased, as is commonly the case in fevers, it
is necessary not only to avoid all means of in-
creasing it further, but it seems proper also to
apply air of a cooler temperature; or at least
to apply it more entirely and freely, than in a
state of health.
Some late experiments in the small pox and
in continued fevers, show that the free admis-
sion of cool air to the body is a powerful rem-
edy in moderating the violence of reaction;
but what is the mode of its operation, to what
circumstances of fever it is peculiarly adapt-
ed, or what limitations it requires, I shall not
venture to determine, till more particularly
instructed by further experience.
CXXXIV.
A second sedative power which may be em-
ployed in fevers, is that of certain medicines,
known,


131 OF PHYSIC.
known, in the writings on the Materia Medi-
ca, under the title of Refrigerants.
The chief of these are acids of all kinds,
when sufficiently diluted; and they are, in
several respects, remedies adapted to continu-
ed fevers. Those especially in use are, the
Vitriolic and Vegetable; and, on many ac-
counts, we prefer the latter.
CXXXV.
Another let of refrigerants are, the Neutral
Salts, formed of the vitriolic, nitrous or vege-
table acids; with alkalines, either fixed or
volatile. All these neutrals, while they are
dissolving in water, generate cold; but as
that cold ceases soon after the solution is
finished, and as the salts are generally exhib-
ited in a dissolved state, their refrigerant pow-
er in the animal body does not at all depend
upon their power of generating cold with wa-
ter. The neutral chiefly employed as a refrig-
erant, is Nitre; but all the others, com-
pounded as above mentioned, partake more or
less of the same quality.
CXXXVI.
Besides these neutrals, some metallic salts
also have been employed as refrigerants in
fevers; and particularly the Sugar of Lead.
But the refrigerant powers of this are not well
ascertained; and its deleterious qualities are
too well known to admit of its being freely
used,
F 6 CXXXVII.

132 PRACTICE
CXXXVII.
Under the third general head (CXXVIII.
3.) of the means to be employed for moderat-
ing the violence of reaction, are comprehend-
ed the several means of diminishing the ten-
sion, tone, and activity, of the sanguiferous
system. As the activity of this system de-
pends, in a great measure, upon the tone, and
this again upon the tension of the vessels, giv-
en to them by the quantity of fluids they
contain, it is evident, that the diminution
of the quantity of these, must diminish the
activity of the sanguiferous system.
CXXXVIII.
The quantity of fluids contained in the
sanguiferous system, may be diminished most
conveniently by the evacuations of blood let-
ting and purging.
CXXXIX.
Nothing is more evident, than that blood
letting is one of the most powerful means of
diminishing the activity of the whole body,
especially of the sanguiferous system; and it
must therefore be the most effectual means of
moderating the violence of reaction in fevers.
Taking this as a fact, I omit inquiring into its
mode of operation, and shall only consider in
what

133 OF PHYSIC.
what circumstances of fevers it may be most
properly employed.
CXL.
When the violence of reaction, and its con-
stant attendant, a phlogistic diathesis, are suf-
ficiently manifest; when these constitute the
principal part of the disease, and may be ex-
pected to continue throughout the whole of it,
as in the cases of synocha; then blood letting
is the principal remedy, and may be employed
as far as the symptoms of the disease may seem
to require, and the constitution of the patient
will bear. It is, however, to be attended to,
that a greater evacuation than is necessary,
may occasion a flower recovery, may render
the person more liable to a relapse, or may
bring on other diseases.
CXLI.
In the case of synocha, therefore, there is
little doubt about the propriety of blood let-
ting; but there are other species of fever, as
the synochus, in which a violent reaction and
phlogistic diathesis appear, and prevail dur-
ing some part of the course of the disease;
while, at the same time, these circumstances
do not constitute the principal part of the dis-
ease, nor are to be expected to continue dur-
ing the whole course of it; and it is well
known, that, in many cases, the state of violent
reaction 

134 PRACTICE
reaction is to be succeeded, sooner or later, by
a state of debility, from the excess of which
the danger of the disease is chiefly to arise. It
is, therefore, necessary, that, in many cases,
blood letting should be avoided; and even al-
though during the inflammatory state of the
disease, it may be proper, it will be necessary
to take care that the evacuation be not so large
as to increase the state of debility which is to
follow.
CXLII.
From all this it must appear, that the em-
ploying blood letting, in certain fevers, re-
quires much discernment and skill, and is to
be governed by the consideration of the fol-
lowing circumstances:
l. The nature of the prevailing epidemic.
2. The nature of the remote cause.
3. The season and climate in which the
disease occurs.
4. The degree of phlogistic diathesis pres-
nt.
5. The period of the disease.
6. The age, vigour, and plethoric state of
the patient.
7. The patient's former diseases and habits
of blood letting.
8. The appearance of the blood drawn out.
9. The effects of the blood letting that
may have been already practised.
CXLIII.         

135 OF PHYSIC.
CXLIII.
When, after the consideration of these cir-
cumstances, blood letting is determined to be
necessary, it should be observed, that it  is
more effectual, according as the blood is more
suddenly drawn off, and as the body is at the
same time more free from all irritation, and
consequently when in a posture in which the
fewest muscles are in action.
CXLIV.
Another evacuation whereby the quantity
of fluids contained in the body can be consid-
erably diminished, is that of Purging.
CXLV.
If we consider the quantity of fluids con-
stantly present in the cavity of the interlines,
and the quantity which may be drawn from the
innumerable excretories that open into this
cavity, it will be obvious, that a very great
evacuation can be made by purging; and, if
this be done by a stimulus applied to the intes-
tines, without being at the same time commu-
nicated to the rest of the body, it may, by emp-
tying both the cavity of the intestines, and the
arteries which furnish the excretions poured
into it, induce a considerable relaxation in
the whole system; and therefore, purging
seems 

136 PRACTICE
seems to be a remedy suited to moderate the
violence of reaction in fevers.
CXLVI.
But it is to be observed, that, as the fluid
drawn from the excretories opening into the
intestines, is not all drawn immediately from
the arteries, as a part of it is drawn from the
mucous follicles only; and as what is even
more immediately drawn from the arteries, is
drawn off slowly; so the evacuation will not,
in proportion to its quantity, occasion such a
sudden depletion of the red vessels as blood
letting does; and therefore cannot operate so
powerfully in taking off the phlogistic diathe-
sis of the system.
CXLVII.
At the same time, as this evacuation may
induce a considerable degree of debility; so,
in those cases in which a dangerous state of
debility is likely to occur, purging is to be
employed with a great deal of caution; and
more especially as the due measure of the
evacuation is more difficult to be applied than
in the case of blood letting.
CXLVIII.
As we shall presently have occasion to ob-
serve, that it is of great importance, in the
cure 

137 OF PHYSIC.
cure of fevers, to restore the determination of
the blood to the vessels on the surface of the
body; so purging, as in some measure taking
off that determination, seems to be an evacua-
tion not well adapted to the cure of fevers.
CXLIX.
If, notwithstanding these doubts, (CXLVI.
CXLVII.and CXLVlII.) it shall be asserted,
that purging, even from the exhibition of
purgatives, has often been useful in fevers; I
would beg leave to maintain, that this has not
happened from a large evacuation; and, there-
fore, not by moderating the violence of reac-
tion, excepting in the case of a more purely
inflammatory fever, or of exanthemata of an
inflammatory nature. In other cases of fever,
I have seen a large evacuation by purging, of
mischievous conference; and if, upon occa-
sion, a more moderate evacuation has appear-
ed to be useful, it is apprehended to have been
only by taking off the irritation retained
fæces, or by evacuating corrupted humours
which happened to be present in the intes-
tines; for both of which purposes, frequent
laxatives may be properly employed.
CL.
Another set of means (CXXVII. 2.) for
moderating the violence of reaction in fevers,
are those suited to take off the spasm of the
extreme                   

138 PRACTICE
extreme vessels, which we believe to be the ir-
ritation that chiefly supports the reaction.
Though I have put here this indication of
taking off the spasm of the extreme vessels, as
subordinate to the general indication of mod-
erating the violence of reaction; it is howev-
er to be observed here, that as fever univer-
sally consists in an increased action of the
heart, either in frequency or in force, which
in either case is supported by a spasm of the
extreme vessels, so the indication for remov-
ing this is a very general one, and applicable
in almost every  circumstance of fever, or at
least with a few exceptions, to be taken notice
of hereafter.
CLI.
For taking off the spasm of the extreme
vessels, the means to be employed are either
internal or external.
CLII.
The internal means (CLI.) are,
1. Those which determine the force of the
circulation to the extreme vessels on the surface
of the body, and, by restoring the tone and
activity of these vessels, may overcome the
spasm on their extremities.
2. Those medicines which have the power
of taking off spasm in any part of the system,
and which are known under the title of AN-
TISPASMODICS. CLIII. 

139 OF PHYSIC.
CLIII.
Those remedies which are fit to determine
to the surface of the body, are,
1. DILUENTS.
2. NEUTRAL SALTS.
3. SUDORIFICS.
4. EMETICS.
CLIV.
Water enters, in a large proportion, into
the composition of all the animal fluids, and a
large quantity of it is always diffused through
the whole of the common mass. Indeed, in
a found state, the fluidity of the whole mass
depends upon the quantity of water present
in it. Water, therefore, is the proper diluent
of our mass of blood; and other fluids are dil-
uent only in proportion to the quantity or-
water they contain.
CLV.
Water may be said to be the vehicle of the
several matters which ought to be excerned;
and in a healthy state the fulness of the ex-
treme vessels, and the quantity of excretions,
are nearly in proportion to the quantity of
water present in the body. In fever, how-
ever, although the excretions are in some
measure interrupted, they continue in such
quantity 

140 PRACTICE
quantity as to exhale the more fluid parts of
the blood; and while a portion of them is at
the same time necessarily retained in the larger
vessels, the smaller and the extreme vessels,
both from the deficiency of fluid, and their
own contracted state, are less filled, and there-
fore allowed to remain in that condition.
CLVI.
To remedy this contracted state, nothing is
more necessary than a large supply of water or
watery fluids, taken in by drinking or other-
wise; for as any superfluous quantity of water
is forced off by the several excretories such a
force applied, may be a means of dilating the
extreme vessels, and of overcoming the spasm
affecting their extremities.
CLVII.
Accordingly the throwing in of a large
quantity of watery fluids has been, at all times,
a remedy much employed in fevers; and in
no instance more remarkably, than by the
Spanish and Italian physicians, in the use of
what they call the Diæta aquea.
CLVIII.
This practice consists in taking away every
other kind of aliment and drink, and in giv-
ing in divided portions every day, for several
days 

141 OF PHYSIC.
days together, fix or eight pounds of plain
water, generally cold, but sometimes warm.
All this, however, is to be done only after the
disease has continued for some time, and, at
least, for a week.
CLIX.
A second means (CLIII. 2.) of determin-
ing to the surface of the body, is by the use of
neutral salts. These, in a certain dose taken
into the stomach, produce, soon after, a sense
of heat upon the surface of the body; and, if
the body be covered close and kept warm, a
sweat is readily brought out. The same med-
icines, taken during the cold stage of a fever,
very often put an end to the cold stage, and
bring on the hot; and they are also remarka-
ble for stopping the vomiting which so fre-
quently attends the cold stage of fevers. All
this shows, that neutral salts have a power of
determining the blood to the surface of the
body, and may therefore be of use in taking
off the spasm which in fevers subsists there.
CLX.
The neutral most commonly employed in
fevers, is that formed of an alkali with the
native acid of vegetables; but all the other
neutrals have more or less of the same virtue;
and perhaps some of them, particularly the am-
moniacal salts, possess it in a stronger degree.
CLXI.                    

142 PRACTICE
CLXI.
As cold water taken into the stomach, oft-
en shows the same diaphoretic effects with the
neutral salts, it is probable that the effect of
the latter depends upon their refrigerant pow-
ers mentioned above, (CXXXIV.) What is the
effect of the neutral salts, given when they are
forming and in a state of effervescence? It is
probable that this circumstance may increase
the refrigerant power of these salts, and may
introduce into the body a quantity of fixed
air; but for these purposes it would seem prop-
er to contrive that the whole of the efferves-
cence should take place in the stomach.
CLXII.
A third means (CLIII. 3.) of determining
to the surface of the body, and taking off the
spasm subsisting there, is by the use of sudo-
risic medicines, and of sweating.
CLXIII.
The propriety of this remedy has been
much disputed; and specious arguments may
be adduced both for and against the practice.
In favour of the practice, it may be said;
1. That, in healthy persons, in every case
of increased action of the heart and arteries, a
sweating takes place, and is seemingly the
means

143 OF PHYSIC.
means of preventing the bad effects of such
increased action.
2. That, in fevers, their most usual solu-
tion and termination is by spontaneous sweat-
ing.
3. That, even when excited by art, it has
been found manifestly useful, at certain peri-
ods, and in certain species of fever.
CLXIV.
Upon the other hand, it may be urged a-
gainst the practice of sweating;
1. That as in fevers a spontaneous sweating
does not immediately come on, so there must
be in these some circumstances different from
those in the state of health, and which may
therefore render it doubtful whether the sweat-
ing can be safely excited by art.
2. That, in many cases, the practice has
been attended with bad consequences. The
means commonly employed have a tendency
to produce an inflammatory diathesis; which,
if not taken off by the sweat following their
use, must be increased with much danger.
Thus sweating employed to prevent the ac-
cessions of intermitting fevers, has often chang-
ed them into a continued form, which is al-
ways dangerous.
3. The utility of the practice is further
doubtful, because sweating, when it happens,
does not always give a final determination;
as must be manifest in the case of intermit-
tents,

144 PRACTICE
tents, as well as in many continued fevers,
which are sometimes in the beginning attend-
ed with sweatings that do not prove final; and,
on the contrary, whether spontaneous or ex-
cited by art, seem often to aggravate the dis-
ease.
CLXV.
From these considerations, it is extremely
doubtful if the practice of sweating can be ad-
mitted very generally; but, at the same time,
it is also doubtful, if the failure of the practice,
or the mischiefs said to have arisen from it, have
not been owing to the improper conduct of
the practitioner.
With respect to this last, it is almost agreed
among physicians,
1. That sweating has been generally hurt-
ful when excited by stimulant, heating, and
inflammatory medicines.
2. That it has been hurtful when excited
by much external heat, and continued with a
great increase of the heat of the body.
3. That it is always hurtful when it does
not soon relieve, but rather increases, the fre-
quency and hardness of the pulse, the anxiety
and difficulty of breathing, the headach, and
delirium.
4. That it is always hurtful if it be urged
when the sweat is not fluid, and when it is
partial, and on the superior parts of the body
only.
CLXVI.

145 OF PHYSIC.
CLXVI.
In these cases, it is probable, that either an
inflammatory diathesis is produced, which in-
creases the spasm on the extreme vessels; or
that, from other causes, the spasm is too much
fixed to yield easily to the increased action of
the heart and arteries; and, upon either sup-
position, it must be obvious, that urging the
sweat, as ready to produce a hurtful determi-
nation to some of the internal parts, may be
attended with very great danger.
CLXVII.
Though the doubts started (CLXIV.) are
to be attended to; and although the practices
(CLXV.) having been found hurtful, are
therefore to be rejected; it still remains true,
1. That sweating has certainly been often
useful in preventing the accession of fevers,
when the times of this have been certainly
foreseen, and a proper conduct employed.
2. That, even after fevers have in some
measure come on, sweating, when properly
employed, either at the very beginning of the
disease, or during its approach and gradual
formation, has often prevented their further
progress.
3. That, even after pyrexiæ have continu-
ed for some time, sweating has been success-
fully employed in curing them, as particular-
ly in the case of rheumatism.
G 4. That

146 PRACTICE
4. That certain fevers, produced by a very
powerful sedative contagion, have been gener-
ally treated, so far as we yet know, most suc-
essfully by sweating.
CLXVIII.
These instances (CLXVII.) are in favour
of sweating, but give no general rule; and it
must be left to further experience to deter-
mine how far any general rule can be estab-
lished in this matter. In the mean time, if
the practice of sweating is to be attempted, we
can venture to lay down the following rules
for the conduct of it.
1. That it should be excited without the
use of stimulant inflammatory medicines.
2. That it should be excited with as little
external heat, and with as little increase of the
heat of the bod), as possible.
3. That, when excited, it should be contin-
ued for a due length of time, not less than
twelve hours, and sometimes for twenty four
or forty eight hours; always, however, pro-
viding that it proceeds without the circum-
stances mentioned (CLXV. 3. 4.)
4. That for some part of the time, and as
long as the person can easily bear, it should
be carried on without admitting of sleep.
5. That it should be rendered universal
over the whole body; and, therefore, particu-
larly, that care be taken to bring the sweating
to the lower extremities.
6. That

147 OF PHYSIC.
6. That the practice should be rendered
safer by moderate purging, excited at the same
time.
7. That it should not be suddenly checked
by cold any how applied to the body.
CLXIX.
When attention is to be given to these
rules, the sweating may be excited, 1. By
warm bathing, or a fomentation of the lower
extremities. 2. By frequent draughts of
tepid liquors, chiefly water, rendered more
grateful by the addition of a light aromatic,
or more powerful by that of a small quantity
of wine. 3. By giving some doses of neutral
salts. 4. Most effectually, and perhaps most
safely, by a large dose of an opiate, joined with
a portion of neutral salts, and of an emetic.
In what cases may cold water, thrown into
the stomach in large quantities, be employed
to excite sweating? See Celsus, Lib. III.
chap, vii.-ix.
CLXX.
The fourth means (CLIII. 1.)  of deter-
mining to the surface of the body, and thereby
taking off the spasm affecting the extreme ves-
sels, is by the use of emetics.
G 2 CLXXI.

148 PRACTICE
CLXXI.
Emetics, and particularly antimonial emet-
ics, have been employed in the cure of fevers
ever since the introduction of chemical med-
icines; but, for a long time, they were em-
ployed by chemists and chemical practitioners
only; and although of late the use of them
has become very general, their efficacy is still
disputed, and their manner of operating is not
commonly explained.
CLXXII.
Vomiting is, in many respects, useful in fe-
vers; as it evacuates the contents of the stom-
ach; as it emulges the biliary and pancreatic
ducts; as it evacuates the contents of the du-
odenum, and perhaps also of a larger portion
of the intestines; as it agitates the whole of
the abdominal viscera, expedes the circulation
in them, and promotes their several secretions;
and, lastly, as agitating also the viscera of the
thorax, it has like effects there. All these
several effects are, in many cases and circum-
stances of fever, procured with advantage; but
do not properly fall under our view here, where
we are to consider only the effect of vomiting
in determining to the surface of the body.
CLXXIII.

149 OF PHYSIC.
CLXXIII.
This effect we do not impute to the exercise
of vomiting in agitating the whole frame; but
to the particular operation of emetics upon the
muscular fibres of the stomach, whereby they
excite the action of the extreme arteries on the
surface of the body, so as thereby effectually
to determine the blood into these vessels, re-
move the atony, and take off the spasm affect-
ing them.
CLXXIV.
That such is the power of emetics, will ap-
pear from the several considerations mention-
ed above (XLIV.); and, therefore, that they
are remedies well suited to the cure of fevers.
CLXXV.
Emetics, for that purpose, are administered
in two different ways; that is, either in such
doses as may excite full and repeated vomit-
ings 1 or in such doses as may excite sickness
and nausea only, with little or no vomiting at
all.
CLXXVI.
Full vomiting is best suited to the several
purposes mentioned CLXXII.; and is also
G 3 well

150 PRACTICE
well suited to determine to the surface of the
body, so as thereby to obviate the atony and
spasm which lay the foundation of fever.
Thus vomiting, excited a little before the ex-
pected accession of the paroxysm of an inter-
mittent, has been found to prevent the parox-
ysm altogether. And it has been observed
also, that, when contagion has been applied to
a person, and first discovers its operation, a
vomit given will prevent the fever, which was
otherwise to have been expected. See LIND
on Fevers and Infection.
CLXXVII.
These are advantages to be obtained by ex-
citing vomiting at the first approach of fevers,
or of the paroxysms of fevers; and after fevers
are formed, vomiting may also be employed,
to take off, perhaps entirely, the atony and
spasm, or at least to moderate these, so that the
fever may proceed more gently and safely.
CLXXVIII.
It is seldom, however, that vomiting is found
to produce a final solution of fevers ; and, af-
ter they are once formed, it is commonly nec-
essary to repeat the vomiting several times;
but this is attended with inconvenience, and
sometimes with disadvantage. The operation
of full vomiting commonly soon ceases, and
the exercise of vomitting is often a debilitating
power;

151 OF PHYSIC.
power; and therefore, when the vomiting does
not remove the atony and spasm very entirely,
it may give occasion to their recurring with
greater force.
CLXXIX.
For these reasons, after fevers are fully
formed, physicians have thought proper to
employ emetics in nauseating doses only.
These are capable of exciting the action of
the extreme vessels, and their operation is more
permanent. At the same time, they often
show their power by exciting some degree of
sweat; and their operation is rendered more
safe, by their commonly producing some evac-
uation by stool.
CLXXX.
Such are the advantages to be procured by
nauseating doles of emetics and it only re-
mains to mention, what are the medicines most
fit to be employed in that manner, what are the
most proper times for exhibiting, and what is
the best manner of administering them.
CLXXXI.
The emetics at present chiefly in use, are,
Ipecacuanha and Antimony.
The former may be employed for every
purpose of emetics, particularly those men-
tioned CLXXII. It may likewise be em-
G 4 ployed,

152 PRACTICE
ployed, either in larger or smaller doses, for
determining to the surface of the body; but,
even in very small doses, it so readily excites
vomiting, as to be with difficulty employed
for the purpose of nauseating only; and, how-
ever employed, there is reason to believe, that
its effects are less permanent, and less power-
fully communicated from the stomach to the
rest of the system, than those of Antimony.
CLXXXII.
This, therefore, is generally preferred, and
its preparations, seemingly various, may all
be referred to two heads; the one compre-
hending those in which the reguline part is in
a condition to be acted upon by acids; and
therefore, on meeting with acids in the stom-
ach, becomes active; and the other compre-
hending those preparations in which the regu-
line part is already joined with an acid, ren-
dering it active.
CLXXXIII.
Of each kind there are great numbers, but
not differing essentially from one another.
It will be enough for us to compare the Calx
Antimonii Nitrata of the Edinburgh Dispen-
satory with the Emetic Tartar of the same.
The former, as I judge, is nearly the same with
what is called James's Powder. Which of
these is best suited to the cure of fevers, as
above 

153 OF PHYSIC.
above explained, seems doubtful; but it ap-
pears to me, that, although the former may
have some advantages from its flower opera-
tion, and may thereby seem to be more cer-
tainly sudorific and purgative, yet the uncer-
tainty of its dose renders it inconvenient, has
often given occasion to the timid to be dis-
appointed, and to the bold to do mischief.
On the other hand, die dose of the Emetic
Tartar can be exactly ascertained; and I think
it may be exhibited in such a manner as to
produce all the advantages of the other.
CLXXXIV.
Which soever of these preparations be em-
ployed, I judge the most proper time for ex-
hibiting them, to be the time of accessions; or
a little before, when that can be certainly
known. In continued fevers, the exacerba-
tions are not always very observable; but there
is reason to think, that one commonly hap-
pens about noon, or soon, after it, and anoth-
er in the evening; and that these, therefore,
are the most proper times for exhibiting
emetics.
CLXXXV.
With respect to the manner of administra-
tion, that of the Calx Nitrata is simple, as the
whole of what is judged a proper dose is given
G 5 at          

154 PRACTICE
at once, and no more can properly be given
till the time of the next accession.
The administration of the Emetic Tartar is
different. It is to be given in small doses, not
sufficient to excite vomiting; and these doses,
after short intervals, are to be repeated for
several times, till sickness, nausea, and some,
but not much, vomiting, come on. The dif-
ference of this administration must depend
upon the dose, and the length of the intervals
at which it is given. If it be intended that
the medicine should certainly operate by
stool, the doses are made small, and the inter-
vals long. On the contrary, when vomiting
is proper, or when much purging ought to be
avoided, and therefore some vomiting must be
admitted, the doses are made larger and the
intervals shorter.
CLXXXVI.
With respect to both kinds of preparations,
the repetition is to be made at the times of ac-
cession, but not very often; for if the first ex-
hibitions, duly managed, have little effect, it is
seldom that the after exhibitions have much;
and it sometimes happens that the repeated
vomitings, and especially repeated, purgings,
do harm by weakening the patient.
CLXXXVII.
The other set of internal medicines, (CLII.
2.) which I suppose may be useful in taking
off 

155 OF PHYSIC.
off the spasm of the extreme vessels, are those
named Antispasmodic. How many of these
may be properly employed, I am uncertain;
and their mode of operation is involved in
great obscurity. It is certain, however, that
opium, camphor, musk, and perhaps some
others, have been employed in fevers with ad-
vantage; but the circumstances in which they
are especially proper and safe. I find difficult
to ascertain; and therefore cannot venture
here to lay down any general doctrine con-
cerning them.
CLXXXVIII.
The external means (CLI.) suited to take
off the spasm of the extreme vessels are Blis-
tering and WARM BATHING.
CLXXXIX.
What are the effects of Blistering, so frequent-
ly employed in fevers, is not yet agreed upon
among physicians; and many different opin-
ions have been maintained on this subject,
drawn not only from reasoning, but also from
presumed experience. I must not, however,
enter into controversy; but shall deliver my
own opinion in a few words.
CXC.
I am persuaded, that the small quantity of
cantharides absorbed from a buffering plaster,
G 6 is 

156 PRACTICE.
is not sufficient to change the consistence of
the mass of blood; and therefore that such a
quantity can neither do good, by resolving
phlogistic lentor, if it exists; nor do harm,
by increasing the dissolution of the blood aris-
ing from a putrid tendency in it. I there-
fore neglect entirely the effects of cantharides
upon the fluids.
CXCI.
The inflammation produced by the ap-
plication of cantharides to the skin, affords
a certain proof of their stimulant power;
but, in many persons, the effect of that stim-
ulus is not considerable; in many, it is
not communicated to the whole system;
and, even when the effect does take place in
the whole system, it seems to be taken off,
very entirely, by the effusion and evacuation
of serum from the blistered part. I conclude,
therefore, that neither much good is to be
expected, nor much harm to be apprehended,
from the stimulant power of blistering; and
the certainty of this conclusion is established,
by the great benefit arising from the proper
practice of blistering in inflammatory diseases.
CXCII.
Much has been imputed to the evacuation
occasioned by blistering; but it is never so
considerable as to affect the whole system;
and therefore can neither, by sudden deple-
tion, 

157 OF PHYSIC.
tion, relax the sanguiferous vessels, nor, by
any revulsion, affect the general distribution
of the fluids.
CXCIII.
The evacuation, however, is so consider-
able as to affect the neighbouring vessels;
and the manifest utility of blistering near the
part affected, in inflammatory diseases, leads
me to believe, that blistering, by deriving to
the skin, and producing an effusion there,
relaxes the spasm of the deeper seated vessels.
I apprehend it to be in this manner that the
tumour of a joint, from an effusion into the
cellular texture under the skin, takes off the
rheumatic pain affecting that joint.
CXCIV.
Analogous to this, it may be held, that the
good effects of blistering in continued fevers,
arise from its relaxing the spasm of the ex-
treme vessels, by a communication of the
blistered part with the rest of the skin; and
this is illustrated by the effect of blistering in
colic and dysentery.
CXCV.
It appears to me, that blistering may be
employed at any period of continued fevers,
but that it will be of most advantage in the
advanced 

158 PRACTICE
advanced state of such fevers, when, the reac-
tion being weaker, all ambiguity from the
stimulant power of blistering is removed, and
when it may best concur with other circum-
stances tending to a final solution of the spasm.
CXCVI.
From the view of this matter given in
(CXCIII. and CXCIV.) it will appear, that
the part of the body to which blisters ought
to be applied, is indifferent, excepting upon
the suspicion of topical affection, when the
blistering ought to be made as near as possible
to the part affected.
CXCVII.
Whether SINAPISMS, and other RUBE-
FACIENTIA, act in a manner analogous to
what we have supposed of blistering, may be
doubtful; but their effects in rheumatism,.
and other inflammatory diseases, render it
probable.
CXCVIII.
The other external means of taking off the
spasm of the extreme vessels, is Warm Bath-
ing. This was frequently, and in various
circumstances, employed by the ancients; but
till very lately has been neglected by modern
physicians. As the heat of the bath slimu-
lates 

159 OF PHYSIC.      
lates the extreme vessels, and, with the con-
currence of moisture, also relaxes them, it
seems to be a safe stimulus, and well suited
to take off the spasm affecting them.
CXCIX.
It may be applied to the whole body by
immersion; but this is, in many respects,
inconvenient; and whether some of the in-
conveniences of immersion might not be
avoided by a vapour bath, I have not learned
from experience. I know, however, from
much experience, that most of the purposes
of warm bathing can be obtained by a foment-
ation of the legs and feet, if properly admin-
istered, and continued for a due length of
time, which ought not to be less than an hour.
CC.
The marks of the good effects of such a
fomentation, are, the patient's bearing it easily,
its relieving delirium, and inducing sleep.
CCI.
Having now considered the several means
of satisfying the first general indication in the
cure of fevers, I proceed to the second,
(CXXVI.), which is, To remove the cause, or
obviate the effects, of debility.
CCII.

