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;
Of 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,
REVISED, CORRECTED and ENLARGED, by the AUTHOR.
IN THREE VOLUMES.
VOL. II.
PRINTED at WORCESTER, MASSACHUSETTS,
BY ISAIAH THOMAS.
Sold at his BOOKSTORE in WORCESTER, and by him and
COMPANY in BOSTON.
MDCCXC.  



CONTENTS
OF VOL. II.
PART I.
BOOK III.
Page
OF EXANTHEMA-
TA, OR ERUPTIVE FEVERS 13
CHAP. I.
Of the SMALL POX — — 15
CHAP. II.
Of the CHICKEN POX — — 44
CHAP. III.
Of the MEASLES — — 46
CHAP. IV.
Of the SCARLET FEVER — — 55
CHAP. 

viii CONTENTS.	
Page
CHAP. V.
Of the PLAGUE - - - 64
Sect. I. Of the Phenomena of the
Plague - - - 64
Sect. II. Of the Prevention of the	
Plague - - - 67	
Sect. III. Of the Cure of the Plague 74
CHAP. VI.	
Of ERYSIPELAS, or St. Anthony's Fire 78
CHAP. VII.	
Of the MILIAR FEVER - - 86
CHAP. VIII.	
Of the remaining EXANTHEMATA:
URTICARIA, PEMPHIGUS, and APH-	
THA - - - 97
BOOK IV.	
OF HEMORRHAGES - 100
CHAP.

ix CONTENTS. 
Page
CHAP. I.
Of HEMORRHAGY in general - 100
Sect. I. Of the Phenomena of Hemor-
rhagy - - - 102
Sect. II. Of the Proximate Cause of
Hemorrhagy - - - 104
Sect. III. Of the Remote Causes of
Hemorrhagy - - - 124
Sect. IV. Of the Cure of Hemorrhagy 126
CHAP. II.
Of the EPISTAXIS, or Hemorrhagy of
the Nose - - - 140
CHAP. III.
Of the HEMOPTYSIS, or Hemorrhagy
from the Lungs - - - 151
Sect. I. Of the Phenomena and Causes
of Hemoptysis - - - 151
Sect. II. Of the Cure of Hemoptysis 160
CHAP. 

x CONTENTS.
Page
CHAP. IV.
Of the PHTHISIS PULMONALIS, or Con-
sumption of the Lungs - - - 164
Sect. I. Of the Phenomena and Causes
of the Phthisis Pulmonalis - 164
Sect. II. Of the Cure of Phthisis 193
CHAP. V.
Of the HEMORRHOIS, or of the Hemor-
rhoidal Swelling and Flux - 207
Sect. I. Of the Phenomena and Causes
of the Hemorrhois - 207
Sect. II. Of the Cure of Hemorrhoidal
Affections - - 218
BOOK IV.
CHAP. VI.
Of the MENORRHAGIA, or the Immod-
erate Flow of the Menses - 228
CHAP. VII.
Of the LEUCORRHOEA, Fluor Albus, or
Whites - - - 237
CHAP.

xi CONTENTS. 
Page
CHAP. VIII.
Of the AMENORRHOEA, or Interruption
of the Menstrual Flux - 242
CHAP. IX.
Of SYMPTOMATIC HEMORRHAGIES 253
Sect. I. Of the HEMATEMESIS, or
Vomiting of Blood - 254
Sect. II. Of the HEMATURIA, or the
Voiding of Blood from the Urinary
Passage - - 264
BOOK V.
OF PROFLUVIA, or FLUXES WITH
PYREXIA - - 273
CHAP. I.
Of the CATARRH - - 275
CHAP. II.
Of the DYSENTERY - - 287
PART II.
OF NEUROSES, OR NERVOUS DIS-
EASES - - 301
BOOK 

xii CONTENTS.
Page
BOOK I.
OF COMATA, OR THE LOSS OF
VOLUNTARY MOTIONS 303
CHAP. I.
Of APOPLEXY - - 304
CHAP. II.
Of PALSY - - - 333
BOOK II.
OF ADYNAMIÆ, OR DISEASES
CONSISTING IN A WEAKNESS OR
LOSS OF MOTION IN EITHER
THE VITAL OR NATURAL
FUNCTIONS - - 350
CHAP. I.
Of SYNCOPE, or Fainting - 350
CHAP. II.
Of DYSPEPSIA, or Indigestion. - 363
CHAP. III.
Of HYPOCHONDRIASIS, or the Hypo-
chondriac Affection, commonly called
Vapours or Low Spirits - 382
FIRST

FIRST LINES
OF THE
PRACTICE OF PHYSIC.
BOOK III.
OF EXANTHEMATA, OR
ERUPTIVE FEVERS.
DLXXXV.
THE diseases comprehended
under this title, which make
the third Order of Pyrex-
iæ in our Nosology, are
in general such as do not a-
rise but upon occasion of a
specific contagion applied,
which first produces fever, and afterwards an
VOL. II. B eruption 

14 PRACTICE
eruption upon the surface of the body; and 
which diseases, for the most part, affect per-
sons but once in the course of their lives.
DLXXXVI.
Whether the character of the Order may
be thus limited, or if the Order may be al-
lowed to comprehend also the eruptive fevers
produced by a matter generated in the body
itself, and likewise those cases of eruption
which do not depend upon contagion, or up-
on a matter generated before the fever, but
upon a matter generated in the course of the
fever, I am not ready to determine. Of the
diseases enumerated by the Nosologists as
Exanthemata, there are certainly three differ-
ent kinds, which may be distinguished by the
circumstances mentioned in this and the pre-
ceding paragraph. Of the first kind are the
Small Pox, the Chicken Pox, the Measles,
the Scarlet Fever, and the Plague. Of the
second kind seems to be the Erysipelas; and
of the third kind I judge the Miliaria and
Petechia to be. But as I am not sufficiently
confident in the facts which should support
these distinctions, or which would enable us
to apply them in all cases; I go on in this
book to treat of almost all the exanthemata
enumerated by preceding Nosologists, with
only some difference in the arrangement from
what it was in my former editions.
CHAP.

15 OF PHYSIC.
CHAP. I.
OF THE SMALL POX.
DLXXXVII.
THE small pox is a disease
arising from a contagion of a specific nature,
which first produces a fever, and on the third or
fourth day thereof, produces an eruption of
small red pimples. These are afterwards form-
ed into pustules, containing a matter, which,
in the course of eight days from the time of
the eruption, is changed into pus. After this,
the matter dries, and falls off in crusts.
DLXXXVIII.
This is a general idea of the disease; but
there are two particular forms or varieties of
it, well known under the appellations of the
Distinct and Confluent, which require to be
specially described.
B2 DLXXXIX. 

16 PRACTICE
DLXXXIX.
In the former, or the distinct small pox, the
eruptive fever is moderate, and appears to be
evidently of the inflammatory kind, or what
we name a Synocha. It generally comes on
about mid day, with some symptoms of a cold
stage, and commonly with a considerable lan-
guor and drowsiness. A hot stage is soon
formed, and becomes more considerable on
the second and third days. During this
course, children are liable to frequent startings
from their slumbers; and adults, if they are
kept abed, are disposed to much sweating.
On the third day, children are sometimes af-
fected with one or two epileptic fits. To-
wards the end of the third day, the eruption
commonly appears, and gradually increases
during the fourth; appearing first upon the
face, and successively on the inferior parts, so
as to be completed over the whole body on
the fifth day.
From the third day the fever abates; and
against the fifth it entirely ceases. The erup-
tion appears first in small red spots, hardly
eminent, but by degrees rising into pimples.
These are generally upon the face in small
number; but even when more numerous, they
are separate and distinct from one another.
On the fifth or sixth day, a small vesicle, con-
taining an almost colourless or whey coloured
fluid, appears upon the top of each pimple.
For 

17 OF PHYSIC.
For two days, these vesicles increase in breadth
only, and there is a small hollow pit in their
middle; so that it is only against the eighth
day that they are raised into spheroidical pus-
tules.
These vesicles or pustules, from their first
formation, continue to be surrounded with an
exactly circular inflamed margin, which, when
the pustules are numerous, diffuses some in-
flammation over the neighbouring skin, so as
to give somewhat of a damask rose colour to
the spaces between the pustules. As the pus-
tules increase in size, if they be numerous on
the face, against the eighth day the whole of
the face becomes considerably swelled; and
in particular, the eyelids are so much swelled
as entirely to shut the eyes.
As the disease thus proceeds, the matter in
the pustules becomes by degrees more opaque
and white, and at length of a yellowish colour.
On the eleventh day, the swelling of the face
is abated, and the pustules seem quite full.
On the top of each a darker spot appears;
and at this place the pustule, on the eleventh
day, or soon after, is spontaneously broken,
and a portion of the matter oozes out; in
consequence of which, the pustule is shrivel-
led, and subsides; while the matter oozing out
dries, and forms a crust upon its surface.
Sometimes a little only of the matter oozes
out; and what remains in the pustule becomes
thick, and even hard. After some days, both
the crusts and the hardened pustules fall off,
B3 leaving 

18 PRACTICE
leaving the skin which they covered of a brown
red colour; and it is only after many days
that the skin in these places resumes its nat-
ural colour. In some cases, where the matter
of the pustules has been more liquid, the crusts
formed by it are later in falling off, and the
part they covered suffer some desquamation,
which leaves in it a small pit or hollow.
This is the course of things on the face;
and successively, the pustules on the rest of the
body take the same. The matter of the pus-
tules, on the arms and hands, is frequently
absorbed; so that, at the height of the disease,
these pustules appear as empty vesicles. On
the tenth and eleventh days, as the swelling
of the face subsides, a swelling arises in the
hands and feet; but which, again, subsides as
the pustules come to maturity.
When the pustules on the face are nume-
rous, some degree of pyrexia appears on the
tenth and eleventh days, but disappears again
after the pustules are fully ripened; or per-
haps remains in a very slight degree till the
pustules on the feet have finished their course.
It is seldom that in the distinct small pox the
fever continues longer.
When the pustules on the face are nume-
rous, some uneasiness in the throat, with a
hoarseness of the voice, comes on upon the
sixth or seventh day, and a thin liquid is
poured out from the mouth. These symp-
toms increase with the swelling of the face;
and the liquids of the mouth and throat be-
coming 

OF PHYSIC. 19
coming thicker, are more difficultly thrown
out. There is, at the same time, some diffi-
culty of swallowing; so that liquids taken in
to be swallowed are frequently rejected, or
thrown out by the nose. But all these affec-
tions of the fauces abate as the swelling of the
face subsides.
DXC.
In the other form of small pox, or what is
called the Confluent, the course of the disease
is, in general, the same with that we have de-
scribed; but the symptoms of every stage are
more violent, and several of the circumstances
are different.
In particular, the eruptive fever is more
violent; the pulse is more frequent and more
contracted, approaching to that state of pulse
which is found in the typhus; the coma is
more considerable; and there is frequently a
delirium. Vomiting, also, is a common symp-
tom, especially at the coming one of the disease.
In very young infants, epileptic fits are some-
times frequent on the first days of the disease,
and sometimes prove fatal before any eruption
appears; or they usher in a very confluent
and putrid small pox.
DXCI.
The eruption appears more early on the third
day, and it is frequently preceded or accom-
B4 panied 

20 PRACTICE
panied with an erysipelatous efflorescence.
Sometimes the eruption appears in clusters,
like that of the measles. When the eruption
is completed, the pimples are always more nu-
merous upon the face, and at the same time
smaller and less eminent. After the eruption,
the fever suffers some remission, but never goes
off entirely; and, after the fifth or sixth day,
it again increases, and continues considerable
through the remaining course of the disease.
The vesicles formed on the tops of the
pimples appear sooner; and while they in-
crease in breadth, do not retain a circular, but
are every way of an irregular figure. Many
of them run into one another, insomuch that
very often the face is covered rather with one
vesicle than with a number of pustules. The
vesicles, so far as they are any wise separated,
do not arise to a spheroidical form, but re-
main flat, and sometimes the whole of the face
is of an even surface. When the pustules are
in any measure separated, their circumference
is not bounded by an inflamed margin, and
the part of the skin that is free from pustules
is commonly pale and flaccid.
The liquor that is in the pustules changes
from a clear to an opaque appearance, and be-
comes whitish or brownish, but never acquires
the yellow colour and thick consistence that
appear in the distinct small pox.
DXCII. 

21 OF PHYSIC.
DXCII.
The swelling of the face which attends the
distinct small pox, when they are numerous,
and almost then only, always attends the con-
fluent, comes on more early, and arises to a
greater degree; but abates on the tenth day,
and on the eleventh still more. At this time
the pustules or vesicles break, and shriveling
pour out a liquor that is formed into brown
or black crusts, which do not fall off for many
days after. Those of the face, in falling off,
leave the parts they cover subject to a des-
quamation, which pretty certainly produces
pittings.
On the other parts of the body, the pustules
of the confluent small pox are more distinct
than upon the face, but never acquire the same
maturity and consistence of pus as in the
properly distinct kind.
The salivation which only sometimes at-
tends the distinct small pox, very constantly
attends the confluent; and both the salivation
and the affection of the fauces abovemen-
tioned are, especially in adults, in a higher
degree. In infants, a diarrhœa comes fre-
quently in place of the salivation.
In the confluent small pox, there is often a
considerable putrescency of the fluids, as ap-
pears from petechiæ, from serous vesicles, un-
der which the skin shows a disposition to gan-
grene, and from bloody urine or other hem-
VOL. 2. B5 orrhagy, 

22 PRACTICE
orrhagy, all which symptoms frequently ac-
company this disease.
In the confluent small pox, the fever, which
had only suffered a remission from the time of
eruption to that of maturation, is often, at or
immediately after this period, renewed with
considerable violence. This is what has been
called the Secondary Fever; and is, in differ-
ent cases, of various duration and event.
DXCIII.
We have thus endeavoured to describe the
various circumstances of the small pox; and
from the difference of these circumstances, the
event of the disease may be determined. The
whole of the prognosis may be nearly com-
prised in the following propositions.
The more exactly the disease retains the
form of the distinct kind, it is the safer; and
the more completely the disease takes the form
of the confluent kind it is the more dangerous.
It is only when the distinct kind shows a
great number of pustules on the face, or oth-
erwise, by fever or putrescency, approaches to
the circumstances of the confluent, that it is
attended with any danger.
In the confluent small pox there is always
danger; and this is always more considerable
and certain, according as the fever is more vi-
olent and permanent, and especially as the
marks and symptoms of putrescency are more
evident.
When 

23 OF PHYSIC.
When the putrid disposition is very great,
the disease sometimes proves fatal before the
eighth day; but in most cases it is on the
eleventh that death happens, and sometimes it
is put off till the fourteenth or seventeenth
day.
Though the small pox should not be im-
mediately fatal, the more violent kinds are
often followed by a morbid state of the body,
of various kind and event. These conse-
quences, as I judge, may be imputed some-
times to an acrid matter produced by the pre-
ceding disease, and deposited in different
parts; and sometimes to an inflammatory di-
athesis produced, and determined to particu-
lar parts of the body. 
DXCIV.
It is, I think agreed among practitioners,
that, in the different cases of small pox, the
difference chiefly depends upon the appear-
ance of distinct or confluent; and, from the
above description of these kinds, it will ap-
pear, that they chiefly differ in the period of
the eruption, in the number of pustules
produced, in the form of the pustules, in the
state of the matter contained in them, in the
continuance of the fever, and lastly in the
danger of the disease.
B6 DXCV.

24 PRACTICE
DXCV.
Upon inquiring into the causes of these
differences, we might readily suspect, that
they depended upon a difference of the con-
tagion producing the disease. This, howev-
er, is not probable; for there are innumerable
instances of the contagion, arising from a per-
son labouring under the small pox of the dis-
tinct kind, producing the confluent; and on
the contrary. Since the practice of inocula-
tion became frequent, we have known the
same variolous matter produce in one person
the distinct, and in another the confluent
small pox. It is therefore highly probable,
that the difference of the small pox does not
depend upon any difference of the contagion,
but upon some difference in the state of the
persons to whom it is applied, or in the state
of certain circumstances concurring with the
application of the contagion.
DXCVI.
To find out wherein the difference in the
state of the persons to whom the contagion of
the small pox is applied consists, I observe,
that the difference between the distinct and
confluent small pox consists especially in the
number of pustules produced; which, in the
distinct, are generally few; in the confluent
always many. If, therefore, we shall be able
to 

25 OF PHYSIC.
to discover what, in the state of different per-
sons, can give occasion to more or fewer pus-
tules, we shall probably be able to account for
all the other differences of the distinct and
confluent small pox.
DXCVII.
It is evident, that the contagion of the
small pox is a ferment with respect to the hu-
man fluids, and assimilates a great part of
them to its own nature; and it is probable,
that the quantity thus assimilated, is, in pro-
portion to the bulk of their several bodies, near-
ly the same in different persons. This quan-
tity passes again out of the body, partly by in-
sensible perspiration, and partly by being de-
posited in pustules; but if the quantities gen-
erated be nearly equal, the quantities passing
out of the body by the two ways mentioned
are very unequal in different persons; and
therefore, if we can explain the causes which
determine more to pass by the one way than
by the other, we may thereby discover the
causes which give occasion to more pustules in
one person than in another.
DXCVIII.
The causes which determine more of the
variolous matter to pass by perspiration, or to
form pustules, are probably certain circum-
stances of the skin, that determine more or
less 

26 PRACTICE
less of the variolous matter to stick in it, or
to pass freely through it.
DXCIX.
The circumstance of the skin, which seems
to determine the variolous matter to stick in
it, is a certain state of inflammation, depend-
ing much upon the heat of it: Thus we have
many instances of parts of the body, from be-
ing more heated, having a greater number of
pustules than other parts. In the present
practice of inoculation, in which few pustules
are produced, much seems to be owing to the
care that is taken to keep the skin cool.
Parts covered with plasters, especially with
those of a stimulant kind, have more pustules
than other parts. Further, certain circum-
stances, such as adult age, and full living, de-
termining to a phlogistic diathesis, seem to
produce a greater number of pustules; while
the contrary circumstances have contrary ef-
fects.
DC.
It is therefore probable, that an inflamma-
tory state of the whole system, and more par-
ticularly of the skin, gives occasion to a great-
er number of pustules; and the causes of this
may likewise produce most of the other cir-
cumstances of the confluent small pox; such
as the period of eruption; the continuance of
the 

27 OF PHYSIC.
the fever; the effusion of a more putrescent
matter, and less fit to be converted into pus;
and what arises from thence, the form and oth-
er circumstances of the pustules.
DCI.
Having thus attempted to account for the
chief difference which occurs in the state of
the small pox, we shall now try the truth of
our doctrine, by its application to practice.
DCII.
In considering the practice, we view it first,
in general, as suited to render the disease more
generally benign and safe, and this by the
practice of inoculation.
DCIII.
It is not necessary here to describe the op-
eration of inoculating; and what we name the
practice of inoculation, comprehends all the
several measures which precede or follow that
operation, and are supposed to produce its
salutary effects.
These measures are chiefly the following.
1. The choosing for the subject of inocu-
lation persons otherwise free from disease, and
not liable, from their age or other circum-
stances, to any incidental disease.
2. The 

28 PRACTICE
2. The choosing a person at the time of
life most favourable to a mild disease.
3. The choosing for the practice a season
the most conducive to the mildness of the
disease.
4. The preparing the person to be inocu-
lated, by abstinence from animal food for some
time before inoculation.
5. The preparing the person by courses of
mercurial and antimonial medicines.
6. The taking care, at the time of inocula-
tion, to avoid cold, intemperance, fear, or oth-
er circumstances which might aggravate the
future disease.
7. After these preparations and precautions,
the choosing a fit matter to be employed in
inoculation, by taking it from a person of a
sound constitution, and free from any disease
or suspicion of it; by taking it from a person
who has had the small pox of the most be-
nign kind; and, lastly, by taking the matter
from such persons, as soon as it has appeared
in the pustules, either in the part inoculated,
or on other parts of the body.
8. The introducing, by inoculation, but a
small portion of the contagious matter.
9. After inoculation, the continuing the
vegetable diet, as well as the employment of
mercurial and antimonial medicines; and, at
the same time, frequently employing purga-
tives.
10. Both before and after inoculation, tak-
ing care to avoid external heat, either from
the 

29 OF PHYSIC.
the sun, artificial fires, warm chambers, much
clothing, or being much in bed; and, on the
contrary, exposing the person to a free and
cool air.
11. Upon the appearance of the eruptive fe-
ver, the rendering that moderate by the em-
ployment of purgatives; by the use of cooling
and antiseptic acids; and especially by expos-
ing the person frequently to a cool and even a
cold air, at the same time giving freely of cold
drink.
12. After the eruption, the continuing the
application of cold air, and the use of purga-
tives, during the course of the disease, till the
pustules are fully ripened.
DCIV.
These are the measures proposed and prac-
tised in the latest and most improved state of
inoculation; and the advantages obtained by
the whole of the practice, or at least by most
of the measures abovementioned, are now as-
certained by a long experience to amount to
this, That, in ninety nine cases of the hun-
dred, inoculation gives a distinct small pox
only, and that also very generally of the mild-
est form; but it will still be useful, for the
proper conduct of inoculation, to consider the
importance and utility of the several measures
abovementioned, that we may thereby more
exactly determine upon what the advantages
of inoculation more certainly depend.
DCV.

30 PRACTICE
DCV.
As the common infection may often seize
persons labouring under another disease,
which may render the small pox more violent,
it is obvious that inoculation must have a
great advantage, by avoiding such concur-
rence. But as the avoiding such concurrence
may often, in the mean while, leave persons
exposed to the common infection, it merits
inquiry, whether every diseased state should
restrain from the practice of inoculation, or
what are the particular diseases that should do
so. This is not yet sufficiently ascertained by
observation; and we have frequently remark-
ed, that the small pox have often occurred
with a diseased state of the body, without be-
ing thereby rendered more violent. In par-
ticular, we have observed, that a scrophulous
habit, or even the presence of scrophula, did
not render the small pox more violent; and
we have observed also, that several diseases of
the skin are equally innocent. I am of opin-
ion, that they are the diseases of the febrile
kind, or ailments ready to induce or aggravate
a febrile state, that especially give the concur-
rence which is most dangerous with the small
pox. I dare not attempt any general rules;
but I am disposed to maintain, that though a
person be in a diseased state, if that state be of
uncertain nature and effect, and at the same
time the small pox be exceedingly rise, so as 
to

31 OF PHYSIC.
to render it extremely difficult to guard against
the common infection, it will always be safer
to give the small pox by inoculation, than to
leave the person to take them by the common
infection.
DCVI.
Though inoculation has been practised with
safety upon persons of all ages; yet, from what
has actually occurred in the cases of common
infection, and from several other considera-
tions, there is reason to conclude, that adults
are more liable to a violent disease than persons
of younger years. At the same time, it is ob-
served, that children, in the time of their first
dentition, are liable, from this irritation, to
have the small pox rendered more violent;
and that infants, before the time of dentition,
upon receiving the contagion of the small pox,
are liable to be affected with epileptic fits,
which frequently prove fatal. It is therefore,
upon the whole, evident, that though circum-
stances may admit, and even render inocula-
tion at any age proper; yet, for the most part,
it will be still more advisable to choose per-
sons at an age, after the first dentition is over,
and before the time of puberty.
DCVII.
Though inoculation has been practised
with safety at every season of the year; yet,
as

32 PRACTICE
as it is certain that the cold of winter may
increase the inflammatory, and the heats of
summer increase the putrescent state of the
small pox, it is highly probable that inocula-
tion may have some advantage, from avoiding
the extremes either of heat or cold.
DCVIII.
Although the original temperament and
constitutions of men are not to be readily
changed; it is sufficiently certain, that the
conditions of the human body may, by va-
rious causes, in many respects be occasionally
very much changed; and therefore, as the use
of animal food may increase both the inflam-
matory and putrescent state of the human
body, so it must render persons, on receiving
the contagion of the small pox, less secure a-
gainst a violent disease; and, therefore, inoc-
ulation may derive some advantage from ab-
stinence from animal food for some time be-
fore the inoculation is performed; but I am
of opinion, that a longer time than that usual-
ly prescribed may be often necessary; and I
am persuaded, that the Scottish mothers who
avoid giving their children animal food till
they are past the small pox, render this disease
in them of a milder kind.
DCIX.
I cannot deny that mercurial and antimo-
nial medicines may have some effect in deter-
mining 

33 OF PHYSIC. 
mining to a more free perspiration, and there-
fore may be of some use in preparing a per-
son for the small pox; but there are many ob-
servations which render me doubtful as to
their effect. The quantity of both these
medicines, particularly of the antimony, com-
monly employed, is too inconsiderable to pro-
duce any effect. It is true, that the mercuri-
als have often been employed more freely;
but even their salutary effects have not been
evident, and their mischievous effects have
sometimes appeared. I doubt, therefore,
upon the whole, if inoculation derives any
advantage from these pretended preparatory
courses of medicines.
DCX.
As it has been often observed, in the case
of almost all contagions, that cold, intemper-
ance, fear, and some other circumstances,
concurring with the application of the conta-
gion, have greatly aggravated the future dis-
ease, so it must be the same in the case of the
small pox; and it is undoubted, that inoc-
ulation must derive a great, and perhaps its
principal, advantage, from avoiding the con-
currences abovementioned.
DCXI.
It has been commonly supposed, that inoc-
ulation has derived some advantage from the
choice 

34 PRACTICE
choice of the matter employed in it; but,
from what has been observed in DXCV, it
must appear very doubtful if any choice be
necessary, or can be of any benefit, in deter-
mining the state of the disease.
DCXII.
It has been supposed by some, that inocu-
lation has an advantage, by introducing a
small portion only of the contagious matter:
But this rests upon an uncertain foundation.
It is not known what quantity is introduced
by the common infection, and it may be a
small quantity only. Although it were larg-
er than that thrown in by inoculation, it is
not ascertained that the circumstance of quan-
tity would have any effect. A certain quan-
tity of ferment may be necessary to excite fer-
mentation in a given mass; but, that quantity
given, the fermentation and assimilation are
extended to the whole mass; and we do not
find that a greater quantity than is just neces-
sary, either increases the activity of the fer-
mentation, or more certainly secures the as-
similation of the whole. In the case of the
small pox, a considerable difference in the
quantity of contagious matter introduced, has
not discovered any effect in modifying the
disease.
DCXIII. 

35 OF PHYSIC. 
DCXIII.
Purging has the effect of diminishing the
activity of the sanguiferous system, and of
obviating its inflammatory state. It is there-
fore probable, that the frequent use of cool-
ing purgatives is a practice attending inocula-
tion which may be of considerable advantage;
and, probably, it is also useful by diminishing
the determination to the skin. It appears to
me, that mercurials and antimonials, as they
are commonly managed, are useful only as
they make a part of the purging course.
DCXIV.
It is probable, that the state of the small
pox depends very much upon the state of the
eruptive fever, and particularly upon mode-
rating the inflammatory state of the skin; and,
therefore, it is probable, that the measures
taken for moderating the eruptive fever and
inflammatory state of the skin, afford the
greatest improvement which has been made in
the practice of inoculation. The tendency of
purging, and the use of acids, for this pur-
pose, is sufficiently obvious; and upon the
same grounds, we should suppose that blood-
letting might be useful; but probably this has
been omitted, for the same reason that perhaps
might have led to the omission of other reme-
dies also; which is, that we have found a
more 

36 PRACTICE
more powerful and effectual one in the appli- 
cation of cold air, and the use of cold drink.
Whatever doubts or difficulties our theory
might present to us on this subject, they may
be entirely neglected, as the practice of In-
dostan had long ago, and the practice of this
country has lately, by a large and repeated ex-
perience, ascertained the safety and efficacy of
this remedy; and as it may and can be more
certainly employed with the practice of inoc-
ulation, than it can be in cases of common in-
fection, it must give a singular advantage to
the former.
DCXV.
After the eruption, when a few pimples
only have appeared on the face, the continuing
the application of cold air, and the employ-
ment of purgatives, has indeed been the prac-
tice of many inoculators; but, I think, these
practices cannot be said to give any peculiar
advantages to inoculation; for when the state
of the eruption is determined, when the num-
ber of pustules is very small, and the fever has
entirely ceased, I hold the safety of the disease
to be absolutely ascertained, and the further
use of remedies entirely superfluous. In such
cases, I judge the use of purgatives to be not
only unnecessary, but that they may be often
hurtful. 
DCXVI. 

37 OF PHYSIC.
DCXVI.
I have thus considered the several circum-
stances and practices accompanying inocula-
tion, and have endeavoured to ascertain the
utility and importance of each. Upon the
whole, I hope I have sufficiently ascertained
the general utility and great advantage of this
practice, especially consisting in this, that if
certain precautions, preparations, and reme-
dies, are of importance, all of them can be
employed with more certainty in the practice
of inoculation than in the case of common
infection.
It remains now that I should offer some re-
marks on the conduct of the small pox, as re-
ceived by infection, or even when, after in-
oculation, the symptoms shall prove violent.
The latter sometimes happens, although ev-
ery precaution and remedy have been em-
ployed. The cause of this is not well known;
but it appears to me to be commonly owing
to a disposition of the fluids to putrescency.
But, however this may be, it will appear, that,
not only in the case of common infection, but
even in that of inoculation, there may be oc-
casion for studying the conduct of this disease,
in all its possible varying circumstances.
DCXVII.
When, from the prevailing of small pox as
an epidemic, and more especially when it is
VOL. II. C known 

38 PRACTICE
known that a person not formerly affected
with the disease has been exposed to the in-
fection, if such person should be seized with
the symptoms of fever, there can be little
doubt of its being an attack of the small pox;
and therefore he is to be treated in every re-
spect as if the disease had been received by in-
oculation. He is to be freely exposed to a
cool air, to be purged, and to have cooling
acids given liberally.
DCXVIII.
If these measures moderate the fever, noth-
ing more is necessary: But if the nature of
the fever attacking a person be uncertain; or,
if, with suspicions of the small pox, the symp-
toms of the fever be violent; or even if,
knowing the disease to be small pox, the meas-
ures mentioned DXCVII, shall not mode-
rate the fever sufficiently; it will be proper
to let some blood; and this will be more es-
pecially proper, if the person be an adult, of
a plethoric habit, and accustomed to full liv-
ing.
DCXIX.
In the same circumstances, we judge it will
be always proper to give a vomit, as useful in
the commencement of all fevers, and more
especially in this, where a determination to
the 

39 OF PHYSIC.
the stomach appears from pain and sponta-
neous vomiting.
DCXX.
It frequently happens, especially in infants,
that, during the eruptive fever of the small
pox, convulsions occur. Of these, if only
one or two fits appear on the evening preced-
ing the eruption, they give a favourable prog-
nostic of a mild disease, and require no reme-
dy; but if they occur more early, and be vio-
lent and frequently repeated, they are very
dangerous, and require a speedy remedy.
For this purpose, bleeding is hardly ever of
service; blistering always comes too late; and
the only remedy I have found effectual is an
opiate given in a large dose.
DCXXI.
These are the remedies necessary during the
eruptive fever; and if, upon the eruption, the
pimples upon the face be very few and dis-
tinct, the disease is no further of any danger,
requires no remedies, and the purgatives,
which, as has been said before, are by some
practitioners continued, prove often hurtful.
But when, upon the eruption, the pimples
on the face are very numerous; when they
are not distinct; and especially, when upon
the fifth day, the fever does not suffer a con-
C2 siderable 

40 PRACTICE
siderable remission; the disease will still re-
quire a great deal of attention.
DCXXII.
If, after the eruption, the fever shall con-
tinue, the avoiding heat, and the continuing
to expose the body to a cool air, will still be
proper. If the fever be considerable, with a
full and hard pulse, in an adult person, a
bleeding will be necessary; and, more certain-
ly, a cooling purgative. It is, however, sel-
dom that a repetition of the bleeding will be
proper, as a loss of strength does usually come
on very soon; but the repetition of a purga-
tive, or the frequent use of laxative glysters,
is commonly useful. 
DCXXIII.
When a loss of strength, with other marks
of a putrescent tendency of the fluids appears,
it will be necessary to exhibit the Peruvian
bark in substance, and in large quantity. In
the same case, the free use of acids, and of ni-
tre, is useful; and it is commonly proper al-
so to give wine very freely.
DCXXIV.
From the fifth day of the disease, onward
through the whole course of it, it is proper to
give an opiate once or twice a day; taking
care, 

41 OF PHYSIC.
care, at the same time, to obviate costiveness
by purgatives or laxative glysters.
DCXXV.
In a violent disease, from the eighth to the
eleventh day, it is proper to lay on blisters
successively on different parts of the body, and
that without regard to the parts being covered
with pustules.
DCXXVI.
If, in this disease, the tumour of the fauces
be considerable; the deglutition difficult; the
saliva and mucus viscid, and with difficulty
thrown out; it will be proper to apply blis-
ters to the external fauces, and to employ dil-
igently detergent gargles.
DCXXVII.
During the whole course of the disease,
when any considerable fever is present, the
frequent exhibition of antimonial medicines,
in nauseating doses, has been found useful;
and these, for the most part, sufficiently answer
the purpose of purgatives.
C3 DCXXVIII. 

42 PRACTICE
DCXXVIII.
The remedies mentioned from DCXXII,
to DCXXVI, are those frequently necessary,
from the fifth day till the suppuration is fin-
ished. But as, after that period, the fever is
sometimes continued and increased; or, as
sometimes, when, after there has been little
or no fever before, a fever now arises, and
continues with considerable danger; this is
what is called the Secondary Fever, and re-
quires particular treatment.
DCXXIX.
When the secondary fever follows the dis-
tinct small pox, and the pulse is full and hard,
the case is to be treated as an inflammatory af-
fection, by bleeding and purging. But, if the
secondary fever follow the confluent small
pox, and be a continuance or exacerbation of
the fever which had subsisted before, it is to
be considered as of the putrid kind; and in
that case, bleeding is improper. Some purg-
ing may be necessary; but the remedies to be
chiefly depended on, are the Peruvian bark
and acids.
When the secondary fever first appears,
whether it is after a distinct or a confluent
small pox, it will be useful to exhibit an anti-
monial emetic in nauseating doses, but in such
manner as to produce some vomiting.
DCXXX. 

43 OF PHYSIC.
DCXXX.
For avoiding the pits which frequently fol-
low the small pox, many different measures
have been proposed; but none of them appear
to be sufficiently certain.
C4 CHAP.

44 PRACTICE
CHAP. II.
OF THE CHICKEN POX.
DCXXXI.
THIS disease seems to de-
pend upon a specific contagion, and to affect
persons but once in their lives. It is hardly
ever attended with any danger; but as it seems
frequently to have given occasion to the sup-
position of a person's having the small pox
twice, it is proper to study this disease, and to
distinguish it from the genuine small pox.
DCXXXII.
This may be generally done by attending
to the following circumstances.
The eruption of the chicken pox comes on
with very little fever preceding it, or with fe-
ver of no determined duration.
The 

45 OF PHYSIC.
The pimples of the chicken pox, more quick-
ly than those of the small pox, are formed into
little vesicles, or pustules.
The matter in these pustules remains fluid,
and never acquires the colour or consistence
of the pus which appears in the pustules of the
small pox.
The pustules of the chicken pox are always
in three or four days from their first appear-
ance, formed into crusts.
See Dr. Heberden in Med. Transact. Vol.
I. art. xvii.
VOL. 2. C5 CHAP.

46 PRACTICE
CHAP. III.
OF THE MEASLES.
DCXXXIII.
THIS disease also depends
upon a specific contagion, and affects persons
but once in their lives.
DCXXXIV.
It occurs most frequently in children; but
no age is exempted from it, if the persons
have not been subjected to it before.
DCXXXV.
It commonly appears as an epidemic, first
in the month of January, and ceases soon af-
ter the summer solstice; but various acci-
dents, introducing the contagion may produce
the disease at other times of the year.
DCXXXVI. 

47 OF PHYSIC.
DCXXXVI.
The disease always begins with a cold stage,
which is soon followed by a hot, with the or-
dinary symptoms of thirst, heat, anorexia,
anxiety, sickness, and vomiting; and these
are more or less considerable in different
cases. Sometimes from the beginning, the
fever is sharp and violent; often, for the first
two days, it is obscure and inconsiderable, but
always becomes violent before the eruption,
which usually happens upon the fourth day.
DCXXXVII.
This eruptive fever, from its commence-
ment, is always attended with hoarseness, with
a frequent hoarse dry cough, and frequently
with some difficulty of breathing. At the
same time, the eye lids are somewhat swelled,
the eyes are a little inflamed, and pour out
tears; and, together with these symptoms,
there is a coryza, and frequent sneezing.
For the most part, a constant drowsiness at-
tends the beginning of this disease.
DCXXXVIII.
The eruption, as we have said, commonly
appears upon the fourth day; first on the
face, and successively on the lower parts of the
body. It discovers itself first in small red
C6 points; 

48 PRACTICE
points; but, soon after, a number of these ap-
pear in clusters, which do not arise into visible
pimples, but by the touch are found to be a
little prominent. This is the case on the face;
but on other parts of the body, the promi-
nence, or roughness, is hardly to be perceived.
On the face the eruption retains its redness,
or has that increased for two days; but, on
the third, the vivid redness is changed to a
brownish red; and, in a day or two more,
the eruption entirely disappears, while a
mealy desquamation takes place. During
the whole time of the eruption, the face is
somewhat turgid, but seldom considerably
swelled.
DCXXXIX.
Sometimes, after the eruption has appear-
ed, the fever ceases entirely; but this is sel-
dom the case; and more commonly the fever
continues, or is increased after the eruption,
and does not cease till after the desquama-
tion. Even then the fever does not always
cease, but continues with various duration
and effect.
DCXL.
Though the fever happen to cease upon
the eruption's taking place, it is common for
the cough to continue till after the desquama-
tion, and sometimes much longer.
In 

49 OF PHYSIC.
In all cases, while the fever continues, the
cough also continues, generally with an in-
crease of the difficulty of breathing; and both
of these symptoms sometimes arise to a degree
that denotes a pneumonic affection. This
may arise at any period of the disease; but
very often it does not come on till after the
desquamation of the eruption.
After the same period, also, a diarrhœa
frequently comes on, and continues for some
time.
DCXLI.
It is common for the measles, even when
they have not been of a violent kind, to be
succeeded by inflammatory affections, partic-
ularly ophthalmia and phthisis.
DCXLII.
If the blood be drawn from a vein during
the measles, with the circumstances necessary
to favour the separation of the gluten, this al-
ways appears separated, and lying on the sur-
face of the crassamentum, as in inflammatory
diseases.
DCXLIII.
For the most part the measles, even when
violet, are without any putrid tendency; but
in some cases such a tendency appears, both
in 

50 PRACTICE
in the course of the disease; and especially af-
ter the ordinary course of it is finished. See
Dr. Watson, in London Med. Observations,
Vol. IV. art. xi.
DCXLIV.
From what is delivered (from DCXXXVII,
to DCXLII) it will appear, that the measles
are distinguished by a catarrhal affection, and
by an inflammatory diathesis to a considera-
ble degree; and therefore the danger attend-
ing them arises chiefly from the coming on
of a pneumonic inflammation.
DCXLV.
From this consideration it will be obvious,
that the remedies especially necessary are those
which may obviate and diminish the inflam-
matory diathesis; and therefore, in a particu-
lar manner, bloodletting. This remedy may
be employed at any time in the course of the
disease, or after its ordinary course is finished.
It is to be employed more or less according
to the urgency of the symptoms of fever,
cough, and dyspnœa; and generally may be
employed very freely. But, as the symptoms
of pneumonic inflammation seldom come on
during the eruptive fever; and as this fever
is sometimes violent immediately before the
eruption, though a sufficiently mild disease be
to follow; so bleeding is seldom very, necessa-
ry 

51 OF PHYSIC.
ry during the eruptive fever, and may often
be reserved for the periods of greater danger
which are perhaps to ensue.
DCXLVI.
In all cases of measles, where there are no
marks of putrescency, and where there is no
reason, from the known nature of the epidem-
ic, to apprehend putrescency, bleeding is the
remedy to be depended upon; but assistance
may also be obtained from cooling purgatives;
and particularly from blistering on the sides,
or between the shoulders.
DCXLVII.
The dry cough may be alleviated by the
large use of demulcent pectorals, mucilagin-
ous, oily, or sweet. It may, however, be ob-
served, with respect to these demulcents, that
they are not so powerful in involving and
correcting the acrimony of the mass of blood
as has been imagined; and that their chief
operation is by besmearing the fauces, and
thereby defending them from the irritation of
acrids, either arising from the lungs or distill-
ing from the head.
DCXLVIII.
For moderating and quieting the cough in
this disease, opiates certainly prove the most
effectual 

52 PRACTICE
effectual means, whenever they can be safely
employed. In the measles, in which an in-
flammatory state prevails in a considerable
degree, opiates may be supposed to be inad-
missible; and, in those cases in which a high
degree of pyrexia and dyspnœa show either
the presence, or at least the danger, of pneu-
monic inflammation, I think that opiates might
be very hurtful. In cases, however, in which
the dyspnœa is not considerable, and where
bleeding, to obviate or abate the inflammatory
state, has been duly employed, and where the
cough and watchfulness are the urgent symp-
toms, I think that opiates may be safely ex-
hibited, and with great advantage. I think,
further, that, in all the exanthemata, there
is an acrimony diffused over the system,
which gives a considerable irritation; and, for
obviating the effects of this, opiates are useful,
and always proper, when no particular con-
traindication prevails.
DCXLIX.
When the desquamation of the measles is
finished, though there should then be no dis-
order remaining, physicians have thought it
necessary to purge the patient several times,
with a view to draw off the dregs of this dis-
ease, that is, a portion of the morbific matter
which is supposed to remain long in the body.
I cannot reject this supposition; but, at the
same time, cannot believe, that the remains of
the 

53 OF PHYSIC.
the morbific matter, diffused over the whole
mass of blood, can be entirely drawn off by
purging; and it appears to me, that to avoid
the consequences of the measles, it is not the
drawing off the morbific matter which we need
to study, so much as the obviating and re-
moving the inflammatory state of the system
which had been induced by the disease. With
this last view, indeed, purging may still be a
proper remedy; but bleeding, in proportion
to the symptoms of inflammatory disposition,
is yet more so.
DCL.
From our late experience of the benefit of
cold air in the eruptive fever of the small pox,
some physicians have been of opinion, that
the practice might be transferred to the mea-
sles; but we have not yet had trials sufficient
to ascertain this. There is no doubt that ex-
ternal heat may be very hurtful in the mea-
sles, as in most other inflammatory diseases;
and therefore the body ought to be kept in a
moderate temperature during the whole course
of the measles; but how far, at any period of
the disease, cold air may be applied with safe-
ty, we are yet uncertain. Analogy, though
so often the resource of physicians, is, in gen-
eral, fallacious; and further, though the an-
alogy with the small pox might lead to the
application of cold air during the eruptive fe-
ver of the measles, the analogy with catarrh
seems 

54 PRACTICE
seems to be against the practice. After the
eruption had appeared upon the skin, we have
had many instances of cold air making it disap-
pear, and thereby producing much disorder in
the system; and have also had frequent ex-
amples of such disorder being removed by re-
storing the heat of the body, and thereby a-
gain bringing forth the eruption.
CHAP. 

55 OF PHYSIC.
CHAP. IV.
OF THE SCARLET FEVER.
DCLI.
IT may be doubted if the
scarlet fever be a disease specifically different
from the Cynanche Maligna above described.
The latter is almost always attended with a
scarlet eruption; and, in all the instances I
have seen of what may be called the Scarlet
Fever, the disease, in almost every person af-
fected, has been attended with an ulcerous
sore throat.
DCLII.
This view of the matter may create some
doubt; but I am still of opinion, that there is
a scarlet fever which is a disease specifically
different from the Cynanche Maligna.
Doctor Sydenham has described a scarlet
fever, which he had seen prevailing as an ep-
idemic, 

56 PRACTICE
idemic, with all the circumstances of the fever
and eruption, without its being accompanied
with any affection of the throat; at least he
does not take notice of any such affection,
which such an accurate observer could not fail
to have done, if any such symptom, as we have
commonly seen making a principal part of the
disease, had attended those cases which he had
observed. Several other writers have describ-
ed the scarlet fever in the same manner, and
I know physicians who have seen the disease
in that form; so that there can be no doubt of
there being a scarlet fever not necessarily con-
nected with an ulcerous sore throat, and there-
fore a disease different from the Cynanche
Maligna.
DCLIII.
But, further, although in all the instances
of scarlet fever which I have seen, (and in the
course of forty years I have seen it six or seven
times prevailing as an epidemic in Scotland),
the disease, in almost all the persons affect-
ed, was attended with an ulcerous sore throat,
or was what Sauvages names the Scarlatina
Anginosa; and although, in some instances the
ulcers of the throat were of a putrid and
gangrenous kind, and at the same time the dis-
ease in all its symptoms resembled very exact-
ly the cynanche maligna; yet I am still per-
suaded, that not only the Scarlatina of Sy-
denham, but that even the Scarlatina Angino- 
sa.