160 PRACTICE
CCII.
MoSt of the sedative powers inducing de-
bility, cease to act soon after they have been
first applied; and, therefore, the removing
them is not an object of our present indication.
There is only one which may be supposed to
continue to act for a long time; and that is,
the contagion applied; but we know nothing
of the nature of contagion that can lead us to
any measures for removing or correcting it.
We know only its effects as a sedative power
inducing debility, or as a ferment inducing a
tendency to putrefaction in the fluids. The
obviating the latter will be considered under
our third general indication, and the former
alone is to be considered here.
CCIII.
The debility induced in fevers by contagion,
or other causes, appears especially in the
weaker energy of the brain; but in what this
consists, or how it may be directly restored,
we do not well know. As Nature, however,
does, seemingly for this purpose, excite the
action of the heart and arteries, we ascribe the
continuance of debility to the weaker reaction
of the sanguiferous system; so that the means
to be employed for obviating debility, are
immediately directed to support; and increase
the action of the heart and arteries; and the
remedies used are TONICS or STIMULANTS.
CCIV.

161 OF PHYSIC.
CCIV.
In contagious diseases, both from the effects
which appear, and from dissections, it is known,
that the tone of the heart and arteries is con-
siderably diminished; and that tonic reme-
dies, therefore, are properly indicated.
These are to be considered as of two kinds;
the first being the power of cold, the second
that of tonic medicines.
CCV.
The power of cold, as a tonic, I have
mentioned above (XC.); and it is employed,
in fevers, in two ways; either as the cold
matter is thrown into the stomach, or as it is
applied to the surface of the body.
CCVI.
As it has been shown above, that the tonic
power of cold can be communicated from any
one part to every other part of the system; so
it will readily be allowed, that the stomach is a
part as fit for this communication as any
other; and that cold drink, taken into the
stomach, may, therefore, prove an useful tonic
in fevers.
CCVII.
This the experience of all ages has confirm-
ed; but, at the same time, it has been fre-
quently

162 PRACTICE
quently observed, that, in certain circum-
stances, cold drink, taken into the stomach,
has proved very hurtful; and, therefore, that
the use of cold drink in fevers requires some
limitations. What these limitations should
be, and what are all the circumstances which
may forbid the use of cold drink, is difficult
to determine; but it seems clearly forbidden,
in all cases where a phlogistic diathesis pre-
vails in the system, and more especially when
there are topical affections of an inflammatory
nature.
CCVIII.
The other method of employing cold as a
tonic, is, by applying it to the surface of the
body. The application of cold air to the sur-
face of the body, as a refrigerant power fit
to moderate the violence of reaction, I have
spoken of above (CXXXIII.); but probably
it may also be considered here as a tonic, and
useful in cases of debility.
CCIX.
Not only cool air, but cold water also, may
be applied to the surface of the body, as a
refrigerant, and perhaps as a tonic. The an-
cients frequently applied it with advantage,
to particular parts, as a tonic; but it is a dis-
covery of modern times, that in the case of
putrid fevers, attended with much debility,
the body may be washed all over with cold
water,
CCX.

163 OF PHYSIC.
CCX.
This was first practiced at Breslaw in Silesia,
as appears from a dissertation, under the title
of Epidemia verna quaœ Wratislaviam, anno
1737, afflixisy to be found in the appendix to
the Acta Nat. Curios. Vol. X. And from
other writers we find, that the practice has
parted into some of the neighbouring countries;
although in this island, so far as I know, we
have hitherto had no experience of it.
CCXI.
The medicines which have been employed
in fevers, as tonics, are various. If the Sac-
charum Saturni has been found useful, it is,
probably, as a tonic, rather than as a refriger-
ant; and the Ens Veneris, or other prepa-
rations of iron which have been employed,
can act as tonics only. The preparations of
copper, from their effects in epilepsy, are pre-
sumed to possess a tonic power; but, whether
their use in fevers be founded upon their tonic
or their emetic powers, may be uncertain. The
use of arsenic and of alum, in intermittent
fevers, seems manifestly to depend upon their
tonic power. And, upon the whole, there
may occur cases of continued fevers, which
may be cured by tonics taken from the fossil
kingdom; but the use of these has been rare,
as

164 PRACTICE
as well as the effects uncertain; and physicians
have employed, more commonly, the vege-
table tonics.
CCXII.
A great variety of these has been employed
in the cure of intermittent fevers; but how
many of them may be employed in continued
fevers, or in what circumstances of these
fevers, is not well ascertained; and I shall
now only consider the question with respect
to the most celebrated of these tonics, the
Peruvian Bark.
CCXIII.
This bark has been commonly considered
as a specific, or as a remedy of which the
operation was not understood. But it is cer-
tainly allowable to inquire into this matter;
and I apprehend it may be explained.
CCXIV.
To this purpose it is to be remarked, that
as, in many cases, the effects of the bark are
perceived soon after its being taken into the
stomach, and before it can possibly be con-
veyed to the mass of blood, we may conclude,
that its effects do not arise from its Operating
on the fluids; and must, therefore, depend
upon its operating on the nerves of the stom-
ach, 

165 OF PHYSIC.
ach, and being thereby communicated to
the rest of the nervous system. This opera-
tion seems to be a tonic power, the bark being
a remedy in many cases of debility, particu-
larly in gangrene; and, as the recurrence of
the paroxysms of intermittent fevers depends
upon a recurrence of atony, (XXXV. and
XXXVI.); so probably the bark, by its
tonic power, prevents the recurrence of these
paroxysms; and this is greatly confirmed by
observing, that many other tonic medicines
answer the same purpose.
CCXV.
If the operation of the bark may be thus
explained, from its possessing a tonic power,
it is easy to perceive why it is improper when
a phlogistic diathesis prevails; and, from the
same view, we can ascertain in what cases of
continued fever it may be admitted. These
are either after considerable remissions have
appeared, when it may be employed to pre-
vent the return of exacerbations, on the same
footing that it is used in intermittent fevers,
or in the advanced state of fevers, when all
suspicion of an inflammatory state is removed,
and a general debility prevails in the system;
and its being then employed is sufficiently
agreeable to the present practice.
CCXVI.          

166 PRACTICE.
CCXVI.
With respect to the use of the bark, it is
proper to add, that good effects are to be ex-
pected from it, almost only when given in
substance and in large quantity.
CCXVII.
Another set of medicines to be employed
for obviating debility and its effects, are the
direct stimulants (CCIII.). These, in some
measure, increase the tone of the moving
fibres; but they are different from the tonics,
as more directly exciting and increasing the
action of the heart and arteries. This mode
of their operation renders the use of them
ambiguous; and when an inflammatory dia-
thesis is present, as so often happens in the be-
ginning of fevers, the effects of these stimu-
lants may be very hurtful; but it still re-
mains probable, that, in the advanced state
of fevers, when debility prevails, they may
be useful.
CCXVIII.
What are the stimulants that may be most
properly employed, I am uncertain, as the
use of them in this age has been rare; but I
am disposed to believe that, of all kinds, wine
is the best.
CCXIX.

167 OF PHYSIC.
CCXIX.
Wine has the advantage of being grateful
to the palate and, stomach, and of having its
stimulant parts so much diluted, that it can be
conveniently given in small doses; so that it
may be employed with to sufficient caution; but
it is of little service, unless taken pretty largely.
CCXX.
It may be supposed, and on good grounds
that wine has an operation analogous to that
of opium and some other narcotic medicines.
It may indeed be said, that we can distinctly
mark its stimulant power only, which renders
its effects in the phrenitic delirium manifestly
hurtful, and, in the mild delirium, depending
on debility, as remarkably usefuL But in all
this the analogy with opium is still obvious;
and it is probable, that both wine and opium
are more useful by their sedative and anti-
spasmodic, than by their stimulant powers.
CCXXL
These are the means of answering our sec-
ond general indication (CXXVI. 2.); and I
now proceed to the third, which is, To obviate
or to correct the tendency of the fluids to putre-
faction.
CCXXII.

168 PRACTICE
CCXXII.
This may be done,
1. By avoiding any new application of pu-
trid or putrescent matter.
2. By evacuating the putrid or putrescent
matter already present in the body.
3. By correcting the putrid or putrescent
matter remaining in the body.
4. By supporting the tone of the vessels, and
thereby refilling further putrefaction, or ob-
viating its effects.
CCXXIII.
The further application of putrid or pu-
trescent matter may be avoided,
1. By removing the patient from places fill-
ed with corrupted air.
2. By correcting the air from which he can-
not be removed.
3. By preventing the accumulation of the
patient's own effluvia, by a constant ventila-
tion, and by a frequent change of bed clothes
and body linen.
4. By the careful and speedy removal of
all excremental matters from the patient's
chamber.
5. By avoiding animal food, or correcting it.
CCXXIV.

169 OF PHYSIC.
CCXXIV.
The putrid or putrescent matter, already
present in the body, may be evacuated, partly
by evacuating frequently the contents of the
intestines; and more effectually still, by sup-
porting the excretions of perspiration and
urine, by the plentiful use of diluents.
CCXXV.
The putrid or putrescent matter, remaining
in the body, may be rendered more mild and
innocent by the use of diluents; or may be
corrected by the use of antiseptics. These last
are of many and various kinds; but which of
them are conveniently applicable, or more
particularly suited to the case of fevers, is not
well ascertained. Those most certainly ap-
plicable and useful, are acescent aliments, acids
of all kinds, neutral salts, and fixed air.
CCXXVI.
The progress of putrefaction may be consid-
erably retarded, and its effects obviated, by
supporting the tone of the vessels; and this
may be done by tonic remedies; the chief of
which are, Cold, and Peruvian Bark, both suf-
ficiently treated of above, (CCV. Et seq.)
H CCXXVII.

170 PRACTICE
CCXXVII.
I have now finished the consideration of the
three general indications to be formed in the
cure of continued fevers; and have mentioned
most of the remedies which have been, upon
any occasion, employed in this business. It
was necessary, in the first place, to consider
these indications and remedies separately, and
to explain the operation of the latter more
generally; but, from what has been now de-
livered, compared with what was said above,
concerning the difference of fevers, and the
signification of their several symptoms in form-
ing the prognostic, I expect it will not be dif-
ficult to assign the indication, and to select
and combine the several remedies mentioned,
so as to adapt them to the several species and
circumstances of continued fevers.
I think

171 OF PHYSIC.
I think it may be useful for my Readers to
have the whole of the cure of CONTINUED
FEVERS brought under one View, as in the
following TABLE.
IN THE CURE OF CONTINUED FEVERS,
THE INDICATIONS are,
1. To moderate the violence of reaction.
Which may be done, by
1. Diminishing the action of the heart and arteries, by
A. Avoiding or moderating those irritations which are
almost constantly applied to the body; as,
a. The impressions made upon our senses, particu-
larly,
α. Increased heat, whether arising from
αα. External heat, or,
ΒΒ. The accumulation of the heat of the body.
b. The exercise of the body,
c. The exercise of the mind,
d. The taking in of aliment.
e. Particular irritations arising from
α. The sense of thirst,
Β. Crudities, or corrupted humours, in the stom-
ach,
γ. The preternatural retention of fæces,
δ. A general acrimony of the fluids.
B. Employing certain sedative powers; as,
a. Cold,
b. Refrigerants; the chief of which are,
α. Acids of all kinds,
Β. Neutral salts,
y. Metallic salts.
C. Diminishing
H 2

172 PRACTICE
C. Diminishing the tendon and tone of the arterial
system, by
a. Bloodletting,
b. Purging.
2. Taking off the spasm of the extreme vessels, by
A. Internal means; which are,
a. Those remedies which determine to the surface, as,
α. Diluents,
β. Neutral salts,
y. Sudorifics,
δ. Emetics.
b. Those remedies named antispasmodics.
B. External means ; as,
a. Blistering,
b. Warm bathing.
II. To remove the causes, or obviate the effects,
of debility, by
1.Supporting and increasing the action of the heart
an d arteries, by
A. Tonics, as,
a. Cold,
b. Tonic medicines, which are either,
α. Fossil, as,
αα. Saccharum saturni, &c. or,
β. Vegetable, as,
αα. Peruvian bark.
B. Stimulants, as,
a. Aromatics, &c.
b. Wine.
III. To obviate or correct the tendency of the
fluids to putrefaction, by
1. Avoiding the application of putrid or putrescent
matter, by
A. Removing the patient from places filled with
corrupted air.
B. Correcting the air, from which he cannot be
removed.
C. Avoiding 

173 OF PHYSIC.
C. Avoiding the accumulation of the patient's own
effluvia, by
a. A constant ventilation,
b. Frequently changing the bed clothes and body
linen.
D. Removing carefully and speedily all excremental
matters.
E. Avoiding animal food, or correcting it.
2. Evacuating the putrid or putrescent matter already
present in the body, by
A. Evacuating frequently the intestines.
B. Supporting the excretions of perspiration and
urine, by
a. Diluents,
b. Neutral salts.
3. Correcting the putrid or putrescent matter remaining
in the body, by
A. Diluents,
B. Antiseptics,
C. Fixed air.
4. Refilling farther putrefaction, or obviating its ef-
fects, by
Supporting the tone of the vessels, by
Tonic remedies.
SECT. II.
Of the CURE of INTERMITTENT FEVERS.
CCXXVIII.
It still remains to consider the cure of in-
termittent fevers; and, with respect to these,
we form also three general indications.
1. In the time of intermission, to prevent the
recurrence of paroxysms,
H 3 2. In     

174 PRACTICE
2. In the time of paroxysms, to conduct these
so as to obtain a final solution of the disease.
3. To take off certain circumstances which
might prevent the fulfilling of the two first indi-
cations.
CCXXIX.
The first indication may be answered in
two ways:
1. By increasing the action of the heart
and arteries some time before the period of
accession, and supporting that increased action
till the period of the accession be over, so as
thereby to prevent the recurrence of the atony
and spasm of the extreme vessels which give
occasion to the recurrence of paroxysms.
2. Without increasing the action of the
heart and arteries, the recurrence of parox-
ysms may be prevented, by supporting the
tone of the vessels, and thereby preventing
atony, and the consequent spasm.
CCXXX.
For the purpose mentioned in (CCXXIX.
1.), the action of the heart and arteries may
be increased;
1. By various stimulant remedies, inter-
nally given, or externally applied, and that
without exciting sweat.
2. By the same remedies, or others so man-
aged as to excite sweating, and to support that
sweating

175 OF PHYSIC.
sweating till the period of accession be for
some time past.
3. By nauseating doses of emetics, given
about an hour before the time of accession,
thereby supporting and increasing the tone
and action of the extreme vessels.
CCXXXL
The tone of the extreme vessels may be sup-
ported without increasing the action of the
heart and arteries (CCXXIX. 2.), by various
tonic medicines; as,
1. Astringents alone.
2. Bitters alone.
3. Astringents and bitters conjoined.
4. Astringents and aromatics conjoined.
5. Certain metallic tonics.
6. Opiates.
Lastly, An impression of horror.
A good deal of exercise, and as full a diet
as the condition of the patient's appetite and
digestion may allow of, will be proper during
the time of intermission, and may be considered
as belonging to this head.
CCXXXII.
Of all the tonic remedies mentioned
(CCXXXI.), the most celebrated, and  per-
haps the most certainly effectual, is the Pe-
ruvian bark, the tonic power of which we
have endeavoured to demonstrate above
H 4 (CCXIV.)

176 PRACTICE
(CCXIV.), and have at the same time ex-
plained its use in continued fevers.
The same observation as made in CCXVI.
is especially proper in the case of intermittents;
and further with respect to these, the follow-
ing observations or rules are offered here.
1. That the bark may be employed with
safety at any period of intermittent fevers,
providing that, at the same time, there be
neither a phlogistic diathesis prevailing in the
system, nor any considerable or fixed con-
gestion present in the abdominal viscera.
2. The proper time for exhibiting the bark
in intermittent fevers, is during the time of
intermission; and where intermissions are to
be expected, it is to be abstained from in
the time of paroxysms.
3. In remittents, though no entire apy-
rexia occurs, the Bark may be given during
the remissions; and it should be given, even
though the remissions be inconsiderable, if, from
the known nature of the epidemic, inter-
missions or considerable remissions are not to
be soon expected, and that great danger is
apprehended from repeated exacerbations.
4. In the case of genuine intermittents, while
a due quantity of Bark is to be employed, the
exhibition of it ought to be brought as near
to the  time of accession as the condition of the
patient's stomach will allow.
5. In general, in all cases of intermittents,
it is not sufficient that the recurrence of parox-
ysms be stopped for once by the use of the
bark; 

177 OF PHYSIC.
bark; a relapse is commonly to be expected,
and should be prevented by the exhibition of
the bark, repeated at proper intervals.
CCXXXIII.
Our second general indication for con-
ducting the paroxysms of intermittent fevers,
so as to obtain a final solution of the disease,
may be answered,
1. By exhibiting emetics during the time
of the cold stage, or at the beginning of the
hot.
2. By opiates given during the time of the
hot stage.
CCXXXIV.
The circumstances which may especially
prevent the fulfilling of those two indications,
and therefore give occasion to our third, are
a phlogistic diathesis prevailing in the system,
and congestions fixed in the abdominal viscera.
The first must be removed by bloodletting
and the antiphlogistic regimen; the second,
by vomiting and purging.
Where these measures are not immediately
effectual, I hold it safer to attempt the cure
of the disease by the means pointed out in
general in CCXXIX. rather than by those in
article second of the same paragraph.
H 5 BOOK           

178
BOOK II.
OF INFLAMMATIONS, OR
PHLEGMASIÆ
CHAP. I.
OF INFLAMMATION IN GENERAL.
SECT. I.
Of the PHENOMENA of INFLAMMATION.
CCXXXV.
WHEN any part upon the
surface of the body is affected with unusual
redness, heat, pain, and tumour, we name
the disease an Inflammation or Phlegma-
sia. These symptoms of inflammation are
never considerable, without the whole system
being, at the same time, affected with pyrex-
CCXXXVI.


179 OF PHYSIC.
CCXXXVI.
As the external, so likewise the internal
parts may be affected with inflammation; and
we judge them to be so, when, together with
pyrexia, there is a fixed pain in any internal
part, attended with some interruption in the
exercise of its functions.
CCXXXVII.
We judge of the presence of inflamma-
tion also from the state of the blood drawn
out of the veins. When the blood, after
cooling and concreting, shows a portion of
the gluten separated from the rest of the mass,
and lying on the surface of the crassamentum;
as such separation happens in all cases of more
evident phlegmasia; so, in ambiguous cases
we, from this appearance, joined with other
symptoms, infer the presence of inflammation.
At the same time, it must be observed, that
as several circumstances in bloodletting, may
prevent this separation of gluten from taking
place in blood otherwise disposed to it; so,
from the absence of such appearance, we can-
not always conclude against the presence of
inflammation.
CCXXXVIII.
I cannot easily give any other general
History of the phenomena of inflammation
H 6 than

180 PRACTICE
than what is contained in the three preceding
paragraphs; and the variations which may
take place in its circumstances, will occur to
be more properly taken notice of under the
several heads of the particular genera and
species to be hereafter mentioned. I proceed,
therefore, to inquire into the proximate cause
of inflammation in general.
SECT. II.
Of the PROXIMATE CAUSE of INFLAM-
MATION..
CCXXXIX.
The phenomena of inflammation
(CCXXXV.) all concur in showing, that
there is an increased impetus of the blood in
the vessels of the part affected; and as, at the
same time, the action of the heart is not
always evidently increased, there is reason to
presume, that the increased impetus of the
blood in the particular part is owing espec-
ially to the increased action of the vessels of
that part itself.
CCXL.
The cause of this increased action in the
vessels of a particular part is, therefore, what
we 

181 OF PHYSIC.
we are to inquire after, and to consider as the
proximate cause of inflammation.
In many cases, we can manifestly perceive,
that inflammation arises from the application
of stimulant substances to the part. When
the application of such stimulants, therefore,
is evident, we seek for no other cause of in-
flammation; but as, in many cases, such ap-
plication is neither evident, nor, with any
probability, to be supposed, we must, in such
cases, seek for some other cause of the increas-
ed impetus of the blood in the vessels of the
part.
CCXLI.
Many physicians have supposed, that an ob-
struction of the extreme vessels, any how pro-
duced, may prove a cause of inflammation;
and particularly, that this may arise from an
obstruction formed by a matter stopping up
these vessels. But many difficulties attend
this doctrine.
1. The opinion seems chiefly to have arisen
from the appearance of the blood described in
CCXXXVII. when the separated gluten
was considered as a preternatural and morbid
matter; but we now know very certainly,
that this gluten is constantly a constituent part
of the human blood; and that it is only a
peculiar separation of the parts of the blood
that happens in consequence of inflammation
and          

182 PRACTICE
and some other circumstances, which gives
occasion to the appearance that was falsely
considered as a mark of a morbid lentor in the
blood.
2. There are no experiments directly in
proof of a preternatural lentor prevailing in
the mass of blood; nor is there any evidence
of certain parts of the blood occasionally ac-
quiring a greater density and force of cohesion
than ordinary; neither is there any proof of
the denser, or more coherent parts, being
present in the mass of blood in such greater
proportion than usual, as to occasion a danger-
ous spissitude. The experiments of Dr.
Browne Langrish on this subject afford no
conclusion, having been made on certain
parts of the blood separated from the rest,.
without attending to the circumstances of
bloodletting, which very much alter the flate
of the separation and concretion of the blood
drawn out of the veins.
3. The supposition of a preternatural lentor
or viscidity of the blood, is not well founded;.
for it is probable, that nature has specially
provided against a state of the fluids, so in-
compatible with the exercise of the most im-
portant functions of the animal economy.
While motion continues to prevent any sepa-
ration of parts, and heat continues to preserve
the fluidity of the more viscid, there seems to
be always so large a proportion of water pres-
ent as to give a sufficient fluidity to the whole.
I must own that this is not absolutely con-
clusive;

183 OF PHYSIC.
clusive; but I still repeat it, as giving a
probability to the general argument.
4. In the particular case of inflammation,
there are several circumstances which render
it probable that the blood is then more fluid
than usual.
5. I presume that no such general lentor,
as Boerhaave and his disciples have supposed,
does ever take place; because if it did, it must
show more considerable effects than commonly
appear.
6. Besides the supposition of an obstructing
lentor, physicians have supposed, that an ob-
struction may be formed by an impermeable
matter of another kind, and that such an ob-
struction may also be the cause of inflam-
mation. This supposition is what is well
known in the schools under the title of an
error loci; but it is an opinion that I can-
not find to be at all probable; for the mo-
tion of the blood in the extreme vessels
is so weak and slow, as readily to admit a. ret-
rograde course of it; and therefore, if a parti-
cle of blood should happen to enter a vessel
whose branches will not allow of its passage,
it will be moved backwards, till it meet with
a vessel fit for transmitting it; and the fre-
quent ramifications and anastomoses of the
extreme arteries are very favourable to this,
I must own indeed, that this argument is not
absolutely conclusive; because I allow it to
be pretty certain, that an error loci does
actually upon, occasion happen; but, for the
reasons

184 PRACTICE
reasons I have given, it is probable that it
seldom happens, and is therefore rarely the
cause of inflammation; or if it be, that it is
not merely by the obstruction that it produces;
as, among other reasons, I conclude particu-
larly from the following argument.
7. Though an obstruction should be suppos-
ed to take place, it will not be sufficient for pro-
ducing the effects, and exhibiting the phe-
nomena, that appear in inflammation. The
theory that has been commonly employed on
this occasion is by no means satisfying; and,
in fact, it appears, from many observations
and experiments, that considerable obstruc-
tions may be formed, and may subsist, with-
out producing the symptoms of inflammation.
CCXLII.
Obstruction, therefore, from a matter flop-
ping up the vessels, Gaub. Pathol. 249. i. is
not to be considered as the primary cause of
inflammation; but, at the same time, it is
sufficiently probable, that some degree of ob-
struction does take place in every case of in-
flammation. The distention, pain, redness,
and tumour attending inflammation, are to
be explained only by supposing, that the ex-
tremities of the arteries do not readily transmit
the unusual quantity of blood impelled into
them by the increased action in the course of
these vessels. Such an obstruction may be
supposed to happen in every case of an in-
creased

185 OF PHYSIC.
creased impetus of the blood; but it is prob-
able, that, in the case of inflammation, there
is also a preternatural resistance to the free
passage of the fluids.
CCXLIII.
From the doctrine of fever, we are led
to believe, that an increased action of the
heart and arteries is not supported for any
length of time by any other means than a
spasm affecting the extreme vessels; and that
the same spasm takes place in inflammation,
seems likely, because that every considerable
inflammation is introduced by a cold stage,
and is accompanied with that and other cir-
cumstances of pyrexia. It seems also probable,
that something analogous to this occurs even
in the case of those inflammations which appear
less considerable, and to be purely topical.
CCXLIV.
From all this, the nature of inflammation
may in many cases be explained in the follow-
ing manner. Some causes of inequality in the
distribution of the blood may throw an unusual
quantity of it upon particular vessels, to which
it must necessarily prove a stimulus. But,
further, it is probable, that, to relieve the
congestion, the vis medicatrix naturæ increases
still more the action of these vessels; and
which, as in all other febrile diseases, it effects
by

186 PRACTICE
by the formation of a spasm on their extremi-
ties.
CCXLV.
A spasm of the extreme arteries, supporting
an increased action in the course of them, may
therefore be considered as the proximate cause
of inflammation; at least, in all cases not
arising from direct stimuli applied; and even
in this case the stimuli may be supposed to
produce a spasm of the extreme vessels.
CCXLVI.
That, in inflammation, there is the con-
currence of a constriction of the extreme
vessels, with an increased action in the other
parts of them, seems probable, from the con-
sideration of Rheumatism. This is a species
of inflammation which is often manifestly pro-
duced, either by cold applied to over distend-
ed vessels, or by causes of an increased impetus,
and over distention in vessels previously con-
stricted. Hence the disease especially appears
at seasons liable to frequent and considerable
vicissitudes of heat and cold.
To this we may add, that the parts of the
body most frequently affected with inflamma-
tion, are those exposed, both to over disten-
tion, from a change in the distribution of the
fluids, and, at the same time, to the immediate
action of cold. Hence, quinsies, and pneu-
monic

187 OF PHYSIC.
monic inflammations, are more frequent than
any others.
CCXLVII.
That a spasm of the extreme vessels takes
place in inflammation, is to be further pre-
sumed from what is at the same time the state
of the whole arterial system. In every con-
siderable inflammation, though arising in one
part only, an affection is communicated to the
whole system, in consequence of which an in-
flammation is readily produced in other parts
beside that first affected. This general affec-
tion is well known among physicians, under
the name of the DIATHESIS PHLOGISTICA.
It appears most commonly in persons of the
most rigid fibres; is often manifestly induced
by the tonic or astringent powers of cold; is
increased by all tonic and stimulant powers
applied to the body; is always attended with
a hardness of the pulse; and is most effectual-
ly taken off by the relaxing power of blood-
letting. From these circumstances, it seems
probable, that the diathesis phlogistica con-
sists in an increased tone, or contractility, and
perhaps in an increased contraction of the
muscular fibres of the whole arterial system.
Such a state of the system seems often to arise,
and subsist for some time, without the apparent
inflammation of any particular part; but such
a state of the system renders it likely, that a
spasm may, at the same time, readily arise in
any

188 PRACTICE
any of the extreme vessels, and a particular
inflammation be there produced. It does,
however, appear also, that the general diathe-
sis frequently arises from inflammation begun
in a particular part.
CCXLVIII.
I have thus endeavoured, in the case of in-
flammation, to explain the state of the whole
system, as well as that of the part more par-
ticularly affected. The latter I have consid-
ered as when in its first formation; but after
it has subsisted for some time, various changes
take place in the part affected; and of these;
must now take notice.
SECT III.
Of the TERMINATIONS of INFLAMMATION.
CCXLIX.
If an inflammation be cured while the state
and texture of the part remain entire the
disease is said to be terminated by Resolu-
tion.
This happens when the previous congestion
and spasm have been in a moderate degree,
and the increased impetus of the blood has
been sufficient to overcome the spasm, to di-
late the vessels, and to remove the congestion,
so 

189 OF PHYSIC.
so that the part is restored to its ordinary and
healthy state.
A resolution takes place also when the in-
creased impetus of the fluids has produced an
increased exhalation into the adjoining cellu-
lar texture, or an increased excretion in some
neighbouring part, and has thereby relaxed
the spasm, and relieved the congestion, in the
vessels of the part more particularly affected.
Lastly, A resolution may take place, when
the increased impetus of the blood in the
whole system occasions an evacuation, which,
though in a distant part, may prove sufficient
to take off the phlogistic diathesis of the
whole system, and thereby relieve the conges-
tion and spasm of the particular part affected
by inflammation. 
CCL.
The tumour which appears in inflamma-
tion may be imputed in part to the congestion
of fluids in their proper vessels; but is owing
chiefly to an effusion of matter into the ad-
joining cellular texture; and, accordingly, tu-
mours seldom appear but in parts adjoining
to a lax cellular texture. If, in this case, the
matter effused be only a larger quantity of the
ordinary exhaling fluid, this, when the free
circulation in the vessels is restored, will be
readily absorbed, and the state of the part will
become the same as before. But, if the in-
creased impetus of the blood in an inflamed
part,          

190 PRACTICE.
part, dilate the exhalant vessels to such a de-
gree, that they pour out an entire serum, this
will not be so readily reabsorbed; and, from
the experiments of Sir John Pringle, and
especially from those of Mr. Gaber, Miscell.
Taurin, Vol. II. we learn, that the serum,
under stagnation, may suffer a particular
change, by having the gluten present in it
changed into a white, opaque, moderately vis-
cid, mild liquor, which we name Pus.
When this change takes place in the in-
flamed part, as it is at the same time attended
with an abatement of the redness, heat, and
pain, which before distinguished the inflame-
mation, so the disease is said to be terminated
by Suppuration; and an inflamed part,
containing a collection of pus, is called an
ABSCESS.
CCLI.
In inflammation, the tendency of it to sup-
puration may be discovered, by the long con-
tinuance of the inflammation, without the
symptoms of resolution; by some remission of
the pain of distention; by the pain becoming
of a throbbing kind, more distinctly connected
with the pulsation of the arteries; by the
pulse of the arteries being fuller and softer;
and often by the patient's being frequently
affected with cold shiverings. The period at
which this takes place is not determined, but
may be sometimes sooner, sometimes later.
When

191 OF PHYSIC.
When the tendency is determined, the time
necessary to a complete suppuration is differ-
ent in different cases.
When pus is completely formed, the pain
in the part entirely ceases, and a weight is felt
in it. If the collection be formed immediate-
ly under the skin, the tumour becomes point-
ed, the part becomes soft, and the fluctuation
of the fluid within can commonly be perceiv-
ed; while, at the same time, for the most part,
the redness of the skin formerly prevailing is
very much gone.
CCLII.
In abscesses, while the pus is formed of one
part of the matter which had been effused,
the other and thinner parts  are reabsorbed, so
that, in the abscess, when opened, a pus alone
appears. This pus, however, is not the con-
verted gluten alone; for the conversion of this
being the effect of a particular fermentation,
which may affect the solid substance of the
part, and perhaps every solid of animal bod-
ies; so it most readily, and particularly, af-
fects the cellular texture, eroding much of it,
which thereby becomes a part of the pus. It
generally happens also, that some of the small-
er red vessels are eroded, and thereby some
red blood often appears mixed with the pus in
abscesses. Upon the whole, the internal sur-
face of an abscess is to be considered as an ul-
cerated part.
CCLIII.