57 OF PHYSIC.
sa of Sauvages, is a different disease from the
Cynanche Maligna; and I have formed this
opinion from the following considerations.
DCLIV.
1st, There is a scarlet fever entirely free
from any affection of the throat, which some-
times prevails as an epidemic; and therefore
there is a specific contagion producing a scar-
let eruption without any determination to the
throat.
2dly, The Scarlatina, which, from its matter
being generally determined to the throat, may
be properly termed Anginosa, has, in many
cases of the same epidemic, been without any
affection of the throat; and therefore the con-
tagion may be supposed to be more especially
determined to produce the eruption only.
3dly, Though in all the epidemics that I
could allege to be those of the Scarlatina An-
ginosa, there have been some cases, which, in
the nature of the ulcers, and in other circum-
stances, exactly resembled the cases of the
Cynanche Maligna; yet I have as constantly
remarked, that these cases have not been a-
bove one or two in a hundred, while the rest
have all of them been with ulcers of a benign
kind, and with circumstances hereafter to be
described, somewhat different from those of
the Cynanche Maligna.
4thly, On the other hand, as I have two or
three times seen the Cynanche Maligna epi-
demically 

58 PRACTICE
demically prevailing; so, among the persons
affected, I have seen instances of cases as mild
as those of the Scarlatina Anginosa usually
are; but here the proportion was reversed; and
these mild cases were not one fifth of the whole,
while the rest were of the putrid and malignant
kind.
Lastly, It applies to the same purpose to
observe, that of the Cynanche Maligna, most
of the instances terminate fatally; while, on
the other hand, that is the event of very few
of the cases of the Scarlatina Anginosa.
DCLV.
From these considerations, though it may
appear that there is some affinity between the
Cynanche Maligna and Scarlatina Anginosa,
it will still remain probable that the two dis-
eases are specifically different. I have been
at some pains to establish this opinion; for,
from all my experience, I find, that those two
diseases require a different treatment; and I
therefore now proceed to mention more par-
ticularly the circumstances of the Scarlatina
Anginosa.
DCLVI.
This disease commonly appears about the
beginning of winter, and continues through-
out that season. It comes on with some cold
shivering, and other symptoms of the fever
which 

59 OF PHYSIC.
which usually introduces the other exanthe-
mata. But here there is no cough, nor the other
catarrhal symptoms which attend the measles;
nor is there that anxiety and vomiting which
commonly introduce the confluent small pox,
and which more certainly introduce the Cy-
nanche Maligna.
Early in the disease some uneasiness is felt
in the throat; and frequently the deglutition is
difficult, generally more so than in the Cy-
nanche Maligna. Upon looking into the fau-
ces, a redness and swelling appear, in colour
and bulk approaching to the state of these
symptoms in the Cynanche Tonsillaris; but
in the Scarlatina, there is always more or less
of sloughs, which seldom appear in the Cy-
nanche Tonsillaris; and the sloughs are com-
monly whiter than those in the Cynanche
Maligna.
While these appearances are discovered in
the fauces, upon the third or fourth day a
scarlet eruption appears on the skin, in the
same form as described in (CCCXIV.) This
eruption is commonly more considerable and
universal than in the Cynanche; but it sel-
dom produces a remission of the fever. The
eruption for the most part remains till the
third or fourth day after its first appearance;
but then goes off, ending in a mealy des-
quamation. At this time the fever usually
subsides; and, generally, at the same time,
some degree of sweat comes on.
The

60 PRACTICE
The sloughs, on the fauces, which appeared
early in the disease, continue for some days;
but then falling off, discover the swelling a-
bated, and an ulcer formed on one or both
tonsils showing a laudable pus; and soon af-
ter the fever has subsided, these ulcers heal
up entirely. For the most part this disease
has much less of coryza attending it than the
Cynanche Maligna; and, when there is a co-
ryza attending the Scarlatina, the matter dis-
charged is less acrid, and has not the fetid
smell which it has in the other disease.
In the Scarlatina, when the eruption has
entirely disappeared, it frequently happens,
that, in a few days after, the whole body is af-
fected with an anasarcous swelling; which,
however, in a few days more, gradually sub-
sides.
We have thus described the most common
circumstances of the Scarlatina Anginosa;
and have only to add, that, during the time of
its being epidemic, and especially upon its
first setting in, there are always a few cases in
which the circumstances of the disease ap-
proach very nearly to those of the Cynanche
Maligna; and it is only in these instances that
the disease is attended with any danger.
DCLVII.
With respect to the cure of this disease,
when the symptoms of it are nearly the same
with those of the Cynanche Maligna, it
requires 

61 OF PHYSIC.
requires exactly the same treatment as directed
in (CCCXVII.)
DCLVIII.
When the scarlet fever appears without any
affection of the throat, the treatment of it is
very simple, and is delivered by Dr. Syden-
ham. An antiphlogistic regimen is common-
ly all that is requisite; avoiding, on one hand,
the application of cold air; and, on the other,
any increase of external heat.
DCLIX.
In the ordinary state of the Scarlatina An-
ginosa, the same treatment is, in most cases,
sufficient; but as here the fever is commonly
more considerable, and there is likewise an af-
fection of the throat, some remedies may be
often necessary.
DCLX.
When there is a pretty high degree of fe-
ver, with a full pulse, and a considerable
swelling of the tonsils, bleeding is very prop-
er, especially in adults; and it has been fre-
quently practised with advantage; but as,
even in the Cynanche Tonsillaris, much
bleeding is seldom necessary, (CCCV); so, in
the Scarlatina, when the state of the fever and
the appearances of the fauces render the na-
VOL. II. D ture

62 PRACTICE
ture of the disease ambiguous, bleeding may
be omitted; and, if not altogether avoided, it
should at least not be large, and ought not to
be repeated.
DCLXI.
Vomiting, and especially nauseating doses
of emetics, notwithstanding the inflamed state
of the fauces, have been found very useful
in this disease. An open belly is proper in
every form of this disease; and when the
nauseating doses of emetics operate a little
downwards, they are more serviceable.
DCLXII.
In every form of the Scarlatina Anginosa,
through the whole course of it, detergent gar-
gles should be employed, and more or less as
the quantity of sloughs and the viscid mucus
in the fauces may seem to require.
DCLXIII.
Even in the milder states of the Scarlatina
Anginosa, it has been common with practi-
tioners to exhibit the Peruvian bark through
the whole course of the disease; but we are
assured, by much experience, that in such cases
it may be safely omitted, though in cases any
ways ambiguous it may not be prudent to
neglect this remedy. 
DCLXIV. 

63 OF PHYSIC.
DCLXIV.
The anasarcous swelling, which frequently
follows the Scarlatina Anginosa, seldom re-
quires any remedy; and, at least, the purga-
tives so much inculcated, and so commonly
exhibited, soon take off the anasarca.
D2 CHAP. 

64 PRACTICE
CHAP. V.
OF THE PLAGUE.
SECT. I.
Of the PHENOMENA of the PLAGUE.
DCLXV.
THE Plague is a disease
which always arises from contagion; which
affects many persons about the same time;
proves fatal to great numbers; generally pro-
duces fever; and, in most persons, is attended
with buboes or carbuncles.
DCLXVI.
These are the circumstances which, taken
together, give the character of the disease;
but

65 OF PHYSIC.
but it is accompanied with many symptoms
almost peculiar to itself, that in different per-
sons are greatly diversified in number and de-
gree, and should be particularly studied. I
would wish to lay a foundation for this; but
think it unfit for a person who has never seen
the disease to attempt its particular history.
For this, therefore, I must refer to the au-
thors who have written on the subject; but
allowing those only to be consulted, who have
themselves seen and treated the disease in all
its different forms.
DCLXVII.
From the accounts of such authors, it ap-
pears to me, that the circumstances which par-
ticularly distinguish this disease, and especially
the more violent and dangerous states of it,
are,
1st, The great loss of strength in the ani-
mal functions, which often appears early in
the disease.
2dly, The stupor, giddiness, and consequent
staggering, which resembles drunkenness, or
the headach, and various delirium; which are
all of them symptoms denoting a great disor-
der in the functions of the brain.
3dly, The anxiety, palpitation, syncope,
and especially the weakness and irregularity
of the pulse, which denote a considerable dis-
turbance in the action of the heart.
D3 4thly, The 

66 PRACTICE
4thly, The nausea and vomiting, particu-
larly the vomiting of bile, which shows an ac-
cumulation of vitiated bile in the gall bladder
and biliary ducts, and from thence derived
into the intestines and stomach; all of which
symptoms I suppose to denote a considerable
spasm, and loss of tone, in the extreme vessels
on the surface of the body.
5thly, The buboes or carbuncles, which
denote an acrimony prevailing in the
fluids. And,
Lastly, The petechiæ, hemorrhagies, and
colliquative diarrhœa, which denote a putres-
cent tendency prevailing to a great degree in
the mass of blood.
DCLXVIII.
From the consideration of all these symp-
toms, it appears, that the plague is especially
distinguished by a specific contagion, often
suddenly producing the most considerable
symptoms of debility in the nervous system
or moving powers, as well as of a general pu-
trescency in the fluids; and it is from the con-
sideration of these circumstances as the prox-
imate cause, that I think both the prevention
and cure of the plague must be directed.
DCLXIX.
If this disease should revisit the northern
parts of Europe, it is probable, that, at the
time, 

67 OF PHYSIC.
time, there will be no physician then alive,
who, at the first appearance of the disease,
can be guided by his former experience, but
must be instructed by his study of the writers
on this subject, and by analogy. It is, there-
fore, I hope, allowable for me, upon the same
grounds, to offer here my opinion with respect
to both the prevention and cure of this dis-
ease.
This paragraph was written before I had
any notice of the plague of Moscow anno
1771; but I think it will still apply to the
case of Greatbritain and of many other north-
ern states.
SECT. II.
Of the PREVENTION of the PLAGUE.
DCLXX.
WITH respect to the prevention: As we
are firmly persuaded that the disease never a-
rises in the northern parts of Europe, but in
consequence of its being imported from some
other country; so the first measure necessary,
is the magistrate's taking care to prevent the
importation; and this may generally be done
by a due attention to bills of health, and to
the proper performance of quarantines.
D4 DCLXXI. 

68 PRACTICE
DCLXXI.
With respect to the latter, we are persuad-
ed, that the quarantine of persons may safely
be much less than forty days; and, if this were
allowed, the execution of the quarantine would
be more exact and certain, as the temptation
to break it would be in a great measure re-
moved.
DCLXXII.
With respect to the quarantine of goods;
it cannot be perfect, unless the suspected
goods be unpacked and duly ventilated, as
well as the other means employed for cor-
recting the infection they may carry; and, if
all this were properly done, it is probable that
the time commonly prescribed for the quar-
antine of goods might also be shortened.
DCLXXIII.
A second measure, in the way of preven-
tion, becomes requisite, when an infection has
reached and prevailed in any place, to pre-
vent that infection from spreading into other
places. This can be done only by preventing
the inhabitants, or the goods, of any infected
place, from going out of it, till they have un-
dergone a proper quarantine.
DCLXXIV. 

69 OF PHYSIC.
DCLXXIV.
The third measure for prevention, to be
employed with great care, is to hinder the
infection from spreading among the inhab-
itants of the place in which it has arisen.
The measures necessary for this, are to be di-
rected by the doctrine laid down in LXXXII;
and from that doctrine we infer, that all per-
sons who can avoid any near communication
with infected persons, or goods, may escape
the infection.
DCLXXV.
For avoiding such communication, a great
deal may be done by the magistrate; 1. By
allowing as many of the inhabitants as are free
from the infection, and not necessary to the
service of the place, to go out of it. 2. By
prohibiting all assemblies, or unnecessary in-
tercourse, of the people. 3. By taking care
that necessary communications be performed
without contact. 4. By making such ar-
rangements and provisions as may render it
easy for the families remaining to shut them-
selves up in their own houses. 5. By allow-
ing persons to quit houses in which an infec-
tion appears, upon condition that they go in-
to lazarettoes. 6. By ventilating and purify-
ing, or destroying at the public expense, all
infected goods. Lastly, By avoiding hospi-
VOL. 2. D5 tals. 

70 PRACTICE
tals, and providing separate apartments for in-
fected persons.
The execution of these measures will re-
quire great authority, and much vigilance and
attention, on the part of the magistrate; but
it is not our province to enter into any detail
on this subject of the public police.
DCLXXVI.
The fourth and last part of the business of
prevention, respects the conduct of persons
necessarily remaining in infected places, es-
pecially of those obliged to have some com-
munication with persons infected.
DCLXXVII.
Of those obliged to remain in infected
places, but not obliged to have any near com-
munication with the sick, they may be preserv-
ed from the contagion by avoiding all near
communication with other persons, or their
goods; and, it is probable, that a small dis-
tance will answer the purpose, if, at the same
time, there be no stream of air to carry the
effluvia of persons, or goods, to some distance.
DCLXXVIII.
For those who are necessarily obliged to
have a near communication with the sick, it is
proper to let them know, that some of the most
powerful 

71 OF PHYSIC.
powerful contagions do not operate, but when
the bodies of men exposed to the contagion
are in certain circumstances which render
them more liable to be affected by it, or when
certain causes concur to excite the power of
it; and therefore, by avoiding these circum-
stances and causes, they may often escape in-
fection.
DCLXXIX.
The bodies of men are especially liable to
be affected by contagions, when they are any
ways considerably weakened by want of food,
and even by a scanty diet, or one of little nour-
ishment; by intemperance in drinking, which,
when the stupor of intoxication is over, leaves
the body in a weakened state; by excess in
venery; by great fatigue; or by any con-
siderable evacuation.
DCLXXX.
The causes which, concurring with conta-
gion, render it more certainly active, are cold,
fear, and full living.
The several means, therefore, of avoiding,
or guarding against the action of cold (XCIV,
to XCVI) are to be carefully studied.
DCLXXXI.
Against fear the mind is to be fortified as
well as possible, by inspiring a favourable idea
D6 of 

72 PRACTICE
of the power of preservative means; by de-
stroying the opinion of the incurable nature
of the disease; by occupying mens' minds with
business or labour; and by avoiding all ob-
jects of fear, as funerals, passing bells, and any
notice of the death of particular friends.
DCLXXXII.
A full diet of animal food increases the ir-
ritability of the body, and favours the opera-
tion of contagion; and indigestion, whether
from the quantity or quality of food, has the
same effect.
DCLXXXIII.
Besides giving attention to obviate the sev-
eral circumstances (DCX, DCLXXIX, to
DCLXXXII) which favour the operation of
contagion, it is probable that some means may
be employed for strengthening the bodies of
men, and thereby enabling them to resist con-
tagion.
For this purpose, it is probable, that the
moderate use of wine, or of spirituous liquors,
may have a good effect.
It is probable also, that exercise, when it
can be employed, if so moderate as to be nei-
ther heating nor fatiguing to the body, may
be employed with advantage.
Persons who have tried cold bathing, and
commonly feel invigorating effects from it, if
they 

73 OF PHYSIC.
they are anywise secure against having already
received infection, may possibly be enabled to
resist it by the use of the cold bath.
It is probable, that some medicines also may
be useful in enabling men to resist infection;
but amongst these I can hardly admit the nu-
merous alexipharmics formerly proposed; or,
at least, very few of them, and those only of
tonic power. Amongst these last we reckon
the Peruvian bark; and it is perhaps the most
effectual. If any thing is to be expected from
antiseptics, I think camphire, whether inter-
nally or externally employed, is one of the
most promising.
Every person is to be indulged in the use
of any means of preservation of which he has
conceived a good opinion, whether it be a
charm or a medicine, if the latter be not di-
rectly hurtful.
Whether issues be useful in preserving from,
or in moderating the effects of, contagion, I
cannot determine from the observations I have
yet read.
DCLXXXIV.
As neither the atmosphere in general, nor
any considerable portion of it, is tainted or
impregnated with the matter of contagions;
so the lighting of fires over a great part of the
infected city, or other general fumigations in
the open air, are of no use for preventing the
disease, and may perhaps, be hurtful.
DCLXXXV. 

74 PRACTICE
DCLXXXV.
It would probably contribute much to
check the progress of infection, if the poor were
enjoined to make a frequent change of cloth-
ing, and were suitably provided for that pur-
pose; and if they were, at the same time, in-
duced to make a frequent ventilation of their
houses and furniture.
SECT. III.
Of the CURE of the PLAGUE.
DCLXXXVI.
IN the cure of the plague, the indications
are the same as those of fever in general
(CXXVI); but here they are not all equally
necessary and important.
DCLXXXVII.
The measures for moderating the violence
of reaction, which operate by diminishing the
action of the heart and arteries (CXXVIII),
have seldom any place here, excepting so far
as the antiphlogistic regimen is generally prop-
er. Some physicians, indeed, have recom-
mended 

75 OF PHYSIC.
mended bleeding; and there may occur cases
in which bleeding may be useful; but, for the
most part, it is unnecessary, and in many
cases it might be very hurtful.
Purging has also been recommended; and,
in some degree, it may be useful in drawing
off the bile, or other putrescent matters fre-
quently present in the intestines; but a large
evacuation this way may certainly be hurtful.
DCLXXXVIII.
The moderating the violence of reaction,
so far as it can be done by taking off the
spasm of the extreme vessels (CLI), is a meas-
ure of the utmost necessity in the cure of the
plague; and the whole of the means (CLII,
to CC) suited to this indication are extremely
proper.
DCLXXXIX.
The giving an emetic at the very first ap-
proach of the disease, would probably be of
great service; and it is likely, that at some
other periods of the disease, emetics might be
useful, both by evacuating bile abundant in
the alimentary canal, and by taking off the
spasm of the extreme vessels.
DCXC.
From some principles with respect to fever
in general, and with respect to the plague in
particular, 

76 PRACTICE
particular, I am of opinion, that, after the ex-
hibition o£ the first vomit, the body should be
disposed to sweat; which ought to be raised
to a moderate degree only, but continued for
at least twenty four hours, or longer if the pa-
tient bear it easily.
DCXCI.
This sweating should be excited and con-
ducted agreeably to the rules laid down in
(CLXVIII.) It is to be promoted by the
plentiful use of diluents, rendered more grate-
ful by vegetable acids, or more powerful by
being impregnated with some portion of neu-
tral salts.
DCXCII.
To support the patient under the continu-
ance of the sweat, a little weak broth, acidu-
lated with juice of lemons, may be given fre-
quently; and sometimes a little wine, if the
heat of the body be not considerable.
DCXCIII.
If sudorific medicines are judged to be nec-
essary, opiates are the most effectual and safe;
but they should not be combined with aro-
matics; and probably may be more effectual,
if joined with a portion of emetics and of
neutral salts.
DCXCIV. 

77 OF PHYSIC. 
DCXCIV.
If, notwithstanding the use of emetics and
sudorifics, the disease should still continue,
the cure must depend upon the employment
of means for obviating debility and putrescen-
cy; and, for this purpose, the various reme-
dies proposed above (from CCI, to CCXXVII),
may all be administered, but especially the ton-
ics; and of those the chief are cold drink and
the Peruvian bark.
DCXCV.
In the cure of the plague, some attention is
due to the management of buboes and car-
buncles; but we do not touch this, as it be-
longs to the province of surgery.
CHAP. 

78 PRACTICE
CHAP. VI.
OF ERYSIPELAS, OR ST. ANTHONY'S
FIRE.
DCXCVI.
In CCLXXIV I mentioned
the distinction which I proposed to make be-
tween the diseases to be named the Erythema
and the Erysipelas; and from thence it will
appear, that Erysipelas, as an Erythema fol-
lowing fever, may have its place here.
DCXCVII.
I suppose the Erysipelas to depend on a
matter generated within the body, and which,
analogous to the other cases of exanthemata,
is, in consequence of fever, thrown out upon
the surface of the body. I own it may be dif-
ficult to apply this to every particular case of
erysipelas; but I take the case in which it is
generally supposed to apply, that of the ery-
sipelas 

79 OF PHYSIC. 
sipelas of the face; which I shall therefore
consider here.
DCXCVIII.
The Erysipelas of the face comes on with a
cold shivering, and other symptoms of pyrex-
ia. The hot stage of this is frequently attend-
ed with a confusion of head, and some de-
gree of delirium; and almost always with
drowsiness, or perhaps coma. The pulse is
always frequent, and commonly full and hard.
DCXCIX.
When these symptoms have continued for
one, two, or at most three days, there appears,
on some part of the face, a redness, such as
that described in (CCLXXV) as the appear-
ance of Erythema. This redness, at first, is
of no great extent; but gradually spreads
from the part it first occupied to the other
parts of the face, commonly till it has affected
the whole; and frequently from the face it
spreads over the hairy scalp, or descends on
some part of the neck. As the redness
spreads, it commonly disappears, or at least
decreases, in the parts it had before occupied.
All the parts upon which the redness appears
are, at the same time, affected with some swell-
ing, which continues for some time after the
redness has abated. The whole face becomes
considerably 

80 PRACTICE
considerably turgid; and the eyelids are often
so much swelled, as entirely to shut up the
eyes.
DCC.
When the redness and swelling have proceed-
ed for some time, there commonly arise, soon-
er or later, blisters of a larger or smaller size,
on several parts of the face. These contain a
thin yellowish or almost colourless liquor,
which sooner or later runs out. The surface
of the skin, in the blistered places, sometimes
becomes livid and blackish; but this livor sel-
dom goes deeper than the surface, or discovers
any degree of gangrene affecting the skin.
On the parts of the face not affected with blis-
ters, the cuticle suffers, towards the end of the
disease, a considerable desquamation.
Sometimes the tumour of the eyelids ends
in a suppuration.
DCCI.
The inflammation coming upon the face
does not produce any remission of the fever
which had before prevailed; and sometimes
the fever increases with the increasing and
spreading inflammation.
DCCII. 

81 OF PHYSIC.
DCCII.
The inflammation usually continues for
eight or ten days; and for the same time, the
fever and symptoms attending it also con-
tinue.
DCCIII.
In the progress of the inflammation the de-
lirium and coma attending it sometimes go on
increasing, and the patient dies apoplectic on
the seventh, ninth, or eleventh day of the dis-
ease. In such cases, it has been commonly
supposed that the disease is translated from
the external to the internal parts. But I have
not seen any instance in which it did not appear
to me, that the affection of the brain was
merely a communication of the external af-
fection, as this continued increasing at the
same time with the internal.
DCCIV.
When the fatal event does not take place,
the inflammation, after having affected a part,
commonly the whole of the face, and perhaps
the other external parts of the head, ceases.
With the inflammation, the fever also ceases;
and, without any evident crisis, the patient
returns to his ordinary state of health.
DCCV. 

82 PRACTICE
DCCV.
This disease is not commonly contagious;
but as it may arise from an acrid matter ex-
ternally applied, so it is possible that the dis-
ease may sometimes be communicated from
one person to another.
Persons who have once laboured under this
disease are liable to returns of it.
DCCVI.
The event of this disease may be foreseen
from the state of the symptoms which denote
more or less affection of the brain. If neither
delirium nor coma come on, the disease is sel-
dom attended with any danger; but when
these symptoms appear early in the disease,
and are in a considerable degree, the utmost
danger is to be apprehended.
DCCVII.
As this disease often arises in the part, at
the same time with the coming on of the py-
rexia; as I have known it, with all its symp-
toms, arise from an acrimony applied to the
part; as it is commonly attended with a full,
and frequently a hard pulse; as the blood
drawn in this disease shows the same crust upon
its surface that appears in the phlegmasiæ;
and, lastly, as the swelling of the eyelids, in 
this 

83 OF PHYSIC.
this disease, frequently ends in a suppuration;
so, from these considerations, it seems doubt-
ful if this disease be properly, in Nosology,
separated from the Phlegmasiæ. At any
rate, I take the disease I have described to be
what physicians have named the Erysipelas
Phlegmonodes, and that it partakes a great
deal of the nature of the Phlegmasiæ.
DCCVIII.
Upon this conclusion, the Erysipelas of
the face is to be cured very much in the same
manner as phlegmonic inflammations, by
bloodletting, cooling purgatives, and by em-
ploying every part of the antiphlogistic regi-
men; and our experience has confirmed the
fitness of this method of cure.
DCCIX.
The evacuations of bloodletting and purg-
ing are to be employed more or less according
to the urgency of symptoms, particularly those
of the pyrexia, and of those which mark an
affection of the brain. As the pyrexia con-
tinues, and often increases with the inflam-
mation of the face; so the evacuations men-
tioned may be employed at any time in the
course of the disease.
DCCX. 

84 PRACTICE
DCCX.
In this, as in other diseases of the head, it
is proper to put the patient, as often as he
can easily bear it, into somewhat of an erect
posture.
DCCXI.
As in this disease there is always an exter-
nal affection, and as in many instances there
is no other; so various external applications to
the part affected have been proposed; but al-
most all of them are of doubtful effect.
The narcotic, refrigerant, and astringent
applications, are suspected of disposing to
gangrene; spirituous applications seem to in-
crease the inflammation; and all oily or watery
applications seem to occasion its spreading.
The application that seems most safe, and
which is now most commonly employed, is
that of a dry mealy powder frequently sprin-
kled upon the inflamed parts.
DCCXII.
An Erysipelas Phlegmonodes frequently
appears on other parts of the body beside the
face; and such other erysipelatous inflamma-
tions frequently end in suppuration. These
cases are seldom dangerous. At coming on,
they are sometimes attended with drowsiness, 
and 

85 OF PHYSIC. 
and even with some delirium; but this rarely
happens; and these symptoms do not continue
after the inflammation is formed. I have never
seen an instance of the translation of this in-
flammation from the limbs to an internal part;
and though these inflammations of the limbs
be attended with pyrexia, they seldom require
the same evacuations as the erysipelas of the
face. At first they are to be treated by dry
mealy applications only; and all humid ap-
plications, as fomentations, or poultices, are
not to be applied, till, by the continuance of
the disease, by the increase of swelling, or by
a throbbing felt in the part, it appears that the
disease is proceeding to suppuration.
DCCXIII.
We have hitherto considered erysipelas as
in a great measure of a Phlegmonic nature;
and, agreeably to that opinion, we have pro-
posed our method of cure. But it is probable,
that an erysipelas is sometimes attended with,
or is a symptom of, a putrid fever; and, in
such cases, the evacuations proposed above
may be improper, and the use of the Peruvian
bark may be necessary; but I cannot be ex-
plicit upon this subject, as such putrid cases
have not come under my observation.
VOL. II. E CHAP. 

86 PRACTICE
CHAP. VII.
OF THE MILIARY FEVER.
DCCXIV.
THIS disease is said to have
been unknown to the ancients, and that it ap-
peared, for the first time, in Saxony, about
the middle of the last century. It is said to
have spread from thence into all the other parts
of Europe; and, since the period mentioned, to
have appeared in many countries in which it
had never appeared before.
DCCXV.
From the time of its having been first par-
ticularly observed, it has been described and
treated off by many different writers; and by
all of them, till very lately, has been consid-
ered as a peculiar idiopathic disease.
It is said to have been constantly attended
with peculiar symptoms. It comes on with
a cold stage, which is often considerable. The
hot stage which succeeds, is attended with
great

87 OF PHYSIC.
great anxiety, and frequent sighing. The
heat of the body becomes great, and soon pro-
duces profuse sweating; preceded, however,
by a sense of pricking, as of pin points, in the
skin; and the sweat is of a peculiarly rank and
disagreeable odour. The eruption appears
sooner or later in different persons, but at no
determined period of the disease. It seldom
or never appears on the face; but discovers
itself first upon the neck and breast, and from
thence often spreads over the whole body.
DCCXVI.
The eruption named Miliary is said to be
of two kinds; the one named the Red, the
other the White Miliary. The former, which
in English is strictly named a Rash, is com-
monly allowed to be a symptomatic affection;
and as the latter is the only one that has any
pretentions to be considered as an idiopathic
disease, it is this alone that I shall more par-
ticularly describe and treat of in the present
chapter.
DCCXVII.
What then is called the White Miliary
eruption, appears at first like the red, in very
small red pimples, for the most part distinct,
but sometimes clustered together. Their
slight prominence is distinguished better by
the finger than by the eye. Soon after the
E2 appearance 

88 PRACTICE
appearance of this eruption, and at least on
the second day, a small vesicle appears upon
the top of each pimple. At first the vesicle
is whey coloured; but soon becomes white
and stands out like a little globule on the top
of the pimple. In two or three days, these
globules break, or are rubbed off; and are
succeeded by small crusts, which soon after
fall off in small scales. While one set of pim-
ples takes this course, another set succeeds; so
that the disease often continues upon the skin
for many days together. Sometimes when
one crop of this eruption has disappeared, an-
other, after some interval, is produced. And
it has been further observed, that in some per-
sons there is such a tendency to this disease
that they have been affected with it several
times in the course of their lives.
DCCXVIII.
This disease is said to affect both sexes, and
persons of all ages and constitutions; but it
has been observed, at all times, to affect espec-
ially, and most frequently, lying in women.
DCCXIX.
This disease is often accompanied with vio-
lent symptoms, and has frequently proved fa-
tal. The symptoms attending it, are, howev-
er, very various. They are, in one or other
instance, all the several symptoms attending
febrile 

89 OF PHYSIC.
febrile diseases; but I cannot find that any
symptom or concourse of symptoms are stead-
ily the same in different persons, so as to fur-
nish any specific character to the disease.
When the disease is violent, the most common
symptoms are phrenitic, comatose, and con-
vulsive affections, which are also symptoms of
all fevers treated by a very warm regimen.
DCCXX.
While there is such a variety of symptoms
appearing in this disease, it is not to be ex-
pected that any one particular method of cure
can be proposed; and accordingly we find,
in different writers, different methods and
remedies prescribed; frequent disputes about
the most proper; and those received and
practised by some, opposed and rejected by
others.
DCCXXI.
I have thus given an account of what I have
found delivered by authors who have consid-
ered the white miliary fever as an idiopathic
disease; but, now, after having often observed
the disease, I must say that I doubt much if
it ever be such an idiopathic as has been sup-
posed; and I suspect that there is much falla-
cy in what has been written on the subject.
E3 DCCXXII. 

90 PRACTICE
DCCXXII.
It seems to me very improbable, that this
should have been really a new disease when it
was first considered as such. There appear
to me very clear traces of it in authors who
wrote long before that period; and though
there were not, we know that the descriptions
of the ancients were inaccurate and imperfect,
particularly with respect to cutaneous affec-
tions; whilst we know also very well, that
those affections which usually appeared as
symptomatic only, were commonly neglected,
or confounded together under a general ap-
pellation.
DCCXXIII.
The antecedent symptoms of anxiety, sigh-
ing, and pricking of the skin, which have
been spoken of as peculiar to this disease, are,
however, common to many others; and, per-
haps, to all those in which sweatings are forced
out by a warm regimen.
Of the symptoms said to be concomitant of
this eruption, there are none which can be said
to be constant and peculiar but that of sweat-
ing. This, indeed, always precedes and ac-
companies the eruption; and, while the mili-
ary eruption attends many different diseases,
it never, however, appears in any of these, but
after sweating; and, in persons labouring un- 
der

91 OF PHYSIC.
der these diseases, it does not appear, if sweat-
ing be avoided. It is therefore probable, that
the eruption is the effect of sweating; and
that it is the produce of a matter, not before
prevailing in the mass of blood, but generat-
ed, under particular circumstances, in the skin
itself. That it depends upon particular cir-
cumstances of the skin, appears further from
hence, that the eruption seldom or never ap-
pears upon the face, although it affects the
whole of the body besides; that it comes
upon those places especially which are more
closely covered; and that it can be brought
out upon particular parts by external appli-
cations.
DCCXXIV.
It is to be observed, that this eruptive dis-
ease differs from the other exanthemata in
many circumstances; in its not being conta-
gious, and therefore never epidemic; that the
eruption appears at no determined period of
the disease; that the eruption has no deter-
mined duration; that successive eruptions fre-
quently appear in the course of the same fe-
ver; and that such eruptions frequently recur
in the course of the same person's life.
All these circumstances render it extremely
probable, that, in the miliary fever, the mor-
bific matter is not a subsisting contagion com-
municated to the blood, and thence, in conse-
quence of fever and assimilation, thrown out
E4 upon

92 PRACTICE
upon the surface of the body; but a matter
occasionally produced in the skin itself, by
sweating.
DCCXXV.
This conclusion is further rendered proba-
ble from hence, that, while the miliary erup-
tion has no peculiar symptoms, or concourse
of symptoms, belonging to it; yet, upon oc-
casion, it accompanies almost all febrile diseas-
es, whether inflammatory or putrid, if these
happen to be attended with sweating; and
from thence it may be presumed, that the mil-
iary eruption is a symptomatic affection only,
produced in the manner we have said.
DCCXXVI.
But, as this symptomatic affection does not
always accompany every instance of sweating,
it may be proper to inquire, what are the cir-
cumstances which especially determine this e-
ruption to appear? To this, however, I can
give no full and proper answers. I cannot
say that there is any one circumstance which
in all cases gives occasion to this eruption;
nor can I say what different causes may, in
different cases, give occasion to it. There is
only one observation I can offer to the pur-
pose of this inquiry; and it is, that, of the
persons sweating under febrile diseases, those
are especially liable to the miliary eruption,
who 

93 OF PHYSIC.
who have been previously weakened by large
evacuations, particularly of blood. This will
explain why it happens to lying in women
more frequently than to any other persons;
and to confirm this explanation, I have re-
marked, that the eruption happened to women
not in childbed, but who had been much
subjected to a frequent and copious menstru-
ation, and to an almost constant fluor albus.
I have also had occasion to observe it happen
to men in fevers, after wounds from which
they had suffered a great loss of blood.
Further, that this eruption is produced by
a certain state of debility, will appear proba-
ble, from its often occurring in fevers of the
putrid kind, which are always attended with
great debility. It is true, that it also some-
times attends inflammatory diseases, when it
cannot be accounted for in the same manner;
but I believe it will be found to attend espec-
ially those inflammatory diseases in which the
sweats have been long protracted or frequent-
ly repeated, and which have thereby produc-
ed a debility, and perhaps a debilitating pu-
trid diathesis.
DCCXXVII.
It appears so clearly to me that this erup-
tion is always a symptomatic and factitious af-
fection, that I am persuaded it may be in most
cases prevented merely by avoiding sweats.
Spontaneous sweatings, in the beginning of
VOL. 2. E5 diseases, 

94 PRACTICE
diseases, are very rarely critical; all sweatings,
not evidently critical, should be prevented;
and the promoting them, by increasing exter-
nal heat, is commonly very pernicious. Even
critical sweats should hardly be encouraged
by such means. If, therefore, spontaneous
sweats arise, they are to be checked by the
coolness of the chamber; by the lightness and
looseness of the bed clothes; by the persons
laying out their hands and arms, and by their
taking cold drink; and, by these precautions,
I think I have frequently prevented miliary
eruptions, which were otherwise likely to have
appeared, particularly in lying in women.
DCCXXVIII.
But it may happen, when these precautions
have been neglected, or from other circum-
stances, that a miliary eruption does actually
appear; and the question will then be put, how
the case is to be treated? It is a question of
consequence, because I believe that the matter
here generated is often of a virulent kind; it
is frequently the offspring of putrescency; and,
when treated by increasing the external heat
of the body, it seems to acquire a virulence
which produces those symptoms mentioned in
DCCXIX, and proves certainly fatal.
It has been an unhappy opinion with most
physicians, that eruptive diseases were ready
to be hurt by cold; and that it was therefore
necessary to cover up the body very closely, so
as 

95 OF PHYSIC.
as thereby to increase the external heat. We
now know that this is a mistaken opinion;
that increasing the external heat of the body
is very generally mischievous; and that sev-
eral eruptions not only admit, but require the 
application of cold air. We are now persuad-
ed, that the practice which formerly prevailed,
in the case of miliary eruptions, of covering
up the body close, and both by external
means, and internal remedies, encouraging
the sweatings which accompany this eruption,
was highly pernicious, and commonly fatal.
I am therefore of opinion, even when a milia-
ry eruption has appeared, that in all cases
where the sweating is not manifestly critical,
we should employ all the several means of
stopping it that are mentioned above; and I
have sometimes had occasion to observe, that
even the admission of cool air was safe and
useful.
DCCXXIX.
This is, in general, the treatment of miliary
eruptions; but, at the same time, the remedies
suited to the primary disease are to be employ-
ed; and therefore, when the eruption happens
to accompany inflammatory affections, and
when the fulness and hardness of the pulse or
other symptoms show an inflammatory state
present, the case is to be treated by bloodlet-
ting, purging, and other antiphlogistic rem-
edies.
E6 Upon 

96 PRACTICE
Upon the other hand, when the miliary
eruption attends diseases in which debility and
putrescency prevail, it will be proper to avoid
all evacuations, and employ tonic and antisep-
tic remedies, particularly the Peruvian bark,
cold drink, and cold air.
I shall conclude this subject with mention-
ing, that the venerable octogenarian practi-
tioner, de Fischer, when treating of this sub-
ject, in laying down the indications of cure,
has given this as one of them: 'Excretionis
'periphericæ non primariam habere ratio-
'nem.'
CHAP.

97 OF PHYSIC.
CHAP. VIII.
OF THE REMAINING EXANTHE-
MATA.
URTICARIA, PEMPHIGUS, AND APHTHA.
DCCXXX.
THE Nettle Rash is a name
applied to two different diseases. The one is
the chronic eruption described by Dr. He-
berden in the Medical Transactions, Vol. I.
art. xvii. which, as not being a febrile disorder,
does not belong to this place. The other is
the Urticaria of our Synopsis, which, as taken
into every system of Nosology as one of the
Exanthemata Febrilia, is properly to be treat-
ed of here.
DCCXXXI.
I have never observed this disease as conta-
gious and epidemic; and the few sporadic cases
of 

98 PRACTICE
of it which have occurred to me, have seldom
taken the regular course described by authors.
At the same time, as the accounts of different
authors are not very uniform, and hardly con-
sistent, I cannot enter further into the consid- 
eration of this subject; and I hope it is not
very necessary, as on all hands it is agreed to be
a mild disease, and such as seldom requires the
use of remedies. It is generally sufficient to
observe an antiphlogistic regimen, and to keep
the patient in a temperature that is neither
hot nor cold.
DCCXXXII.
The Pemphigus, or Vesicular fever, is a
rare and uncommon disease, and very few in-
stances of it are recorded in the writings of phy-
sicians. As I have never had occasion to see
it, it would be improper for me to treat of it;
and I do not choose to repeat after others,
while the disease has yet been little observed,
and its character does not seem to be exactly
ascertained. Vid. Acta Helvetica, vol. ii. p.
260. Synops. Nosolog. vol. ii. p. 149.
DCCXXXIII
The Aphtha, or Thrush, is a disease better
known; and, as it commonly appears in in-
fants, it is so well understood, as not to need
our treating of it here. As an idiopathic dis-
ease, affecting adults, I have not seen it in this
country;

99 OF PHYSIC.
country; but it seems to be more frequent in
Holland; and, therefore, for the study of it, I
refer to Dr. Boerhaave, and his commentator
Van Swieten, whose works are in every body's
hands.
DCCXXXIV.
The Petechia has been, by all our Nosolo-
gists, enumerated amongst the exanthemata;
but as, according to the opinion of most phy-
sicians, it is very justly held to be always a
symptomatic affection only, I cannot give it
a place here.
BOOK 

100
BOOK IV.
OF HEMORRHAGIES.
CHAP. I.
OF HEMORRHAGY IN GENERAL.
DCCXXXV.
IN establishing a class or or-
der of diseases, under the title of Hemorrha-
gies, Nosologists have employed the single
circumstance of an effusion of red blood, as
the character of such a class or order. By this
means, they have associated diseases which in
their nature are very different; but, in every
methodical distribution, such arbitrary and
unnatural associations should be avoided as 
much as possible. Further, by that manage-
ment 

101 OF PHYSIC.
ment Nosologists have suppressed or lost sight
of an established and well founded distinction
of hemorrhagies into Active and Passive.
DCCXXXVI.
It is my design to restore this distinction;
and I shall therefore here, under the title of
Hemorrhagies, comprehend those only which
have been commonly called Active, that is,
those attended with some degree of pyrexia;
which seem always to depend upon an increas-
ed impetus of the blood in the vessels pouring
it out, and which chiefly arise from an inter-
nal cause. In this I follow Dr. Hoffman,
who joins the active hemorrhagies with the fe-
brile diseases; and have accordingly establish-
ed these hemorrhagies as an order in the class
of pyrexia. From this order I exclude all
those effusions of red blood that are owing en-
tirely to external violence; and all those which,
though arising from internal causes, are, how-
ever, not attended with pyrexia, and which
seem to be owing to a putrid fluidity of the
blood, to the weakness or to the erosion of the
vessels, rather than to any increased impetus
of the blood in them.
DCCXXXVII.
Before proceeding to treat of those proper
hemorrhagies which form an order in our
Nosology, I shall treat of active hemorrhagy
in 

102 PRACTICE
in general; and indeed the several general and
species, to be treated of particularly afterwards,
have so many circumstances in common with
one another, that the general consideration to
be now offered will prove both proper and
useful.
SECT. I.
Of the PHENOMENA of HEMORRHAGY.
DCCXXXVIII.
THE phenomena of hemorrhagy are gen-
erally the following.
Hemorrhagies happen especially in plethor-
ic habits, and to persons of a sanguine tem-
perament. They appear most commonly in
the spring, or in the beginning of summer.
For some time, longer or shorter in differ-
ent cases, before the blood flows, there are
some symptoms of fulness and tension about
the parts from whence the blood is to issue.
In such parts as fall under our view, there are
some redness, swelling, and sense of heat or of
itching; and in the internal parts, from which
blood is to flow, there is a sense of weight and
heat; and, in both cases, various pains are
often felt in the neighbouring parts.
DCCXXXIX. 

103 OF PHYSIC.
DCCXXXIX.
When these symptoms have subsisted for
some time, some degree of a cold stage of py-
rexia comes on, and a hot stage is formed;
during which, the blood flows of a florid col-
our, in a greater or lesser quantity, and contin-
ues to flow for a longer or shorter time; but
commonly, after some time, the effusion spon-
taneously ceases, and together with it the py-
rexia also.
DCCXL.
During the hot stage which precedes an
hemorrhagy, the pulse is frequent, quick, full,
and often hard; but, as the blood flows, the
pulse becomes softer and less frequent.
DCCXLI
In hemorrhagies, blood drawn from a vein
does, upon its concreting, commonly show the
gluten separated, or a crust formed, as in the
cases of Phlegmasiæ. 
DCCXLII.
Hemorrhagies, from internal causes, hav-
ing once happened, are apt, after a certain in-
terval, to return; in some cases very often, and
frequently at stated periods.
DCCXLIII. 