192 PRACTICE
CCLIII.
This account of suppuration explains, why
an abscess, when formed, may either spread
into the cellular texture of the neighbouring
parts; or, by eroding the incumbent tegu-
ments, be poured out upon the surface of the
body, and produce an open ulcer.
CCLIV.
We have here given the idea of an abscess
as a collection of matter following inflam-
mation; but the term has been applied to
every collection of matter effused, and chang-
ed by stagnation in an inclosed cavity.
The matter of abscesses, and of the ulcers
following them, is various, according to the
nature of what is effused, and which may be,
1. A matter thinner than serum.
2. An entire and pure serum.
3. A quantity of red globules.
4. A matter furnished by particular glands
seated in the part.
5. A mixture of matter from different
sources, changed by peculiar fermentation.
It is the second only which affords a proper
pus; the effusion whereof, whether in sup-
purating parts or ulcers, seems to be the peculiar
effect of an inflammatory state of the vessels;
and for this reason it is, that, when ulcers do
not produce a proper pus, a circumstance al-
ways

193 OF PHYSIC.
ways absolutely necessary to their healing, we,
in many cases, bring the ulcers to a state of
proper suppuration, by the application of
stimulants exciting inflammation, such as bal-
sams, mercury, copper, &c.
CCLV.
When the matter effused into the cellular
texture of an inflamed part, is tainted with a
putrid ferment, this produces, in the effused
matter, a state approaching more or less to
that of putrefaction. When this is in a mode-
rate degree, and affects only the fluids effused,
with the substance of the cellular texture, the
part is said to be affected with Gangrene;
but if the putrefaction affect also the vessels
and muscles of the part, the disease is said to
be a SPHACELUS.
CCLVI.
A gangrene, and its consequences, may
arise from a putrid ferment diffused in the
mass of blood, and poured out with the serum
effused, which it operates upon more power-
fully while the serum is stagnant, and retained
in the heat of the body; but it may also arise
from the peculiar nature of the matter effused
being disposed to putrefaction; as particu-
larly seems to be the case of the red globules
of the blood effused in a large quantity. ln a
third manner also, a gangrene seems frequently
I to

194 PRACTICE
to arise from the violent excitement of the in-
flammation destroying the tone of the vessels;
whereby the whole fluids stagnate, and run
into putrefaction, which taking place in any
degree, destroys still further the tone of the
vessels, and spreads the gangrene.
CCLVII.
In inflammation, the tendency to gangrene
may be apprehended from an extreme violence
of pain and heat in the inflamed part, and
from a great degree of pyrexia attending the
inflammation.
The actual coming on of gangrene may be
perceived, by the colour of the inflamed part
changing from a clear to a dark red; by blisters
arising upon the part; by the part becoming
soft, flaccid, and insensible; and by the ceasing
of all pain while these appearances take place.
As the gangrene proceeds, the colour of
the part becomes livid, and, by degrees, quite
black; the heat of the part entirely ceases;
the softness and flaccidity of the part increase;
it loses its consistence, exhales a cadaverous
smell, and may then be considered as affected
with sphacelus.
CCLVIII.
Gangrene is thus a third manner in which
inflammation terminates; and the schools
have commonly marked a fourth termination
of 

195 OF PHYSIC.
of inflammation; which is, by a scirrhus, or an
indolent hardness of the part formerly affected
with inflammation. This, however, is a rare
occurrence, and does not seem to depend so
much upon the nature of inflammation, as
upon the circumstances of the part affected.
It is in glandular parts chiefly that scirrhosity
is observed; and it is probably owing to the
parts readily admitting a stagnation of the
fluids. I have observed, that inflammation
seldom induces scirrhus; but that this more
commonly arises from other causes; and when
inflammation supervenes, which it is sooner or
later apt to do, it does not so commonly in-
crease as change the scirrhosity into some kind
of abscess. From these considerations, it does
not seem necessary to take any further notice
of scirrhus as a termination of inflammation.
CCLIX.
There are, however, some other termina-
tions of inflammation not  commonly taken
notice of, but now to be mentioned.
One is, by the effusion of a portion of the
entire mass of blood, either by means of rup-
ture or of anastomosis, into the adjoining cel-
lular texture. This happens especially in-
flammations of the lungs, where the effused
matter, by compressing the vessels, and stop-
ping the circulation, occasions a fatal suffoca-
tion; and this is perhaps the manner in which
I 2 pneumonic

196 PRACTICE
pneumonic inflammation most commonly
proves fatal.
CCLX.
Another kind of termination is, that of cer-
tain inflammations on the surface of the body,
when there is poured out under the cuticle a
fluid, which being too gross to pass through
its pores, therefore separates it from the skin,
and raises it up into the form of a vesicle con-
taining the effused fluid;  and by which effu-
fion the previous inflammation is taken off.
CCLXI.
Beside these already mentioned, I believe
there is still another manner in which inflam-
mation terminates. When the internal parts
are affected with inflammation, there seems to
have been almost always upon their surface
an exudation, which appears partly as a viscid
concretion upon their surface, and partly as a
thin serous fluid effused into the cavities in
which the inflamed viscera are placed. Though
we have become acquainted with these ap-
pearances only, as very constantly accompa-
nying those inflammations which have proved
fatal, it is however probable, that like circum-
stances may have attended those which were
terminated by resolution, and may have con-
tributed to that event. It is in favour of this
supposition

197 OF PHYSIC.
supposition that there are instances of pneu-
monic inflammation terminating in a hy-
drothorax.
SECT. IV.
Of the REMOTE CAUSES of INFLAMMATION.
CCLXII.
The remote causes of inflammation may be
reduced to five heads.
1. The application of stimulant substances;
among which are to be reckoned the action
of fire, or burning.
2. External violence operating mechanically
in wounding, bruising, compressing, or over-
stretching the parts.
3. Extraneous substances, lodged in any
part of the body, irritating by their chemical
acrimony or mechanical form, or compressing
by their bulk or gravity.
4. Cold, in a certain degree, not sufficient
immediately to produce gangrene.
5. An increased impetus of the blood deter-
mined to a particular part.
It will not be difficult to understand how
these remote causes, singly, or in concurrence,
produce the proximate cause of inflammation.
I 3 CCLXIII.

198 PRACTICE
CCLXIII.
It does not appear, that, in different cases
of inflammation, there is any difference in the
state of the proximate cause, except in the de-
gree of it; and though some difference of inflam-
mation may arise from the difference of the re-
mote causes, yet this is not necessary to be taken
notice of here; because the different appear-
ances which attend different inflammations may
be referred, for the most part, to the difference
of the part affected; as will appear when we
shall consider the several genera and species
marked in the Nosology. When I come to
treat of these, I shall find a more proper oc-
casion for taking notice of the different states
of the proximate, or of the differences of the
remote cause, than by treating of them in
general here.
SECT. V.
Of the CURE of INFLAMMATION.
CCLXIV.
The indications of cure in inflammation are
different, according as it may Still be capable of
resolution, or may have taken a tendency to the
several 

199 OF PHYSIC.
several other terminations abovementioned. As
the tendency to these terminations is not always
immediately evident, it is always proper, upon
the first appearance of inflammation, to at-
tempt the cure of it by resolution. For this
purpose, the indications of cure are,
1. To remove the remote causes, when
they are evident, and continue to Operate.
2. To take off the phlogistic diathesis
affecting either the whole system, or the par-
ticular part.
3. To take of the spasm of the particular
part, by remedies applied either to the whole
systern, or to the part itself.
CCLXV.
The means of removing the remote causes
will readily occur, from considering the par-
ticular nature and circumstances of the different
kinds. Acrid matters must be removed, or
their action must, be prevented, by the ap-
plication of correctors or demulcents. Com-
pressing and overstretching powers must be
taken away; and, from their several circum-
stances, the means of doing so will be obvious.
CCLXVI.
The means of taking off the phlogistic
diathesis of the system are the same with those
for moderating the violence of reaction in
I 4 fever,      

200 PRACTICE
fever, which are mentioned and treated of
from CXXVII. to CXLIX. and therefore
need not be repeated here. I only observe,
that, in the use of those remedies, there is
less occasion for any reserve than in many
cases of fever; and more particularly, that
topical bleedings are here  particularly in-
dicated and proper.
CCLXVII.
The means of taking off the spasm of the
particular part are nearly the same as those
mentioned above, for taking off the spasm of
the extreme vessels in the case of fever, and
which are treated of from CL. to CC. Only
it is observed here, that some of these are here
especially indicated, and that some of them
are to be directed more particularly to the
part especially affected; the management of
which will be more properly considered when
we shall treat of particular inflammations.
CCLXVIII.
When a tendency to suppuration (CCLI.)
is distinctly perceived, as we suppose it to
depend upon the effusion of a fluid which
cannot be easily reabsorbed, so it becomes
necessary that this fluid be converted into pus,
as the only natural means of obtaining its
evacuation; 

201 OF PHYSIC.
evacuation; and as the effusion is, perhaps,
seldom made without some rupture of the
vessels, to the healing of which a pus is ab-
solutely necessary; so, in the case of a tendency
to suppuration, the indication of cure always
is, to promote the production of a perfect
pus as quickly as possible.
CCLXIX.
For this purpose, various remedies, sup-
posed to possess a specific power, have been
proposed; but I can perceive no such power
in any of them; and, in my opinion, all that
can be done is, to favour the suppuration by
such applications as may support a proper
heat in the part, as by some tenacity may
confine the perspiration of the part, and as,
by an emollient quality, may weaken the
cohesion of the teguments, and favour their-
erosion.
CCLXX.
As, in the case of certain effusions, a sup-
puration is not only unavoidable, but desirable,
it may be supposed, that most of the means of
resolution formerly mentioned should be
avoided; and accordingly our practice is
commonly so directed. But as we observe,
on the one hand, that a certain degree of in-
creased impetus, or of the original circum-
stances of inflammation, is requisite to pro-
I 5 duces          

202 PRACTICE
duce a proper suppuration; so it is then espec-
ially necessary to avoid those means of res-
olution that may diminish too much the
force of the circulation. And as, on the
other hand, the impetus of the blood, when
violent, is found to prevent the proper suppu-
ration; so, in such cases, although a tenden-
cy to suppuration may have begun, it may be
proper to continue those means of resolution
which moderate the force of the circulation.
With respect to the opening of abscesses,
when completely formed, I refer to the writings
on surgery.
CCLXXI.
When an inflammation has taken a tend-
ency to gangrene, that event is to be pre-
vented by every possible means; and these
must be different, according to the nature of
the several causes occasioning that tendency,
as may be understood from what has been al-
ready said of them. After a gangrene has in
some degree, taken place, it can be cured
only by the separation of the dead from the
living parts. This, in certain circumstances,
can be performed by the knife, and always
most properly, when it can be so done.
In other cases, it can be done by exciting
a suppuratory inflammation on the verge of
the living part, whereby its cohesion with the
dead may be every where broken off, so that
the latter may fall off by itself. While this
is

203 OF PHYSIC.
is doing, it is proper to prevent the further
putrefaction of the part, and its spreading
wider. For this purpose, various antiseptic
applications have been proposed: But it ap-
pears to me, that, while the teguments are
entire, these applications can hardly have any
effect; and, therefore, that the fundamental
procedure must be to scarify the part so as to
reach the living substance, and, by the wounds
made there, to excite the suppuration required.
By the same incisions also, we give access to
antiseptics, which may both prevent the prog-
ress of the putrefaction in the dead, and ex-
cite the inflammation, necessary on the verge
of the living part..
CCLXXII.
When the gangrene proceeds from a loss of
tone; and when this, communicated to the
neighbouring parts, prevents that inflammation
which, as I have said, is necessary to the sepa-
ration; the dead part from the living; it
will be proper to obviate this loss of tone by
tonic medicines given internally; and, for
this purpose, the Peruvian bark has been found
to be especially effectual. That this medicine
operates by a tonic power, I have endeavour-
ed to prove above (CCXIV.); and from what
is said in CCXV. the limitations to be ob-
served in emyloying it may also be learned,
When the gangrene arises from the violence
of inflammation, the bark may not only fail
I 6 of

204 PRACTICE
of proving a remedy, but may do harm; and
its power as a tonic is especially suited to those
cases of gangrene which proceed from an orig-
inal loss of tone, as in the case of palsy and
œdema; or to those cases of inflammation
where a loss of tone takes place, while the
original inflammatory symptoms are removed.
CCLXXIII.
The other terminations of inflammation
either do not admit of any treatment except
that of preventing them by the means of res-
olution; or they belong to a treatise of
surgery, rather than to this place.
Having thus, therefore, delivered the general
doctrine, I proceed now to consider the partic-
ular genera and species of inflammation.
It has been hinted above (CCLXIII.),
that the difference of inflammation arises
chiefly from the difference of the part affect-
ed: I have therefore arranged them, as they
are cutaneous, visceral, or articular;
and in this order they are now to be consid-
ered.
CHAP.

205 OF PHYSIC.
CHAP. II.
OF INFLAMMATION, MORE STRICTLY
CUTANEOUS.
CCLXXIV.
CUTANEOUS inflammations
are of two kinds, commonly distinguished by
the names of PHLEGMON and ERYSIPELAS.
Of the latter there are two cases, which
ought to be distinguished by different appel-
lations. When the disease is an affection of the
skin alone, and very little of the whole system,
or when the affection of the system is only
symptomatical of the external inflammation, I
shall give the disease the name of ERYTHEMA;
but when the external inflammation is an ex-
anthema, and symptomatical of an affection
of the whole system, I shall then name the
disease ERYSIPELAS.
CCLXXV.
It is the erythema only that I am to con-
sider here.
For the distinction between Erythema and
Phlegmon, I have formerly referred to the
characters given of them in our Nosology. See
Synops,

206 PRACTICE
Synops. Nosolog. Meth. Vol. II. p. 5. gen. vii.
spec. 1. and 2. But I think it proper now to de-
liver the characters of them more fully and ex-
actly here, as follows.
A Phlegmon is an inflammatory affection
of the skin, with a swelling, rising generally to
a more considerable eminence in the middle
of it; of a bright red colour; both the swell-
ing and colour being pretty exactly circum-
scribed; the whole being attended with a pain
of distention, often of a Hounding or throb-
bing kind, and frequently ending in suppu-
ration.
An Erythema, Rose, or St, Anthony's
Fire, is an inflammatory affection of the skin,
with hardly any evident swelling; of a mixed
and not very bright red colour, readily dis-
appearing upon pressure, but quickly return-
ing again; the redness of no regular circum-
scription, but spreading unequally, and con-
tinuing almost constantly to spread upon the
neighbouring part; with a pain like to that:
from burning; producing blisters, sometimes
of a small, sometimes of a larger size; and
always ending in a desquamation of the scarf
skin, sometimes in gangrene.
This subject I am not to prosecute here, as
properly belonging to surgery, the business of
which I am seldom to enter upon in this work;
and shall therefore observe only as necessary
here, that the difference of these appearances
seems to depend on the different seat of the
inflammation. In the phlegmon, the inflam-
mation 

207 OF PHYSIC.
mation seems to affect especially the vessels on
the internal surface of the skin communicating
with the lax subjacent cellular texture;
whence a more copious effusion, and that of
serum, convertible into pus, takes place. In
the erythema, the inflammation seems to have
its feat in the vessels on the external surface
of the skin, communicating with the rete
mucosum, which does not admit of any
effusion, but what separates the cuticle, and
gives occasion to the formation of a blister,
while the smaller size of the vessels admits
only of the effusion of a thin fluid, very sel-
dom convertible into pus.
Besides these differences in the circum-
stances of these two kinds of inflammation, it
is probable that they also differ with respect
to their causes. Erythema is the effect of all
kinds of acrids externally applied to the skin;
and, when arising from an internal cause, it
is from an acrimony poured out on the surface
of the skin under the cuticle. In the phleg-
mon, an acrimony is not commonly evident.
CCLXXVI.
These differences in the seat and causes of
the phlegmon and erythema being admitted,
it will be evident, that when an erythema
affects any internal part, it can take place in
those only whose surfaces are covered with an
epithelion, or membrane analogous to the
cuticle.
CCLXXVII.

208 PRACTICE
CCLXXVII.
The same distinction between the feat and
causes of the two diseases will, as I judge,
readily explain what has been delivered by
practical writers, with respect to the cure of
these different cutaneous inflammations. But
I shall not, however, prosecute this here, for
the reason given above (CCLXXV.); and;
for the same reason, shall not say any thing of
the variety of external inflammation, that
might otherwise be considered here.
CHAP.

209 OF PHYSIC.
CHAP. III.
OF OPHTHALMIA, OR INFLAMMA-
TION OF THE EYE.
CCLXXVIII.
THE inflammation of the eye
may be considered as of two kinds; according
as it has its feat in the membranes of the ball
of the eye, when I would name it OPHTHAL-
MIA MEMBRANARUM; or as it has its seat in
the sebaceous glands placed in the tarsus, or
edges of the eyelids, in which case it may be
termed Ophthalmia Tarsi.
These two kinds are very frequently com-
bined together, as the one may readily excite
the other; but they are still to be distinguish-
ed according as the one or the other may hap-
pen to be the primary affection, and properly as
they often arise from different causes.
CCLXXIX
The inflammation of the membranes of the
eye affects especially, and most frequently, the
adnata, appearing in a turgescence of its ves-
sels; so that the red vessels which are natural-
ly there, become not only increased in size,
but

210 PRACTICE
but there appear many more than did in a
natural state. This turgescence of the vessels
is attended with pain, especially upon the mo-
tion of the ball of the eye; and this, like ev-
ery other irritation applied to the surface of
the eye, produces an effusion of tears from the
lachrymal gland.
This inflammation commonly, and chiefly,
affects the adnata spread on the anterior part
of the bulb of the eye; but usually spreads al-
so along the continuation of that membrane
on the inside of the palpebræ; and, as that is
extended on the tarsus palpebrarum, the ex-
cretories of the selbaceous glands opening there
are also frequently affected. When the af-
fection of the adnata is considerable, it is fre-
quently communicated to the subjacent mem-
branes of the eye, and even to the retina itself,
which thereby acquires, so great a senfibility,
that the slightest impression of light becomes
painful.
CCLXXX.
The inflammation of the membranes: of the
eye is in different degrees, according as the
adnata is more or less affected, or according
as the inflammation is either of the adnata
alone, or of the subjacent membranes also;
and, upon these differences; different species
have been established, and different appella-
tions given to them. But I shall not, howev-
er, prosecute the consideration of these, being
of

211 OF PHYSIC.
of opinion, that all the cases of the Ophithal-
mia membranarum differ only in degree, and
are to be cured by remedies o£ the same kind,
more or less employed.
The remote causes of Ophthalmia are
many and various; as,
1. External violence, by blows, contusions,
and wounds, applied to the eyes; and even
very slight impulses applied, whilst the eyelids
are open, to the ball of the eye itself, are some-
times sufficient for the purpose.
2. Extraneous, bodies introduced under the
eyelids, either of an acrid quality, as smoke
and other acrid vapours or of a bulk sufficient
to impede the free motion of the eyelid upon
the surface of the eyeball.
3. The application of strong light, or even
of a moderate light long continued.
4. The application of much heat, and par-
ticularly of that with moisture.
5. Much exercise of the eyes in viewing
minute objects.
6. Frequent intoxication.
7. Irritation from other and various diseasi-
es of the eyes.
8. An acrimony prevailing in the mass of
blood; and deposited in the sebaceous glands
on the edges of the eyelids.
9. A change in the distribution of the
bloody whereby either a more than usual
quantity of blood, and with more than usual
force, is impelled; into the vessels of the head,
or

212 PRACTICE
or whereby the free return of the venous blood
from the vessels of the head is interrupted.
10. A certain consent of the eyes with the
other parts of the system, whereby, from a
certain state of these parts, either a limultane-
ous, or an altering affection of the eyes, is
produced.
CCLXXXI.
The proximate cause of Ophthalmia is not
different from that of inflammation in general;
and the different circumstances of Ophthal-
mia may be explained by the difference of its
remote causes, and by the different parts of
the eye which it happens to affect. This may
be understood from what has been already
said; and I shall now therefore proceed to
consider the CURE.
CCLXXXII.
In the cure of Ophthalmia, the first atten-
tion will be always due to the removing of the
remote causes, and the various means necessary
for this purpose will be directed by the con-
sideration of these causes enumerated above.
The Ophthalmia membranarum requires
the remedies proper for inflammation in gen-
eral; and, when the deeper seated membranes
are affected, and especially when a pyrexia is
present, large general bleedings may be neces-
sary. But this is seldom the case; as the
Ophthalmia, 

213 OF PHYSIC.
Ophthalmia, for the most part, is an affection
purely local, accompanied with little or no py-
rexia. General bleedings, therefore, from the
arm or foot, have little effect upon it; and the
cure is chiefly to be obtained by topical bleed-
ings, that is, blood drawn from vessels near the
inflamed part; and opening the jugular vein
or the temporal artery, may be considered as
in some measure of this kind. It is common-
ly sufficient to apply a number of leeches
round the eye; and it is perhaps better still
to draw blood from the temples, by cupping
and scarifying. In many cases, a very effec-
tual remedy is, that of scarifying the internal
surface of the inferiour eyelid; and more so
still, is cutting the turgid vessels upon the ad-
nata itself.
CCLXXXIII.
Besides bloodletting, purging, as a remedy
suited to inflammation in general, has been
considered as peculiarly adapted to inflamma-
tions in any of the parts of the head, and
therefore to Ophthalmia; and it is sometimes
useful; but, for the reasons given before with
respect to general bleeding, purging in the
case of Ophthalmia does not prove useful in
any degree in proportion to the evacuation
excited.
CCLXXXIV. 

214 PRACTICE
CCLXXXIV.
For relaxing the spasm in the part, and
taking off the determination of the fluids to
it, blistering near the part has commonly
been found useful.
CCLXXXV.
Electrical sparks taken from the eye will
often suddenly discuss the inflammation of the
adnata; but the effect is seldom permanent,
and even a frequent repetition seldom gives
an entire cure.
CCLXXXVI.
Ophthalmia, as an external inflammation,
admits of topical applications. All those,
however, that increase the heat and relax the
vessels of the part, prove commonly hurtful;
and the admission of cool air to the eye, the
proper application of cold water immediately
to the ball of the eye, and the application of
various cooling and astringent medicines,
which at the same time do not produce much
irritation, prove generally useful; even spirit-
uous liquors, employed in moderate quantity,
have often been of service.
CCLXXXVII.

215 OF PHYSIC.
CCLXXXVII.
In the cure of Ophthalmia, much care is
requisite to avoid all irritation, particularly
that of light; and the only safe and certain
means of doing this, is by confining the pa-
tient to a very dark chamber.
CCLXXXVIII.
These are, the remedies of the Ophthalmia
membranarum; and in the Ophthalmia tarsi,
so far as it is produced by the Ophthalmia
membranarum, the same remedies may be
necessary. As, however, the Ophthalmia
tarsi may often depend upon an acrimony de-
posited in the sebaceous glands of the part, so
it may require various internal remedies ac-
cording to the nature of the acrimony in fault;
for which I must refer to the consideration of
scrophula, syphilis, or other diseases with
which this Ophthalmia may be connected;
and when the nature of the acrimony is not
ascertained, certain remedies, more generally
adapted to the evacuation of acrimony, such,
for instance, as mercury, may be employed.
CCLXXXIX.
In the Ophthalmia tarsi, it almost constant-
ly happens, that some ulcerations are formed
on the tarsus. These require the application
of

416 PRACTICE
of mercury or copper, either of which may by
itself sometimes entirely cure the affection;
and these may even be useful when the disease
depends upon a fault of the whole system.
CCXC.
Both in the Ophthalmia membranarum,
and in the Ophthalmia tarsi, it is necessary to
obviate that gluing or sticking together of the
eyelids which commonly happens in sleep;
and this may be done by insinuating a little
of any mild unctuous medicine of some tenac-
ity between the eyelids before the patient
shall go to sleep.
CHAP.

217 OF PHYSIC. 
CHAP. IV.
OF PHRENSY, OR PHRENITIS.
CCXCI.
THIS disease is an inflamma-
tion of the parts contained in the cavity of the
cranium; and may affect either the mem-
branes of the brain, or the substance of the
brain itself. Nosologists have apprehended,
that these two cases might be distinguished by
different symptoms, and therefore by different
appellations; but this does not seem to be
confirmed by observation and dissection; and
therefore I shall treat of both cases under the
title of Phrensy, or Phrenitis.
CCXCII.
An idiopathic phrensy is a rare occurrence,
a sympathic more frequent; and the ascer-
taining either the one or the other is, upon
many occasions, difficult. Many of the symp-
toms by which the disease is most commonly
judged to be present, have appeared, when,
from certain considerations, it was presumed,
and even from dissection it appeared, that
K there

218 PRACTICE
there had been no internal inflammation; and,
on the other hand, dissections have shown,
that the brain had been inflamed, when few
of the peculiar symptoms of phrensy had be-
fore appeared.
CCXCIII.
The symptoms by which this disease may be
most certainly known are, a vehement pyrexia,
a violent deep seated headach, a redness and
turgescence of the face and eyes, an impatience
of light or noise, a constant watching, and
a delirium impetuous and furious. Some
nosologists have thought these symptoms pecu-
liar to an inflammation of the membranes,
and that the inflammation of the substance of
the brain was to be distinguished by some de-
gree of coma attending it. It was for this
reason that in the Nosology I added the Ty-
phomania to the character of Phrenitis; but,
upon farther reflection, I find no proper
foundation for this; and, if we pass from the
characters above delivered, there will be no
means of fixing the variety that occurs.
I am here, as in other analogous cases, of
opinion, that the symptoms above mentioned
of an acute inflammation, always mark in-
flammations of membranous parts; and that an
inflammation of the paronchyma or substance
of viscera, exhibits, at least commonly, a more
chronic affection.
CCXCIV

219 OF PHYSIC.
CCXCIV.
The remote causes of phrensy, are all those
which directly stimulate the membranes, or
substance of the brain; and particularly all
those which increase the impetus of the blood
in the vessels of the brain. Among these the
exposure of the naked head to the direct rays
of a very warm sun, is a frequent cause. The
passions of the mind, and certain poisons, are
amongst the remote causes of phrensy; but in
what manner they operate, is not well under-
stood.
The cure of phrensy is the same with that
of inflammation in general; but in phrensy
the most powerful remedies are to be imme-
diately employed. Large and repeated blood-
letting is especially necessary; and the blood
should be drawn from vessels as near as pos-
sible to the part affected. The opening of
the temporal artery has been recommended,
and with some reason; but the practice is
attended with inconvenience; and I apprehend,
that opening the jugular veins may prove
more effectual; but, at the same time, it will
be generally proper to draw blood from the
temples by cupping and scarifying.
K 2 CCXCVI.