104 PRACTICE
DCCXLIII.
These are, in general, the phenomena of
hemorrhagy; and if in some cases all of them
be not exquisitely marked, or if perhaps some
of them do not at all appear, it imports only,
that, in different cases, the system is more or
less generally affected; and that, in some cas-
es, there are purely topical hemorrhagies, as
there are purely topical inflammations.
SECT. II.
Of the PROXIMATE CAUSE of HEMOR-
RHAGY.
DCCXLIV.
THE pathology of hemorrhagy seems to be
sufficiently obvious. Some inequality in the
distribution of the blood, occasions a congest-
ion in particular parts of the sanguiferous
system; that is, a greater quantity of blood is
poured into certain vessels than their natural
capacity is suited to receive. These vessels
become thereby preternaturally distended;
and this distention, proving a stimulus to
them, excites their action to a greater degree
than usual, which, pushing the blood with un-
usual 

105 OF PHYSIC.
usual force into the extremities of these vessels,
opens them by anastomosis, or rupture; and,
if these extremities be loosely situated on ex-
ternal surfaces, or on the internal surfaces of
certain cavities that open outwardly, a quanti-
ty of blood flows out of the body.
DCCXLV.
This, reasoning will, in some measure, ex-
plain the production of hemorrhagy. But it
appears to me, that, in most cases, there are
some other circumstances that concur to pro-
duce it; for it is probable, that in consequence
of congestion, a sense of resistance arises, and
excites the action of the Vis Medicatrix Na-
turæ; the exertions of which are usually made
by the formation of a cold stage of pyrexia,
inducing a more vigorous action of the ves-
sels; and the concurrence of this exertion
more effectually opens the extremities, and
occasions the flowing out of the blood.
DCCXLVI.
What has been delivered in the two preced-
ing paragraphs, seems to explain the whole
phenomena of hemorrhagy, except the cir-
cumstance of its frequent recurrence, which I
apprehend may be explained in the following
manner. The congestion and consequent ir-
ritation being taken off by the flowing of the
blood; this, therefore, soon after, spontane-
ously 

106 PRACTICE
ously ceases; but, at the same time, the in-
ternal causes which had before produced the
unequal distribution of the blood, commonly
remain, and must now operate the more read-
ily, as the overstretched and relaxed vessels of
the part will more easily admit of a congest-
ion of blood in them, and, consequently, pro-
duce the same series of phenomena as before.
DCCXLVII.
This may sufficiently explain the ordinary
return of hemorrhagy; but there is still an-
other circumstance, which, as commonly con-
curring, is to be taken notice of; and that is,
the general plethoric state of the system,
which renders every cause of unequal distri-
bution of more considerable effect. Though
hemorrhagy may often depend upon the state
of the vessels of a particular part being favour-
able to a congestion's being formed in them;
yet, in order to that state's producing its ef-
fect, it is necessary that the whole system
should be at least in its natural plethoric con-
dition; and, if this should be in any degree
increased beyond what is natural, it will still
more certainly determine the effects of topical
conformation to take place. The return of
hemorrhagy, therefore, will be more cer-
tainly occasioned, if the system becomes pre-
ternaturally plethoric; but hemorrhagy has
always a tendency to increase the plethoric 
state 

107 OF PHYSIC.
state of the system, and, consequently, to oc-
casion its own return.
DCCXLVIII.
To show that hemorrhagy does contribute
to produce or increase the plethoric state of
the system, it is only necessary to observe,
that the quantity of serous fluids being given;
the state of the excretions depends upon a cer-
tain balance between the force of the larger
arteries propelling the blood, and the resist-
ance of the excretories; but the force of the
arteries depends upon their fulness and dis-
tention, chiefly given to them by the quanti-
ty of red globules and gluten, which are, for
the greatest part, confined to the red arteries;
and therefore, the spoliation made by an hem-
orrhagy, being chiefly of red globules and
gluten, the effusion of blood must leave the
red arteries more empty and weak. In con-
sequence of the weaker action of the red ar-
teries, the excretions are in proportion dimin-
ished; and, therefore, the ingesta continuing
the same, more fluids will be accumulated in
the larger vessels. It is by this means that
the loss of blood by hemorrhagies, whether ar-
tificial or spontaneous, if within certain bounds,
is commonly so soon recovered; but, as the
diminution of the excretions, from a less
quantity of fluid being impelled into the ex-
cretories, gives occasion to these vessels to fall
into a contracted state; so, if this shall contin-
ue 

108 PRACTICE
ue long, these vessels will become more rigid
and will not yield to the same impelling force as
before. Although the arteries, therefore, by
new blood collected in them, shall have recov-
ered their former fulness, tension, and force;
yet this force will not be in balance with the
resistance of the more rigid excretories, so as
to restore the former state of excretion; and
consequently, a further accumulation will take
place in the arteries, and an increase of their
plethoric state be thereby induced. In this
manner, we perceive more clearly, that hem-
orrhagy, as producing a more plethoric state
of the system, has a tendency to occasion its
own recurrence with greater violence; and,
as the renewal and further accumulation of
blood require a determinate time, so, in the
several repetitions of hemorrhagy, that time
will be nearly the same; and therefore the re-
turns of hemorrhagy will be commonly at
stated periods, as has been observed frequent-
ly to happen.
DCCXLIX.
I have thus explained the nature of hem-
orrhagy in general, as depending upon some
inequality in the distribution of the blood,
occasioning a congestion of it in particu-
lar parts of the sanguiferous system. It is in-
deed probable, that, in most persons, the sev-
eral parts of the sanguiferous system are in
balance with one another; and that the den-
sity,

109 OF PHYSIC.
sity, and consequently the resistance, in the
several vessels, is in proportion to the quantity
of blood which each should receive; from
whence it frequently happens, that no ine-
quality in the distribution of the blood takes
place in the course of a long life. If, howev-
er, we consider that the sanguiferous system
is constantly in a plethoric state, that is, that
the vessels are constantly distended beyond
that size which they would be if free from
any distending force, we shall be satisfied that
this state may be readily changed. For as,
on the one hand, the vessels are elastic, so as to
be under a constant tendency to contract up-
on the withdrawing of any part of the distend-
ing force; and, on the other hand, are not so
rigid but that, by an increase of the impetus
of the blood in them, they may be more than
ordinarily distended; so we can easily under-
stand how, in most persons, causes of an in-
creased contraction or distention may arise in
one part or other of the system, or that an un-
equal distribution may take place; and how,
in an exquisitely distended or plethoric system,
a small inequality in the distribution of the
blood may form those congestions which give
occasion to hemorrhagy.
DCCL.
In this manner I endeavour to explain how
hemorrhagy may be occasioned at any period
of life, or in any part of the body; but hem-
VOL. II. F orrhagies 

110 PRACTICE
orrhagies happen in certain parts more fre-
quently than in others, and at certain periods
of life more readily than at others; and there-
fore, in delivering the general doctrine of
hemorrhagy, it may be required that I should
explain those circumstances which produce
the specialties mentioned; and I shall now
attempt it.
DCCLI.
The human body, from being of a small
bulk at its first formation, grows afterwards to
a considerable size. This increase of bulk
consists, in a great measure, in the increase of
the quantity of fluids, and a proportional en-
largement of the containing vessels. But, at
the same time, the quantity of solid matter is
also gradually increased; and, in whatever
manner we may suppose this to be done, it is
probable that the progress, in the whole of
the growth of animal bodies, depends upon
the extension of the arterial system; and such
is the constitution of the sanguiferous system,
that the motion of the blood in the arteries
has a constant tendency to extend them in ev-
ery dimension.
DCCLII.
As the state of the animal solid is, at the
first formation of the body, very lax and
yielding; so the extension of the system pro-
ceeds, 

111 OF PHYSIC.
ceeds, at first, very fast; but, as the extension
gives occasion to the apposition of more mat-
ter to the solid parts, these are, in proportion
to their extension, constantly acquiring a great-
er density, and therefore giving more resist-
ance to their further extension and growth.
Accordingly, we observe, that as the growth
of the body advances, its increase, in any giv-
en time, becomes proportionally less and less,
till at length it ceases altogether.
DCCLIII.
This is the general idea of the growth of
the human body, till it attain the utmost bulk
which it is capable of acquiring; but it is to
be remarked, that this growth does not pro-
ceed equally in every part of the body; it
being requisite for the economy of the system,
that certain parts should be first evolved, and
should also acquire their full bulk sooner than
others. This appears particularly with re-
spect to the head; the parts of which appear
to be first evolved, and soonest to acquire their
full size.
DCCLIV.
To favour this unequal growth, it is pre-
sumed, that the dimensions or the laxity of
the vessels of the head, or that the direction
of the force of the blood, are adapted to the
purpose; and from what has been said in
F2 DCCLII, 

112 PRACTICE
DCCLII, it will also certainly follow, that as
the vessels of the head grow fastest, and soon-
est acquire their full size, so they will soonest
also acquire that density which will prevent
their further extension. While, however, the
force of the heart, and the quantity of the flu-
ids, with respect to the whole system, remain
the same, the distending and extending pow-
ers will be directed to such parts as have not
yet acquired the same density and dimensions
as those first evolved; and thus the distending
and extending powers will proceed to operate
till every part of the system, in respect of den-
sity and resistance, shall have been brought to
be in balance with every other, and till the
whole be in balance with the force of the heart,
so that there can be no further growth in any
particular part, unless some preternatural cir-
cumstance shall happen to arise.
DCCLV.
In this process of the growth of the body,
as it seems in general to depend upon a cer-
tain balance between the force of the heart or
distending power, and the resistance of the
solids; so it will appear, that, while the solids
remain very lax and yielding, some occasion-
al increase of the distending power may arise
without producing any very perceptible dis-
order in the system. But, it will also appear,
that, in proportion as the distending power
and resistance of the solids come to be more
nearly 

113 OF PHYSIC.
nearly in exact balance with one another, so
any increase of the distending power will more
readily produce a rupture of vessels, which
do not easily yield to extension.
DCCLVI.
From all this, it must follow, that the ef-
fects of any unusually plethoric state of the
system, will be different according as this shall
occur at different periods of the growth of
the body. Accordingly, it is evident, that if
the plethoric state arises while the head is yet
growing, and while the determination of the
blood is still more to the head than to the
other parts, the increased quantity of the
blood will be especially determined to the
head; and as there also, at the same time, the
balance between the distending and extending
powers is most nearly adjusted, so the deter-
mination of the blood will most readily pro-
duce in that part a rupture of the vessels, or an
hemorrhagy. Hence it is, that hemorrhagies
of the nose so frequently happen in young
persons; and in these more readily, as they
approach nearer to their acmé, or full growth;
or, it may be said, perhaps more prop-
erly, as they approach nearer to the age of
puberty, when perhaps, in both sexes, but es-
pecially in the female, a new determination
arises in the system.
F3 DCCLVII. 

114 PRACTICE
DCCLVII.
The determination of a greater quantity of
blood to the vessels of the head, might be sup-
posed to occasion a rupture of vessels in other
parts of the head as well as in the nose; but
such a rupture does not commonly happen;
because, in the nose, there is, for the purpose
of sense, a considerable network of blood ves-
sels expanded on the internal surface of the
nostrils, and covered only with thin and weak
teguments. From this circumstance it is, that
upon any increased impetus of the blood in
the vessels of the head, those of the nose are
most easily broken; and the effusion from the
nose taking place, it not only relieves the oth-
er extremities of the external carotid, to which
the arteries of the nose chiefly belong, but
relieves also, in a great measure, the system of
the internal carotid. For, from the internal
carotid, certain branches are sent to the nose,
are spread out on its internal surface, and
probably inosculated with the extremities of
the external carotid; so that, whichsoever of
the extremities are broken, the vis deriva-
tionis of Haller will take place; the effusion
will relieve the whole sanguiferous system of
the head; and the same effusion will also com-
monly prevent an hemorrhagy happening at
the same time in any other part of the body.
DCCLVIII.

115 OF PHYSIC.
DCCLVIII.
From these principles, it will appear why
hemorrhagies of the nose, so frequent before
the period of puberty, or of the acmé, seldom
happen after these periods; and I must ob-
serve further, that although they should oc-
cur, they would not afford any objection to
my doctrine, as such hemorrhagies might be
imputed to a peculiar laxity of the vessels of
the nose, and perhaps to a habit acquired with
respect to these vessels, while the balance of
the system might be otherwise duly adjusted.
DCCLIX.
When the process of the growth of the
body goes on regularly, and the balance of
the system is properly adjusted to the gradu-
al growth of the whole, as well as to the suc-
cessive growth of the several parts, even a ple-
thoric state does not produce any hemorrhagy,
or at least any after that of the nose; but if,
while the plethoric state continues, any ine-
quality shall also subsist in any of the parts of
the system, congestions, hemorrhagic or in-
flammatory, may be still readily formed.
DCCLX.
In general, it may be observed, that, when
the several parts of the system of the aorta
F4 have 

116 PRACTICE
have attained their full growth, and are duly
balanced with one another, if then any con-
siderable degree of plethora remain or arise,
the nicety of the balance will be between the
systems of the aorta and pulmonary artery, or
between the vessels of the lungs and those of
all the rest of the body. And although the
lesser capacity of the vessels of the lungs is
commonly compensated by the greater veloci-
ty of the blood in them; yet if this velocity
be not always adjusted to the necessary com-
pensation, it is probable that a plethoric state
of the whole body will always be especially
felt in the lungs; and therefore, that an hem-
orrhagy, as the effect of a general plethora,
may be frequently occasioned in the lungs,
even though there be no fault in their con-
formation.
DCCLXI.
In some cases, perhaps, an hemorrhagy
from the lungs, or an hemoptysis, does arise
from the general plethoric state of the body;
but an hemoptysis more frequently does, and
may be expected to happen, from a faulty pro-
portion between the capacity of the lungs and
that of the rest of the body.
DCCLXII.
When such a disproportion takes place, it
will be evident that an hemoptysis will espec-
ially 

117 OF PHYSIC.
ially happen about the time that the body is
approaching to its acmé; that is, when the
system of the aorta has arrived at its utmost
extension and resistance, and when therefore,
the plethoric state of the whole must especial-
ly affect the lungs.
DCCLXIII.
Accordingly it has been constantly observ-
ed that the hemoptysis especially occurs
about the time of the body's arriving at its
acmé; but I must remark also, that the hem-
orrhagy may occur sooner or later, according
as the balance between the vessels of the lungs,
and those of the system of the aorta, happens
to be more or less exactly adjusted to one an-
other; and it may therefore often occur much
later than the period mentioned, when that
balance, though not quite even, is however
not so ill adjusted, but that some other con-
curring causes are necessary to give it effect.
DCCLXIV.
It was anciently remarked by Hippocrates,
and has been confirmed by modern observa-
tion, that the hemoptysis generally occurs in
persons between the age of fifteen and that of
five and thirty; that it may happen at any
time between these two periods; but that it
seldom happens before the former, or after the
VOL. 2. F5 latter; 

118 PRACTICE
latter; and it may be proper here to inquire
into the reason of these two limitations.
DCCLXV.
With respect to the first, the reason of it
has been already explained in DCCLXII
and DCCLXIII.
With respect to the second limitation, I
expect that the reason of it will be understood
from the following considerations.
It has been already observed, that the ex-
tension and growth of the body require the
plethoric state of the arterial system; and
nature has provided for this, partly by the
constitution of the blood being such, that
a great portion of it is unfit to pass into the
exhalants and excretories; partly by giving
a certain density and resistance to the several
exhalants and excretories through which the
fluids might pass out of the red arteries; and
partly, but especially, by a resistance in the
veins to the free passage of the blood into
them from the arteries.
DCCLXVI.
With respect to this last and chief circum-
stance, it appears from the experiments of
Sir Clifton Wintringham, in his Experiment-
al Inquiry, that the proportional density of
the coats of the veins to that of the coats of
the arteries, is greater in young than in old
animals: 

119 OF PHYSIC.
animals: From which it may be presumed
that the resistance to the passage of the blood
from the arteries into the veins, is greater
in young animals than in old; and, while this
resistance continues, the plethoric state of the
arteries must be constantly continued and sup-
ported. As however the density of the coats
of the vessels, consisting chiefly of a cellular
texture, is increased by pressure; so, in pro-
portion as the coats of the arteries are more
exposed to pressure by distention than
those of the veins, the former, in the prog-
ress of the growth of the body, must increase
much more in density than the latter; and
therefore the coats of the arteries, in respect
of density and resistance, must come in time,
not only to be in balance with those of the
veins, but to prevail over them: A fact which
is sufficiently proved by the experiments of
the above mentioned ingenious author.
By these means, the proportional quanti-
ties of blood in the arteries and veins must
change in the course of life. In younger
animals, the quantity of blood in the arteries
must be proportionally greater than in old
ones; but, by the increasing density of the
arteries, the quantity of blood in them must
be continually diminishing, and that in the
veins be proportionally increasing, so as at
length to be in a proportionally greater quan-
tity than that in the arteries. When this
change happens in the proportional quanti-
ties of the blood in the arteries and veins, it
F6 must 

120 PRACTICE
must be evident that the plethoric state of the
arteries will be in a great measure taken off;
and therefore that the arterial hemorrhagy is
no longer likely to happen; but that, if a
general plethoric state afterwards take place
in the system, it must especially appear in
the veins.
DCCLXVII.
The change I have mentioned to happen
in the state of the arterial and venous systems,
is properly supposed to take place in the hu-
man body about the age of thirty five; when
it is manifest that the vigour of the body,
which depends so much upon the fulness and
tension of the arterial system, no longer
increases; and therefore it is, that the same
age is the period, after which the arterial
hemorrhagy, hemoptysis, hardly ever ap-
pears. It is true there are instances of the
hemoptysis happening at a later period; but
it is for the reasons given (DCCLVIII),
which show that an hemorrhagy may happen
at any period of life, from accidental causes
forming congestions, independent of the state
of the balance of the system at that particular
period.
DCCLXVI.
I have said (DCCLXVI), that if after
the age of thirty five, a general and preter-
natural 

121 OF PHYSIC.
natural plethoric state occur, it must espec-
ially appear in the venous system; and I must
now observe, that this venous plethora may
also give occasion to hemorrhagy.
DCCLXIX.
If a plethoric state of the venous system
take place, it is to be presumed, that it will
especially and in the first place affect the sys-
tem of the vena portarum, in which the mo-
tion of the venous blood is more slow than
elsewhere; in which the motion of the blood
is little assisted by external compression; and
in which, from the want of valves in the
veins that form the vena portarum, the mo-
tion of the blood is little assisted by the com-
pression that is applied; while, from the same
want of valves in those veins, the blood is
more ready to regurgitate in them. Wheth-
er any regurgitation of the blood can pro-
duce an action in the veins, and which invert-
ed or directed towards their extremities, can
force these, and occasion hemorrhagy, may
perhaps be disputed: But it appears to me,
that an hemorrhagy, produced by a plethor-
ic state of the veins, may be explained in
another and more probable manner. If the
blood be accumulated in the veins, from any
interruption of its proper course, that accu-
mulation must resist the free passage of the
blood from the arteries into the veins. This,
again, must produce some congestion in the
extremities

122 PRACTICE
extremities of the red arteries, and therefore
some increased action in them, which must be
determined with more than usual force,
both upon the extremities of the arteries, and
upon the exhalants proceeding from them;
and this force may occasion an effusion of
blood, either by anastomosis or rupture.
DCCLXX.
In this manner I apprehend the hemor-
rhoidal flux is to be explained, so far as it
depends upon the state of the whole system.
It appears most commonly to proceed from
the extremities of the hemorrhoidal vessels;
which being the most dependent and distant
branches of those veins that form the vena
portarum, are therefore the most readily af-
fected by every accumulation of blood in that
system of veins, and consequently by any
general plethora in the venous system.
DCCLXXI.
It is here to be observed, that I have spok-
en of this hemorrhagy as proceeding from the
hemorrhoidal vessels only, as indeed it most
commonly does; but it will be readily under-
stood, that the same accumulation and resist-
ance to the venous blood may, from various
causes, affect many of the extremities of the
vena portarum, which lie very superficially
upon the internal surface of the alimentary
canal, 

123 OF PHYSIC. 
canal, and give occasion to what has been
called the Morbus Niger or Melœna.
DCCLXXII.
Another part, in which an unusually ple-
thoric state of the veins may have particular
effects, and occasion hemorrhagy, is the head.
In this, the venous system is of a peculiar con-
formation, and such as seems intended by na-
ture to give there a slower motion to the ven-
ous blood. If, therefore, the plethoric state
of the venous system in general, which seems
to increase as life advances, should at length
increase to a great degree, it may very readily
affect the venous vessels of the head, and pro-
duce there such a resistance to the arterial
blood, as to determine this to be poured out
from the nose, or into the cavity of the crani-
um. The special effect of the latter effusion
will be to produce the disease termed Apo-
plexy; and which, therefore, is properly
named by Doctor HOFFMAN, Hæmorrhagia
Cerebri: And the explanation of its cause,
which I have now given, explains well why it
happens especially to men of large heads and
short necks, and to men in the decline of life,
when the powers promoting the motion of the
blood are much weakened.
DCCLXXIII.
I have thus attempted to give the history
of the plethoric and hemorrhagic states of
the 

124 PRACTICE
the human body, as they occur at the differ-
ent periods of life; and hope I have thereby
explained, not only the nature of hemorrha-
gy in general, but also of the particular hem-
orrhagies which most commonly appear, and
as they occur successively at the different pe-
riods of life.
SECT. III.
Of the REMOTE CAUSES of HEMORRHAGY.
DCCLXXIV.
IN the explanation hitherto given, I have
especially considered the predisposition to
hemorrhagy; but it is proper also, and even
necessary, to take notice of the occasional
causes, which not only concur with the pre-
disponent, in exciting hemorrhagy, but may
also sometimes be the sole causes of it.
DCCLXXV. 
These occasional causes are,
1. External heat, which, by rarefying the
blood, produces or increases the plethoric
state of the body; and the same heat, as giv-
ing a stimulus to the whole system, must urge
any particular determinations before establish- 
ed, 

125 OF PHYSIC.
ed, still further, or may urge to excess any
inequality, otherwise innocent; so that, in
either way, external heat may immediately
excite hemorrhagies, to which there was a
predisposition; or may form congestions
where there were none before, and thereby oc-
casion hemorrhagy.
2. A considerable and sudden diminution
of the weight of the atmosphere, which seems to
occasion the same effects as heat, by produc-
ing also an expansion of the blood.
3. Whatever increases the force of the cir-
culation, and thereby the velocity of the
blood, may operate in the same manner as
heat, in urging not only previous determina-
tions with violence, but also in urging to ex-
cess inequalities, otherwise innocent. All vi-
olent exercise, therefore, and especially all
violent efforts, which, not only by a larger
and longer inspiration, but also, by the simul-
taneous action of many muscles interrupting
the free motion of the blood, impel it with un-
usual force into the extreme vessels more gen-
erally, and, according to the different pos-
tures of the body, and mode of the effort, into
certain vessels more particularly.
Among the causes increasing the force of
the circulation, anger and other violent active
passions are to be reckoned.
4. The violent exercise of particular parts
of the body. If these are already affected
with congestions, or liable to them, such ex-
ercise may be considered as a stimulus applied
to 

126 PRACTICE
to the vessels of that particular part. Thus,
any violent exercise of respiration may excite
hemoptysis, or occasion its return.
5. The postures of the body increasing de-
terminations, or ligatures occasioning accu-
mulations of the blood in particular parts of
the body.
6. A determination into certain vessels ren-
dered habitual by the frequent repetition of
hemorrhagy from them.
7. Cold, externally applied, as changing
the distribution of the blood, and determin-
ing it in greater quantity into the internal
parts.
SECT. IV.
Of the CURE of HEMORRHAGY.
DCCLXXVI.
HAVING thus considered the proximate
and remote causes of hemorrhagy in general,
our next business is, to treat of the cure of the
disease in the same manner.
In entering upon this subject, the first
question which presents itself, is, Whether
the cure of hemorrhagies ought to be at-
tempted by art, or if they should be left to the
conduct of nature?
DCCLXXVII. 

127 OF PHYSIC.
DCCLXXVII.
The latter opinion was the favourite doc-
trine of the celebrated Dr. STAHL, and his
followers. They maintained, that the hu-
man body is much disposed to a plethoric
state; and, consequently, to many disorders
which nature endeavours to obviate and re-
lieve by exciting hemorrhagy: That this,
therefore, is often necessary to the balance
and health of the system: That it is accord-
ingly to be generally encouraged, sometimes
solicited, and is not to be suppressed, unless
when it goes to great excess, or happens in
parts in which it may be dangerous.
DCCLXXVIII.
Much of this doctrine may be admitted.
The human body, upon many occasions, be-
comes preternaturally plethoric; and the
dangerous consequences which might from
thence be apprehended, seem to be obviated
by an hemorrhagy taking place: And, fur-
ther, the necessity of hemorrhagy often ap-
pears from hence, that the suppression of it
seems to occasion many disorders.
All this seems to be just; but in the con-
clusion drawn from it there is a fallacy.
DCCLXXIX. 

128 PRACTICE
DCCLXXIX.
It appears to me certain, that hemorrhagy,
either upon its first attack, or upon its after
recurrence, is never necessary to the health of
the body, excepting upon the supposition,
that the plethoric state which seems to require
the evacuation, cannot be otherwise prevent-
ed or removed; and as I imagine it possible
by other means to prevent or remove a ple-
thoric state, so I do not think that hemorrhagy
is, in all cases, necessary. In general, I am
of opinion that hemorrhagy is to be avoided,
1. Because it does not always happen in
parts where it is safe.
2. Because often, while it does relieve a
plethoric state, it may, at the same time, in-
duce a very dangerous disease.
3. Because it may often go to excess, and
either endanger life, or induce a dangerous
infirmity.
And, lastly, Because it has a tendency to
increase the plethoric state it was meant to re-
lieve; to occasion its own recurrence,
(DCCXXI); and thereby to induce a habit,
which, if left to the precarious and unequal
operation of nature, may, from the frequent
errors of this, be attended with much danger.
DCCLXXX.
It is further to be considered, that hemor-
rhagies do not always arise from the necessities
of 

129 OF PHYSIC.
of the system, but often proceed from inci-
dental causes. It appears to me that all
hemorrhagies of the latter kind may be im-
mediately suppressed, and the repetition of
them, as it induces a plethora, and a habit
not otherwise necessary, may be prevented
with great advantage.
DCCLXXXI.
Upon the whole of this subject, I conclude,
that every preternatural hemorrhagy, or, in
other words, every one except that of the
menses in females, is to be avoided, and es-
pecially the returns of it prevented; and I
therefore now proceed to mention, how hem-
orrhagy, and its recurrences, may, and
should be prevented.
DCCLXXXII.
From the principles delivered above, it
will immediately appear, that the prevention,
either of the first attacks, or of the returns of
hemorrhagy, will chiefly, and in the first
place, depend upon the preventing or re-
moving any considerable degree of a plethoric
state which may happen to prevail in the
body. It is true, that, where the hemorrhagy
depends upon the particular conformation of
certain parts, rather than upon the general
plethoric state of the whole; the measures for
removing or preventing the latter, may not
always 

130 PRACTICE
always be sufficient for preventing hemorrha-
gy: But at the same time it must be evident,
that determinations in consequence of the
conformation of particular parts, will always
be urged more or less, in proportion to the
greater or lesser degree of the plethoric state of
the whole system; and, therefore, that, even
in the cases depending upon particular con-
formation, the preventing or removing an un-
usually plethoric state, will always be a chief
means of preventing hemorrhagy. It is fur-
ther to be attended to, that there may be sev-
eral inequalities in the balance of the system,
which may have little or no effect unless when
the system becomes preternaturally plethor-
ic; and therefore, that in cases, the pre-
venting or removing of the plethoric state
of the system will be a chief means of prevent-
ing the first attacks, or the returns of hemor-
rhagy. It now, therefore, remains to ex-
plain, how the plethoric state of the system is
to be prevented or removed.
DCCLXXXIII.
The fluids of the human body are in con-
tinual waste by the excretions, but are com-
monly replaced by the aliments taken in;
and if the quantity of aliments in any measure
exceed that of the excretions, an increase of
the quantity of the fluids of the body, or, in
other words, a plethoric state, must necessarily
arise. This, to a certain degree, is requisite for 
the

131 OF PHYSIC.
the growth of the body: But even then, if
the proportion of the aliments to the excre-
tions be greater than is suited to the growth
of the body; and more certainly still, if,
after the growth is completed, when an
equality between the ingesta and the excreta
should be established, the disproportion still
continue, a preternaturally plethoric state
must arise. In both cases, it is evident, that
the plethora must be prevented or corrected
by adjusting the ingesta and excreta to each
other; which generally may be done, either
by diminishing the ingesta, or by increasing
the excreta. The former may be effected by
the management of diet, the latter by the
management of exercise.
DCCLXXXIV.
The ingesta may be diminished, either by
giving aliment in less quantity than usual, or
by giving aliments of a less nutritious quality;
that is, aliments of a substance, which, under
the same bulk and weight, contain less of a
matter capable of being converted into animal
fluids, and more of a matter ready to pass
off by the excretions, and consequently less of
a matter to be retained and accumulated in
the vessels.
The choice of aliments suited to these pur-
poses, must be left to be directed by the doc-
trines of the Materia Medica.
DCCLXXXV. 

132 PRACTICE
DCCLXXXV.
The increasing of the excreta, and thereby
diminishing the plethoric state of the system
is to be obtained by increasing the exer-
cise of the body; and generally for adjust-
ing the balance between the ingesta and ex-
creta, and thereby obviating the plethoric
state, it is necessary that exercise, in a due
measure, be very constantly employed.
DCCLXXXVI.
The observing abstinence, and the em-
ployment of exercise, for obviating or remov-
ing the plethoric state of the body, were for-
merly considered pretty fully, when treating
of the gout, (DXLVIII) to (DLII); so
that the less is necessary to be said here: And
it is now only requisite to observe, that the same
doubts, as in cases of the gout, do not occur
here with regard to the safety of those meas-
ures, which, in a plethoric state of the body
disposing to hemorrhagy, are always admis-
sible and proper. Here, however, it is to be
observed, that some choice in the mode of ex-
ercise is necessary, and that it should be dif-
ferent according to the particular determina-
tions which may happen to prevail in the sys-
tem. In general, in the case of plethora dis-
posing to hemorrhagy, bodily exercise will
always be hazardous, and gestation more
commonly safe.
DCCLXXXVII. 

133 OF PHYSIC.
DCCLXXXVII.
Artificial evacuations may be employed to
diminish the plethoric state of the body; and
when, at any time, it has become considera-
ble, and immediately threatens a disease,
these evacuations should be made to the
quantity that the symptoms seem to require.
But it is constantly to be attended to, that
bloodlettings are improperly, employed to
prevent a plethora, as they have a tendency
to increase it (DCCXXI); and as they re-
quire to be often repeated, and are thereby
apt to induce a habit which may be attend-
ed with much danger.
DCCLXXXVIII.
While a plethora, and thereby the predis-
position to hemorrhagy, is avoided, or re-
moved, the other measures necessary for pre-
venting the occurrence of this, are those for
avoiding the remote causes. These have
been enumerated in (DCCLXXV); and
the means of avoiding them, so far as within
our power, are sufficiently obvious.
DCCLXXXIX.
Having thus mentioned the means of pre-
venting either the first attacks, or the recur-
rence of hemorrhagy; I must next say how
VOL. II. G it 

134 PRACTICE
it is to be managed when it has actually come
on.
DCCXC. 
When an hemorrhagy has come on which
appears to have arisen from a preternaturally
plethoric state, or from some change in the
balance of the sanguiferous system, no meas-
ures are to be immediately taken for sup-
pressing it; as we may expect, that, when
the quantity of blood necessary for the re-
lief of the system is poured out, the effusion
will spontaneously cease.
DCCXCI.
In many cases, however, it may be sus-
pected, that the quantity of blood poured
out, is not exactly in proportion to the ne-
cessities of the system, either for relieving a
general plethora or a particular congestion,
but that it is often to a greater quantity than
these require. This we supposed to happen 
in consequence of an inflammatory diathesis
prevailing, and of a febrile spasm being
formed; and therefore it is in many cases
proper, as well as for the most part safe, to
moderate the evacuation; and when it threat-
ens to go to excess, to suppress it altogether.
DCCXCII. 

135 OF PHYSIC.
DCCXCII.
An hemorrhagy may be moderated by
avoiding any irritation that might concur to
increase it; so that every part of the anti-
phlogistic regimen is to be observed; in par-
ticular external heat, both as it rarefies the
fluids, and stimulates the solids, is to be care-
fully avoided: And it is probable, that in all
cases an hemorrhagy may be safely moderated
by cool air applied, and cold drink exhibited.
DCCXCIII.
A second means for the same purpose, is
the use of refrigerant medicines, and partic-
ularly of acids and nitre.
DCCXCIV.
A third means which has been frequently
employed, is that of bloodletting. The pro-
priety of this practice may be doubtful, as
the quantity of blood poured out by the hem-
orrhagy may be supposed to answer the
purpose of an evacuation in any other way;
and I am ready to allow, that the practice
has been often superfluous, and sometimes
hurtful, by making a greater evacuation than
was necessary or safe. At the same time, I
apprehend it is not for the mere purpose of
evacuating, that bloodletting is to be prac-
tised in the cure of hemorrhagy; but that it
G2 is 

136 PRACTICE
is further necessary for taking off the inflam-
matory diathesis which prevails, and the fe-
brile spasm that has been formed. Accord-
ingly, in the case of hemorrhagy, when the
pulse is not only frequent but quick and full,
and does not become softer or slower upon
the flowing of the blood, and that the effu-
sion is profuse, and threatens to continue so,
it appears to me, that bloodletting may be
necessary, and I have often found it useful.
It seems probable also, that the particular cir-
cumstances of venesection may render it more
powerful for taking off the tension and in-
flammatory irritation of the system, than any
gradual flow from an artery.
DCCXCV.
That a spasm of the extreme vessels has a
share in supporting hemorrhagy, appears to
me probable from hence, that blistering has
been often found useful in moderating and
suppressing the disease.
DCCXCVI.
Do emetics and vomiting contribute to the
cure of hemorrhagy? See Dr. BRYAN ROB-
INSON on the Virtues and Power of Med-
icines.
DCCXCVII.
When an hemorrhagy is very profuse, and
seems to endanger life, or even threatens to
induce 

137 OF PHYSIC.
induce a dangerous infirmity, it is agreed on
all hands, that it is to be immediately suppress-
ed by every means in our power; and partic-
ularly, that, besides the means above men-
tioned for moderating the disease, astringents,
internal or external where the latter can be ap-
plied, are to be employed for suppressing it.
DCCXCVIII.
The internal astringents are either vegeta-
ble or fossil.
The vegetable astringents are seldom very
powerful in the cure of any hemorrhagies,
except those of the alimentary canal.
The fossil astringents are more powerful;
but some choice amongst the different kinds
may be proper.
The chalybeates, so frequently employed,
do not appear to me to be very powerful.
The preparations of lead are certainly more
so; but are otherwise of so pernicious a qual-
ity, that they should not be employed ex-
cept in cases of the utmost danger. The
Tinctura Saturnina, or Antiphthisica, as it
has been called, appears to be of little effi-
cacy; but whether from the small portion of
lead which it contains, or from the state in
which the lead is in it, I am uncertain.
The fossil astringent that appears to me the
most powerful, and at the same time the most
safe, is alum.
G3 DCCXCIX 

138 PRACTICE
DCCXCIX.
External astringents, when they can be ap-
plied, are more effectual than the internal.
The choice of these is left to the surgeons.
DCCC.
The most powerful of all astringents ap-
pears to me to be cold, which may be em-
ployed, either by applying cold water to the
surface of the body, or by throwing it into
the internal parts.
DCCCI.
For suppressing hemorrhagies, many su-
perstitious remedies and charms have been
recommended, and pretended to have been
employed with success. The seeming suc-
cess of these, however, has been generally
owing to the bystanders' mistaking a spontane-
ous ceasing of the hemorrhagy for the effect
of the remedy. At the same time, I believe,
that those remedies may have been some-
times useful, by impressing the mind with
horror, awe, or dread.
DCCCII.
Upon occasion of profuse hemorrhagies,
opiates have been employed with advantage;
and, 

139 OF PHYSIC.
and, when the fulness and inflammatory di-
athesis of the system have been previously
taken off by the hemorrhagy itself, or by
bloodletting, I think opiates may be em-
ployed with safety.
DCCCIII.
For restraining hemorrhagy, ligatures have
been applied upon the limbs, in the view of
retarding the return of the venous blood from
the extremities; but they appear to me to
be of uncertain and ambiguous use.
DCCCIV.
In the case of profuse hemorrhagies, no
pains are to be taken to prevent a Deliquium
Animi, or fainting, as the happening of this
is often the most certain means of stopping the
hemorrhagy.
DCCCV.
Having thus delivered the general doctrine
of hemorrhagy, I proceed to consider the
particular cases of it. It may perhaps be re-
marked, that I have marked fewer of these
than are commonly enumerated by the nosol-
ogists; but my reasons for differing from
these authors, must be left to a nosological
discussion, to be entered into elsewhere more
properly than here.
G4 CHAP. 

140 PRACTICE
CHAP. II.
OF THE EPISTAXIS, OR HEMOR-
RHAGY OF THE NOSE.
DCCCVI.
THE state of the vessels upon
the internal surface of the nose being such as
already mentioned (DCCLVII), renders an
hemorrhagy from that more frequent than
from any other part of the body.
DCCCVII.
The blood commonly flows from one nos-
tril only; and probably because an hemor-
rhagy from one vessel relieves the congestion
in all the neighbouring vessels.
The blood flowing from both nostrils at
the same time, shows commonly a more con-
siderable disease.
DCCCVIII. 

141 OF PHYSIC.
DCCCVIII.
This hemorrhagy happens to persons of ev-
ery constitution and temperament, but most
frequently to those of a plethoric habit and
sanguine temperament. It happens to both
sexes, but most frequently to the male.
DCCCIX.
This hemorrhagy may occur at any time
of life; but most commonly happens to
young persons, owing to the state of the bal-
ance of the system peculiar to that age, as
mentioned in (DCCLVI.)
DCCCX.
Although generally it happens to persons
before they have arrived at their full growth,
and more rarely afterwards; yet sometimes
it happens to persons after their acmé, and
during the state of manhood: And it must
then be imputed to an unusually plethoric
state of the system; to an habitual determina-
tion of the blood to the vessels of the nose;
or to the particular weakness of these.
DCCCXI.
In all these cases the disease may be con-
sidered as an hemorrhagy purely arterial, and
VOL. 2 G5 depending 

142 PRACTICE
depending upon an arterial plethora; but it
sometimes occurs in the decline of life, when
probably it depends upon and may be con-
sidered as a mark of a venous plethora of the
vessels of the head. See DCCLXXII.
DCCCXII.
This hemorrhagy happens also at any pe-
riod of life, in certain febrile diseases, which
are altogether or partly of an inflammatory
nature, and which show a particular deter-
mination of the blood to the vessels of the
head. These diseases often admit of a solu-
tion by this hemorrhagy, when it may be
properly termed critical.
DCCCXIII.
The disease sometimes comes on without
any previous symptoms; particularly when
some external violence has a share in produc-
ing it. But when it proceeds entirely from
an internal cause, it is commonly preceded
by headachs, redness of the eyes, a florid col-
our of the face, an unusual pulsation in the
temples, a sense of fulness about the nose,
and an itching of the nostrils. A bound bel-
ly, pale urine, coldness of the feet, and cold
shivering over the whole body, are also some-
times among the symptoms that precede the
disease.
DCCCXIV. 

143 OF PHYSIC.
DCCCXIV.
From the weakness of the vessels of the nose,
the blood often flows from them without any
considerable effort of the whole system, and
therefore without any observable febrile dis-
order; which, however, in many cases, is,
in all its circumstances, very discernible.
DCCCXV.
An hemorrhagy of the nose happening to
young persons, is, and may generally be,
considered as a slight disease of little conse-
quence, and hardly requiring any remedy.
But, even in young persons, when it recurs
very frequently, and is very copious, it will
require particular attention, as it is to be
considered as a mark of arterial plethora; and
as frequently returning, it may increase the
plethoric state; which in a more advanced
stage of life, may give the blood a determina-
tion to parts from which the hemorrhagy
would be more dangerous. All this will
more particularly require attention, accord-
ing as the marks of plethora, and of particu-
lar congestion, preceding the hemorrhagy,
are more considerable; and as the flowing of
the blood is attended with a more considera-
ble degree of febrile disorder.
G6 DCCCXVI. 

144 PRACTICE
DCCCXVI.
When the epistaxis happens to persons
after their acmé, returning frequently, and
flowing copiously, it is always to be consid-
ered as a dangerous disease, and as more
certainly threatening the consequences men-
tioned in the last paragraph.
DCCCXVII.
When this hemorrhagy happens in the
decline of life, it may be considered as in it-
self very salutary: But at the same time, it is,
to be considered as a mark of a very dan-
gerous state of the system; that is, as a mark
of a very strong tendency to a venous pleth-
ora in the vessels of the head: And I have
accordingly observed it often followed by
apoplexy, palsy, or such like diseases.
DCCCXVIII.
When an hemorrhagy from the nose hap-
pens in febrile diseases, as mentioned in
DCCCXII, and is in pretty large quantity,
it may be considered as critical and salutary;
but it is very apt to be profuse, and even in
this way dangerous.
It upon some occasions occurs during the
eruptive fever of several exanthemata, and is
in such cases sometimes salutary; but, if these
exanthemata 

145 OF PHYSIC.
exanthemata be accompanied with any putrid
tendency, this hemorrhagy, like artificial
bloodlettings, may have very bad effects.
DCCCXIX.
Having thus explained the several circum-
stances of epistaxis, I proceed to consider the
management and cure of it. I use the ex-
pression of management, because it has been
usually thought to require no cure, but that
nature should be allowed to throw out blood
in this way very frequently; and as often as
it appears to arise from internal causes, that
is, from a state of the system supposed to re-
quire such evacuation.
DCCCXX.
I am however of opinion, for the reasons
given in DCCLX XIX, that this disease is
very seldom to be left to the conduct of na-
ture; and that in all cases it should be mode-
rated by keeping the patient in cool air; by
giving cold drink; by keeping the body and
head erect; by avoiding any blowing of the
nose, speaking, or other irritation: And,
when the blood has flowed for some time,
without showing any tendency to cease, a
profuse bleeding is to be prevented by meas-
ures employed to stop it, such as pressing the
nostril from which the blood flows, washing
the 

146 PRACTICE
the face with cold water, or applying this to
other parts of the body.
DCCCXXI.
Even in the case of young persons, where
the disease is least hazardous, and even in
the first attacks, I judge such measures to be
proper: But they will be still more proper
if the disease frequently recurs without any
external violence; if the returns shall happen
to persons of a habit disposed to be plethoric;
and more particularly, if the marks of a ple-
thoric state appear in the precedent symp-
toms (DCCCXIII.)
DCCCXXII.
Even in young persons, if the bleeding
be very profuse and long continued, and
more especially if the pulse become weak and
the face pale, I apprehend it will be proper
to suppress the hemorrhagy by every means
in our power. See DCCXCVII, and fol-
lowing paragraphs.
DCCCXXIII.
Further, in the same case of young persons,
when the returns of this hemorrhagy become
frequent, and especially with the marks of a
plethoric habit, I think it necessary to employ
such a regimen as may prevent a plethoric
state, 

147 OF PHYSIC.
state, (DCCLXXXIII——DCCLXXXVII).
At the same time, care should be taken to
avoid all circumstances which may determine
the blood more fully to the vessels of the head,
or prevent its free return from them; and,
by keeping an open belly to make some de-
rivation from them.
DCCCXXIV.
In adult persons, liable to frequent returns
of the epistaxis, the whole of the measures
proposed (DCCCXXIII) are more certain-
ly and freely to be employed. When with
the circumstances mentioned in DCCCXIII,
the tendency to a profuse hemorrhagy ap-
pears, a bleeding at the arm may be proper,
even in young persons; but in the case of a-
dults, it will be still more allowable, and
even necessary.
DCCCXXV.
In persons of any age liable to frequent
returns of this hemorrhagy, when the meas-
ures proposed in DCCCXVII, et seq. shall
have been neglected, or from peculiar cir-
cumstances in the balance of the system, shall
have proved ineffectual, and the symptoms
threatening hemorrhagy (DCCCXXXVIII)
shall appear, it will then be proper, by blood-
letting, cooling purgatives, and every part
of the antiphlogistic regimen, to prevent the
hemorrhagy, 

148 PRACTICE
hemorrhagy, or at least to prevent its being
profuse when it does happen.
DCCCXXVI.
In the circumstances just now mentioned
(DCCCXXV), the measures proposed are
proper, and even necessary; but it should
at the same time be observed, that these are
practised with much less advantage than those
pointed out in DCCCXXIV: Because,
though those suggested here may prevent the
coming on of the hemorrhagy for the present,
they certainly, however, dispose to the return
of that plethoric state which required their be-
ing used; and there can be no proper secu-
rity against returns of the disease, but by pur-
suing the means proposed in DCCCXXIII.
DCCCXXVII.
When the hemorrhagy of the nose hap-
pens to persons approaching to their full
growth, and when its returns have been pre-
ceded by the symptoms DCCCXIII, it
may be supposed, that, if the returns can
be prevented by the measures proposed in
DCCCXXV, these may be safely employed;
as the plethoric state induced will be render-
ed safe, by the change which is soon to take
place in the balance of the system. This,
however, cannot be admitted; as the evacu-
ations practised upon this plan will have all
the 

149 OF PHYSIC.
the consequences which, I have already ob-
served, may follow the recurrence of the
hemorrhagy itself.
DCCCXXVIII.
When the hemorrhagy of the nose shall
be found to make its returns at nearly stated
periods, the measures for preventing it
(DCCCXXV) maybe practised with great
certainty; and, upon every repetition of
bloodletting, by diminishing the quantity
taken away, its tendency to induce a pletho-
ra may be in some measure avoided. When
indeed, the repetition of evacuations is truly
unavoidable, the diminishing them upon
every repetition is properly practised: But
it is a practice of nice and precarious manage-
ment, and should by no means be trusted to,
so far as to supersede the measures proposed in
DCCCXXV, wherever these can be admit-
ted.
DCCCXXIX.
When the hemorrhagy of the nose hap-
pens in consequence of a venous plethora in
the vessels of the head, as in DCCLXXII,
the flowing of the blood pretty largely may
be allowed, especially when it happens after
the suppression or ceasing of the menstrual
or hemorrhoidal flux. But though the flow-
ing of the blood is, on its first occurring, to
be 

150 PRACTICE
be allowed, there is nothing more proper
than guarding against its returns. This is to be
done not only by the measures proposed in
DCCLXXXIII, et seq. but, as the effects
of a plethoric state of the vessels of the head
are very uncertain; so, upon any appearance
of it, and especially upon any threatening of
hemorrhagy, the plethora is to be removed,
and the hemorrhagy to be obviated immedi-
ately by proper evacuations, as bloodletting,
purging, and issues; or by restoring sup-
pressed evacuations, where this can be done.
CHAP. 