220 PRACTICE
CCXCVI.
It is probable, that purging, as it may
operate by revulsion, may be of more use in
this than in some other inflammatory affections.
For the same purpose of revulsion, warm
pediluvia are a remedy; but, at the same
time, somewhat ambiguous. The taking off
the force of the blood in the vessels of the head
by an erect posture, is generally useful.
CCXCVII.
Shaving of the head is always proper and
necessary for the admission of other remedies.
Blistering is commonly useful in this disease,
but chiefly when applied near to the part
affected.
CCXCVIII.
Every part of the antiphlogistic regimen is
here necessary, and particularly the admission
of cold air. Even cold substances, applied
close to the head, have been found safe
and highly useful; and the application of such
refrigerants as vinegar, is certainly proper.
CCXCIX.
It appears to me certain, that opiates are
hurtful in every inflammatory state of the
brain;

221 OF PHYSIC. 
brain; and it is to be observed, that, from
the ambiguity mentioned in CCXCII. the
accounts of practitioners, with regard to the
juvantia and lædentia in this disease, are of
very uncertain application.
K 3 CHAP.

222 PRACTICE
CHAP. V.
OF THE QUINSY, OR CYNANCHE.
CCC.
THIS name is applied to
every inflammation of the internal sauces;
but these inflammations are different, accord-
ing to the part of the sauces which may be
affected, and according to the nature of the
inflammation. In the Nosology, therefore,
after giving the character of the Cynanche as
a genus, I have distinguished five different
species, which must here likewise be separate-
ly considered.
SECT. I.
OF THE CYNANCHE TONSILLARIS.
CCCI.
THIS is an inflammation of the mucous
membrane of the sauces, affecting especially
that congeries of mucous follicles which forms
the tonsils, and spreading from thence along
the velum and uvula, so as frequently to affect
every part of the mucous membrane.
CCCII.


223 OF PHYSIC.
CCCII.
The disease appears by some tumour, some-
times considerable, and by a redness of the
parts; is attended with a painful and difficult
deglutition; with a pain sometime shooting
into the ear; with a troublesome clamminess
of the mouth and throat; with a frequent, but
difficult, excretion of mucous; and the whole
is accompanied with a pyrexia.
CCCIII.
This species of quinsy is never contagious.
It terminates frequently by resolution, some-
times by suppuration, but hardly ever by gan-
grene; although in this disease some sloughy
spots, commonly supposed to be forerunners
of gangrene, sometimes appear upon the
fauces.
CCCIV.
This disease is commonly occasioned by
cold externally applied, particularly about
the neck. It affects especially the young and
sanguine, and a disposition to it is often ac-
quired by habit; so that from every consider-
able application of cold to any part of the
body, this disease is readily induced. It
K 4 occurs

224 PRACTICE
occurs especially in spring and autumn, when
vicissitudes of heat and cold frequently take
place. The inflammation and tumour are
commonly at first most considerable in one
tonsil; and afterwards, abating in that, in-
crease in the other.
CCCV.
In the cure of this inflammation, some
bleeding may be proper; but large general
bleedings will seldom be necessary. The
opening of the ranular veins seems to be an
insignificant remedy; and leeches set upon
the external sauces are of more efficacy.
CCCVI.
At the beginning of the disease, full vom-
iting has been frequently found to be of
great service.
CCCVII.
This inflammation may be often relieved
by moderate astringents, and particularly by
acids applied to the inflamed parts. In many
cases, however, nothing has been found to
give more relief than the vapour of warm
water received into the sauces by a proper
apparatus.
CCCVIII.

225 OF PHYSIC.
CCCVIII.
The other remedies of this disease are rube-
facient or blistering medicines, applied ex-
ternally to the neck; and, with these, the
employment of antiphlogistic purgatives, as
well as every part of the antiphlogistic regi-
men, excepting the application of cold.
CCCIX.
This disease, as we have said, often ter-
minates by resolution, frequently accompani-
ed with sweating; which is therefore to be
prudently favoured and encouraged.
CCCX. 
When this disease shall have taken a tend-
ency to suppuration, nothing will be more
useful, than the frequent taking into the
sauces the steams of warm water. When the
abscess is attended with much swelling, if it
break not spontaneously, it should be opened
by a lancet; and this does not require much
caution, as even the inflammatory state may
be relieved by some scarification of the tonsils.
I have never had occasion to see any case re-
quiring bronchotomy.
K 5 SECT. II.

226 PRACTICE
SECT. II.
Of the CYNANCHE MALIGNA.
CCCXI.
THIS is a contagious disease, seldom sporad-
ic, and commonly epidemic. It attacks per-
sons of all ages, but more commonly those in
a young and infant state. It attacks persons
of every constitution when exposed to the
contagion, but most readily the weak and
infirm.
CCCXII.
This disease is usually attended with a con-
siderable pyrexia; and the symptoms of the
accession of this, such as frequent cold shiver-
ings, sickness, anxiety, and vomiting, are often
the first appearances of the disease. About
the same time, a stiffness is felt in the neck,
with some uneasiness in the internal sauces,
and some hoarseness of the voice. The inter-
nal sauces, when viewed, appear of a deep red
colour, with some tumour; but this last is
seldom considerable, and deglutition is seldom
difficult or painful. Very soon, a number of
white or ash coloured spots appear upon the
inflamed 

227 OF PHYSIC.
inflamed parts. These spots spread and unite,
covering almost the whole sauces with thick
sloughs; which falling off, discover ulcera-
tions. While these symptoms proceed in the
sauces, they are generally attended with a co-
ryza, which pours out a thin acrid and fetid
matter, excoriating the nostrils and lips.
There is often also, especially in infants, a fre-
quent purging; and a thin acrid matter flows
from the anus, excoriating this and the neigh-
bouring parts.
CCCXIII.
With these symptoms, the pyrexia proceeds
with a small, frequent, and irregular pulse;
and there occurs a manifest exacerbation every
evening, and some remission in the mornings.
A great debility appears in the animal func-
tions; and the sensorium is affected with de-
lirium, frequently with coma.
CCCXIV.
On the second day, or sometimes later,
efflorescences appear upon the skin, which are
sometimes in small points hardly eminent;
but, for the most part, in patches of a red col-
our, spreading and uniting so as to cover the
whole skin. They appear first about the
face and neck, and in the course of some days
spread by degrees to the lower extremities.
The scarlet redness is often considerable on
K 6 the 

228 PRACTICE.
the hands and extremities of the fingers, which
feel stiff and swelled. This eruption is often
irregular, as to the time of its appearance, as
to its steadiness, and as to the time of its
duration. It usually continues four days,
and goes off by some desquamation of the
cuticle; but neither on its first appearance,
nor on its desquamation, does it always pro-
duce a remission of the pyrexia, or of the other
symptoms.
CCCXV.
The progress of the disease depends on the
state of the sauces and of the pyrexia. When
the ulcers on the sauces, by their livid and
black colour, by the fetor of the breath, and
by many marks of acrimony in the fluids,
show a tendency to gangrene, this takes place
to a considerable degree; and, the symptoms
of a putrid fever constantly increasing, the
patient dies, often on the third day, some-
times later, but for the most part before the
seventh. The acrimony poured out from the
diseased sauces must necessarily, in part, pass
into the pharynx, and there spread the in-
section into the œsophagus, and sometimes
through the whole of the alimentary canal,
propagating the putrefaction, and often ex-
hausting the patient by a frequent diarrhœa.
The acrid matter poured out in the sauces
being again absorbed, frequently occasions
large swellings of the lymphatic glands about
the

229 OF PHYSIC.
the neck, and sometimes to such a degree as
to occasion suffocation.
It is seldom that the organs of respiration
escape entirely unhurt, and very often the in-
flammatory affection is communicated to them.
From dissections it appears, that, in the Cyn-
anche maligna, the larynx and trachea are
often affected in the same manner as in the
Cynanche trachealis; and it is probable, that,
in consequence of that affection, the Cynanche
maligna often proves fatal by such a sudden
suffocation as happens in the proper Cynanche
trachealis; but there is reason to suspect that
upon this subject dissectors have not always
distinguished properly between the two dis-
eases.
CCCXVI.
These are the several fatal terminations of
the Cynanche maligna; but they do not always
take place. Sometimes the ulcers of the
sauces are of a milder nature; and the fever
is more moderate, as well as of a less putrid
kind. And when, upon the appearance of
the efflorescence on the skin, the fever suffers
a remission; when the efflorescence continues
for three or four days, till it has spread over
the whole body, and then ends by a desqua-
mation, giving a further remission of the fe-
ver; this often entirely terminates, by gentle
sweats, on or before the seventh day; and the
rest of the disease terminates in a few days
more,

230 PRACTICE
more, by an excretion of sloughs from the
sauces, while sleep, appetite, and the other
marks of health, return.
From what is said in this and the preceding
paragraph, the prognostics in this disease may
be readily learned.
CCCXVII.
In the cure of this disease, its septic tend-
ency is chiefly to be kept in view. The de-
bility, with which it is attended, renders all
evacuations by bleeding and purging improp-
er, except in a few instances where the debil-
ity is less, and the inflammatory symptoms
more considerable. The sauces are to be pre-
served from the effects of the acrid matter
poured out upon them, and are therefore to
be frequently washed out by antiseptic gar-
gles or injections; and the septic tendency
of the whole system should be guarded against
and corrected by internal antiseptics, espec-
ially by the Peruvian bark given in substance,
from the beginning, and continued through
the course of the disease. Emetics, both by
vomiting and nauseating, prove useful, espec-
ially when employed early in the disease.
When any considerable tumour occurs, blis-
ters applied externally will be of service, and,
in any case, may be fit to moderate the in-
ternal inflammation.
SECT.

231 OF PHYSIC.
SECT. III.
Of the CYNANCHE TRACHEALIS.
CCCXVIII.
THIS name has been given to an inflam-
mation of the glottis, larynx, or upper part of
the trachea, whether it affect the membranes
of these parts, or the muscles adjoining. It
may arise first in these parts, and continue to
subsist in them alone; or it may come to af-
fect these parts from the Cynanche tonsillaris
or maligna spreading into them.
CCCXIX.
In either way it has been a rare occurrence,
and few instances of it have been marked and
recorded by physicians. It is to be known by
a peculiar ringing found of the voice, by diffi-
cult respiration, with a sense of straitening
about the larynx, and by a pyrexia attending
it.
CCCXX.
From the nature of these symptoms, and
from the dissection of the bodies of persons
who had died of this disease, there is no doubt
of

232 PRACTICE
of its being of an inflammatory nature. It
does not, however, always run the course of
inflammatory affections; but frequently pro-
duces such an obstruction of the passage of the
air, as suffocates, and thereby proves sudden-
ly fatal.
CCCXXI.
If we judge rightly of the nature of this
disease, it will be obvious, that the cure of it
requires the most powerful remedies of in-
flammation, to be employed upon the very
first appearance of the symptoms. When a
suffocation is threatened, whether any reme-
dies can be employed to prevent it, we have
not had experience to determine.
CCCXXII.
The accounts which books have hitherto
given us of inflammations of the larynx, and
the parts connected with it, amount to what
we have now said; and the instances record-
ed have almost all of them happened in adult
persons; but there is a peculiar affection of
this kind happening especially to infants,
which till lately has been little taken notice
of. Dr. Home is the first who has given any
distinct account of it; but, since he wrote,
several other authors have taken notice of it,
(see MICHAELIS De angina polyposa five mem-
branacia, Argentorati 1778); and have given
different 

233 OF PHYSIC.
different opinions with regard to it. Con-
cerning this diversity of opinions I shall not
at present inquire; but shall deliver the his-
tory and cure of this disease, in so far as these
have arisen from my own observation, from
that of Dr. Home, and of other skilful per-
sons in this neighbourhood.
CCCXXIII.
This disease seldom attacks infants till after
they have been weaned. After this period,
the younger they are, the more they are liable
to it. The frequency of it becomes less as
children become more advanced; and there
are no instances of children above twelve
years of age being affected with it. It attacks
children of the midland countries, as well as
those who live near the sea. It does not ap-
pear to be contagious, and its attacks are fre-
quently repeated in the same child. It is oft-
en manifestly the effect of cold applied to the
body; and therefore appears most frequently
in the winter and spring seasons. It very
commonly comes on with the ordinary symp-
toms of a catarrh; but sometimes the peculiar
symptoms of the disease show themselves at
the very first.
CCCXXIV.
These peculiar symptoms are the follow-
ing: A hoarseness, with some shrillness and
ringing 

234 PRACTICE
ringing sound, both in speaking and cough-
ing, as if the noise came from a brazen tube.
At the same time there is a sense of pain about
the larynx, some difficulty of respiration, with
a whizzing sound in inspiration, as if the pas-
sage of the air were straitened. The cough
which attends it, is commonly dry; and, if
any thing be spit up, it is a matter of a puru-
lent appearance; and sometimes films resem-
bling portions of a membrane. Together
with these symptoms, there is a frequency of
pulse, a restlessness, and an uneasy sense of heat.
When the internal fauces are viewed, they are
sometimes without any appearance of inflam-
mation; but frequently a redness, and even
swelling, appear; and sometimes in the fauces,
there is an appearance of matter like to that re-
jected by coughing. With the symptoms
now described, and particularly with great
difficulty of breathing, and a sense of stran-
gling in the fauces, the patient is sometimes
suddenly taken off.
CCCXXV.
There have been many dissections made of
infants who had died of this disease; and al-
most constantly there has appeared a preter-
natural membrane lining the whole internal
surface of the upper part of the trachea, and
extending in the same manner downwards in-
to some of its ramifications. This preternat- 
ural membrane may be easily separated, and
sometimes

235 OF PHYSIC.
sometimes has been found separated in part,
from the subjacent proper membrane of the
trachea. This last is commonly found entire,
that is, without any appearance of erosion or
ulceration; but it frequently shows the vest-
iges of inflammation, and is covered by a
matter resembling pus, like to that rejected by
coughing; and very often a matter of the same
kind is found in the bronchiæ, sometimes in
considerable quantity.
CCCXXVI.
From the remote causes of this disease;
from the catarrhal symptoms commonly at-
tending it; from the pyrexia constantly pres-
ent with it; from the same kind of preternat-
ural membrane being found in the trachea
when the cynanche maligna is communicated
to it; and from the vestiges of inflammation
on the trachea discovered upon dissection;
we must conclude, that the disease consists in
an inflammatory affection of the mucous
membrane of the larynx and trachea, produc-
ing an exudation analogous to that found on
the surface of inflamed viscera, and appearing
partly in a membranous crust, and partly in
a fluid resembling pus.
CCCXXVII.
Though this disease manifestly consists in
an inflammatory affection, it does not com-
monly

236 PRACTICE
monly end either in suppuration or gangrene.
The peculiar and troublesome circumstance
of the disease seems to consist in a spasm of
the muscles of the glottis, which, by inducing a
suffocation, prevents the common consequen-
ces of inflammation.
CCCXXVIII.
When this disease terminates in health, it is
by a resolution of the inflammation, by a ceas-
ing of the spasm of the glottis, by an expecto-
ration of the matter exuding from the trachea,
and of the crusts formed there; and frequent-
ly it ends without any expectoration, or at
least with such only as attends an ordinary
catarrh.
CCCXXIX.
When the disease ends fatally, it is by a
suffocation; seemingly, as we have said, de-
pending upon a spasm affecting the glottis;
but sometimes, probably, depending upon a
quantity of matter filling the bronchiæ.
CCCXXX.
 As we suppose the disease to be an inflam-
matory affection, so we attempt the cure of it
by the usual remedies of inflammation, and
which for the most part I have found effec-
tual. Bleeding, both general and topical, has
often

237 OF PHYSIC.
often given immediate relief; and, by being
repeated, has entirely cured the disease. Blis-
tering also, near to the part affected, has been
found useful. Upon the first attack of the
disease, vomiting, immediately after bleeding,
seems to be of considerable use, and sometimes
suddenly removes the disease. In every stage
of the disease, the antiphlogistic regimen is
necessary, and particularly the frequent use of
laxative glysters. Though we suppose that a
spasm affecting the glottis is often fatal in this
disease, I have not found antispasmodic medi-
cines to be of any use.
SECT. IV.
Of the CYNANCHE PHARYNGÆA.
CCCXXXI.
IN the Cynanche tonsillaris, the inflamma-
tion of the mucous membrane often spreads
upon the pharynx, and into the beginning of
the œsophagus, and thereby renders degluti-
tion more difficult and uneasy; but such a case
does not require to be distinguished as a dif-
ferent species from the common Cynanche
tonsillaris; and only requires that bloodlet-
ting, and other remedies, should be employed
with greater diligence than in ordinary cases.
We

238 PRACTICE
We have never seen any case in which the in-
flammation began in the pharynx, or in which
this part alone was inflamed; but practical
writers have taken notice of such a case; and
to them, therefore, I must refer, both for the
appearances which distinguish it, and for the
method of cure.
SECT. V.
Of the CYNANCHE PAROTIDÆA.
CCCXXXII.
THIS is a disease known to the vulgar, and
among them has got a peculiar appellation in
every country of Europe; but has been little
taken notice of by medical writers. It is often
epidemic, and manifestly contagious. It
comes on with the usual symptoms of pyrexia,
which is soon after attended with a consider-
able tumour of the external fauces and neck.
This tumour appears first as a glandular move-
able tumour at the corner of the lower jaw;
but the swelling soon becomes uniformly dif-
fused over a great part of the neck, sometimes
on one side only, but more commonly on both.
The swelling continues to increase till the
fourth day; but from that period it declines,
and in a few days more passes off entirely.
As

239 OF PHYSIC.
As the swelling of the fauces recedes, some tu-
mour affects the testicles in the male sex, or
the breasts in the female. These tumours are
sometimes large, hard, and somewhat painful;
but, in this climate, are seldom either very
painful or of long continuance. The pyrexia
attending this disease is commonly slight, and
recedes with the swelling of the fauces; but
sometimes, when the swelling of the testicles
does not succeed to that of the fauces, or when
the one or the other has been suddenly re-
pressed, the pyrexia becomes more considera-
ble, is often attended with delirium, and has
sometimes proved fatal.
CCCXXXIII.
As this disease commonly runs its course
without either dangerous or troublesome
symptoms, so it hardly requires any remedies.
An antiphlogistic regimen, and avoiding cold,
are all that will be commonly necessary. But
when upon the receding of the swellings of the
testicles in males, or of the breasts in females,
the pyrexia comes to be considerable, and
threatens an affection of the brain, it will be
proper, by warm fomentations, to bring back
the swelling; and, by vomiting, bleeding, or
blistering, to obviate the consequences of its
absence.
CHAP.

240 PRACTICE
CHAP. VI.
OF PNEUMONIA, OR PNEUMONIC
INFLAMMATION.
CCCXXXIV.
UNDER this title I mean to
comprehend the whole of the inflammations
affecting either the viscera of the thorax or the
membrane lining the interior surface of that
cavity; for neither do our diagnostics serve
to ascertain exactly the feat of the disease;
nor does the difference in the feat of the dis-
ease exhibit any considerable variation in the
state of the symptoms, nor lead to any differ-
ence in the method of cure.
CCCXXXV.
Pneumonic inflammation, however various
in its feat, seems to me to be always known and
distinguished by the following symptoms;
pyrexia, difficult breathing, cough, and pain
in some part of the thorax. But these symp-
toms are, on different occasions, variously
modified.
CCCXXXVI.

241 OF PHYSIC.
CCCXXXVI.
The disease almost always comes on with a
cold stage, and is accompanied with the other
symptoms of pyrexia; though, in a few in-
stances, the pulse may not be more frequent,
nor the heat of the body increased beyond
what is natural. Sometimes the pyrexia is
from the beginning accompanied with the oth-
er symptoms; but frequently it is formed for
some hours before the other symptoms become
considerable, and particularly before the pain
be felt. For the most part, the pulse is fre-
quent, full, strong, hard, and quick; but, in a
few instances, especially in the advanced state
of the disease, the pulse is weak and soft, and
at the same time irregular.
CCCXXXVII.
The difficulty of breathing is always pres-
ent, and most considerable in inspiration; both
because the lungs do not easily admit of a full
dilatation, and because the dilatation aggra-
vates the pain attending the disease. The
difficulty of breathing is also greater when the
patient is in one posture of his body rather
than another. It is generally greater when
he lies upon the side affected; but sometimes
the contrary happens. Very often the patient
cannot lie easy upon either side, finding ease
only when lying on his back; and sometimes
L he

242 PRACTICE
he cannot breathe easily, except when in some-.
what of an erect posture.
CCCXXXVIII.
A cough always attends this disease; but,
in different cases, is more or less urgent and
painful. It is sometimes dry, that is, without
any expectoration, especially in the beginning
of the disease; but more commonly it is, even
from the first, moist, and the matter spit up
various both in consistence and colour; and
frequently it is streaked with blood.
CCCXXXIX.
The pain attending this disease, is, in dif-
ferent cases, felt in different parts of the tho-
rax, but most frequently in one sides. It has
been said to affect the right side more fre-
quently than the left; but this is not certain;
while, on the other hand, it is certain, that the
left side has been very often affected. The
pain is felt sometimes as if it were under the
sternum; sometimes in the back between the
shoulders; and, when in the sides, its place
has been higher or lower, more forward or
backward; but the place of all others most
frequently affected, is about the sixth or sev-
enth rib, near the middle of its length, or a
little more forward. The pain is often severe
and pungent; but sometimes more dull and
obtuse, with a sense of weight rather than of
pain. 

243 OF PHYSIC.
pain. It is most especially severe and pun-
gent when occupying the place last mentioned.
For the most part it continues fixed in one
place; but sometimes shoots from the side to
the scapula on one hand, or to the sternum
and clavicle on the other.
CCCXL.
The varying state of symptoms now men-
tioned does not always ascertain precisely the
feat of the disease. To me it seems probable,
that the disease is always seated, or at least be-
gins, in some part of the pleura; taking that
membrane in its greatest extent, as now com-
monly understood; that is, as covering not
only the internal surface of the cavity of the
thorax, but also as forming the mediastinum,
and as extended over the pericardium and
over the whole surface of the lungs.
CCCXLI.
There is, therefore, little foundation for dis-
tinguishing this disease by different appellations
taken from the part which may be supposed
to be chiefly affected. The term Pleuri-
sy, might with propriety be applied to every
case of the disease; and has been very im-
properly limited to that inflammation which
begins in, and chiefly affects, the pleura costalis.
I have no doubt that such a case does truly
occur; but, at the same time, I apprehend it
L 2 to

244 PRACTICE
to be a rare occurrence; and that the disease
much more frequently begins in, and chiefly
affects, the pleura investing the lungs, pro-
ducing all the symptoms supposed to belong
to what has been called the Pleuritis vera.
CCCXLII.
Some physicians have imagined, that there
is a case of pneumonic inflammation particu-
larly entitled to the appellation of Peripneu-
mony; and that is, the case of an inflamma-
tion beginning in the parenchyma or cellular
texture of the lungs, and having its seat chief-
ly there. But it seems to me very doubtful,
if any acute inflammation of the lungs, or any
disease which has been called Peripneumony,
be of that kind. It seems probable, that ev-
ery acute inflammation begins in membranous
parts; and, in every dissection of persons dead
of peripneumony, the external membrane of
the lungs, or some part of the pleura, has ap-
peared to have been considerably affected.
CCCXLIII.
An inflammation of the pleura covering the
upper surface of the diaphragm, has been dis-
tinguished by the appellation of Paraphreni-
as, as supposed to be attended with the pecu-
liar symptoms of delirium, risus sardonicus,
and other convulsive motions; but it is certain,
that an inflammation of that portion of the
pleura, 

245 OF PHYSIC.
pleura, and affecting also even the muscular
substance of the diaphragm, has often taken place
without any of these symptoms; and I have
not met with either dissections, or; my ac-
counts of dissections, which support the opin-
ion, that an inflammation of the pleura cover-
ing the diaphragm, is attended with delirium
more commonly than any other pneumonic
inflammation.
CCCXLIV.
With respect to the seat of pneumonic in-
flammation, I must observe further, that al-
though, it may arise and subsist chiefly in one
part of the pleura only, it is however frequent-
ly communicated to other parts of the same,
and commonly communicates a morbid affec-
tion through its whole extent.
CCCXLV.
The remote cause of pneumonic inflamma-
Tion, is commonly, cold applied to the body,
obstructing perspiration, and determining to
the lungs; while at the same time the lungs
themselves are exposed to the action of cold.
These circumstances operate especially, when
an inflammatory diathesis prevails in the sys-
tem; and consequently, upon persons of the
greatest vigour; in cold climates; in the win-
ter season; and particularly in the spring,
when vicissitudes of heat and cold are fre-
L 3 quent. 

246 PRACTICE
quent. The disease, however, may arise in any
season when such vicissitudes occur.
Other remote causes also may have a share
in this matter; such as every means of ob-
structing, straining, or otherwise injuring, the
pneumonic organs.
Pneumonic inflammation may happen to
persons of any age, but rarely to those under
the age of puberty; and most commonly it
affects persons somewhat advanced in life, as
those between forty five and sixty years; those,
too, especially of a robust and full habit.
The pneumonic inflammation has been
sometimes so much an epidemic, as to occa-
sion a suspicion of its depending upon a spe-
cific contagion; but I have not met with any
evidence in proof of this. See MORGANI
de causis et sedibus morborum, epist. xxi. art. 26.
CCCXLVI.
The pneumonic, like other inflammations,
may terminate by resolution, suppuration, or
gangrene; but it has also a termination pecu-
liar to itself, as has been hinted above,
(CCLIX); and that is, when it is attended
with an effusion of blood into the cellular
texture of the lungs, which soon interrupting
the circulation of the blood through this vis-
cus, produces a fatal suffocation. This, in-
deed, seems to be the most common termina-
tion of pneumonic inflammation, when it ends
fatally; 

247 OF PHYSIC.
fatally; for, upon the dissection of almost ev-
ery person dead of the disease, it has appeared
that such an effusion had happened.
CCCXLVII.
From these dissections also we learn, that
pneumonic inflammation commonly produces
an exudation from the internal surface of the
pleura; which appears partly as a soft viscid
crust, often of a compact, membranous form,
covering every where the surface of the pleu-
ra, and particularly those parts where the
lungs adhere to the pleura costalis, or medias-
tinum; and this crust seems always to be the
cement of such adhesions.
The same exudation shows itself, also, by a
quantity of a serous whitish fluid, commonly
found in the cavity of the thorax; and some
exudation or effusion is usually found to have
been made likewise into the cavity of the pe-
ricardium.
CCCXLVIII.
It seems probable, too, that a like effusion
is sometimes made into the cavity of the
bronchiæ; for, in some persons who have di-
ed after labouring under a pneumonic inflam-
mation for a few days only, the bronchiæ have
been found filled with a considerable quantity
of a serous and thickish fluid; which, I think,
must be considered rather as the effusion men-
L 4 tioned,

248 PRACTICE
tioned, having had its thinner parts taken off
by respiration, than as a pus so suddenly
formed in the inflamed part.
CCCXLIX.
It is, however, not improbable, that this
effusion, as well as that made into the cavi-
ties of the thorax and pericardium, may be a
matter of the same kind with that which, in
other inflammations, is poured into the cellu-
lar texture of the parts inflamed, and there
converted into pus; but, in the thorax and
pericardium, it does not always assume that
appearance, because the cruft covering the
surface prevents the absorption of the thinner
part. This absorption, however, may be
compensated in the bronchiæ by the drying
power of the air; and therefore the effusion
into them may put on a more purulent ap-
pearance.
In many cases of pneumonic inflammation,
when the SPUTA are very copious, it is diffi-
cult to suppose that the whole of them pro-
ceed from the mucous follicles of the bron-
chiæ. It seems more probable that a great
part of them may proceed from the effused se-
rous fluid we have been mentioning; and this
too will account for the sputa being so often
of a purulent appearance. Perhaps the same
thing may account for that purulent expecto-
ration, as well as that purulent matter found
in the bronchiæ, which the learned Mr. de
Haen

249 OF PHYSIC.
Haen says he had often observed, when there
was no ulceration of the lungs; and this ex-
planation, is at least more probable, than Mr.
de Haen's supposition of a pus formed in the
circulating blood.
CCCL.
To conclude this subject, it would appear,
that the effusion into the bronchiæ, which we
have mentioned, often concurs with the effu-
sion of red blood in occasioning the suffoca-
tion, which fatally terminates pneumonic in-
flammation; that the effusion of serum alone
may have this effect; and, that the serum
poured out in a certain quantity, rather than
any debility in the powers of expectoration, is
the cause of that ceasing of expectoration
which very constantly precedes the fatal event.
For, in many cases, the expectoration has
ceased, when no other symptoms of debility
have appeared, and when, upon dissection, the
bronchiæ have been found full of liquid mat-
ter. Nay, it is even probable, that, in some-
cases, such an effusion may take place, with-
out any symptoms of violent inflammation;
and, in other cases, the effusion taking place,
may seem to remove the symptoms of inflam-
mation which hail appeared before, and thus-
account for those unexpected fatal termina-
tions which have sometimes happened. Pos-
sibly this effusion may account also for many of
the phenomena of the Peripneumonia Notha.
L 5 CCCLI.

250 PRACTICE
CCCLI.
Pneumonic inflammation seldom terminates
by resolution, without being attended with
some evident evacuation. An hemorrhagy
from the nose happening upon some of the
first days of the disease, has sometimes put an
end to it; and it is aid, that an Evacuation
from the hemorrhoidal veins, a bilious evac-
uation by stool, and an evacuation of urine
with a copious sediment, have severally had
the same effect; but such occurrences have
been rare and unusual.
The evacuation most frequently attending,
and seeming to have the greatest effect in pro-
moting resolution, is an expectoration of a
thick white or yellowish matter, a little streak-
ed with blood, copious, and brought up
without either much or violent coughing.
Very frequently the resolution of this dis-
ease is attended with, and perhaps produced
by, a sweat, which is warm, fluid, copious
over the whole body, and attended with an
abatement of the frequency of the pulse, of
the heat of the body, and of other febrile
symptoms.
CCCLII.
The prognostics in this disease are formed
from observing the state of the principal
symptoms.
A violent pyrexia is always dangerous.
The

251 OF PHYSIC.
The danger, however, is chiefly denoted by
the difficulty of breathing. When the patient
can lie on one side only; when he can lie on
neither side, but upon his back only; when
he cannot breathe with tolerable ease, except
the trunk of his body be erect; when, even
in this posture, the breathing is very difficult,
and attended with a turgescene and flushing
of the face, together with partial sweats about
the head and neck, and an irregular pulse;
these circumstances mark the difficulty of
breathing in progressive degrees, and, conse-
quently, in proportion, the danger of the
disease.
A frequent violent cough aggravating the
pain, is always the symptom of an obstinate
disease.
As I apprehend that the disease is hardly
ever resolved, without some expectoration;
so a dry cough must be always an unfavourable
symptom.
As the expectoration formerly described,
marks that the disease is proceeding to a res-
olution; so an expectoration which has not
the conditions there mentioned, must denote
at least a doubtful state of the disease; but
the marks taken from the colour of the matter,
are for the most part fallacious.
An acute pain, very much interrupting in—
spiration, is always the mark of a violent dis-
ease; though not of one more dangerous, than
an obtuse pain, attended with very difficult
respiration.
L 6 When

252 PRACTICE
When the pains, which at first had affected
one side only, have afterwards spread into the
other; or when, leaving the side first affected,
they entirely pass into the other; these are
always marks of an increasing, and therefore
of a dangerous, disease.
A delirium coming on during a pneumonic
inflammation, is constantly a symptom de-
noting much danger.
CCCLIII.
When the termination of this disease proves
fatal, it is on one or other of the days of the
first week, from the third to the seventh. This
is the most common case; but in a few instan-
ces, death has happened at a later period of
the disease.
When the disease is violent, but admitting
of resolution, this also happens frequently in
the course of the first week; but, in a more
moderate state of the disease, the resolution is
often delayed to the second week.
The disease, on some of the days from the
third to the seventh, generally suffers a re-
mission; which, however, may be often falla-
cious, as the disease does sometimes return
again with as much violence as before, and
then with great danger.
Sometimes the disease disappears on the
second or third day, while an erysipelas makes;
its appearance on some external part; and, if
this 

253 OF PHYSIC.
this continue fixed, the pneumonic inflam-
mation does not recur.
CCCLIV.
Pneumonia, like other inflammations, often
ends in suppuration or gangrene.
CCCLV.
When a pneumonia, with symptoms neither
very violent nor very slight, has continued
for many days, it is to be feared it will end in
a suppuration. This, however, is not to be
determined precisely by the number of days;
for, not only after the fourth, but even after
the tenth day, there have been examples of
a pneumonia ending by a resolution; and if
the disease has suffered some intermission, and
again recurred, there may be instances of a
resolution happening at a much later period
from the beginning of the disease, than that
just now mentioned.
CCCLVI.
But if a moderate disease, in spite of proper
remedies employed, be protracted to the four-
teenth day without any considerable remission,
a suppuration is pretty certainly to be expect-
ed; and it will be still more certain, if no
signs of resolution have appeared, or if an ex-
pectoration which had appeared shall have
again 

254 PRACTICE
again ceased, and the difficulty of breathing
has continued or increased, while the other
symptoms have rather abated.
CCCLVII.
That, in a pneumonia, the effusion is made,
which may lay the foundation of a suppu-
ration, we conclude from the difficulty of
breathing becoming greater when the patient
is in a horizontal posture, or when he can
lie more easily upon the affected side.
CCCLVIII.
That, in such cases, a suppuration has
actually begun, may be concluded from the
patient's being frequently affected with slight
cold shiverings, and with a sense of cold felt
sometimes in one and sometimes in another
part of the body. We form the same con-
clusion also from the state of the pulse, which
is commonly less frequent and softer, but some-
times quicker and fuller, than before.
CCCLIX.
That a suppuration is already formed, may
be inferred from there being a considerable
remission of the pain which had before sub-
sisted, while, along with this, the cough, and
especially the dyspnœa, continue, and are
rather augmented. At the same time, the fre-
quency 

255 OF PHYSIC.
quency of the pulse is rather increased; the
feverish state suffers considerable exacerbations
every evening, and by degrees a hectic in all
its circumstances comes to be formed.
CCCLX.
The termination of Pneumonia by gangrene,
is much more rare than has been imagined;
and, when it does occur, it is usually
joined with the termination by effusion
(CCCXLVI), and the symptoms of the one
are hardly to be distinguished from those of
the other.
CCCLXI.
The cure of pneumonic inflammation must
proceed upon the general plan (CCLXIV);
but the importance of the part affected and
the danger to which it is exposed, require
that the remedies be fully, as well as early,
employed.
CCCLXII.
The remedy chiefly to be depended upon,
is that of bleeding at the arm; which will be
performed with most advantage in the arm of
the side affected; but may be done in either
arm, as may be most convenient for the patient
or the surgeon. The quantity drawn must
be suited to the violence of the disease, and to
the 

256 PRACTICE
the vigour of the patient; and generally ought
to be as large as this last circumstance wilI allow.
The remission of pain, and the relief of res-
piration during the flowing of the blood, may
limit the quantity to be then drawn; but if
these symptoms of relief do not appear, the
bleeding should be continued till the symp-
toms of a beginning syncope come on. It is
seldom that one bleeding, however large, will
prove a cure of this disease; and although the
pain and difficulty of breathing may be much
relieved by the first bleeding, these symptoms
commonly, and after no long interval, recur;
often with as much violence as before. In the
event of such recurrence, the bleeding is to
be repeated, even in the course of the same
day, and perhaps to the same quantity as before.
Sometimes the second bleeding may be
larger than the first. There are persons who,
by their constitution, are ready to faint even
upon a small bleeding; and, in such persons,
this may prevent the drawing so much blood
at first as a pneumonic inflammation might re-
quire; but, as the same persons are frequent-
ly found to bear after bleedings better than the
first, this allows the second and subsequent
bleedings to be larger, and to such a quantity
as the symptoms of the disease may seem to
demand.
CCCLXIII.
It is according to the state of the symptoms
that bleedings are to be repeated; and they
will 

257 OF PHYSIC.
will be more effectual when practised in the
course of the first three days, than afterwards;
but they are not to be omitted, although four
days of the disease may have already elapsed.
If the physician shall not have been called in
sooner; or if the bleedings practised during
the first days shall not have been large enough,
or even although these bleedings shall have
procured some remission; yet, upon the re-
currence of the urgent symptoms, the bleeding
should be repeated at any period of the dis-
ease, especially within the first fortnight; and
even afterwards, if a tendency to suppuration
be not evident, or if, after a seeming solution,
the disease shall have again returned.
CCCLXIV.
With respect to the quantity of blood which
ought, or which with safety may be taken
away, no general rules can be delivered, as
it must be very different, according to the
state of the disease, and the constitution of the
patient. In an adult male of tolerable
strength, a pound of blood, avoirdupois, is
a full bleeding. Any quantity above twenty
ounces is a large, and any quantity below
twelve a small, bleeding. A quantity of from
four to five pounds, in the course of two or
three days, is generally as much as such
patients will safely bear; but, if the intervals
between the bleedings and the whole of the
time during which the bleedings have been
employed 

258 PRACTICE
employed have been long, the quantity taken
upon the whole may be greater.
CCCLXV.
When a large quantity of blood has been
already taken from the arm, and when it is
doubtful if more can with safety be drawn in
that manner, some blood may still be taken
by cupping and scarifying. Such a measure
will be more particularly proper, when the
contiuance or recurrence of pain, rather than
the difficulty of breathing, becomes the urgent
symptom; and then the cupping and scar-
ifying should be made as near to the pained
part as can conveniently be done.
CCCLXVI.
An expectoration takes place sometimes
very early in this disease; but if, notwith-
standing that, the urgent symptoms should
still continue, the expectoration must not
supersede the bleedings mentioned; and
during the first days of the disease, its solution
is not to be trusted to the expectoration alone.
It is in a more advanced stage only, when the
proper remedies have been before employed,
and when the symptoms have suffered a con-
siderable remission, that the entire cure may
be trusted to a copious and free expectoration.
CCCLXVII 

259 OF PHYSIC.
CCCLXVII.
During the first days of the disease, I have
not found that bleeding stops expectoration.
On the contrary, I have often observed bleed-
ing promote it; and it is in a more advanced
stage of the disease only, when the patient, by
large evacuations, and the continuance of the
disease, has been already exhausted, that
bleeding seems to stop expectoration. It
appears to me, that even then bleeding does
not stop expectoration so much by weakening
the powers of expectoration, as by fa-
vouring the serous effusion into the bronchiæ
(CCCXLVIII), and thereby preventing it.
CCCLXVIII.
While the bleedings we have mentioned shall
be employed, it will be necessary to employ
also every part of the antiphlogistic regimen
(CXXX—CXXXII), and particularly to
prevent the irritation which might arise from
any increase of heat. For this purpose, it
will be proper to keep the patient out of bed,
while he can bear it easily; and, when he
cannot, to cover him very lightly while he
lies in bed. The temperature of his chamber
ought not to exceed sixty degrees of Faren-
heit's thermometer; and whether it may be
at any time colder, I am uncertain.
CCCLXIX. 

260 PRACTICE
CCCLXIX.
Mild and diluent drinks, moderately tepid,
at least never cold, given by small portions at
a time, ought to be administered plentifully.
These drinks may be impregnated with vegeta-
ble acids. They may be properly accompanied
also with nitre, or some other neutrals; but these
salts should be given separately from the drink.
It has been alleged, that both acids and
nitre are ready to excite coughing, and in some
persons they certainly have this effect; but,
except in persons of a peculiar habit, I have
not found their effects in exciting cough so
considerable or troublesome as to prevent our
seeking the advantages otherwise to be obtain-
ed from these medicines.
CCCLXX.
Some practitioners have doubted, if purga-
tives can be safely employed in this disease
and indeed a spontaneous diarrhœa occurring
in the beginning of the disease has seldom
proved useful; but I have found the mode-
rate use of cooling laxatives generally safe; and;
have always found it useful to keep the belly
open by frequent emollient glysters.
CCCLXXI.
To excite full vomiting by emetics, I judge
to be a dangerous practice in this disease; but
I 

261 OF PHYSIC.
I have found it useful to exhibit nauseating
doses; and, in a somewhat advanced state of
the disease, I have found such doses prove the
best means of promoting expectoration.
CCCLXXII.
Fomentations and poultices applied to the
pained part have been recommended, and may
be useful; but the application of them is oft-
en inconvenient, and may be entirely omitted
for the fake of the more effectual remedy,
blistering.
Very early in the disease, a blister should
be applied as near to the pained part as possi-
ble. But as, when the irritation of a blister
is present, it renders bleeding less effectual; so
the application of the blister should be delayed
till a bleeding shall have been employed. If
the disease be moderate, the blister may be
applied immediately after the first bleeding;
but if the disease be violent, and it is presum-
ed that a second bleeding may be necessary
soon after the first, it will then be proper to
delay the blister till after the second bleeding,
when it may be supposed that any farther
bleeding may be postponed till the irritation
arising from the blister shall have ceased. It
may be frequently necessary in this disease to
repeat the blistering; and, in that case, the
plasters should always be applied somewhere
on the thorax; for, when applied to more dis-
tant parts, they have little effect. The keeping
the 

262 PRACTICE
the blistered parts open, and making what is
called a perpetual blister, has much less effect
than a fresh blistering.
CCCLXXIII.
As this disease often terminates by an ex-
pectoration, so various means of promoting
this have been proposed; but none of them
appear to be very effectual; and some of them,
being acrid stimulant substances, cannot be
very safe.
The gums usually employed seem too
heating; squills seem to be less so; but they
are not very powerful, and sometimes incon-
venient by the constant nausea they induce.
The volatile alkali may be of service as an
expectorant; but it should be reserved for an
advanced state of the disease.
Mucilaginous and oily demulcents appear
to be useful, by allaying that acrimony of the
mucus which occasions too frequent cough-
ings; and which coughing prevents the stagna-
tion and thickening of the mucus, and thereby
its becoming mild.
The receiving into the lungs the steams of
warm water impregnated with vinegar, has
often proved useful in promoting expectora-
tion.
But, of all other remedies, the most power-
ful for this purpose, are antimonial medicines,
given in nauseating doses, as in CLXXIX.
Of these, however, I have not found the
kermes

263 OF PHYSIC.
kermes mineral more efficacious than emetic
tartar, or antimonial wine; and the dose of the
kermes is much more uncertain than that of
the others.
CCCLXXIV.
Though a spontaneous sweating often
proves the crisis of this disease, it ought not
to be excited by art, unless with much cau-
tion. At least, I have not yet found it either
so effectual or safe, as some writers have alleg-
ed. When, after some remission of the symp-
toms, spontaneous sweats of a proper kind a-
rise, they may be encouraged; but it ought to
be without much heat, and without stimulant
medicines. If, however, the sweats be partial
and clammy only, and a great difficulty of
breathing still remain, it will be very danger-
ous, to encourage them.
CCCLXXV.
Physicians have differed much in opinion
with regard to the use of opiates in pneumon-
ic inflammation. To me it appears, that, in
the beginning of the disease, and before bleed-
ing and blistering have produced some remission
of the pain, and of the difficulty of breathing,
opiates have a very bad effect, by their in-
creasing the difficulty of breathing, and other
inflammatory symptoms. But in a more ad-
vanced state of the disease, when the difficulty
of

264 PRACTICE
of breathing has abated, and when the urgent
symptom is a cough, proving the chief cause of
the continuance of the pain and of the want
of sleep, opiates may be employed with great
advantage and safety. The interruption of the
expectoration, which they seem to occasion, is
for a short time only ; and they seem often to
promote it, as they occasion a stagnation of
what was by frequent coughing dissipated in-
sensibly, and therefore give the appearance of
what physicians have called Concocted Mat-
ter.
CHAP.

265 OF PHYSIC.
CHAP. VII.
OF THE PERIPNEUMONIA NOTHA,
OR BASTARD PERIPNEUMONY.
CCCLXXVI.
A DISEASE under this name
is mentioned in some medical writings of the
sixteenth century; but it is very doubtful if
the name was then applied to the same disease
to which we now apply it. It appears to me,
that unless some of the cases described under
the title of Catarrhus Sussocativus be suppos-
ed to have been of the kind I am now to treat
of, there was no description of this disease giv-
en before that by Sydenham, under the title I
have employed here.
CCCLXXVII.
After Sydenham, Boerhaave was the first
who in a system took notice of it as a distinct
disease; and he has described it in his aphor-
isms, although with some circumstances differ-
ent from those in the description of Sydenham.
Of late, Mr. Lieutaud has with great consi-
dence asserted, that Sydenham and Boerhaave
M had,

266 PRACTICE
had, under the same title, described different
diseases; and that, perhaps, neither of them
had on this subject delivered any thing but
hypothesis.
CCCLXXVIII.
Notwithstanding this bold assertion, I am
humbly of opinion, and the Baron Van
Swieten seems to have been of the same, that
Sydenham and Boerhaave did describe under
the same title, one and the same disease. Nay,
I am further of opinion, that the disease de-
scribed by Mr. Lieutaud himself, is not essen-
tially different from that described by both the
other authors. Nor will the doubts of the very
learned, but modest Morgagni, on this subject,
disturb us, if we consider, that while very few
describers of diseases either have it in their
power, or have been sufficiently attentive in
distinguishing between the essential and acci-
dental symptoms of disease; so, in a disease
which may have not only different, but a
greater number of symptoms, in one person
than it has in another, we need not wonder
that the descriptions of the same disease by
different persons should come out in some re-
spects different. I shall, however, enter no
further into this controversy; but endeavour
to describe the disease as it has appeared to
myself; and, as I judge, in the essential symp-
toms, much the same as it has appeared to all
the other authors mentioned.
CCCLXXIX.

267 OF PHYSIC.
CCCLXXIX.
This disease appears at the same seasons
that other pneumonic and catarrhal affections
commonly do; that is, in autumn and in spring.
Like these diseases, also, it is seemingly occa-
sioned by hidden changes of the weather from
heat to cold. It appears, also, during the prev-
alence of contagious catarrhs; and it is fre-
quently under the form of the Peripneumonia
Notha, that these catarrhs prove fatal to elder-
ly persons.
This disease attacks most commonly per-
sons somewhat advanced in life, especially
those of a full phlegmatic habit; those who
have before been frequently liable to catarrhal
affections, and those who have been much ad-
dicted to the large use of fermented and spir-
ituous liquors.
The disease commonly comes on with the
same symptoms as other febrile diseases; that
is, with alternate chills and heats; and the
symptoms of pyrexia are sometimes sufficiently
evident; but in most cases these are very
moderate, and in some hardly at all appear.
With the first attack of the disease, a cough
comes on; usually accompanied with some
expectoration; and in many cases there is a
frequent throwing up of a considerable quan-
tity of a viscid opaque mucus. The cough
often becomes frequent and violent; is some-
times accompanied with a rending headach;
M 2 and,

268 PRACTICE
and, as in other cases of cough, a vomiting is
sometimes excited by it. The face is some-
times flushed, and some giddiness or drowsi-
ness often attends the disease. A difficulty
of breathing, with a sense of oppression, or
straitening in the chest, with some obscure
pains there, and a sense of lassitude over the
whole body, very constantly attend this dis-
ease. The blood drawn in this disease, shows
a buffy surface, as in other inflammatory af-
fections.
The disease has often the appearance only
of a more violent catarrh, and after the em-
ployment of some remedies is entirely relieved
by a free and copious expectoration. In oth-
er cases, however, the feverish and catarrhal
symptoms are at first very moderate, and even
slight; but, after a few days, these symptoms
suddenly become considerable, and put an end
to the patient's life when the indications of
danger were before very little evident.
CCCLXXX.
From the different circumstances in which
this disease appears, the pathology of it is dif-
ficult. It is certainly often no other at first than
a catarrhal affection, which, in elderly persons,
is frequently attended with a large afflux of
mucus to the lungs; and it was on this foot-
ing that Sydenham considered it as only dif-
fering in degree from his Febris Hyemalis.
A catarrh, however, is strictly an affection of
the

269 OF PHYSIC.
the mucous membrane and follicles of the
bronchiæ alone; but it may readily have, and
frequently has, a degree of pneumonic inflam-
mation joined to it; and in that case may
prove more properly the peculiar disease we
treat of here. But, further, as pneumonic in-
flammation very often produces an effusion
of serum into the bronchiæ (CCCXLVIII),
so this, in elderly persons, may occur in con-
sequence of a slight degree of inflammation;
and when it does happen, will give the exqui-
site and fatal cases of the peripneumonia notha.
CCCXXXI.
After this attempt to establish the patholo-
gy, the method of cure in the different cir-
cumstances of the disease will not be difficult.
In case the fever, catarrhal and pneumonic
symptoms, are immediately considerable, a
bloodletting will certainly be proper and nec-
essary; but, where these symptoms are mode-
rate, a bloodletting will hardly be requisite;
and, when an effusion is to be feared, the rep-
etition of bloodletting may prove extremely
hurtful.
In all cases, the remedies chiefly to be de-
pended upon, are vomiting and blistering.
Full vomiting may be frequently repeated,
and nauseating doses ought to be constantly
employed.
M 3 Purging

270 PRACTICE
Purging may perhaps be useful; but as it
is seldom so in pneumonic affections, nothing
but gentle laxatives are here necessary.
In all the circumstances of this disease, the
antiphlogistic regimen is proper; cold is to be
guarded against; but much external heat is
to be as carefully avoided.
CCCLXXXII.
It a person sweats easily, and it can be
brought out by the use of mild tepid liquors
only, the practice may in such persons be tri-
ed. See MORGAGNI De Sed. et Caus. Epist.
xiii. Art. 4.
CCCLXXXIII.
I might here, perhaps, give a separate section
on the Carditis and Pericarditis, or the In-
flammations of the Heart and Pericardium;
but they hardly require a particular consid-
eration. An acute inflammation of the peri-
cardium is almost always a part of the same
pneumonic affection I have been treating of;
and is not. always distinguished by any differ-
ent symptoms; or, if it be, does not require
any different treatment. The same may be
said of an acute inflammation of the heart it-
self; and when it happens that the one or oth-
er is discovered by the symptoms of palpita-
tion or syncope, no more will be implied than
that

271 OF PHYSIC.
that the remedies of pneumonic inflammation
should be employed with greater diligence.
From dissections, which show the heart and
pericardium affected with erosions, ulcerations,
and abscesses, we discover, that these parts had
been before affected with inflammation; and
that in cases where no symptoms of pneumon-
ic inflammation had appeared; it may there-
fore be alleged, that those inflammations of
the heart and pericardium should be consider-
ed as diseases independent of the pneumonic.
This indeed is just; but the history of such
cases proves, that those inflammations had
been of a chronic kind, and hardly discovering
themselves by any peculiar symptoms; or, if
attended with symptoms marking an affection
of the heart, these were, however, such as have
been known frequently to arise from other
causes than inflammation. There is, there-
fore, upon the whole, no room for our treat-
ing more particularly of the inflammation of
the heart or pericardium.
M 4 CHAP

272 PRACTICE
CHAP. VIII.
OF THE GASTRITIS, OR INFLAMMA-
TION OF THE STOMACH.
CCCLXXXIV.
AMONG the inflammations
of the abdominal region, I have given a place
in our Nosology to the Peritonitis; compre-
hending under that title, not only the inflam-
mations affecting the peritonæum lining the
cavity of the abdomen, but also those affecting
the extensions of this membrane in the
omentum and mesentery. It is not, however,
proposed to treat of them here, because it is
very difficult to say by what symptoms they are
always to be known; and farther, because,
when known, they do not require any reme-
dies beside those of inflammation in general.
I proceed, therefore, to treat of those inflam-
mations, which, affecting viscera of peculiar
functions, both give occasion to peculiar symp-
toms, and require some peculiarities in the
method of cure; and I shall begin with the
inflammation of the stomach.
CCCLXXXV. 

273 OF PHYSIC.
CCCLXXXV.
The inflammation of the stomach is of
two kinds; Phlegmonic, or Erythematic*.
The first may be seated in what is called the
Nervous Coat of the stomach, or in the peri-
tonæum inverting it. The second is always
seated in the villous coat and cellular texture
immediately subjacent.
CCCLXXXVI.
The Phlegmonic inflammation of the stom-
ach, or what has been commonly treated of
under the title of Gastritis, is known by an
acute pain in some part of the region of the
stomach, attended with pyrexia, with frequent
vomiting, especially upon occasion of any
thing being taken down into the stomach, and
frequently with hickup. The pulse is com-
monly small and hard; and there is a greater
loss of strength in all the functions of the
body, than in the case of almost any other in-
flammation.
CCCLXXXVII.
This inflammation maybe produced by va-
rious causes; as, by external contusion; by
M 5 acrids
* This is a new term; but whoever considers what is;
said in CCLXXIV, will, I expect, perceive the proprie-
ty, and even the necessity, of it.

274 PRACTICE
acrids of various kinds taken into the stom-
ach; frequently by very cold drink, taken in-
to it, while the body is very warm; and some-
times by over distention, from the having tak-
en in a large quantity of food of difficult di-
gestion. All these may be considered as ex-
ternal causes; but the disease sometimes arises
also from internal causes not so well under-
stood. It may arise from inflammations of
the neighbouring parts communicated to the
stomach, and is then to be considered as a
symptomatic affection only. It may arise al-
so from various acrimonies generated within
the body, either in the stomach itself, or in
other parts, and poured into the cavity of the
stomach. These are causes more directly ap-
plied to the stomach; but there are perhaps
others originating elsewhere, and affecting the
stomach only sympathetically. Such may be
supposed to have acted in the case of putrid
fevers and exanthematic pyrexiæ; in which,
upon dissection, it has been discovered that
the stomach had been affected with inflam-
mation.
CCCLXXXVIII.
From the sensibility of the stomach, and its
communication with the rest of the system, it
will be obvious, that the inflammation of this
organ, by whatever causes produced, may be
attended with fatal consequences. In partic-
ular, by the great debility which such an in-
flammation

275 OF PHYSIC.
flammation suddenly produces, it may quickly
prove fatal, without running the common
course of inflammations.
When it lasts long enough to follow the or-
dinary course of other inflammations, it may
terminate by resolution, gangrene, or suppu-
ration. The scirrhosities which are often dis-
covered affecting the stomach, are seldom
known to be the consequences of inflam-
mation.
CCCLXXXIX.
The tendency of this disease to admit of
resolution, may be known by its having arisen
from no violent cause; by the moderate state
of the symptoms; and by a gradual remission
of these, especially in consequence of remedies
employed in the course of the first, or at far-
thest the second, week of the disease.
CCCXC.
The tendency to suppuration may be known
by the symptoms continuing, in a moderate
degree, for more than one or two weeks; and
likewise by a considerable remission of the
pain, while a sense of weight and anxiety still
remain.
When an abscess has been formed, the fre-
quency of the pulse is at first abated; but soon
after, it is again increased, with frequent cold
shiverings, and with marked exacerbations in
M 6 the

276 PRACTICE
the afternoon and evening, followed by night
sweatings and other symptoms of hectic fever.
These at length prove fatal, unless the abscess
open into the cavity of the stomach, the pus
be evacuated by vomiting, and the ulcer soon
heal.
CCCXCI.
The tendency to gangrene may be suspect-
ed from the violence of the symptoms not
yielding to the remedies employed during the
first days of the disease; and that a gangrene
has already begun, may be known from the
sudden remission of the pain, while the fre-
quency of the pulse continues, and at the same
time becomes weaker, accompanied with other
marks of an increasing debility in the whole
system.
CCCXCII.
From the dissection of dead bodies it ap-
pears, that the stomach very often has been
affected with inflammation, when the charac-
teristic symptoms of it (CCCLXXXVI) had
not appeared; and therefore it is very difficult
to lay down any general rules for the cure of
this disease.
CCCXCIII.
It is only in the case of phlegmonic inflam-
mation, as characterised in CCCLXXXVI.
that 

277 OF PHYSIC.
that we can advise the cure or resolution to
be attempted by large and repeated bleedings
employed early in the disease; and we are not
to be deterred from these by the smallness of
the pulse; for, after bleeding, it commonly
becomes fuller and softer. After bleeding, a
blister ought to be applied to the region of the
stomach; and the cure will be assisted by so-
mentations of the whole abdomen, as well as
by frequent emollient and laxative glysters.
CCCXCIV.
In this disease, the irritability of the stom-
ach will not admit of any medicines being
thrown into it; and, if any internal medicines
can be supposed necessary, they must be ex-
hibited in glysters. The giving of drink may
be tried; but it ought to be of the very mild-
est kind, and in very small quantities at a time,
CCCXCV.
Opiates, in whatever manner exhibited, are
very hurtful during the first days of the dis-
ease; but when its violence shall have abated,
and when the violence of the pain and vomit-
ing recur at intervals only, opiates given in
glysters may be cautiously tried, and some-
times have been employed with advantage.
CCCXCVI. 