151 OF PHYSIC.
CHAP. III.
OF THE HEMOPTYSIS, OR HEMOR-
RHAGY FROM THE LUNGS.
SECT. I.
Of the PHENOMENA and CAUSES of
HEMOPTYSIS.
DCCCXXX.
WHEN, after some affec-
tion of the breast, blood is thrown out from
the mouth, and is brought out with more or
less of coughing, there can be no doubt that
it comes from the lungs; and this generally
ascertains the disease of which I am now to
treat. But there are cases in which the source
of the blood spit out is uncertain; and there-
fore some other considerations, to be mention- 
ed

152 PRACTICE
ed hereafter, are often necessary to ascertain
the existence of an hemoptysis.
DCCCXXXI.
The blood vessels of the lungs are more nu-
merous than those of any other part of the bo-
dy of the same bulk. These vessels of the larg-
est size, as they arise from the heart, are more
immediately than in any other part subdivid-
ed into vessels of the smallest size; and these
small vessels spread out near to the internal
surfaces of the bronchial cavities, are situated
in a loose cellular texture, and covered by a
tender membrane only: So that, considering
how readily and frequently these vessels are
gorged with blood, we may understand why
an hemorrhagy from them is, next to that of
the nose, the most frequent of any; and par-
ticularly, why any violent shock given to the
whole body so readily occasions an hemop-
tysis.
DCCCXXXII.
An hemoptysis may be occasioned by ex-
ternal violence, at any period of life; and I
have explained above (DCCLX), why, in
adult persons, while the arterial plethora still
prevails in the system, that is, from the age of
sixteen to that of five and thirty, an hemop- 
tysis

153 OF PHYSIC.
tysis may at any time be produced, merely
by a plethoric state of the lungs.
DCCCXXXIII.
But it has been also observed above,
(DCCLXI), that an hemoptysis more fre-
quently arises from a faulty proportion be-
tween the capacity of the vessels of the lungs
and that of those of the rest of the body.
Accordingly it is often a hereditary disease,
which implies a peculiar and faulty confor-
mation. And the disease also happens es-
pecially to persons who discover the smaller
capacity of their lungs, by the narrowness of
their chest, and by the prominency of their
shoulders; which last is a mark of their hav-
ing been long liable to a difficult respiration.
DCCCXXXIV.
With these circumstances also the disease
happens especially to persons of a sanguine
temperament; in whom particularly, the ar-
terial plethora prevails. It happens likewise
to persons of a slender delicate make, of
which a long neck is a mark; to persons of
much sensibility and irritability, and therefore
of quick parts, whose bodies are generally
of a delicate structure; to persons who have
been formerly liable to frequent hemorrha-
gies of the nose; to persons who have suffer-
ed a suppression of any hemorrhagy they had
formerly 

154 PRACTICE
formerly been liable to, the most frequent
instance of which is in females who have suf-
fered a suppression of their menstrual flux;
and, lastly, to persons who have suffered the
amputation of any considerable limb.
DCCCXXXV.
In most of these cases (DCCCXXXIV),
the disease happens especially to persons
about the time of their coming to their full
growth, or soon after it, and this for the rea- 
sons fully set forth above.
DCCCXXXVI.
From all that has been said from
DCCCXXXI to DCCCXXXV, the pre-
disponent cause of hemoptysis will be suffi-
ciently understood, and the disease may hap-
pen from the mere circumstance of the pre-
disponent cause arising to a considerable de-
gree. In the predisposed, however, it is
often brought on by the concurrence of va-
rious occasional and exciting causes. One of
these, and perhaps a frequent one, is exter-
nal heat; which, even when in no great de-
gree, will bring on the disease in spring, and
the beginning of summer, while the heat ra-
refies the blood more than it relaxes the solids
which had been before contracted by the
cold of winter. Another exciting cause is a
sudden diminution of the weight of the atmos-
phere, 

155 OF PHYSIC.
phere, especially when concurring with any
effort in bodily exercise. This effort, too,
alone, may often, in the predisposed, be the
exciting cause; and more particularly, any
violent exercise of respiration. In short, in
the predisposed, any degree of external vio-
lence also may bring on the disease.
DCCCXXXVII.
Occasioned by one or other of these causes
(DCCCXXXVI), the disease comes on with
a sense of weight and anxiety in the chest,
some uneasiness in breathing, some pain of
the breast or other parts of the thorax, and
some sense of heat under the sternum; and
very often, before the disease appears, a
saltish taste is perceived in the mouth.
DCCCXXXVIII.
Immediately before the appearance of
blood, a degree of irritation is felt at the top
of the larynx. To relieve this, a hawking is
made, which brings up a little blood, of a
florid colour, and somewhat frothy. The ir-
ritation returns; and, in the same manner,
more blood of a like kind is brought up, with
some noise in the windpipe, as of air passing
through a fluid.
DCCCXXXIX. 

156 PRACTICE
DCCCXXXIX.
This is commonly the manner in which the
hemoptysis begins; but sometimes at the very
first the blood comes up by coughing, or at
least somewhat of coughing accompanies the
hawking just now mentioned.
DCCCXL.
The blood issuing is sometimes at first in
very small quantity, and soon disappears
altogether: But, in other cases, especially
when it repeatedly occurs, it is in greater
quantity, and frequently continues to appear
at times for several days together. It is some-
times profuse; but rarely in such quantity as
either by its excess, or by its sudden suffoca-
tion, to prove immediately mortal. It com-
monly either ceases spontaneously, or is stop-
ped by the remedies employed.
DCCCXLI.
When blood is thrown out from the
mouth, it is not always easy to determine from
what internal part it proceeds; whether from
the internal surface of the mouth itself, from
the fauces, or adjoining cavities of the nose,
from the stomach, or from the lungs. It is
however, very necessary to distinguish the
different 

157 OF PHYSIC.
different cases; and, in most instances, it
may be done by attending to the following
considerations.
DCCCXLII.
When the blood spit out proceeds from
some part of the internal surface of the
mouth itself, it comes out without any hawk-
ing or coughing: And generally, upon in-
spection, the particular source of it becomes
evident.
DCCCXLIII.
When blood proceeds from the fauces,
or adjoining cavities of the nose, it may be
brought out by hawking, and sometimes by
coughing, in the manner we have described
in DCCCXXXVII and DCCCXXXIX;
so that, in this way, a doubt may arise con-
cerning its real source. A patient often lays
hold of these circumstances to please himself
with the opinion of its coming from the fau-
ces, and he may be allowed to do so: But a
physician cannot readily be deceived, if he
consider, that a bleeding from the fauces is more
rare than one from the lungs; that the former
seldom happens but to persons who have been
before liable either to an hemorrhagy of the
nose, or to some evident cause of erosion;
and, in most cases, by looking into the fau-
VOL. II. H ces, 

158 PRACTICE
ces, the distillation of the blood, if it comes
from thence, will be perceived.
DCCCXLIV.
When blood proceeds from the lungs, the
manner in which it is brought up will com-
monly show from whence it comes: But in-
dependent of that, there are may circumstanc-
es which may occur to point it out, such as the
period of life, the habit of body, and other
marks of a predisposition (DCCCXXXIII——
DCCCXXXV); and, together with these,
the occasional causes (DCCCXXXVI) hav-
ing been immediately before applied.
DCCCXLV.
When vomiting accompanies the throw-
ing out of blood from the mouth, as vomit-
ing and coughing often mutually excite each
other; so they may be frequently joined,
and render it doubtful, whether the blood
thrown out proceeds from the lungs or from
the stomach. We may, however, generally
decide, by considering, that blood does not
so frequently proceed from the stomach as
from the lungs: That blood proceeding from
the stomach commonly appears in greater
quantity, than when it proceeds from the
lungs; that the blood proceeding from the
lungs is usually of a florid colour, and mix-
ed with a little frothy mucus only; whereas
the 

159 OF PHYSIC.
the blood from the stomach is commonly of a
darker colour, more grumous, and mixed
with the other contents of the stomach:
That the coughing or vomiting, according as
the one or the other first arises in the cases in
which they are afterwards joined, may some-
times point out the source of the blood; and,
lastly, that much may be learned from the
circumstances and symptoms which have pre-
ceded the hemorrhagy.
Those which precede the hemoptysis
enumerated in DCCCXXXVII, are most
of them evident marks of an affection of the
lungs. And, on the other hand, the hema-
temesis, or issuing of blood from the stomach,
has also its peculiar symptoms and circum-
stances preceding it; as, for instance, some
morbid affection of this organ, or at least
some pain, anxiety, and sense of weight, re-
ferred distinctly to the region of the stomach.
To all this may be added, that the vomiting
of blood happens more frequently to females
than to males; and to the former, in consequence
of a suppression of their menstrual flux:
and, by attending to all these considerations
(DCCCXLII——DCCCXLV), the presence
of the hemoptysis may commonly be suffi-
ciently ascertained.
H2 SECT.

160 PRACTICE
SECT. II.
Of the CURE of HEMOPTYSIS.
DCCCXLVI.
THIS disease is sometimes attended with
little danger; as, when it happens to fe-
males in consequence of a suppression of
the menses; when, without any marks
of a predisposition, it arises from external vio-
lence; or when, from whatever cause arising,
it leaves behind it no cough, dyspnœa, or
other affection of the lungs. Even in such
cases, however, a danger may arise from too
large an wound being made in the vessels of
the lungs; from a quantity of red blood be-
ing left to stagnate in the cavity of the bron-
chiæ; and particularly from any determina-
tion of the blood being made into the vessels
of the lungs, which, by renewing the hemor-
rhagy, may have dangerous consequences.
In every instance therefore of hemoptysis,
the effusion is to be moderated by the several
means mentioned DCCXCII to DCCXCV.
DCCCXLVII. 

161 OF PHYSIC.
DCCCXLVII.
These measures are especially necessary
when the hemoptysis arises in consequence of
predisposition; and in all cases where there is
the appearance of a large effusion, or where
the hemorrhagy frequently returns, the effusion
is not only to be moderated, but to be entire-
ly stopped, and the returns of it prevented
by every means in our power. See
DCCXCVII, and following.
DCCCXLVIII.
To stop an hemoptysis, or prevent the
returns of it, two medicines have been fre-
quently employed; neither of which I can
approve of. These are, chalybeates, and the
Peruvian bark. As both of them contribute
to increase the phlogistic diathesis of the sys-
tem, they can hardly be safe in any case of
active hemorrhagy, and I have frequently
found them hurtful.
DCCCXLIX.
As the hemoptysis, which happens in con-
sequence of predisposition, is always attend-
ed with a phlogistic diathesis; and, as the
bad consequences of the disease are especially
to be apprehended from the continuance of
that diathesis; so this is to be industriously
taken off by bloodletting, in greater or small-
H3 er 

162 PRACTICE
er quantity, and more or less frequently re-
peated, according as the symptoms shall di-
rect. At the same time, cooling purgatives
are to be employed, and every part of the
antiphlogistic regimen is to be strictly enjoin-
ed. The refrigerants may also be adminis-
tered; taking care, however, that the acids,
and more especially the nitre, do not excite
coughing.
DCCCL.
From what was observed in DCCXCV,
it will appear, that blistering upon the breast
or back may be a remedy of hemoptysis,
when it is present; and that issues in the
same places may be useful in preventing the
recurrence of it when it has ceased.
DCCCLI.
The avoiding of motion is generally a prop-
er part of the antiphlogistic regimen; and
in the hemoptysis, nothing is more necessary
than avoiding bodily exercise: But some
kinds of gestation, as sailing, and travelling
in an easy carriage on smooth roads, have
often proved a remedy.
DCCCLII.
Such is the treatment I can propose for the
hemoptysis, considered merely as an hemor-
rhagy; 

163 OF PHYSIC.
rhagy; But when, in spite of all our pre-
cautions, it continues to recur, it is often
followed by an ulceration of the lungs, and a
phthisis pulmonalis. This, therefore, I must
now proceed to consider; but, as it arises
also from other causes besides the hemoptysis,
it must be treated of with a more general
view.
H4 CHAP. 

164 PRACTICE
CHAP. IV.
OF THE PHTHISIS PULMONALIS, OR
CONSUMPTION OF THE LUNGS.
SECT. I.
Of the PHENOMENA and CAUSES of the
PHTHISIS PULMONALIS.
DCCCLIII.
THE Phthisis Pulmonalis I
would define to be, An expectoration of pus
or purulent matter from the lungs, attended
with a hectic fever.
As this is the principal species of phthisis,
I shall frequently in this chapter employ the
general term of phthisis, though strictly
meaning the phthisis pulmonalis.
DCCCLIV. 

165 OF PHYSIC.
DCCCLIV.
I have met with some instances of an ex-
pectoration of purulent matter, continuing
for many years, accompanied with very few
symptoms of hectic, and at least without any
hectic exquisitely formed: But, in none of
these instances, were the persons so entirely
free from symptoms of hectic, as to form
any exception to the general definition.
DCCCLV.
In every instance of an expectoration of
pus, I presume there is an ulceration of the
lungs. The late Mr. de Haen is the only
author that I know of who has advanced an-
other opinion, and has supposed, that pus
may be formed in the blood vessels, and be
from thence poured into the bronchiæ. Ad-
mitting his fact, I have attempted an expla-
nation of the appearance of pus without ul-
ceration in CCCXLIX: But, after all, I can-
not help suspecting the accuracy of his ob-
servations; must entirely reject his explana-
tion of them; must however allow, that we
still want facts to support the explanation I
have offered; and doubt much if it will ap-
ply to any case of phthisis. For these reasons
I still conclude, agreeably to the faith of all
other dissections, and the opinions of all
physicians, that the symptoms mentioned in
VOL. 2. H5 our 

166 PRACTICE
our definition depend always upon an ulcer-
ation formed in the lungs.
DCCCLVI.
It has sometimes happened, that a catarrh
was attended with an expectoration of a mat-
ter so much resembling pus, that physicians
have been often uncertain whether it was
mucus or pus, and therefore whether the
disease was a catarrh or a phthisis. It is oft-
en of consequence to determine these ques-
tions; and it appears to me that it may be
generally done, with sufficient certainty,
from the following considerations, of which
each particular is not always singly decisive,
but when they are taken together can hardly
deceive us.
1. From the colour of the matter; as mu-
cus is naturally transparent, and pus always
opake. When mucus becomes opake, as it
sometimes does, it becomes white, yel-
low, or greenish; but the last mentioned col-
our is hardly ever so remarkable in mucus as
in pus.
2. From the consistence; as mucus is
more viscid and coherent, and pus less so, and
may be said to be more friable. When mu-
cus is thrown into water, it is not readily dif-
fused, but remains united in uniform and cir-
cular masses: But pus, in the same circum-
stances, though not readily diffused, does not
remain 

167 OF PHYSIC.
remain so uniformly united and by a little
agitation is broken into ragged fragments.
3. From the odour; which is seldom per-
ceived in mucus, but frequently in pus. It
has been proposed to try the odour of the
matter expectorated, by throwing it upon
live coals: But in such a trial both mucus and
pus give out a disagreeable smell, and it is
not easy to distinguish between them.
4. From the specific gravity compared
with water; and, indeed, it is usual for the
mucus of the lungs to swim on the surface of
water, and for pus to sink in it. But in this
we may sometimes be deceived; as pus
which has entangled a great deal of air may
swim, and mucus that is free from air may sink.
5. From the mixture which is discernible
in the matter brought up: For it a yellow or
greenish matter appears surrounded with a
quantity of transparent or less opake and less
coloured matter, the more strongly coloured
matter may be generally considered as pus;
as it is not easy to understand how one por-
tion of the mucus of the lungs can be very
considerably changed, while the rest of it
is very little so, or remains in its ordinary state.
6. From the admixture of certain substances
with the matter thrown out from the lungs.
To this purpose we are informed by the ex-
periments of the late Mr. Charles Darwin:
a. That the vitriolic acid dissolves both mu-
cus and pus, but most readily the former:
That, if water be added to such a solution of
H6 mucus, 

168 PRACTICE
mucus, this is separated, and either swims on
the surface, or, divided into flocculi, is sus-
pended in the liquor; whereas, when water
is added to a like solution of pus, this falls to
the bottom, or by agitation is diffused so as
to exhibit an uniformly turbid liquor. b.
That a solution of the caustic fixed alkali, af-
ter some time, dissolves mucus, and generally
pus; and, if water be added to such solu-
tions, the pus is precipitated, but the mucus
is not. From such experiments it is suppos-
ed, that pus and mucus may be certainly dis-
tinguished from each other.
From the expectoration's being attended
with a hectic fever. A catarrh, or expecto-
ration of mucus, is often attended with fever;
but never, so far as I have observed, with
such a fever as I am presently to describe as a
hectic. This, in my opinion, is the most
certain mark of a purulent state in some part
of the body; and if others have thought dif-
ferently, I am persuaded that it has been
owing to this, that, presuming upon the mor-
tal nature of a confirmed or purulent phthisis,
they have considered every case in which a
recovery happened, as a catarrh only: But,
that they may have been mistaken in this, shall
be shown hereafter.
DCCCLVII.
Having thus considered the first part of
the character of the phthisis pulmonalis as a
mark 

169 OF PHYSIC.
mark of an ulceration of the lungs; and hav-
ing just now said, that the other part of the
character, that is, the hectic fever, is a mark
or indication of the same thing; it is proper
now to consider this here, as I had with
that view omitted it before (LXXIV).
DCCCLVIII.
A hectic fever has the form of a remittent,
which has exacerbations twice every day.
The first of these occurs about noon, some-
times a little sooner or later; and a slight re-
mission of it happens about five afternoon.
This last is soon succeeded by another exacer-
bation, gradually increasing till after mid-
night: But after two o'clock of the morning,
a remission takes place, which becomes more
and more considerable as the morning ad-
vances. The exacerbations are frequently
attended with some degree of cold shivering;
or at least, the patient is exceedingly sensible
to any coolness of the air, seeks external
heat, and often complains of a sense of cold,
when, to the thermometer, his skin is preter-
naturally warm. Of these exacerbations,
that of the evening is always the most con-
siderable.
DCCCLIX.
It has commonly been given as a part
of the character of a hectic fever, that an ex-
acerbation 

170 PRACTICE
acerbation of it commonly appears after the
taking food; and it is true that dinner,
which is taken at noon or after it, does seem
to occasion some exacerbation. But this
must not make us judge the midday exacer-
bation to be the effect of eating only; for I
have often observed it to come on an hour
before noon, and often some hours before
dinner; which, in this country at present, is
not taken till some time after noon. It is in-
deed to be observed, that in almost every
person, the taking food occasions some de-
gree of fever: But I am persuaded this would
not appear so considerable in a hectic, were it
not that an exacerbation of fever is present
from another cause; and accordingly, the
taking food in the morning has hardly any
sensible effect.
DCCCLX.
I have thus described the general form of
hectic fever; but many circumstances attend-
ing it are further to be taken notice of.
The fever I have described does not com-
monly subsist long, till the evening exacer-
bations become attended with sweatings;
which continue to recur, and to prove more
and more profuse through the whole course
of the disease.
Almost from the first appearance of the
hectic, the urine is high coloured, and depos-
its a copious branny red sediment, which
hardly 

171 OF PHYSIC.
hardly ever falls close to the bottom of the
vessel.
In the hectic, the appetite for food is gen-
erally less impaired than in any other kind of
fever. 
The thirst is seldom considerable; the
mouth is commonly moist; and as the disease
advances, the tongue becomes free from all
fur, appears very clean; and, in the advanced
stages of the disease, the tongue and fauces
appear to be somewhat inflamed, and become
more or less covered, with aphthæ.
As the disease advances, the red vessels of the
adnate of the eye disappear, and the whole
of the adnata becomes of a pearly white.
The face is commonly pale; but, during
the exacerbations, a florid red, and an almost
circumscribed spot, appear on each cheek.
For some time, in the course of a hectic,
the belly is bound; but, in the advanced
stages of it, a diarrhœa almost always comes
on, and continues to recur frequently during
the rest of the disease, alternating in some
measure with the sweatings mentioned above.
The disease is always attended with a debil-
ity, which gradually increases during the
course of it.
During the same course an emaciation
takes place, and goes to a greater degree than
in almost any other case.
The falling off of the hairs, and the adunque
form of the nails, are also symptoms of the
want of nourishment.
Towards 

172 PRACTICE
Towards the end of the disease, the feet
are often affected with œdematous swellings.
The exacerbations of the fever are seldom
attended with any headach, and scarcely ever
with delirium.
The senses and judgment commonly remain
entire to the very end of the disease; and the
mind, for the most part, is confident and full
of hope.
Some days before death, a delirium comes
on, and commonly continues to the end.
DCCCLXI.
The hectic fever now described
(DCCCLVIII, DCCCLIX) as accompany-
ing a purulent state of the lungs, is perhaps
the case in which it most frequently appears;
but I have never seen it in any case, when
there was not evidently, or when I had not
ground to suppose, there was a permanent
purulency or ulceration in some external or
internal part. It was for this reason that in
LXXIV, I concluded it to be a symptomatic
fever only. Indeed, it appears to me to be
always the effect of an acrimony absorbed
from abscesses or ulcers, although it is not
equally the effect of every sort of acrimony;
for the scorbutic and cancerous kinds often
subsist long in the body without producing a
hectic. What is the precise state of the acri-
mony producing this, I cannot determine, but
it 

173 OF PHYSIC.
it seems to be chiefly that of a vitiated puru-
lency.
DCCCLXII.
However this may be, it appears, that the
hectic's depending in general upon an acrimo-
ny, explains its peculiar circumstances. The
febrile state seems to be chiefly an exacerba-
tion of that frequency of the pulse, which oc-
curs twice every day to persons in health, and
may be produced by acrimony alone. These
exacerbations, indeed, do not happen without
the proper circumstances of pyrexia; but the
spasm of the extreme vessels in a hectic does
not seem to be so considerable as in other fe-
vers; and hence the state of sweat and urine
which appears so early and so constantly in
hectics. Upon the same supposition of an
acrimony corrupting the fluids, and debilitat-
ing the moving powers, I think that most of
the other symptoms may also be explained.
DCCCLXIII.
Having thus considered the characteristical
symptoms and chief part of the proximate
cause of the phthisis pulmonalis, I proceed to
observe, that an ulcer of the lungs, and its
concomitant circumstance of hectic fever, may
arise from different previous affections of the
lungs; all of which however may, in my
opinion, be referred to five heads; that is,
1. To 

174 PRACTICE
1. To an hemoptysis; 2. To a suppuration
of the lungs in consequence of pneumonia;
3. To catarrh; 4. To asthma; or, 5. To a
tubercle. These several affections, as causes
of ulcers, shall now be considered in the or-
der mentioned.
DCCCLXIV.
It has been commonly supposed, that an
hemoptysis was naturally, and almost necessa-
rily, followed by an ulcer of the lungs. But
I will presume to say, that, in general, this is
a mistake; for there have been many instances
of hemoptysis occasioned by external violence,
without being followed by any ulcer of the
lungs; and there have also been many in-
stances of hemoptysis from an internal cause,
without any consequent ulceration. And
this too has been the case, not only when the
hemoptysis happened to young persons, and
recurred for several times, but when it has
often recurred during the course of a long
life. It is indeed easy to conceive, that a
rupture of the vessels of the lungs, like that of
the vessels of the nose, may be often healed,
as the surgeons speak, by the first intention.
It is probable therefore, that it is an hemop-
tysis in particular circumstances only, which
is necessarily followed by an ulcer; but what
these circumstances are, it is difficult to deter-
mine. It is possible, that merely the de-
gree of rupture, or frequently repeated rup-
ture 

175 OF PHYSIC.
ture preventing the wound from healing by
the first intention, may occasion an ulcer; or
it is possible that red blood effused, and not
brought up entirely by coughing, may, by
stagnating in the bronchiæ, become acrid, and
erode the parts. These however are but suppo-
sitions, not supported by any clear evidence.
And, if we consider that those cases of he-
moptysis which follow the predisposition
(DCCCXXXII——DCCCXXXV) are those
especially which end in phthisis, we shall be
led to suspect that there are some other cir-
cumstances which concur here to determine
the consequence of hemoptysis, as I shall
hereafter endeavour to show.
DCCCLXV.
Any supposition, however, which we can
make with respect to the innocence of an
hemoptysis, must not supersede the measures
proposed above for its cure; both because we
cannot certainly foresee what may be the con-
sequences of such an accident, and because
the measures above suggested are safe; for,
upon every supposition, it is a diathesis phlo-
gistica that may urge on every bad conse-
quence to be apprehended.
DCCCLXVI.
The second cause of an ulceration of the
lungs, to be considered, is a suppuration
formed in consequence of pneumonia.
DCCCLXVII. 