278 PRACTICE.
CCCXCVI.
A tendency to suppuration, in this disease,
is to be obviated by the means just now pro-
posed. After a certain duration of the dis-
ease, it cannot be prevented by any means
whatever; and when actually begun, must be
left to nature; the business of the physician
being only to avoid all irritation.
CCCXCVII.
A tendency to gangrene can be obviated in
no other way than by the means suggested
CCCXCIII, employed early in the disease;
and, when it does actually supervene, admits
of no remedy.
CCCXCVIII.
Erythematic inflammations of the stomach,
are more frequent than those of the phlegmon-
ic kind. It appears, at least, from dissections,
that the stomach has often been affected with
inflammation, when neither pain nor pyrexia
had before given any notice of it; and such
inflammation I apprehend to have been chief-
ly of the erythematic kind. This species of
inflammation also, is especially to be expected
from acrimony of any kind thrown into the
stomach; and would certainly occur more
frequently from such a cause, were not the
interior 

279 OF PHYSIC.
interior surface of this organ commonly de-
fended by mucus exuding in large quantities
from the numerous follicles placed immedi-
ately under the villous coat. Upon many oc-
casions, however, the exudation of mueus is
prevented, or the liquid poured out is of a
less viscid kind, so as to be less fitted to defend
the subjacent nerves; and it is in such cases
that matters even of moderate acrimony, may
produce any erythematic affection of the
stomach.
CCCXCIX.
From what has been said it must appear,
that an erythematic inflammation of the stom-
ach may frequently occur; but will not al-
ways discover itself, as it sometimes takes place
without pyrexia, pain, or vomiting.
CCCC.
There are cases, however, in which it may
be discovered. The affection of the stomach
sometimes spreads into the œsophagus, and
appears in the pharynx, as well as on the
whole internal surface of the mouth. When
therefore, an erythematic inflammation affects
the mouth and sauces, and when at the same
time there shall be in the stomach an unusual
sensibility to all acrids, with a frequent vom-
iting, there can be little doubt of the stomach
being affected with the same inflammation
that 

280 PRACTICE
that has appeared in the sauces. Even when
no inflammation appears in the sauces, yet if
some degree of pain be felt in the stomach, if
there be a want of appetite, an anxiety, fre-
quent vomiting, an unusual sensibility with
respect to acrids, some thirst, and frequency
of pulse, there will then be room to suspect
an erythematic inflammation of the stomach;
and we have known such symptoms, after
some time, discover their cause more clearly
by the appearance of the inflammation in the
sauces or mouth.
Erythematic inflammation is often disposed
to spread from one place to another on the,
same surface; and, in doing so, to leave the
place it had at first occupied. Thus, such an
inflammation has been known to spread suc-
cessively along the whole course of the ali-
mentary canal, occasioning in the intestines
diarrhœa, and in the stomach vomitings; the
diarrhœa ceasing when the vomitings came on,
or the vomitings upon the coming on of the
diarrhœa.
CCCCI. 
When an erythematic inflammation of the
stomach shall be discovered, it is to be treated
differently, according to the difference of its
causes and symptoms.
When it is owing to acrid matters taken in
by the mouth, and when these may be sup-
posed still present in the stomach, they are to
be

281 OF PHYSIC.
be washed out by throwing in a large quantity
of warm and mild liquids, and by exciting
vomiting. At the same time, if the nature of
the acrimony and its proper corrector be
known, this should be thrown in; or if a spe-
cific corrector be not known, some general de-
mulcents should be employed.
CCCCII.
These measures, however, are more suited
to prevent the inflammation, than to cure it
after it has taken place. When this last may
be supposed to be the case, if it be attended
with a sense of heat, with pain and pyrexia,
according to the degree of these symptoms the
measures proposed in CCCXCIII, are to be
more or less employed.
CCCCIII.
When an erythematic inflammation of the
stomach has arisen from internal causes, if
pain and pyrexia accompany the disease, some
bleeding in persons not otherwise weakened,
may be employed; but, as the affection often
arises in putrid diseases, and in convalescents
from fever; so in these cases, bleeding is in-
admissible; all that can be done being to avoid
irritation, and to throw into the stomach what
quantity of acids, and of acescent aliments, it
shall be found to bear.
In

282 PRACTICE
In some conditions of the body, in which
this disease arises, the Peruvian bark and bit-
ters may seem to be indicated; but an eryth-
ematic state of the stomach does not common-
ly allow of them.
CHAP.

283 OF PHYSIC.
CHAP. IX.
OF THE ENTERITIS, OR INFLAMMA-
TION OF THE INTESTINES.
CCCCIV.
THE inflammation of the in-
testines, like that of the stomach, may be ei-
ther phlegmonic, or erythematic; but, on the
subject of the latter, I have nothing to add to
what has been said in the last chapter; and
shall here therefore treat of the phlegmonic
inflammation only.
CCCCVI.
This inflammation may be known to be
present, by a fixed pain of the abdomen, at-
tended with pyrexia, costiveness, and vomit-
ing. Practical writers mention the pain in
this case as felt in different parts of the abdo-
men, according to the different seat of the in-
flammation; and so, indeed, it sometimes
happens; but very often the pain spreads
over the whole belly, and is felt more especial-
ly about the navel.
CCCCVII.

284 PRACTICE
CCCCVII.
The Enteritis and Gastritis arise from like
causes; but the former, more readily than the
latter, proceeds from cold applied to the low-
er extremities or to the belly itself. The en-
teritis has likewise its own peculiar causes, as
supervening upon the spasmodic colic, incar-
cerated hernia, and volvulus.
CCCCVIII.
Inflammations of the intestines have the
same terminations as those of the stomach;
and, in both cases, the several tendencies are
to be discovered by the same symptoms
(CCCLXXXIX.-CCCXCI.)
CCCCIX.
The cure of the enteritis is, in general, the
same with that of the gastritis (CCCXCIII. &
seq.) but in the enteritis, there is commonly
more access to the introduction of liquids, of
acid, acescent, and other cooling remedies, and
even of laxatives. As, however, a vomiting
so frequently attends this disease, care must be
taken not to excite that vomiting by either the
quantity or the quality of any thing thrown
into the stomach.
The same observation, with respect to the
use of opiates, is to be made here as in the
case of gastritis.
CCCCX.

285 OF PHYSIC.
CCCCX.
Under the title of Enteritis, it has been
usual with practical writers to treat of the
remedies proper for the colic, and its higher
degree named Ileus; but, although it be true
that the enteritis and Colic do frequently ac-
company each other, I still hold them to be
distinct diseases, to be often occurring sepa-
rately, and accordingly to require and admit
of different remedies. I shall therefore delay
speaking of the remedies proper for the colic,
till I shall come to treat of this disease in its
proper place.
CCCCXI.
What might be mentioned with respect to
the suppuration or gangrene occurring in the
enteritis may be sufficiently understood from
what has been said on the same subject with
respect to the gastritis.
CHAP.

286 PRACTICE
CHAP. X.
OF THE HEPATITIS, OR INFLAMMA-
TION OF THE LIVER.
CCCCXII.
THE inflammation of the liv-
er seems to be of two kinds; the one acute, the
other chronic.
CCCCXIII.
The acute is attended with pungent pain;
considerable pyrexia; a frequent, strong, and
hard pulse; and high coloured urine.
CCCCXIV.
The chronic hepatitis very often does not
exhibit any of these symptoms; and it is only
discovered to have happened, by our finding
in the liver, upon dissection, large abscesses,
which are presumed to be the effect of some
degree of previous inflammation. As this
chronic inflammation is seldom to be certain-
ly known, and therefore does not lead to any
determined practice, we omit treating of it
here.

287 OF PHYSIC.
here, and shall only treat of what relates to
the acute species of the hepatitis.
CCCCXV.
The acute hepatitis may be known by a
pain more or less acute in the right hypochon-
drium, increased by pressing upon the part.
The pain is very often in such a part of the
side as to make it appear like that of a pleuri-
fy; and frequently, like that too, is increased
on respiration. The disease is, in some in-
stances, also attended with a cough, which is
commonly dry, but sometimes humid; and
when the pain thus resembles that of a pleuri-
fy, the patient cannot lie easily except upon
the side affected.
In every kind of acute hepatitis, the pain is
often extended to the clavicle, and to the top
of the shoulder. The disease is attended some-
times with hickup, and sometimes with vom-
iting. Many practical writers have mention-
ed the jaundice, or a yellow colour of the skin
and eyes as a very constant symptom of the
hepatitis; but experience has shown, that it
may often occur without any such symptom.
CCCCXVI.
The remote causes of hepatitis are not al-
ways to be discerned, and many have been as-
signed on a very uncertain foundation. The
following seem to be frequently evident.
1. External

288 PRACTICE.
1. External violence from contusions or falls
and especially those which have occasioned a
fracture of the cranium. 2. Certain passions
of the mind. 3. Violent summer heats.
4. Violent exercise. 5. Intermittent and re-
mittent fevers. 6. Cold applied externally,
or internally; and therefore in many cases the
same causes which produce pneumonic in-
flammation, produce hepatitis; and whence
also the two diseases are sometimes joined to-
gether. 7. Various solid concretions or col-
lections of liquid matter, in the substance of
the liver, produced by unknown causes. Last-
ly, The acute is soften induced by a chronic
inflammation of this viscus.
CCCCXVII.
It has been supposed, that the hepatitis may
be an affection either of the extremities of the
hepatic artery, or of those of the vena porta-
rum; but of the last supposition there is neither
evidence nor probability.
CCCCXVIII.
It seems probable, that the acute hepatitis
is always an affection of either the external mem-
brane of the liver; and that the parenchymat-
ic is of the chronic kind. The acute disease
may be seated either on the convex or on the
concave surface of the liver. In the former
case, a more pungent pan and hickup may be
produced, 

289 OF PHYSIC
produced, and the respiration is more consid-
erably affected. In the latter, there occurs
less pain; and a vomiting is produced, com-
monly by some inflammation communicated
to the stomach. The inflammation of the
concave surface of the liver, may be readily
communicated to the gall bladder and biliary
ducts; and this perhaps is the only case of idi-
opathic hepatitis attended with jaundice.
CCCCXIX.
The hepatitis, like other inflammations, may
end by resolution, suppuration, or gangrene;
and the tendency to the one or the other of
these events, may be known from what has
been delivered above.
CCCCXX.
The resolution of hepatitis is often the con-
sequence of, or is attended with, evacuations
of different kinds. A hemorrhagy, sometimes
from the right nostril, and sometimes from the
hemorrhoidal vessels, gives a solution of the
disease. Sometimes a bilious diarrhœa con-
tributes to the same event; and the resolution
of the hepatitis, as of other inflammations, is
attended with sweating, and with an evacua-
tion of urine, depositing a copious sediment.
Can this disease be resolved by expectoration?
It would seem to be sometimes cured by an
erysipelas appearing in some external part.
N CCCCXXI. 

290 PRACTICE
CCCCXXI.
When this disease has ended in suppura-
tion, the pus collected may be discharged by
the biliary ducts; or, if the suppurated part
does not any where adhere closely to the
neighbouring parts, the pus may be discharged
into the cavity of the abdomen; but if, dur-
ing the first state of inflammation, the af-
fected part of the liver shall have formed a close
adhesion to some of the neighbouring parts,
the discharge of the pus after suppuration
may be various, according to the different seat
of the abscess. When seated on the convex
part of the liver, if the adhesion be to the pe-
ritonæum lining the common teguments, the
pus may make its way through these, and be
discharged outwardly; or, if the adhesion
should have been to the diaphragm, the pus
may penetrate through this, and into the cav-
ity of the thorax, or of the lungs; and through
the latter may be discharged by coughing.
When the abscess of the liver is seated on its
concave part, then, in consequence of adhe-
sions, the pus may be discharged into the stom-
ach or the intestines; and into these last, ei-
ther directly, or by the intervention of the bil-
iary ducts.
CCCCXXII.
The prognostics in this disease are establish-
ed upon the general principles relating to in-
flammation,

291 OF PHYSIC.
flammation, upon the particular circumstances
of the liver, and upon the particular state of
its inflammation.
The cure of this disease must proceed upon
the general plan; by bleeding, more or less,
according to the urgency of pain and pyrexia;
by the application of blisters; by fomenta-
tions, of the external parts in the usual man-
ner, and of the internal parts by frequent
emollient glysters; by frequently opening the
belly by means of gentle laxatives, and by
diluent and refrigerant remedies.
CCCCXXIII.
Although, in many cases, the chronic hepa-
titis does not clearly discover itself; yet, upon
many occasions, it may perhaps be discovered,
or at least suspected, from those causes which
might affect the liver (CCCXVI) having
been applied; from some fulness and some
tenseness of weight in the right hypochondri-
um; from some shooting pains at times felt in
that region; from some uneasiness or pain felt
upon pressure in that part; from some unea-
siness from lying upon the left side; and last-
ly, from some degree of pyrexia, combined
with more or fewer of these symptoms.
When from some of these circumstances a
chronic inflammation is to be suspected, it is
to be treated by the same remedies as in the
last paragraph, employed more or less as the
N 2 degree

292 PRACTICE
degree of the several symptoms shall more
distinctly indicate.
CCCCXXIV.
When from either kind of inflammation a
suppuration of the liver has been formed, and
the abscess points outwardly, the part must be
opened, the pus evacuated, and the ulcer heal-
ed according to the ordinary rules for cleans-
ing and healing such abscesses and ulcers.
CCCCXXV.
I might here consider the Splenitis, or in-
flammation of the spleen; but it does not seem
necessary, because the disease very seldom oc-
curs. When it does, it may be readily known
by the character given in our Nosology; and
its various termination, as well as the practice
which it requires, may be understood from
what has been already said with respect to the
inflammations of the other abdominal viscera.
CHAP.

293 OF PHYSIC.
CHAP. XI.
OF THE NEPHRITIS, OR THE INFLAM-
MATION OF THE KIDNEYS.
CCCCXXVI.
THIS disease, like other in-
ternal inflammations, is always attended with
pyrexia and is especially known from the re-
gion of the kidney being affected by pain,
commonly obtuse, sometimes pungent. This
pain is not increased by the motion of the
trunk of the body, so much as a pain of the
rheumatic kind affecting the same region.
The pain of the nephritis may be often dis-
tinguished by its shooting along the course of
the ureter; and is frequently attended with a
drawing up of the testicle, and with a numb-
ness of the limb on the side affected; although,
indeed, these symptoms most commonly ac-
company the inflammation arising from a cal-
culus in the kidney or in the ureter. The
nephritis is almost constantly attended with
frequent vomiting, and often with costiveness
and colic pains. Usually the state of the urine
is changed; it is most commonly of a deep red
colour, is voided frequently, and in small
N 3 quantity

294 PRACTICE
quantity at a time. In more violent cases,
the urine is sometimes colourless.
CCCCXXVII.
The remote causes of this disease may be
various; as, external contusion; violent or
long continued riding; strains of the muscles
of the back incumbent on the kidneys; vari-
ous acrids in the course of the circulation con-
veyed to the kidney; and perhaps some other
internal causes not yet well known. The most
frequent is that of calculous matter obstruct-
ing the tubuli uriniferi, or calculi formed in
the pelvis of the kidneys, and either sticking
there, or fallen into the ureter.
CCCCXXVIII.
The various event of this disease may be
understood from what has been delivered on
the subject of other inflammations.
CCCCXXIX.
Writers, in treating of the cure of nephri-
tis have commonly at the same time treated of
the cure of the Calculus renalis; but, though
this may often produce nephritis, it is to be
considered as a distinct and separate disease;
and what I have to offer as to the mode of
treating it, must be reserved to its proper place.
Here

295 OF PHYSIC.
Here I shall treat only of the cure of the
Nephritis Vera or Idiopathica.
CCCCXXX.
The cure of this proceeds upon the general
plan, by bleeding, external fomentation, fre-
quent emollient glysters, antiphlogistic purga-
tives, and the free use of mild and demulcent
liquids. The application of blisters is hardly
admissible; or, at least, will require great care,
to avoid any considerable absorption of the
cantharides.
CCCCXXXI.
The Cystitis, or inflammation of the blad-
der, is seldom a primary disease; and there-
fore is not to be treated of here. The treat-
ment of it, so far as necessary to be explained,
may be readily understood from what has been
already delivered.
CCCCXXXII.
Of the visceral inflammations, there remains
to be considered the inflammation of the Ute-
rus; but I omit it here, because the consider-
ation of it cannot be separated from that of the
diseases of child bearing women.
N 4 CHAP.

296 PRACTICE
CHAP. XII.
OF THE RHEUMATISM.
CCCCXXXIII.
OF this disease there are two
species; the one named the Acute, the other
the Chronic rheumatism.
CCCCXXXIV.
It is the Acute Rheumatism which especial-
ly belongs to this place, as from its causes,
symptoms, and methods of cure, it will appear
to be a species of phlegmasia or inflammation.
CCCCXXXV.
This disease is frequent in cold, and more
uncommon in warm, climates. It appears
most frequently in autumn and spring, less
frequently in winter when the cold is consid-
erable and constant, and very seldom during
the heat of summer. It may occur, howev-
er, at any season, if vicissitudes of heat and
cold be for the time frequent.
CCCCXXXVI.

297 OF PHYSIC.
CCCCXXXVI.
The acute rheumatism generally arises from
the application, of cold to the body when any
way unusually warm; or when one part of the
body is exposed to cold whilst the other parts
are kept warm; or lastly, when the applica-
tion of the cold is long continued, as it is
when wet or moist clothes are applied to any
part of the body.
CCCCXXXVII.
These causes may affect persons of all ages;
but the rhuematism seldom. appears in either
very young or in elderly persons, and most
commonly occurs from the age of puberty to
that of thirty five years.
CCCCXXXVIII.
These causes (CCCCXXXVI) may also
affect persons of any constitution; but they most
commonly affect those of a sanguine temper-
ament.
CCCCXXXIX.
This disease is particularly distinguished by
pains affecting the joints, for the most
part the joints alone, but sometimes affecting
also the muscular parts. Very often the pains
N 5 shoot

298 PRACTICE
shoot along the course of the muscles, from
one joint to another, and are always much in-
creased by the action of the muscles belonging
to the joint or joints affected.
CCCCXL.
The larger joints are most frequently af-
fected; such as the hip joint, and knees of
the lower, and the shoulders and elbows of the
upper extremities. The ankles and wrists are
also frequently affected; but the smaller
joints, such as those of the toes or fingers,
seldom suffer.
CCCCXLI.
This disease, although sometimes confined to
one part of the body only, yet very often af-
fects many parts of it; and then it comes on
with a cold stage, which is immediately suc-
ceeded by the other symptoms of pyrexia,
and particularly by a frequent, full, and hard
pulse. Sometimes the pyrexia is formed be-
fore any pains are perceived; but more com-
monly pains are set in particular parts, before
any symptoms of pyrexia appear.
CCCCXLII.
When no pyrexia is present, the pain is
sometimes confined to one joint only; but,
when any considerable pyrexia is present, al-
though

299 OF PHYSIC.
though the pain may be chiefly in one join,
yet it seldom happens but that the pains affect
several joints often at the very same time, but
for the most part shifting their place, and, hav-
ing abated in one joint, become more violent
in another. They do not commonly remain
long in the same joint, but frequently shift
from one to another, and sometimes return to
joints formerly affected; and in this manner
the disease often, continues for a long time.
CCCCXLIII.
The pyrexia attending this disease has an
exacerbation every evening, and is most con-
siderable during the night, when the pains al-
so become more violent; and it is at the same
time that the pains shift their place from one
joint to another. The pains seem to be also
increased during the night, by the body being
covered more closely, and kept warmer.
CCCCXLIV.
A joint, after having been for some time
affected with pain, commonly becomes af-
fected also with some redness and swelling,
which is painful to the touch. It seldom hap-
pens, that a swelling coming on does not al-
leviate the pain of the joint; but the swelling
does not always take off the pain entirely, nor
secure the joint against a return of it.
N6 CCCCXLV.

300 PRACTICE
CCCCXLV.
This disease is commonly attended with
some sweating, which occurs early in the course
of the disease; but it is seldom free or copious,
and seldom either relieves the pains or proves
critical.
CCCCXLVI.
In the course of this disease the urine is
high coloured, and in the beginning without
sediment; but as the disease advances, and
the pyrexia has more considerable remissions,
the urine deposits a lateritious sediment. This,
however, does not prove entirely critical; for
the disease often continues long after such a
sediment has appeared in the urine.
CCCCXLVII.
When blood is drawn in this disease, it al-
ways exhibits the appearance mentioned
CCXXXVII.
CCCCXLVIII.
The acute rheumatism, though it has so
much of the nature of the other phlegmasiæ,
differs from all those hitherto mentioned, in
this, that it is not apt to terminate in suppura-
tion. This almost never happens in rheuma-
tism;

301 OF PHYSIC.
tism; but the disease sometimes produces ef-
fusions of a transparent gelatinous fluid into
the sheaths of the tendons. If we may be al-
lowed to suppose that such effusions are fre-
quent, it must also happen, that the effused
fluid is commonly reabsorbed; for it has sel-
dom happened, and never indeed to my ob-
servation, that considerable or permanent tu-
mours have been produced, or such as requir-
ed to be opened, and to have the contained
fluid evacuated. Such tumours, however,
have occurred to others, and the opening
made in them has produced ulcers difficult to
heal. Vide Storck. Ann. Med. II.
CCCCXLIX.
With the circumstances mentioned from
CCCCXXXIX, to CCCCXLVIII, the dis-
ease often continues for several weeks. It
seldom, however, proves fatal; and it rarely
happens that the pyrexia continues to be con-
siderable for more than two or three weeks.
While the pyrexia abates in its violence, if
the pains of the joints continue, they are less
violent, more limited in their place, being
confined commonly to one or a few joints on-
ly, and are less ready to change their place.
CCCCL.
When the pyrexia attending rheumatism
has entirely ceased; when the swelling, and
particularly

302 PRACTICE
particularly the redness of the joints, are en-
tirely gone; but when pains still continue to
affect certain joints, which remain stiff, which
feel uneasy upon motion, or upon changes of
weather; the disease is named the Chronic
Rheumatism, as it very often continues for a
long time. As the chronic is commonly the
sequel of the acute rheumatism, I think it
proper to treat of the former also in this place.
CCCCLI.
The limits between the acute and chronic
rheumatism are not always exactly marked.
When the pains are still ready to shift their
place; when they are especially severe in the
night time; when, at the same time, they are
attended with some degree of pyrexia, and
with some swelling, and especially with some
redness of the joints; the disease is to be con-
sidered as still partaking the nature of the acute
rheumatism.
But, when there is no degree of pyrexia re-
maining; when the pained joints are without
redness; when they are cold and stiff; when
they cannot easily be made to sweat; or when,
while a free and warm sweat is brought out on
the rest of the body, it is only clammy and
cold on the pained joints; and when, especial-
ly, the pains of these joints are increased by
cold, and relieved by heat applied to them;
the case is to be considered as that of a purely
chronic rheumatism.
CCCCLII.

303 OF PHYSIC.
CCCCLII.
The chronic rheumatism may affect differ-
ent joints; but is especially ready to affect
those joints which are surrounded with many
muscles, and those of which the muscles are
employed in the most constant and vigorous
exertions. Such is the case of the vertebræ
of the loins, the affection of which is named
Lumbago; or that of the hip joint, when the
disease is named Ischias, or Sciatica.
CCCCLIII.
Violent strains and spasms occurring on
sudden and somewhat violent exertions, bring
on rheumatic affections, which at first partake
of the acute, but very soon change into the
nature of the chronic rheumatism.
CCCCLIV.
I have thus delivered the history of rheuma-
tism; and suppose, that, from what has been
said, the remote causes, the diagnosis, and
prognosis, of the disease, may be understood.
The distinction of the rheumatic pains from
those resembling them, which occur in the sy-
philis and scurvy, will be obvious, either from
the feat of those pains, or from the concomi-
tant symptoms peculiar to these diseases. The
distinction of rheumatism from gout will
be

304 PRACTICE
be more fully understood from what is to be
delivered in the following chapter.
CCCCLV.
With respect to the proximate cause of
rheumatism, there have been various opinions.
It has been imputed to a peculiar acrimony;
of which, however, in ordinary cases, I can
find no evidence; and, from the consideration
of the remote causes, the symptoms, and cure
of the disease, I think, the supposition very im-
probable.
The cause of an Ischias Nervosa assigned by
COTUNNIUS, appears to me hypothetical, and
is not supported by either the phenomena or
method of cure. That, however, a disease of
a rheumatic nature may be occasioned by an
acrid matter applied to the nerves, is evident
from the toothach, a rheumatic affection gen-
erally arising from a carious tooth.
That pains resembling those of rheumatism,
may arise from deep seated suppurations, we
know from some cases depending on such a
cause, and which, in their symptoms, resemble
the lumbago or ischias. I believe, however,
that, by a proper attention, these cases de-
pending on suppuration, may be commonly
distinguished from the genuine cases of lum-
bago and ischias; and, from what is said in
CCCCXLVIII, I judge it to be at least im-
probable, that a genuine lumbago or ischias
does, ever end in suppuration.
CCCCLVI.

305 OF PHYSIC.
CCCCLVI.
The proximate cause of rheumatism has
been by many supposed to be a lentor of the
fluids obstructing the vessels of the part; but
the same consideration as in CCXLI. 1, 2, 3,
4, and 5, will apply equally here for rejecting
the supposition of a lentor.
CCCCLVII.
While I cannot, therefore, find either evi-
dence or reason for supposing that the rheu-
matism depends upon any change in the state
of the fluids, I must conclude that the proxi-
mate cause of acute rheumatism, is commonly
the same with that of other inflammations not
depending upon a direct stimulus.
CCCCLVIII.
In the case of rheumatism I suppose, that
the most common remote cause of it, that is,
cold applied, operates especially on the vessels
of the joints, from these being less covered by
a cellular texture than those of the intermedi-
ate parts of the limbs. I suppose further,
that the application of cold produces a con-
striction of the extreme vessels on the surface,
and at the same time an increase of tone or
phlogistic diathesis in the course of them, from
which arises an increased impetus of the blood,
and,

306 PRACTICE
and, at the same time, a resistance to the free
passage of it, and consequently inflammation
and pain. Further, I suppose, that the re-
sistance formed excites the vis medicatrix to a
further increase of the impetus of the blood;
and, to support this, a cold stage arises, a spasm
is formed, and a pyrexia and phlogistic dia-
thesis are produced in the whole system.
CCCCLIX.
According to this explanation, the cause of
acute rheumatism appears to be exactly anal-
ogous to that of the inflammations depending
on an increased afflux of blood to a part while
it is exposed to the action of cold.
But there seems to be also, in the case of
rheumatism, a peculiar affection of the fibres
of the muscles. These fibres seem to be un-
der some degree of rigidity, and therefore less
easily admit of motion; and are pained upon
the exertions of it.
It is also an affection of these fibres which
gives an opportunity to the propagation of
pains from one joint to another, along the
course of the muscles; and which pains are
more severely felt in the extremities of the
muscles terminating in the joints, because be-
yond these the oscillations are not propagated.
This affection of the muscular fibres at-
tending rheumatism, seems to explain why
strains and spasms produce rheumatic affec-
tions; and, upon the whole, shows, that, with
an 

307 OF PHYSIC.
an inflammatory affection of the sanguiferous
system, there is also in rheumatism a peculiar
affection of the muscular fibres, which has a
considerable share in producing the phenome-
na of the disease.
CCCCLX.
Having thus given my opinion of the
proximate cause of rheumatism, I proceed to
treat of the cure.
CCCCLXI.
Whatever difficulty may occur with respect
to the explanation given (CCCCLVIII, and
CCCCLIX) this remains certain, that in acute
rheumatism, at least in all those cases which
do not arise from direct stimuli, there is an
inflammatory affection of the parts, and a
phlogistic diathesis in the whole system; and
upon these is founded the method of cure,
which frequent experience has approved of.
CCCCLXII.
The cure therefore requires, in the first
place, an antiphlogistic regimen, and partic-
ularly a total abstinence from animal food,
and from all fermented or spirituous liquors;
substituting a vegetable or milk diet, and the
plentiful use of bland diluent drinks.
CCCCLXIII.

308 PRACTICE
CCCCLXIII.
Upon the same principle (CCCCL) at least
with perhaps the same exception as above,
bloodletting is the chief remedy of acute rheu-
matism. The blood ought to be drawn in
large quantity, and the bleeding is to be re-
peated in proportion to the frequency, full-
ness, and hardness of the pulse, and to the vi-
olence of the pain. For the most part, large
and repeated bleedings, during the first days
of the disease, seem to be necessary, and ac-
cordingly have been very much employed; but
to this some bounds are to be set; for very
profuse bleedings occasion a slow recovery,
and, if not absolutely effectual, are ready to
produce a chronic rheumatism.
CCCCLXIV.
To avoid that debility of the system, which
general bleedings are ready to occasion, the ur-
gent symptom of pain may be often relieved
by topical bleedings; and, especially when
any swelling and redness have come upon a
joint, the pain of it may be very certainly re-
lieved by such bleedings; but, as the contin-
uance of the disease seems to depend more
upon the phlogistic diathesis of the whole sys-
tem, than upon the affection of particular
parts, so topical bleedings will not always sup-
ply the place of the general bleedings propos-
ed above.
CCCCLXV.

309 OF PHYSIC.
CCCCLXV.
To take off the phlogistic diathesis prevail-
ing in this disease, purging may be useful, if
procured by medicines which do not stimu-
late the whole system, such as the neutral salts,
and which have in some measure a refrigerant
power. Purging, however, is not so powerful
as bleeding, in removing phlogistic diathesis;
and, when the disease has become general and
violent, frequent stools are inconvenient, and
even hurtful, by the motion and pain which
they occasion.
CCCCLXVI.
In acute rheumatism, applications to the
pained parts are of little service.  Fomenta-
tions, in the beginning of the disease, rather
aggravate than relieve the pains. The ru-
befacients and camphire are more effectual in
relieving the pains; but generally they only
shift the pain from one part into another, and
do little towards the cure of the general affec-
tion. Blistering, applied to the pained part,
may also be very effectual in removing the
pain from it; but will be of little use, except
where the pains are much confined to one
part.
CCCCLXVII.

310 PRACTICE
CCCCLXVII.
The several remedies mentioned from
(CCCCLI, to CCCCLV) moderate the vio-
lence of the disease, and sometimes remove it
entirely; but they sometimes fail in this, and
leave the cure imperfect. The attempting a
cure by large and repeated bleedings, is at-
tended with many inconveniences, (see CXL);
and the most effectual and safe method of cur-
ing this disease, is, after some general bleed-
ings for taking off, or at least diminishing the
phlogistic diathesis, to employ sweating, con-
ducted by the rules laid down CLXVIII,
and CLXIX.
CCCCLXVIII.
Opiates, except where they are directed to,
procure sweat, always prove hurtful in every
stage of this disease.
CCCCLXIX.
The Peruvian bark has been supposed a
remedy in some cases of this disease; but we
have seldom found it useful, and, in some
cases, hurtful. It appears to me to be fit in
those cases only, in which the phlogistic dia-
thesis is already much abated; and where at
the same time the exacerbations of the disease
are

311 OF PHYSIC.
are manifestly periodical, with considerable re-
missions interposed.
CCCCLXX.
Calomel, and some other preparations of
mercury, have been recommended in the
acute rheumatism; but I believe they are use-
ful only in cases of the chronic kind, or at
least in cases approaching to the nature of
these.
CCCCLXXI.
Having now treated fully of the cure of the
acute rheumatism, I proceed to treat of the
cure of the chronic, which is so frequently a
sequel of the former.
CCCCLXXII.
The phenomena of the purely chronic
rheumatism, mentioned in CCCCXXXIX,
and CCCCXL, lead me to conclude, that its
proximate cause is an atony, both of the
blood vessels and of the muscular fibres of the
part affected, together with a degree of rigidity
and contraction in the latter, such as frequent-
ly attends them in a state of atony.
CCCCLXXIII.
Upon this view of the proximate cause, the
general indication of cure must be to restore
the

312 PRACTICE
the activity and vigour of the vital principle in
the part; and the remedies for this disease,
which experience has approved of, are chiefly
such as are manifestly suited to the indication
proposed.
CCCCLXXIV.
These remedies are either external or inter-
nal.
The external are, The supporting the heat
of the part, by keeping it constantly covered
with flannel; the increasing the heat of the
part by external heat, applied either in a dry or
in a humid form; the diligent use of the flesh
brush, or other means of friction; the applica-
tion of electricity in sparks or shocks; the ap-
plication of cold water by affusion or immer-
sion; the application of essential oils of the
most warm and penetrating kind; the ap-
plication of salt brine; and, lastly, the em-
ployment of exercise, either of the part itself,
so far as it can easily bear it; or of the whole
body, by riding, or other mode of gestation.
CCCCLXXV.
The internal remedies are, 1. Large doses
of essential oil drawn from resinous substances,
such as turpentine; 2. Substances containing
such oils, as guaiac; 3. Volatile alkaline salts;
4. These, or other medicines directed to pro-
cure sweat, (CLXIX); and lastly, Calomel,
or 

313 OF PHYSIC.
or other preparation of mercury, in small dos-
es, continued for some time.
CCCCLXXVI.
These (CCCCLXIII, CCCCLXIV) are
the remedies successfully employed in the
purely chronic rheumatism; and there are
still others recommended; as bleeding, gen-
eral and topical; burning; blistering; and
issues: But these appear to me to be chiefly,
perhaps only, useful when the disease still par-
takes of the nature of acute rheumatism.
O CHAP.

314 PRACTICE
CHAP. XIII.
OR THE TOOTHACH OR ODONTAL-
GIA.
CCCCLXXVII.
I HAVE formerly considered
this disease as a species of Rheumatism, to be
treated upon the same principles as those de-
livered in the preceding chapter; but now,
from more attentive consideration, I am led to
consider the toothach as a distinct disease.
Whilst the most of what has been delivered in
the last chapter proceeds upon the supposition
that the rheumatism depends upon a certain
state of the blood vessels and of the motion of
the blood in them, without this being produc-
ed by the irritation of any acrid matter appli-
ed; I judge, that in the toothach, though
there are often the same circumstances in the
state of the blood vessels as in the cases of
rheumatism, these circumstances in toothach
always arise from the application of an acrid
matter to the nerves of the teeth.
CCCCLXXVIII.

315 OF PHYSIC.
CCCCLXXVIII.
This disease is often no other than a pain
felt in a particular tooth, without any inflam-
matory affection being at the same time com-
municated to the neighbouring parts. This,
however, is rarely the case; and for the most
part, together with the pain of the tooth, there
is some degree of pain and of inflammatory
affection communicated to the neighbouring
parts, sometimes to the whole of those on the
same side of the head with the affected tooth.
CCCCLXXIX.
This inflammatory affection seems to me to
be always an affection of muscles and of the
membranous parts connected with these, with-
out any tendency to suppuration; and such an
affection, as is excited by cold in similar parts
elsewhere. It is from these circumstances
that I conclude the affection to be of the rheu-
matic kind.
CCCCLXXX.
It is possible that the muscles and mem-
branes of the jaw may be affected by the
same causes which produce the rheumatism
in other parts; and it is also possible, that a
rheumatic diathesis at first produced by irri-
tation, may subsist in the muscles and mem-
O 2 branes

316 PRACTICE
branes of the jaw, so that the inflammatory
affection may he renewed by certain causes
without any new application of acrid matter:
But I am persuaded that either of these oc-
currences are very rare, and I have never been
able to ascertain any cases of toothach to be of
these kinds. I consider it, therefore, as high-
ly probable that this rheumatic affection of
the jaws which we name toothach, is always
dependent upon some immediate application
of acrid matter to the nerves of the teeth.
CCCCLXXXI.
It is however to be observed, that this ap-
plication of acrid matter does not always ex-
cite a pain in the tooth itself, or an inflamma-
tory affection of the neighbouring parts; but
that it very often operates by producing a
diathesis only; so that cold applied to the
neighbouring parts does excite both a pain in
the tooth, and an inflammatory affection of
the neighbouring parts which did not appear
before.
There seems to be also certain states of the
body, which operate upon the same diathesis,
so as to produce toothach. Such seems to be
the case of pregnant women, who are more li-
able to toothach than other women. There
are probably also some cases of increased irri-
tability which render persons more subject to
toothach. Thus women are more liable to
the 

317 OF PHYSIC.
the disease than men, and particularly women
liable to hysteric affections.
CCCCLXXXII.
The acrid matter producing this disease
seems to be generated first in the hard sub-
stances of the teeth; and as it often appears
first upon the external surface of these, it
might be suspected to arise from the applica-
tion of external matters to the teeth: But as
the production of this acrimony is often begun
in the internal cavity of the teeth, where the
operation of external matters cannot be sus-
pected, and as even when it begins upon the
external parts of the teeth, the operation of the
cause is at first in a small portion of the teeth
only, that it is difficult to suppose that any
matter externally applied could act in such a
partial manner; so it is presumed that the
acrid matter occasioning the toothach is pro-
duced by some vice originating in the sub-
stance of the tooth itself. When it begins up-
on the external surface, it is on the enamel; but
upon the internal surface, it must be in the bo-
ny part. From what causes it arises in either
of these substances, I do not at all know; but
I suspect that it often arises from some more
general fault in the fluids of the body. The
frequent use of mercury, especially when
thrown much upon the mouth, and the state
of the fluids in scurvy, seem both of them to
give a disposition to a caries in the teeth; and
O 3 it 

318 PRACTICE
it is possible that some other acrimonious states
of the fluids may have the same effect.
CCCCLXXXIII.
A caries in some part of the teeth, whether
arising upon their internal surface or upon
their external, proceeding so far as to reach
the nerves in the cavity of the teeth, is pretty
manifestly the cause of toothach, and of the
first attacks of it; but when the cavity of the
teeth has been opened, so that the external
air or other matters can reach that cavity,
these are often the exciting causes of toothach,
and serve to prove in general, that acrid mat-
ters applied to the nerves occasion the disease.
CCCCLXXXIV.
What is the nature of the matter produced
in the caries of the teeth, I do not understand,
nor have I found any proper corrector of it;
but I presume it to be of the putrid kind, as it
often taints the breath with a fetid odour.
CCCCLXXXV.
In the cure of this disease, a long experi-
ence has shown, that the extraction of the ca-
rious tooth proves the most effectual, and very
often the only effectual, remedy of the dis-
ease. But as in some cases this extraction is
not proper, and as in many cases it is obsti-
nately

319 OF PHYSIC.
nately avoided, other means of curing the dis-
ease, or at least of relieving the pain, have
been fought for and much practised.
CCCCLXXXVI.
Among these remedies, those are likely to
be the most effectual which entirely destroy
the affected nerve, or at least so much of it as
is exposed to the action of the acrid matter in
the tooth. When an opening is made into
the cavity of the tooth, the nerve of it may be
destroyed most certainly by the actual caute-
ry, and it may also possibly be done by the
application of potential caustics, either of the
alkaline or acid kind.
CCCCLXXXVII.
When these remedies cannot be rendered
effectual, relief may often be obtained by di-
minishing the sensibility of the nerve affected,
by the application of opium, or of the more
acrid aromatic oils, directly to the nerve in
the tooth. It appears also, that the sensibil-
ity of the affected nerve may often be for
some time diminished by the external appli-
cation of opium to the extremities of those
nerves in the skin, which are branches of the
same fifth pair of nerves with those of the
teeth.
O 4 CCCCLXXXVIII.

320 PRACTICE
CCCCLXXXVIII.
When the disease consists entirely in a pain
of the nerve of the tooth, without any consid-
erable affection communicated to the neigh-
bouring parts, the remedies already mentioned
are those especially to be employed; but
when the disease consists very much in an in-
flammatory affection of the muscles and mem-
branes of the jaw, and when at the same time
there is little or no access for the above men-
tioned remedies to the affected nerve, other
measures are to be employed for relieving the
disease.
CCCCLXXXIX.
If the disease be attended with any general
phlogistic diathesis of the system, or with any
considerable degree of pyrexia, a general bleed-
ing may be useful in relieving the disease; but
these circumstances occur very rarely, and the
disease is for the most part a purely topical
affection; in which, as I observed before, a
general bleeding is of very little service. As
this disease, however, is a topical inflammation,
it might be supposed that topical bleedings
would be very useful, and sometimes they are
so; but it is seldom that their effects are ei-
ther considerable or permanent. The rea-
sons of this I take to be, that the disease does
not consist in an affection of the blood vessels
alone, 

321 OF PHYSIC.
alone, as in the ordinary cases of rheumatism;
but in a peculiar affection of the fibres both of
the muscles and of the vessels of the part in-
duced by irritation. The inefficacy of topical
bleedings is with me a proof of the disease be-
ing of the latter kind.
CCCCXC.
The remedies therefore necessary to give re-
lief in this disease, are those which take off
the spasm of the vessels, and especially of the
muscles and membranes affected. Such are
blistering, brought as near to the part affected
as can be conveniently done; and such are al-
so increased excretions excited in the neigh-
bouring parts, as of the saliva and mucus of
If the mouth by the use of acrid masticatories.
It is often sufficient to excite a strong sensa-
tion in the neighbouring parts; as by eau de
luce, spirit of lavender, or Hungary water
snuffed up the nostrils; or by the vitriolic
æther properly applied to the cheek. It is
upon the same footing that I suppose brandy
or other ardent spirit held in the mouth is oft-
en of service.
CCCCXCI.
There are cases of toothach in which it does
not appear that the disease arises from an ac-
rid matter immediately applied to the nerve
of a tooth; but from the external application
O 5 of

322 PRACTICE
of cold, or some other causes immediately ap-
plied to the muscles and membranes of the
jaw; and which therefore seem to require
some remedies different from those above-
mentioned. But in all such cases, it is to be
suspected, that the effects of cold or of other
such causes are owing to a diathesis produced
by an acrid matter applied to the nerve of a
tooth, and continuing in some measure to act
there; and we have accordingly often found,
that the action of those external causes were
to be obviated only by the extraction of the
tooth from which the diathesis had arisen.
CHAP.

323 OF PHYSIC.
CHAP. XIV.
OF THE GOUT.
CCCCXCII.
THE Gout, not only as if
occurs in different persons, but even as it oc-
curs in the same person at different times, is
a disease of such various appearance, that it is
difficult to render the history of it complete
and exact, or to give a character of it that will
universally apply. However, I shall endeav-
our to describe the disease as it most common-
ly appears, and to mark the varieties of it as
well as I can. From such. a history I expect
that a general character may be given; and
such I think is the following, as given in the;
last edition of our Nosology:
GEN. XXIII. PODAGRA.
Morbus hæreditarius, oriens sine causa ex-
terna evidente, sed præeunte plerumque ven-
triculi affectione insolita; pyrexia; dolor ad
articulum et plerumque pedis pollici, certe
pedum et manuum juncturis, potissimum in-
O 6 festus;

324 PRACTICE
festus; per intervalla revertens, et sæpe cum
ventriculi et Internarum partium affectioni-
bus alternans.
CCCCXCIII.
The gout is generally a hereditary disease:
But some persons, without hereditary disposi-
tion, seem to acquire it; and, in some, a hered-
itary disposition may be counteracted by va-
rious causes. These circumstances may seem
to give exceptions to our general position;
but the fact directly supporting it are very
numerous.
CCCCXCIV.
This disease attacks especially the male sex;
but it sometimes, though more rarely, attacks
also the female. The females liable to it are
those of the more robust and full habits; and
it very often happens to such long before the
menstrual evacuation has ceased. I have
found it occurring in several females, whose
menstrual evacuations were more abundant
than usual.
CCCCXCV.
This disease seldom attacks eunuchs; and,
when it does, they seem to be those who hap-
pen to be of a robust habit, to lead an indo-
lent life, and to live very full.
CCCCXCVI.

325 OF PHYSIC.
CCCCXCVI.
The gout attacks especially men of robust
and large bodies, men of large heads, of full
and corpulent habits, and men whose skins
are covered with a thicker rete mucosum, which
gives a coarser surface.
CCCCXCVII.
If, with the ancients, we might ascertain,
by certain terms, the temperaments of men, I
would say that the gout attacks especially men
of a cholerico sanguine temperament, and that
it very seldom attacks the purely sanguine or
melancholic. It is, however, very difficult to
treat this matter with due precision.
CCCCXCVIII.
The gout seldom attacks persons employed
in constant bodily labour, or persons who live
much upon vegetable aliment. It is also said
to be less frequent among those people who
make no use of wine or other fermented
liquors.
CCCCXCIX.
The gout does not commonly attack men,
till after the age of five and thirty; and gener-
ally not till a still later period. There are in-
deed

326 PRACTICE
deed instances of the gout occurring more ear-
ly; but these are few in comparison of the
numbers which agree with what we have given
as the general rule. When the disease does
appear early in life, it seems to be in those
in whom the hereditary disposition is very
strong, and to whom the remote causes to be
hereafter mentioned have been applied in a
considerable degree.
D.
As the gout is a hereditary disease, and af-
fects especially men of a particular habit, its
remote causes may be considered as predispo-
nent and occasional.
DI.
The predisponent cause, so far as expressed
by external appearances, or by the general
temperament, we have already marked; and
physicians have been very confident in assign-
ing the occasional causes: But, in a disease
depending so much upon a predisposition, the
assigning occasional causes must be uncertain;
as, in the predisposed, the occasional causes
may not always appear, and in persons not
predisposed, they may appear without effect.
This uncertainty must particularly affect the
case of the gout; but I shall offer what ap-
pears to me most probable on the subject.
DII.

327 OF PHYSIC.
DII.
The occasional causes of the gout seem to
be of two kinds. First, those which induce a
plethoric state of the body. Secondly, those
which, in plethoric habits, induce a state of
debility.
DIII.
Of the first kind are a sedentary indolent
manner of life, a full diet of animal food, and
the large use of wine or of other fermented
liquors. These circumstances commonly pre-
cede the disease; and if there should be any
doubt of their power of producing it, the
fact, however, will be rendered sufficiently
probable by what has been observed in
CCCCXCVIII.
DIV.
Of the second kind of occasional causes
which induce debility are, excess in venery;
intemperance in the use of intoxicating liq-
ours; indigestion, produced either by the
quantity or quality of aliments; much appli-
cation to study or business; night watching;
excessive evacuations; the ceasing of usual la-
bour; the sudden change from a very full to
a very spare diet; the large use of acids and
acescents; and, lastly, cold applied to the
lower extremities. DV.

328 PRACTICE
DV.
The first (DIII.) seem to act by increasing
the predisposition. The last (DIV) are com-
monly the exciting causes, both of the first
attacks, and of the repetitions of the disease.
DVI.
It is an inflammatory affection of some of
the joints which especially constitutes what we
call a paroxysm of the gout. This sometime
comes on suddenly without any warning, but
is generally preceded by several symptoms;
such as the ceasing of a sweating which the
feet had been commonly affected with before;
an unusual coldness of the feet and legs; a
frequent numbness, alternating with a sense of
prickling along the whole of the lower extrem-
ities; frequent cramps of the muscles of the
legs; and an unusual turgescence of the veins.
DVII.
While these symptoms take place in the
lower extremities, the whole body is affected
with some degree of torpor and languor, and
the functions of the stomach in particular are
more or less disturbed. The appetite is di-
minished; and flatulency, or other symptoms
of indigestion, are felt. These symptoms, and
those of DVI, take place for several days,
sometimes 

329 OF PHYSIC.
sometimes for a week or two, before a parox-
ysm comes on; but commonly, upon the day
immediately preceding it, the appetite be-
comes greater than usual.
DVIII.
The circumstances of paroxysms are the
following: They come on most commonly in
the spring, and sooner or later according as
the vernal heat succeeds sooner or later to the
winter's cold; and perhaps sooner or later also
according as the body may happen to be more
or less exposed to vicissitudes of heat and cold.
DIX.
The attacks are sometimes felt first in the
evening, but more commonly about two or
three o'clock of the morning. The paroxysm
begins with a pain affecting one foot, most
commonly in the ball or first joint of the great
toe, but sometimes in other parts of the foot.
With the coming on of this pain, there is com-
monly more or less of a cold shivering, which,
as the pain increases, gradually ceases, and is
succeeded by a hot stage of pyrexia, which
continues for the same time with the pain it-
self. From the first attack, the pain becomes
by degrees more violent, and continues in this
state with great restlessness of the whole body
till next midnight, after which it gradually
remits; and, after it has continued for twenty
four

330 PRACTICE
four hours from the commencement of the
first attack, it commonly ceases very entirely,
and, with the coming on of a gentle sweat, al-
lows the patient to fall asleep. The patient,
upon coming out of this sleep in the morning,
finds the pained part affected with some red-
ness and swelling, which, after having contin-
ued for some days, gradually abate.
DX.
When a paroxysm has thus come on, al-
though the violent pain after twenty four
hours be considerably abated, the patient is
not entirely relieved from it. For some days
he has every evening a return of more consid-
erable pain and pyrexia, and which continue
with more or less violence till morning. Af-
ter continuing in this manner for several days,
the disease sometimes goes entirely off, not to
return till after a long interval.
DXI.
When the disease, after having thus remain-
ed for some time in a joint, ceases very entire-
ly, it generally leaves the person in very per-
fect health, enjoying greater ease and alacrity
in the functions of both body and mind, than
he had for a long time before experienced.
DXII.

331 OF PHYSIC.
DXII.
At the beginning of the disease, the returns
of it are sometimes only once in three or four
years; but, after some time, the intervals be-
come shorter, and the attacks become annual;
afterwards they come twice each year, and at
length recur several times during the whole
course of autumn, winter, and spring; and as
it happens, that, when the fits are frequent,
the paroxysms become also longer, so, in the
advanced stage of the disease, the patient is
hardly ever tolerably free from it, except per-
haps for two or three months in summer.
DXIII.
The progress of the disease is also marked
by the parts which it affects. At first, it com-
monly affects one foot only, afterwards every
paroxysm affects both feet, the one after the
other; and, as the disease continues to recur,
it not only affects both feet at once, but after
having ceased in the foot which was secondly
attacked, returns again into the foot first af-
fected, and perhaps a second time also into the
other. Its changes of place are not only from
one foot to the other, but also from the feet
into other joints, especially those of the upper
and lower extremities; so that there is hardly
a joint of the body that is not, on one occasion
or other, affected. It sometimes affects two
different

332 PRACTICE
different joints at the same time; but more
commonly it is severe in a single joint only,
and passes successively from one joint to an-
other; so that the patient's affliction is often
protracted for a long time.
DXIV.
When the disease has often returned, and
the paroxysms have become very frequent,
the pains are commonly less violent than they
were at first; but the patient is more affected
with sickness, and the other symptoms of the
atonic gout, which shall be hereafter men-
tioned.
DXV.
After the first paroxysms of the disease, the
joints which have been affected are entirely
restored to their former suppleness and
strength; but after the disease has recurred
very often, the joints affected do neither so
suddenly nor so entirely recover their former
state, but continue weak and stiff; and these
effects at length proceed to such a degree, that
the joints lose their motion altogether.
DXVI.
In many persons, but not in all, after the
disease has frequently recurred, concretions of
a chalky nature are formed upon the outside
of 

333 OF PHYSIC.
of the joints, and for the most part immedi-
ately under the skin. The matter seems to
be deposited at first in a fluid form, but after-
wards becomes dry and firm. In their dry
state, these concretions are a friable earthy
substance, very entirely soluble in acids. Af-
ter they have been formed, they contribute,
with other circumstances, to destroy the mo-
tion of the joint.
DXVII.
In most persons who have laboured under
the gout for many years, a nephritic affection
comes on, and discovers itself by all the symp-
toms which usually attend calculous concre-
tions in the kidneys, and which we shall have
occasion to describe in another place. All that
is necessary to be observed here is, that the
nephritic affection alternates with paroxysms
of the gout; and that the two affections, the
nephritic and the gouty, are hardly ever pres-
ent at the same time. This also may be ob-
served, that children of gouty or nephritic
parents, commonly inherit one or other of
these diseases; but which ever may have been
the principal disease of the parent, some of the
children have the one, and some the other.
In some of them, the nephritic affection oc-
curs alone, without any gout supervening;
and this happens to be frequently the case of
the female offspring of gouty parents.
DXVIII.

334 PRACTIC
DXVIII.
In the whole of the history already given,
I have described the most common form of
the disease; and which therefore, however di-
versified in the manner I have fact, may be
still called the regular state of the gout. Up-
on occasion, however, the disease assumes dif-
ferent appearances; but as I suppose the dis-
ease to depend always upon a certain diathesis
or disposition of the system; so every appear-
ance which we can percieve to depend upon
that same disposition, I still consider as a
symptom and case of the gout. The princi-
pal circumstance in what we term the Regular
Gout, is the inflammatory affection of the
joints; and whatever symptoms we can per-
ceive to be connected with, or to depend up-
on, the disposition which produces that in-
flammatory affection, but without its taking
place, or being present at the same time, we
name the Irregular Gout.
DXIX.
Of such irregular gout there are three dif-
ferent states; which I name the atonic, the
retrocedent, and the misplaced gout.
DXX.
The atonic state is when the gouty diathe-
sis prevails in the system, but, from cer-
tain

335 OF PHYSIC.
tain causes, does not produce the inflammato-
ry affection of the joints. In this case, the
morbid symptoms which appear are chiefly
affections of the stomach; such as loss of ap-
petite, indigestion, and its various circum-
stances of sickness, nausea, vomiting, flatulen-
cy, acid eructations, and pains in the region
of the stomach. These symptoms are fre-
quently accompanied with pains and cramps
in several parts of the trunk, and the upper
extremities of the body, which are relieved by
the discharge of the stomach. To-
gether with these affections of the stomach,
there commonly occurs a costiveness; but
sometimes a looseness with colic pains. These
affections of the alimentary canal are often at-
tended with all the symptoms of hypochon-
driasis; as dejection of mind, a constant and
anxious attention to the slightest feelings, an
imaginary aggravation of these, and an appre-
hension of danger from them.
In the same atonic gout, the viscera of the
thorax also are sometimes affected, and palpi-
tations, faintings, and asthma, occur.
In the head also occur, headachs, giddiness,
apoplectic and paralytic affections.
DXXI.
When the several symptoms now mention-
ed occur in habits having the marks of a gouty
disposition, this may be suspected to have laid
the foundation of them; and especially when
either,

336 PRACTICE
either, in such habits, a manifest tendency to
the inflammatory affection has formerly ap-
peared; or when the symptoms mentioned are
intermixed with, and are not relieved by, some
degree of the inflammatory gout. In such
cases there can be no doubt of considering the
whole as a state of the gout.
DXXII.
Another state of the disease I name the
retrocedent gout. This occurs when an in-
flammatory state of the joints has, in the usual
manner, come on, but which, without arising
to the ordinary degree of pain and inflamma-
tion, or, at least, without these continuing for
the usual time, and receding gradually in the
usual manner, they suddenly and entirely
cease, while some internal part becomes af-
fected. The internal part most commonly
affected is the stomach, which is then affected
with anxiety, sickness, vomiting, or violent
pain; but sometimes the internal part is the
heart, which gives occasion to a syncope;
sometimes it is the lungs which are affected
with asthma; and sometimes it is the head,
giving occasion to apoplexy or palsy. In all
these cases, there can be no doubt of the symp-
toms being all a part of the same disease, how-
ever different the affection may seem to be in
the parts which it attacks.
DXXIII.

337 OF PHYSIC.
DXXIII.
The third state of irregular gout, which we
name the misplaced, is when the gouty diathe-
sis, instead of producing the inflammatory af-
fection of the joints, produces an inflammato-
ry affection of some internal part, and which
appears from the same symptoms that attend
the inflammation of those parts arising from
other causes.
Whether the gouty diathesis does ever pro-
duce such inflammation of the internal parts,
without having first produced it in the joints,
or if the inflammation of the internal part be
always a translation from the joints previ-
ously affected, I dare not determine; but, even
supposing the latter to be always the case, I
think the difference of the affection of the in-
ternal part must still distinguish the misplaced
from what I have named the retrocedent gout.
DXXIV.
What internal parts may be affected by
the misplaced gout, I cannot precisely say, be-
cause I have never met with any cases of the
misplaced gout in my practice; and I find no
cases of it distinctly marked by practical
writers, except that of a pneumonic inflam-
mation.
P DXXV.

338 PRACTICE
DXXV.
There are two cases of a translated gout;
the one of which is an affection of the neck
of the bladder, producing pain, strangury, and
a catarrhus vesicæ: The other is an affection
of the rectum, sometimes by pain alone in that
part, and sometimes by hemorrhoidal swellings
there. In gouty persons, I have known such
affections alternate with inflammatory affec-
tions of the joints: But whether to refer those
affections to the retrocedent, or to the mis-
placed gout, I will not presume to determine.
DXXVI.
From the history which I have now deliver-
ed of the gout, I think it may be discerned
under all its various appearances. It is, how-
ever, commonly supposed, that there are cases
in which it may be difficult to distinguish gout
from rheumatism, and it is possible there may
be such cases; but, for the most part, the two
diseases may be distinguished with great cer-
tainty by observing the predisposition, the an-
tecedents, the parts affected, the recurrences
of the disease, and its connexion with the
other parts of the system; which circumstanc-
es, for the most part, appear very differently
in the two diseases.
DXXVII. 

339 OF PHYSIC.
DXXVII.
With respect to the gout, our next business
is to investigate its proximate cause; which
must be a difficult task, and I attempt it with
some diffidence.
DXXVIII.
Upon this subject, the opinion which has
generally prevailed is, that the gout depends
upon a certain morbific matter, always present
in the body; and that this matter, by certain
causes, thrown upon the joints or other parts,
produces the several phenomena of the disease.
DXXIX.
This doctrine, however ancient and gener-
al, appears to me very doubtful; for,
First, there is no direct evidence of any
morbific matter being present in persons dis-
posed to the gout. There are no experiments
or observations which show that the blood, or
other humours of gouty persons, are in any
respect different from those of other persons.
Previous to attacks of the gout, there appear
no marks of any morbid state of the fluids; for
the disease generally attacks those persons who
have enjoyed the most perfect health, and ap-
pear to be in that state when the disease comes
on. At a certain period of the disease, a pe-
P 2 culiar 

340 PRACTICE
culiar matter indeed appears in gouty persons,
(DXVI); but this, which does not appear in
every instance, and which appears only after
the disease has subsisted for a long time, seems
manifestly to be the effect, not the cause, of
the disease. Further, though there be certain
acrids which, taken into the body, seem to ex-
cite the gout (DIV), it is probable that these
acrids operate otherwise in exciting the disease,
than by affording the material cause of it. In
general, therefore, there is no proof of any
morbific matter being the cause of the gout.
Secondly, The suppositions concerning the
particular nature of the matter producing the
gout, have been so various and so contradic-
tory to each other, as to allow us to conclude,
that there is truly no proof of the existence of
any of them. With respect to many of these
suppositions, they are so inconsistent with
chemical philosophy, and with the laws of the
animal economy, that they must be entirely
rejected.
Thirdly, The supposition of a morbific
matter being the cause of the gout, is not con-
sistent with the phenomena of the disease, par-
ticularly with its frequent and sudden transla-
tions from one part to another.
Fourthly, The supposition is further ren-
dered improbable by this, that, if a morbific
matter did exist, its operation should be similar
in the several parts which it attacks; whereas
it seems to be very different, being stimulant,
and exciting inflammation in the joints, but
sedative 

341 OF PHYSIC.
sedative and destroying the tone in the stom-
ach: Which, upon the supposition of partic-
ular matter acting in both cases, is not to be
explained by any difference in the part af-
fected.
Fifthly, Some facts, alleged in proof of a
morbific matter, are not sufficiently confirm-
ed, such as those which would prove the dis-
ease to be contagious. There is, however, no
proper evidence of this, the facts given being
not only few, but exceptionable; and the
negative observations are innumerable.
Sixthly, Some arguments brought in fa-
vour of a morbific matter, are founded upon
a mistaken explanation. The disease has
been supposed to depend upon a morbific
matter, because it is hereditary: But the in-
ference is not just; for most hereditary dis-
eases do not depend upon any morbific mat-
ter, but upon a particular conformation of the
structure of the body, transmitted from the
parent to the offspring; and this last appears
to be particularly the case in the gout. It
may be also observed, that hereditary diseases,
depending upon a morbific matter, always ap-
pear much more early in life than the gout
commonly does.
Seventhly, The supposition of a morbific
matter being the cause of the gout, has been
hitherto useless, as it has not suggested any
successful method of cure. Particular sup-
positions have often corrupted the practice,
and have frequently led from those views
P 3 which

342 PRACTICE
which might be useful, and from that practice
which experience had approved. Further,
though the supposition of a morbific matter
has been generally received, it has been as
generally neglected in practice. When the
gout has affected the stomach, nobody thinks
of correcting the matter supposed to be pres-
ent there, but merely of restoring the tone of
the moving fibres.
Eighthly, The supposition of a morbific
matter is quite superfluous; for it explains
nothing, without supposing that matter to
produce a change in the state of the moving
powers; and a change in the state of the mov-
ing powers, produced by other causes, ex-
plains every circumstance, without the sup-
position of a morbific matter; and, to this
purpose, it may be observed, that many of the
causes (DIV) exciting the gout, do not ope-
rate upon the state of the fluids, but directly
and solely upon that of the moving powers.
Lastly, The supposition of a morbific mat-
ter is also superfluous; because, without any
such supposition, I think the disease can be
explained in a manner more consistent with
its phenomena, with the laws of the animal
economy, and with the method of cure which
experience has approved.
I now proceed to give this explanation;
but, before entering upon it, I must premise
some general observations.
DXXX.

343 OF PHYSIC.
DXXX.
The first observation is, that the gout is a
disease of the whole system, or depends upon
a certain general conformation and state of
the body; which manifestly appears from
the facts mentioned from CCCCXCIV, to
CCCCXCVII. But the general state of the
system depends chiefly upon the state of its
primary moving powers; and therefore the
gout may be supposed to be chiefly an affec-
tion of these.
DXXXI.
My second observation is, that the gout is
manifestly an affection of the nervous system;
in which the primary moving powers of the
whole system are lodged. The occasional
or exciting causes (DIV) are almost all
such as act directly upon the nerves and ner-
vous system; and the greater part of the symp-
toms of the atonic or retrocedent gout are
manifestly affections of the same system.
(DXX, and DXXII.) This leads us to seek
for an explanation of the whole of the disease
in the laws of the nervous system, and partic-
ularly in the changes which may happen in the
balance of its several parts.
P 4 DXXXII.

344 PRACTICE
DXXXII.
My third observation is, that the stomach,
which has so universal a consent with the rest
of the system, is the internal part that is the
most frequently, and often very considerably,
affected by the gout. The paroxysms of the
disease are commonly preceded by an affec-
tion of the stomach (DVII); many of the ex-
citing causes (DIV) act first upon the stom-
ach; and the symptoms of the atonic and
retrocedent gout (DXX, DXXII) are most
commonly and chiefly affections of the same
organ. This observation leads us to remark,
that there is a balance subsisting between the
state of the internal and that of the external
parts; and, in particular, that the state of the
stomach is connected with that of the external
parts, (XLIV); so that the state of tone in
the one may be communicated to the other.
DXXXIII.
These observations being premised I shall
now offer the following pathology of the gout.
In some persons, there is a certain vigorous
and plethoric state of the system(CCCCXCVI)
which, at  a certain period of life, is liable to a
loss of tone in the extremities (CCCCXCIX,
DVI.) This is in some measure communi-
cated to the whole system, but appears more
especially in the functions of the stomach
(DVII.)

345 OF PHYSIC.
(DVII.) When this loss of tone occurs while
the energy of the brain still retains its vigour,
the vis medicatrix naturae is excited to restore
the tone of the parts; and accomplishes it by
exciting an inflammatory affection in some
part of the extremities. When this has sub-
sisted for some days, the tone of the extremi-
ties, and of the whole system, are restored, and
the patient returns to his ordinary state of
health (DXI.)
DXXXIV.
This is the course of things, in the ordinary
form of the disease, which we name the regu-
lar gout; but there are circumstances of the
body, in which this course is interrupted or
varied. Thus when the atony (DVI, DVII)
has taken place, if the reaction (DIX) do not
succeed, the atony continues in the stomach,
or perhaps in other internal parts, and pro-
duces that state which we have, for reasons
now obvious, named the atonic gout.
DXXXV.
A second case of variation in the course of
the gout is, when, to the atony, the reaction
and inflammation have to a certain degree suc-
ceeded; but, from causes either internal or
external, the tone of the extremities, and per-
haps of the whole system, is weakened; so
that the inflammatory state, before it had ei-
P 5 ther. 

346 PRACTICE
ther proceeded to the degree, or continued
for the time, requisite for restoring the tone of
the system, suddenly and entirely ceases.
Hence the stomach, and other internal parts,
relapse into the state of atony; and perhaps
have this increased by the atony communi-
cated from the extremities: All which ap-
pears in what we have termed the retrocedent
gout.
DXXXVI.
A third case of variation from the ordinary
course of the gout, is, when, to the atony usu-
ally preceding, an inflammatory reaction fully
succeeds; but has its usual determination to
the joints by some circumstances prevented;
and is therefore directed to an internal part,
where it produces an inflammatory affection,
and that state of things which we have named
the misplaced gout.
DXXXVII.
We have thus offered an explanation of the
circumstances of the system in the several states
of the gout; and this explanation we suppose
to be consistent with the phenomena of the
disease, and with the laws of the animal econ-
omy. There are indeed, with respect to the
theory of the disease, several questions which
might be put, to which we have not given any
answer. But, though perhaps we could give
an 

347 OF PHYSIC.
an answer to many of these questions, it does
not here appear necessary; as at present we
intend only to establish such general facts with
regard to this disease, as may lay a foundation
for the cure of it, so far as experience has en-
abled us to prosecute it. Proceeding, there-
fore, upon these several parts of the pathology
given, as so many matters of fact, I shall now
consider what may be attempted towards the
cure of the disease.
DXXXVIII.
In entering upon this, I must observe, in
the first place, that a cure has been commonly
thought impossible; and we acknowledge it
to be very probable, that the gout, as a disease
of the whole habit, and very often depending
upon original conformation, cannot be cured
by medicines, the effects of which are always
very transitory, and seldom extend to the pro-
ducing any considerable change of the whole
habit.
DXXXIX.
It would perhaps have been happy for
gouty persons, if this opinion had been im-
plicitly received by them; as it would have
prevented their having been so often the dupes
of selfinterested pretenders, who have either
amused them with inert medicines, or have
rashly employed those of the most pernicious
P 6 tendency. 

348 PRACTICE
tendency. I am much disposed to believe the
impossibility of a cure of the gout by medi-
cines; and more certainly still incline to think,
that whatever may be the possible power of
medicines, yet no medicine for curing the
gout has hitherto been found. Although al-
most every age has presented a new remedy,
yet all hitherto offered have very soon been
either neglected as useless, or condemned as
pernicious.
DXL.
Though unwilling to admit the power of
medicines, yet I contend, that a great deal
can be done towards the cure of the gout by
a regimen: And from what has been observ-
ed (CCCCXCVIII), I am firmly persuaded,
that any man who, early in life, will enter up-
on the constant practice of bodily labour, and
of abstinence from animal food, will be pre-
served entirely from the disease.
Whether there be any other means of rad-
ically curing the gout, I am not ready to de-
termine. There are histories of cases of the
gout, in which it is said, that by great emo-
tions of mind, by wounds, and by other acci-
dents, the symptoms have been suddenly re-
lieved, and never again returned; but how
far these accidental cures might be imitated by
art, or would succeed in other cases, is at least
extremely uncertain.
DXLI. 

349 OF PHYSIC.
DXLI.
The practices proper and necessary in the
treatment of the gout, are to be considered
under two heads; first, As they are to be em-
ployed in the intervals of paroxysms; or,
secondly, As during the time of these.
DXLII.
In the intervals of paroxysms, the indica-
tions are, to prevent the return of paroxysms,
or at least to render them less frequent, and
more moderate. During the time of parox-
ysms, the indications are, to moderate the vi-
olence, and shorten the duration of them as
much as can be done with safety.
DXLIII.
It has been already observed, that the gout
may be entirely prevented by constant bodily
exercise, and by a low diet; and I am of opin-
ion, that this prevention may take place even
in persons who have a hereditary disposition
to the disease. I must add here, that, even
when the disposition has discovered itself by
several paroxysms of inflammatory gout, I am
persuaded that labour and abstinence will ab-
solutely prevent any returns of it for the rest
of life. These, therefore, are the means of
answering the first indication to be pursued in
the

350 PRACTICE
the intervals of paroxysms; and I must here
offer some remarks upon the proper use of
these remedies.
DXLIV.
Exercise, in persons disposed to the gout, is
directed to two purposes: One of these is the
strengthening of the tone of the extreme ves-
sels; and the other, the guarding against a
plethoric state. For the former, if exercise
be employed early in life, and before intem-
perance has weakened the body, a very mod-
erate degree of it will answer the purpose;
and for the latter, if abstinence be at the same
time observed, little exercise will be necessary.
DXLV.
With respect to exercise, this in general is
to be observed, that it should never be violent;
for, if violent, it cannot be long continued,
and must always endanger the bringing on an
atony in proportion to the violence of the
preceding exercise.
DXLVI.
It is also to be observed, that the exercise
of gestation, though considerable and constant,
if it be entirely without bodily exercise, will
not answer the purpose in preventing the gout.
For this end, therefore, the exercise must be
in 

351 OF PHYSIC.
in some measure that of the body; and must
be moderate, but at the same time constant,
and continued through life.
DXLVII.
In every case and circumstance of the gout
in which the patient retains the use of his
limbs, bodily exercise, in the intervals of par-
oxysms, will always be useful; and, in the be-
ginning of the disease, when the disposition
to it is not yet strong, exercise may prevent a
paroxysm which otherwise might have come
on. In more advanced states of the disease,
however, when there is some disposition to a
paroxysm, much walking will bring it on ei-
ther as it weakens the tone of the lower ex-
tremities, or as it excites an inflammatory dis-
position in them; and it is probable, that in
the same manner strains or contusions often
bring on a paroxysm of the gout.
DXLVIII.
Abstinence, the other part of our regimen
(DXL) for preventing the gout, is of more
difficult application. If an abstinence from
animal food be entered upon early in life,
while the vigour of the system is yet entire,
we have no doubt of its being both safe and
effectual; but if the motive for this diet shall
not have occurred till the constitution shall
have been broken by intemperance, or by the
decline

352 PRACTICE
decline of life, a low diet may then endanger
the bringing on an atonic state.
DXLIX.
Further, if a low diet be entered upon only
in the decline of life, and be at the same time
a very great change in the former manner of
living, the withdrawing of an accustomed
stimulus of the system may readily throw this
into an atonic state.
DL.
The safety of an abstemious course may be
greater or less according to the management
of it. It is animal food which especially dis-
poses to the plethoric and inflammatory state,
and that food is to be therefore especially a-
voided; but, on the other hand, it is vegetable
aliment of the lowest quality that is in danger
of weakening the system too much, by not af-
fording sufficient nourishment; and more par-
ticularly of weakening the tone of the stomach
by its acescency. It is therefore a diet of a
middle nature that is to be chosen; and milk
is precisely of this kind, as containing both an-
imal and vegetable matter.
As approaching to the nature of milk, and
as being a vegetable matter containing the
greatest portion of nourishment, the farinace-
ous seeds are next to be chosen, and are the
food most proper to be joined with milk.
DLI. 

353 OF PHYSIC.
DLI.
With respect to drink, fermented liquors
are useful only when they are joined with an-
imal food, and that by their acescency; and
their stimulus is only necessary from custom.
When, therefore, animal food is to be avoid-
ed, fermented liquors are unnecessary; and, by
increasing the acescency of vegetables, these
liquors may be hurtful. The stimulus of fer-
mented or spirituous liquors, is not necessary
to the young and vigorous; and, when much
employed, impairs the tone of the system.
These liquors, therefore, are to be avoided,
except so far as custom and the declining state
of the system may have rendered them neces-
sary. For preventing or moderating the reg-
ular gout, water is the only proper drink.
DLII.
With respect to an abstemious course, it
has been supposed, that an abstinence from an-
imal food and fermented liquors, or the living
upon milk and farinacea alone for the space
of one year, might be sufficient for a radical
cure of the gout; and it is possible, that, at a
certain period of life, in certain circumstances
of the constitution, such a measure might an-
swer the purpose. But this is very doubtful;
and it is more probable that the abstinence
must, in a great measure, be continued, and
the 

354 PRACTICE
the milk diet be persisted in, for the rest of
life. It is well known, that several persons
who had entered on an abstemious course, and
had been thereby delivered from the gout, have,
however, upon returning to their former man-
ner of full living, had the disease return upon
them with as much violence as before, or in a
more irregular and more dangerous form.
DLIII.
It has been alleged, that, for preventing
the return of the gout, bloodletting, or scari-
fications of the feet, frequently repeated, and
at stated times, may be practised with advan-
tage; but of this I have had no experience.
DLIV.
Exercise and abstinence are the means of
avoiding the plethoric state which gives the
disposition to the gout; and are therefore the
means proposed for preventing paroxysms, or
at least for rendering them less frequent, and
more moderate. But many circumstances
prevent the steadiness necessary in pursuing
these measures; and therefore, in such cases,
unless great care be taken to avoid the exciting
causes, the disease may frequently return;
and, in many cases, the preventing of parox-
ysms is chiefly to be obtained by avoiding those
exciting causes enumerated in DIV. The
conduct necessary for avoiding them, will be
sufficiently 

355 OF PHYSIC.
sufficiently obvious to persons acquainted with
the doctrines of the Hygieine, which I sup-
pose to have been delivered in another place.
DLV.
A due attention in avoiding those several
causes (DIII, DIV) will certainly prevent fits
of the gout; and the taking care that the ex-
citing causes be never applied in a great de-
gree, will certainly render fits more moderate
when they do come on. But, upon the whole,
it will appear, that a strict attention to the
whole conduct of life, is in this matter neces-
sary; and therefore, when the predisposition
has taken place, it will be extremely difficult
to avoid the disease.
DLVI.
I am indeed firmly persuaded, that, by ob-
viating the predisposition, and by avoiding the
exciting causes, the gout may be entirely pre-
vented: But as the measures necessary for
this purpose will, in most cases, be pursued
with difficulty, and even with reluctance, men
have been very desirous to find a medicine
which might answer the purpose without any
restraint on their manner of living. To grat-
ify this desire, physicians have proposed, and,
to take advantage of it, empirics have feigned,
many remedies, as we have already observed.
Of what nature several of these remedies have
been,

356 PRACTICE
been, I cannot certainly say; but, of those
which are unknown, we conclude, from their
having been only of temporary same, and from
their having soon fallen into neglect, that they
have been either inert or pernicious, and there-
fore I make no inquiry after them; and shall
now remark only upon one or two known
remedies for the gout which have been lately
in vogue.
DLVII.
One of these is what has been named in
England the Portland Powder. This is not a
new medicine, but is mentioned by GALEN,
and, with some little variation in its composi-
tion, has been mentioned by the writers of al-
most every age since that time. It appears to
have been at times in fashion, and to have a-
gain fallen into neglect; and I think that this
last has been owing to its having been found
to be, in many instances, pernicious. In ev-
ery instance which I have known of its exhibi-
tion for the length of time prescribed, the per-
sons who had taken it were indeed afterwards
free from any inflammatory affection of the
joints; but they were affected with many
symptoms of the atonic gout; and all, soon
after finishing their course of the medicine,
have been attacked with apoplexy, asthma, or
dropsy, which proved fatal.
DLVIII.

357 OF PHYSIC.
DLVIII.
Another remedy which has had the appear-
ance of preventing the gout, is an alkali in va-
rious forms, such as the fixed alkali both mild
and caustic, lime water, soap, and absorbent
earths. Since it became common to exhibit
these medicines in nephritic and calculous
cases, it has often happened that they were
given to those who were at the same time sub-
ject to the gout; and it has been observed,
that, under the use of these medicines, gouty
persons have been longer free from the fits of
their disease. That, however, the use of these
medicines has entirely prevented the returns
of gout, I do not know; because I never push-
ed the use of those medicines for a long time,
being apprehensive that the long continued
use of them might produce a hurtful change
in the state of the fluids.
DLIX.
With respect to preventing the gout, I have
only one other remark to offer. As the pre-
venting the gout depends very much on sup-
porting the tone of the stomach, and avoiding
indigestion; so costiveness, by occasioning this,
is very hurtful to gouty persons. It is there-
fore necessary for such persons to prevent or
remove costiveness, and by a laxative medicine,
when needful; but it is at the same time prop-
er,

358 PRACTICE
er, that the medicine employed should be such
as may keep the belly regular, without much
purging. Aloetics, rhubarb, magnesia alba,
or flowers of sulphur, may be employed, as
the one or the other may happen to be best
suited to particular persons.
DLX.
These are the several measures (from
DXLII, to DLIX) to be pursued in the in-
tervals of the paroxysms; and we are next to
mention the measures proper during the time
of them.
DLXI.
As during the times of paroxysms the body
is in a feverish state, no irritation should then
be added to it; and every part, therefore,
of the antiphlogistic regimen,(CXXX, to
CXXXIII) except the application of cold,
ought to be strictly observed.
Another exception to the general rule may
occur when the tone of the stomach is weak,
and when the patient has been before much
accustomed to the use of strong drink; for then
it may be allowable, and even necessary, to
give some animal food, and a little wine.
DLXII.

359 OF PHYSIC.
DLXII.
That no irritation is to be added to the sys-
tem during the paroxysms of gout, except in
the cases mentioned, is entirely agreed upon
among physicians: But it is a more difficult
matter to determine whether, during the time
of paroxysms, any measures may be pursued
to moderate the violence of reaction and of
inflammation. Dr. Sydenham has given it as
his opinion, that the more violent the inflam-
mation and pain, the paroxysms will be the
shorter, as well as the interval between the
present and next paroxysm longer; and, if
this opinion be admitted as just, it will forbid
the use of any remedies which might mode-
rate the inflammation; which is, to a certain
degree, undoubtedly necessary for the health of
the body. On the other hand, acute pain
presses for relief; and, although a certain de-
gree of inflammation may seem absolutely
necessary, it is not certain but that a moderate
degree of it may answer the purpose: And it
is even probable, that, in many cases, the vio-
lence of inflammation may weaken the tone
of the parts, and thereby invite a return of
paroxysms. It seems to me to be in this way,
that, as the disease advances, the paroxysms
become more frequent.
DLXIII.

360 PRACTICE
DLXIII.
From these last considerations, it seems
probable, that, during the time of paroxysms,
some measures may be taken to moderate the
violence of the inflammation and pain; and
particularly, that in first paroxysms, and in the
young and vigorous, bloodletting at the arm
may be practised with advantage: But I am
persuaded, that this practice cannot be re-
peated often with safety; because bloodletting
not only weakens the tone of the system, but
may also contribute to produce plethora. I
believe, however, that bleeding by leeches on
the foot, and upon the inflamed part, may be
practised, and repeated with greater safety;
and I have known instances of its having been
practised with safety, to moderate and shorten
paroxysms; but how far it may be carried, we
have not had experience enough to deter-
mine.
DLXIV.
Besides bloodletting, and the antiphlo-
gistic regimen, it has been proposed to employ
remedies for moderating the inflammatory
spasm of the part affected, such as warm bath-
ing and emollient poultices. These have
sometimes been employed with advantage and
safety; but at other times, have been found to
give occasion to a retrocession of the gout.
DLXV. 

361 OF PHYSIC.
DLXV.
Blistering is a very effectual means of re-
lieving and discussing a paroxysm of the gout;
but has also frequently had the effect of ren-
dering it retrocedent.
DLXVI.
The stinging with nettles I consider as
analogous to blistering; and I think it proba-
ble that it would be attended with the same
danger.
DLXVII.
The burning with moxa, or other sub-
stances, I consider as a remedy of the same
kind. I have had indeed no evidence of this
proving hurtful; but neither have I had any
proper evidence of its having proved a radi-
cal cure.
DLXVIII.
Camphire, and some aromatic oils, have
the power of allaying the pain, and of re-
moving the inflammation from the part af-
fected; but these remedies commonly make
the inflammation only shift from one part to
another, and therefore with the hazard of its
falling upon a part where it may be more
Q dangerous;

362 PRACTICE
dangerous; and they have sometimes render-
ed the gout retrocedent.
DLXIX.
From these reflections (DLXIV. et seq.) it
will appear, that some danger must attend ev-
ery external application to the parts affected
during a paroxysm; and that therefore the
common practice of committing the person to
patience and flannel alone, is established up-
on the best foundation.
DLXX.
Opiates give the most certain relief from
pain; but, when given in the beginning of
gouty paroxysms, occasion these to return with
greater violence. When, however, the par-
oxysms shall have abated in their violence, but
still continue to return, so as to occasion pain-
ful and restless nights, opiates may be then
given with safety and advantage, especially in
the case of persons advanced in life, and who
have been often affected with the disease.
DLXXI.
When, after paroxysms have ceased, some
swelling and stiffness shall remain in the joints,
these symptoms are to be discussed by the dili-
gent use of the flesh brush.
DLXXII.

363 OF PHYSIC.
DLXXII.
Purging, immediately after a paroxysm,
will be always employed with the hazard of
bringing it on again.
DLXXIII.
I have now finished what has occurred to
be said upon the means of preventing and cur-
ing the regular gout; and shall now consider
its management when it has become irregular;
of which, as I have observed above, there are
three different cases.
DLXXIV.
In the first case, which I have named the
Atonic Gout, the cure is to be accomplished
by carefully avoiding all debilitating causes;
and by employing, at the same time, the
means of strengthening the system in general,
and the stomach in particular.
DLXXV.
For the avoiding debilitating causes, I must
refer to the doctrines of the Hygieine, as in
DLIV.
DLXXVI.

364 PRACTICE
DLXXVI.
For strengthening the system in gener-
al, I must recommend frequent exercise on
horseback, and moderate walking. Cold bath-
ing also may answer the purpose, and may
be safely employed, if it appear to be power-
ful in stimulating the system, and be not ap-
plied when the extremities are threatened with
any pain.
For supporting the tone of the system in
general, when threatened with atonic gout,
some animal food ought to be employed, and
the more acescent vegetables ought to be a-
voided. In the same case, some wine also
may be necessary; but it should be in mode-
rate quantity, and of the least acescent kinds;
and if every kind of wine shall be found to
increase the acidity of the stomach, ardent
spirits and water must be employed.
DLXXVII.
For strengthening the stomach, bitters and
the Peruvian bark may be employed; but care
must be taken that they be not constantly em-
ployed for any great length of time. Com-
pare DLVII.
The most effectual medicine for strengthen-
ing the stomach is iron, which may be em-
ployed under various preparations; but, to
me, the best appears to be the rust in fine
powder,

365 OF PHYSIC.
powder, which may be given in very large
doses.
For supporting the tone of the stomach, ar-
omatics may be employed; but should be used
with caution, as the frequent and large use of
them may have an opposite effect; and they
should therefore be given only in compliance
with former habits, or for palliating present
symptoms.
When the stomach happens to be liable to
indigestion, gentle vomits may be frequently
given; and proper laxatives should be always
employed to obviate, or to remove, costive-
ness.
DLXXVIII,
In the atonic gout, or in persons liable to
it, to guard against cold is especially necessa-
ry; and the most certain means of doing this,
is, by repairing to a warm climate during the
winter season.
DLXXIX.
In the more violent cases of the atonic gout,
blistering the lower extremities may be useful;
but that remedy should be avoided when any
pain threatens the extremities. In persons
liable to the atonic gout, issues may be estab-
lished in the extremities, as, in some measure,
a supplement to the disease.
DLXXX.

366 PRACTICE
DLXXX.
A second case of the irregular gout, is that
which I have named the Retrocedent. When
this affects the stomach and intestines, relief
is to be instantly attempted by the free use
of strong wines, joined with aromatics, and
given warm; or if these shall not prove power-
ful enough, ardent spirits must be employed,
and are to be given in a large dose. In mod-
erate attacks, ardent spirits impregnated with
garlic, or with asafœtida, may be employed;
or, even without the ardent spirits, a solution
of asafœtida with the volatile alkali may an-
swer the purpose. Opiates are often an ef-
fectual remedy, and may be joined with aro-
matics, as in the Electuarium Thebaicum; or
they may be usefully joined with volatile al-
kali and camphire. Musk has likewise prov-
ed useful in this disease.
When the affection of the stomach is ac-
companied with vomiting, this may be en-
couraged, by taking draughts of warm wine,
at first with water, and afterwards without
it; having at length recourse, if necessary, to
some of the remedies above mentioned, and
particularly the opiates.
In like manner, if the intestines be affected
with diarrhœa, this is to be at first encouraged,
by taking plentifully of weak broth; and when
this shall have been done sufficiently, the tu-
mult is to be quieted by opiates.
DLXXXI.

367 OF PHYSIC.
DLXXXI.
When the retrocedent gout shall affect the
lungs, and produce asthma, this is to be cured
by opiates, by antispasmodics, and, perhaps,
by blistering on the breast or back.
DLXXXII.
When the gout, leaving the extremities,
shall affect the head, and produce pain, verti-
go, apoplexy, or palsy, our resources are very
precarious. The most probable means of re-
lies is, blistering the head; and if the gout
shall have receded very entirely from the ex-
tremities, Millers may be applied to these al-
so. Together with these blisterings, aromat-
ics, and the volatile alkali, may be thrown in-
to the stomach.
DLXXXIII.
The third case of the irregular gout is what
I have named the Misplaced; that is, when
the inflammatory affection of the gout, instead
of falling upon the extremities, falls upon some
internal part. In this case, the disease is to be
treated by bloodletting, and by such other
remedies as would be proper in an idiopathic
inflammation of the same parts.
DLXXXIV.

368 PRACTICE, &c.
DLXXXIV.
Whether the translation so frequently made
from the extremities to the kidneys, is to be
considered as an instance of the misplaced
gout, seems, as we have said before, uncertain;
but I am disposed to think it something differ-
ent; and therefore am of opinion, that, in the
Nephralgia Calculosa produced upon this oc-
casion, the remedies of inflammation are to be
employed no farther than they may be other-
wise sometimes necessary in that disease, aris-
ing from other causes than the gout.
END 
OF VOL. I
PRINTED AT WORCESTER, BY ISAIAH THOMAS,
MDCCXC.