176 PRACTICE
DCCCLXVII.
From the symptoms mentioned in
DCCCLVIII, DCCCLIX, it may with
reason be concluded, that an abscess, or, as it
is called, a vomica, is formed in some part of
the pleura, and most frequently in that por-
tion of it investing the lungs. Here puru-
lent matter frequently remains for some time,
as if inclosed in a cyst; but commonly it is
not long before it comes to be either absorb-
ed, and transferred to some other part of the
body; or that it breaks through into the cav-
ity of the lungs, or into that of the thorax. In
the latter case, it produces the disease called
empyema; but it is only when the matter is
poured into the cavity of the bronchiæ, that
it properly constitutes the phthisis pulmona-
lis. In the case of empyema, the chief cir-
cumstances of a phthisis are indeed also pres-
ent; but I shall here consider that case only
in which the abscess of the lungs gives occa-
sion to a purulent expectoration.
DCCCLXVIII.
An abscess of the lungs, in consequence of
pneumonia, is not always followed by a
phthisis: For sometimes a hectic fever is not
formed; the matter poured into the bronchiæ
is a proper and benign pus, which is frequent-
ly coughed up very readily, and spit out;
and, 

177 OF PHYSIC.
and, though this purulent expectoration
should continue for some time, yet if a hectic
does not come on, the ulcer soon heals, and
every morbid symptom disappears. This has
happened so frequently, that we may conclude,
that neither the access of the air, nor the con-
stant motion of the lungs, will prevent an ul-
cer of these parts from healing, if the matter
of it be well conditioned. An abscess of the
lungs, therefore, does not necessarily produce
the phthisis pulmonalis; and if it be followed
by such a disease, it must be in consequence
of particular circumstances which corrupt the
purulent matter produced, render it unsuitable
to the healing of the ulcer, and at the same
time make it afford an acrimony, which, be-
ing absorbed, produces a hectic and its con-
sequences.
DCCCLXIX.
The corruption of the matter of such ab-
scesses may be owing to several causes; as,
1. That the matter effused during the in-
flammation, had not been a pure serum fit to
be converted into a laudable pus, but had
been united with other matters which pre-
vented that, and gave a considerable acrimony
to the whole: Or, 2. That the matter effus-
ed, and converted into pus, either merely by
a long stagnation in a vomica, or by its con-
nexion with an empyema, had been so cor-
rupted as to become unfit for the purpose of
pus, 

178 PRACTICE
pus, in the healing of the ulcer. These seem
to be possible causes of the corruption of mat-
ter in abscesses, so as to make it the occasion
of a phthisis in persons otherwise sound; but
it is probable, that a pneumonic abscess does
especially produce phthisis when it happens
to persons previously disposed to that disease;
and therefore only as it concurs with some oth-
er causes of it.
DCCCLXX.
The third cause supposed to produce
phthisis, is a catarrh; which in many cases
seems, in length of time, to have the expecto-
ration of mucus proper to it, gradually chang-
ed into an expectoration of pus; and at the
same time, by the addition of a hectic fever,
the disease, which was at first a pure catarrh,
is converted into a phthisis. This supposi-
tion, however, is not easily to be admitted.
The catarrh is properly an affection of the
mucous glands of the trachea and bronchiæ
analogous to the coryza, and less violent kinds
of cynanche tonsillaris, which very seldom
terminate in suppuration. And although a
catarrh should be disposed to such termina-
tion, yet the ulcer produced might readily
heal up, as it does in the case of a cynanche
tonsillaris; and therefore should not produce
a phthisis.
DCCCLXXI. 

179 OF PHYSIC.
DCCCLXXI.
Further, the catarrh, as purely the effect of
cold, is generally a mild disease, as well as of
short duration; and of the numerous instances
of it, there are at most but very few cases
which can be said to have ended in phthisis.
In all those cases in which this seems to have
happened, it is to me probable that the per-
sons affected were peculiarly predisposed to
phthisis. And the beginning of phthisis so
often resembles a catarrh, that the former may
have been mistaken for the latter. Besides,
to increase the fallacy, it often happens that
the application of cold, which is the most fre-
quent cause of catarrh, is also frequently the
exciting cause of the cough which proves the
beginning of phthisis.
DCCCLXXII.
It is to me, therefore, probable, that a
catarrh is very seldom the foundation of
phthisis; but I would not positively assert
that it never is so; for it is possible that the
cases of a more violent catarrh may have
joined with them a pneumonic affection,
which may end in a suppuration; or it may
happen that a long continued catarrh, by the
violent agitation of the lungs in coughing,
will produce some of those tubercles which
are 

180 PRACTICE
are presently to be mentioned as the most
frequent cause of phthisis.
DCCCLXXIII.
It must be particularly observed here, that
nothing said in DCCCLXXII, should allow
us to neglect any appearance of catarrh, as is
too frequently done; for it may be either the
beginning of a phthisis, which is mistaken for
a genuine catarrh; or that even as a catarrh
continuing long, it may produce a phthisis,
as in DCCCLXXII.
DCCCLXXIV.
Many physicians have supposed an acrimo-
ny of the fluids eroding some of the vessels of
the lungs, to be a frequent cause of ulceration
and phthisis. But this appears to me to be a
mere supposition; for in any of the instances
of the production of phthisis which I have
seen, there was no evidence of any acrimony
of the blood capable of eroding the vessels.
It is true, indeed, that in many cases an acri-
mony subsisting in some part of the fluids, is
the cause of the disease; but it is at the same
time probable, that this acrimony operates by
producing tubercles, rather than by any di-
rect erosion.
DCCCLXXV. 

181 OF PHYSIC.
DCCCLXXV.
It has been mentioned in DCCCLXIII,
that an asthma may be considered as one of
the causes of phthisis; and by asthma I mean,
that species of it which has been commonly
named the Spasmodic. This disease frequent-
ly subsists very long without producing any
other, and may have its own peculiar fatal
termination, as shall be explained hereafter.
But I have seen it frequently end in phthisis;
and in such cases I suppose it to operate in
the manner above alleged of catarrh; that is,
by producing tubercles, and their conse-
quences, which shall be presently mentioned.
DCCCLXXVI.
I come now to consider the fifth head of
the cause of phthisis, and which I apprehend
to be the most frequent of any. This I have
said, in general, to be tubercles; by which
term are meant, certain small tumours, which
have the appearance of indurated glands.
Dissections have frequently shown such tuber-
cles formed in the lungs; and although at
first indolent, yet at length they become in-
flamed, and are thereby changed into little ab-
scesses, or vomicæ; which breaking, and
pouring their matter into the bronchiæ, give
a purulent expectoration, and thus lay the
foundation of phthisis.
VOL. II. I DCCCLXXVII. 

182 PRACTICE
DCCCLXXVII.
Though the matter expectorated upon these
occasions has the appearance of pus, it is sel-
dom that of a laudable kind; and, as the ul-
cers do not readily heal, but are attended
with a hectic fever, for the most part ending
fatally, I presume that the matter of the ul-
cers is imbued with a peculiarly noxious ac-
rimony, which prevents their healing, and
produces a phthisis in all its circumstances,
as mentioned above.
DCCCXXVIII.
It is very probable that the acrimony which
thus discovers itself in the ulcers, existed be-
fore and produced the tubercles themselves;
and it is to this acrimony that we must trace
up the cause of the phthisis following these
tubercles. This acrimony is probably, in
different cases, of different kinds; and it will
not be easy to determine its varieties: But to
a certain length I shall attempt it.
DCCCLXXIX.
In one case, and that, too, a very frequent
one, of phthisis, it appears, that the noxious
acrimony is of the same kind with that which
prevails in the scrophula. This may be con-
cluded from observing, that a phthisis, at its
usual

183 OF PHYSIC.
usual periods, frequently attacks persons born
of scrophulous parents; that is, of parents
who had been affected with scrophula in their
younger years: That very often, when the
phthisis appears, there occur at the same time
some lympathic tumours in the external
parts; and very often I have found the tabes
mesenterica, which is a scrophulous affection,
joined with the phthisis pulmonalis. To all
this I would add, that, even when no scrophu-
lous affection has either manifestly preceded
or accompanied a phthisis, this last, however,
most commonly affects persons of a habit re-
sembling the scrophulous; that is, persons of
a sanguine, or of a sanguineo melancholic
temperament, who have very fine skins, rosy
complexions, large veins, soft flesh, and thick
upper lip: And further, that in such persons
the phthisis comes on in the same manner
that it does in persons having tubercles, as
shall be immediately explained.
DCCCLXXX.
Another species of acrimony producing tu-
bercles of the lungs, and thereby phthisis
may be said to be the exanthematic. It is
well known, that the small pox sometimes, and
more frequently the measles, lay the founda-
tion of phthisis. It is probable also, that oth-
er exanthemata have the same effect; and
from the phenomena of the disease, and the
dissections of persons who have died of it, it is
I2 probable, 

184 PRACTICE
probable, that all the exanthemata may occa-
sion a phthisis, by affording a matter which
in the first place produces tubercles.
DCCCLXXXI. 
Another acrimony, which seems sometimes
to produce phthisis, is the siphylitic: But
whether such an acrimony produces phthisis
in any other persons than the previously dis-
posed, does not appear to me certain.
DCCCLXXXII.
What other species of acrimony, such as
from scurvy, from pus absorbed from other
parts of the body, from suppressed eruptions,
or from other sources, may also produce tuber-
cles and phthisis, I cannot now decide, but
must leave to be determined by those who
have had experience of such cases.
DCCCLXXXIII.
There is one peculiar case of phthisis, which
from my own experience I can take notice
of. This is the case of phthisis from a calca-
reous matter formed in the lungs, and cough-
ed up, frequently with a little blood, some-
times with mucus only, and sometimes with
pus. How this matter is generated, or in
what precise part of the lungs it is seated, I
acknowledge myself ignorant. In three cases 
of 

185 OF PHYSIC.
of this kind which have occurred to me, there
was at the same time no appearance of stony
or earthy concretions in any other part of the
body. In one of these cases, an exquisitely
formed phthisis came on, and proved mortal:
While in the other two, the symptoms of
phthisis were never fully formed; and after
some time, merely by a milk diet and avoid-
ing irritation, the patients entirely recovered.
DCCCLXXXIV.
Another foundation for phthisis, analogous,
as I judge, to that of tubercles, is that which
occurs to certain artificers whose employments
keep them almost constantly exposed to dust;
such as stonecutters, millers, flaxdressers, and
some others. I have not observed in this
country many instances of phthisis which
could be referred to this cause; but, from
RAMAZZINI, MORGAGNI, and some other
writers, we must conclude such cases to be
more frequent in the Southern parts of Europe.
DCCCLXXXV.
Besides these now mentioned, there are
probably some other causes producing tuber-
cles, which have not yet been ascertained by
observation; and it is likely, that in the state
of tubercles there is a variety not yet account-
ed for: But all this must be left to future ob-
servation and inquiry.
I3 DCCCLXXXVI. 

186 PRACTICE
DCCCLXXXVI.
It has been frequently supposed by physi-
cians, that the phthisis is a contagious disease;
and I dare not assert that it never is such:
But in many hundred instances of the disease
which I have seen, there has been hardly one
which to me could appear to have arisen from
contagion. It is possible, that in warmer cli-
mates the effects of contagion may be more
discernible.
After having said that a phthisis arises from
tubercles more frequently than from any oth-
er cause; and after having attempted to assign
the variety of these, I now proceed to men-
tion the peculiar circumstances and symptoms
which usually accompany the coming on of
the disease from tubercles.
DCCCLXXXVII.
A tuberculous and purulent state of the
lungs has been observed in very young
children, and in some others at several differ-
ent periods before the age of puberty and full
growth; but instances of this kind are rare;
and the attack of phthisis, which we have rea-
son to impute to tubercles, usually happens at
the same period which I have assigned for the
coming on of the hemoptysis.
DCCCLXXXVIII. 

187 OF PHYSIC.
DCCLXXXVIII.
The phthisis from tubercles does also gen-
erally affect the same habits as the hemopty-
sis; that is, persons of a slender make, of long
necks, narrow chests, and prominent shoul-
ders: But very frequently the persons liable
to tubercles, have less of the florid counte-
nance, and of the other marks of an exqui-
sitely sanguine temperament, than the per-
sons liable to hemoptysis.
DCCCLXXXIX.
This disease, arising from tubercles, usually
commences with a slight and short cough,
which becomes habitual, is often little remark-
ed by those affected, and sometimes so little as
to be absolutely denied by them. At the same
time their breathing becomes easily hurried
by any bodily motion, their body grows lean-
er, and they become languid and indolent.
This state sometimes continues for a year, or
even for two years, without the persons mak-
ing any complaint of it, excepting only that
they are affected by cold more readily than
usual, which frequently increases their cough,
and produces some catarrh. This, again,
however, is sometimes relieved; is supposed
to have arisen from cold alone; and therefore
gives no alarm either to the patient or to his
I4 friends, 

188 PRACTICE
friends, nor leads them to take any precau-
tions.
DCCCXC.
Upon one or other of these occasions of
catching cold, as we commonly speak, the
cough becomes more considerable; is partic- 
ularly troublesome upon the patient's lying
down at night; and in this state continues
longer than is usual in the case of a simple
catarrh. This is more especially to call for
attention, if the increase and continuance of
cough come on during the summer season.
DCCCXCI.
The cough which comes on as in
DCCCLXXXIX, is very often for a long time
without any expectoration; but when, from
repeatedly catching cold, it becomes more
constant, it is then at the same time attended
with some expectoration, which is most con-
siderable in the mornings. The matter of
this expectoration becomes by degrees more
copious, more viscid, and more opake; at
length of a yellow or greenish colour, and of
a purulent appearance. The whole of the
matter, however, is not always at once entire-
ly changed in this manner; but, while one
part of it retains the usual form of mucus, an-
other suffers the changes now described.
DCCCXCII. 

189 OF PHYSIC.
DCCCXCII.
When the cough increases, and continues
very frequent through the night, and when
the matter expectorated undergoes the chang-
es I have mentioned, the breathing at the
same time becomes more difficult, and the
emaciation and weakness go on also increasing.
In the female sex, as the disease advances, and
sometimes early in its progress, the menses
cease to flow; and this circumstance is to be
considered as commonly the effect, although
the sex themselves are ready to believe it the
sole cause of the disease.
DCCCXCIII.
When the cough comes on as in
DCCCLXXXIX, the pulse is often natural,
and for some time after continues to be so;
but the symptoms have seldom subsisted long
before the pulse becomes frequent, and some-
times to a considerable degree, without much
of the other symptoms of fever. At length,
however, evening exacerbations become re-
markable; and by degrees the fever assumes
the exquisite form of hectic, as described in
DCCCLVIII——DCCCLX.
DCCCXCIV.
It is seldom that the cough, expectoration,
and fever, go on increasing, in the manner
VOL. 2. I5 now 

190 PRACTICE
now described, without some pain being felt
in some part of the thorax. It is usually and
most frequently felt at first under the sternum,
and that especially, or almost only, upon occa-
sion of coughing: But very often, and that
too early, in the course of the disease, a pain
is felt on one side, sometimes very constantly,
and so as to prevent the person from lying
easily upon that side; but at other times the
pain is felt only upon a full inspiration, or
upon coughing. Even when no pain is felt,
it generally happens that phthisical persons
cannot lie easily on some one of their sides
without having their difficulty of breathing
increased, and their cough excited.
DCCCXCV.
The phthisis begins, and sometimes pro-
ceeds to its fatal issue, in the manner described
from DCCCLXXXIX, to DCCCXCV,
without any appearance of hemoptysis. Such
cases are, indeed, rare; but it is very common
for the disease to advance far, and even to an
evident purulency and hectic state, without
any appearance of blood in the spitting: So
that it may be affirmed, the disease is fre-
quently not founded in hemoptysis. At the
same time, we must allow, not only that it
sometimes begins with an hemoptysis, as is
said in DCCCLXIV; but further, that it
seldom happens that in the progress of the
disease more or less of an hemoptysis does not
appear. 

191 OF PHYSIC.
appear. Some degree of bloods pitting does,
indeed, appear sometimes in the state men-
tioned DCCCLXXXIX, DCCCXCIII, but
more commonly in the more advanced stages
of the disease only, and particularly upon the
first appearance of purulency. However this
may be, it is seldom, in the phthisis from tu-
bercles, that the hemoptysis is considerable,
or requires any remedies different from those
which are otherwise necessary for the state of
the tubercles.
DCCCXCVI.
I have now described a succession of symp-
toms which, in different cases, occupy more
or less time. In this climate they very often
take up some years, the symptoms appearing
especially in the winter and spring; common-
ly becoming easier, and sometimes almost dis-
appearing, during the summer: But returning
again in winter, they at length, after two or
three years, prove fatal, towards the end off
spring or beginning of summer.
DCCCXCVII.
In this disease, the prognosis is for the most
past unfavourable. Of those affected with it,
the greater number die; but there are also
many of them who recover entirely, after
having been in very unpromising circum-
stances. What are, however, the circum-
I6 stances 

192 PRACTICE
stances more certainly determining to a happy
or to a fatal event, I have not yet been able to
ascertain.
DCCCXCVIII.
The following aphorisms are the result of
my observations.
A phthisis pulmonalis from hemoptysis, is
more frequently recovered than one from tu-
bercles.
An hemoptysis not only is not always fol-
lowed by a phthisis, as we have said above
(DCCCLXIV); but even when followed by
an ulceration, the ulceration is sometimes at-
tended with little of hectic, and frequently
admits of being soon healed. Even when the
hemoptysis and ulceration have happened to
be repeated, there are instances of persons re-
covering entirely after several such repetitions.
A phthisis from a suppuration in conse-
quence of pneumonic inflammation, is that
which most rarely occurs in this climate; and
a phthisis does not always follow such suppu-
ration, when the abscess formed soon breaks
and discharges a laudable pus: But, if the ab-
scess continue long shut up, and till after a
considerable degree of hectic has been form-
ed, a phthisis is then produced, equally dan-
gerous as that from other causes.
A phthisis from tubercles has, I think, been
recovered: But it is of all others the most
dangerous; 

193 OF PHYSIC.
dangerous; and, when arising from a heredita-
ry taint, is almost certainly fatal.
The danger of a phthisis, from whatever
cause it may have arisen, is most certainly to
be judged of by the degree to which the hec-
tic and its consequences have arrived. From
a certain degree of emaciation, debility, pro-
fuse sweating, and diarrhœa, no person re-
covers. 
A mania coming on, has been found to re-
move all the symptoms, and sometimes has
entirely cured the disease; but, in other cases,
upon the going off of the mania, the phthisis
has recurred, and proved fatal.
The pregnancy of women has often retard-
ed the progress of a phthisis; but commonly
it is only till after delivery, when the symp-
toms of phthisis return with violence, and soon
prove fatal.
SECT. II.
Of the CURE of PHTHISIS.
DCCCXCIX.
FROM what has been just now said, it
will readily appear, that the cure of the phthisis
pulmonalis must be exceedingly difficult; and
that even the utmost care and attention in the
employment 

194 PRACTICE
employment of remedies have seldom suc-
ceeded. It may be doubtful whether this
failure is to be imputed to the imperfection
of our art, or to the absolutely incurable na-
ture of the disease. I am extremely averse
in any case to admit of the latter supposition,
and can always readily allow of the former;
but, in the mean time, must mention here
what has been attempted towards either curing
or moderating the violence of this disease.
DCCCC.
It must be obvious, that, according to the
different circumstances of this disease, the
method of cure must be different. Our first
attention should be employed in watching the
approach of the disease, and preventing its
proceeding to an incurable state. 
In all persons of a phthisical habit, and es-
pecially in those born of phthisical parents,
the slightest symptoms of the approach of
phthisis, at the phthisical period of life, ought
to be attended to.
DCCCCI.
When an hemoptysis occurs, though it be
not always followed with ulceration, and
phthisis, these, however, are always to be ap-
prehended; and every precaution is to be
taken against them. This is especially to be
done by employing every means of moderat-
ing 

195 OF PHYSIC.
ing the hemorrhagy, and of preventing its re-
turn, directed in DCCCXCII, et seq. and
these precautions ought to be continued for
several years after the occurrence of the
hemoptysis.
DCCCCII.
The phthisis which follows a suppuration
from pneumonic inflammation, can only be
prevented with certainty, by obtaining a res-
olution of such inflammation. What may be
attempted towards the cure of an abscess and
ulcer which have taken place, I shall speak of
hereafter.
DCCCCIII.
I have said, it is doubtful if a genuine ca-
tarrh ever produces a phthisis; but have al-
lowed that it possibly may; and both upon
this account, and upon account of the ambi-
guity which may arise, whether the appearing
catarrh be a primary disease, or the effect of a
tubercle, I consider it as of consequence to
cure a catarrh as soon as possible after its first
appearance. More especially when it shall
linger, and continue for some time, or shall,
after some intermission, frequently return, the
cure of it should be diligently attempted.
The measures requisite for this purpose shall
be mentioned afterwards, when we come to
treat of catarrh as a primary disease; but, in
the 

196 PRACTICE
the mean time, the means necessary for pre-
venting its producing a phthisis shall be men-
tioned immediately, as they are the same with
those I shall point out as necessary for pre-
venting a phthisis from tubercles.
DCCCCIV.
The preventing of a phthisis from asthma
must be, by curing, if possible, the asthma; or
at least by moderating it as much as may be
done; and as it is probable that asthma occa-
sions phthisis, by producing tubercles, the
measures necessary for preventing phthisis
from asthma, will be the same with those neces-
sary in the case of tubercles, which I am now
about to mention.
DCCCCV.
I consider tubercles as by much the most
frequent cause of phthisis; and even in many
cases where this seems to depend upon he-
moptysis, catarrh, or asthma, it does however
truly arise from tubercles. It is upon this
subject, therefore, that I shall have occasion
to treat of the measures most commonly requi-
site for curing phthisis. 
DCCCCVI.
When, in a person born of phthisical pa-
rents, of a phthisical habit, at the phthisical
period 

197 OF PHYSIC.
period of life, the symptoms DCCCLXXXIX,
in the Spring, or beginning of summer, shall
appear in the slightest degree, we may pre-
sume that a tubercle, or tubercles, either have
been formed, or are forming in the lungs; and
therefore, that every means we can devise for
preventing their formation, or for procuring
their resolution, should be employed imme-
diately, even although the patient himself
should overlook or neglect the symptoms, as
imputing them to accidental cold.
DCCCCVII.
This is certainly the general indication;
but how it may be executed I cannot readily
say. I do not know that, at any time, phy-
sicians have proposed any remedy capable of
preventing the formation of tubercles, or of
resolving them when formed. The analogy
of scrophula, gives no assistance in this matter.
In scrophula the remedies that are seemingly of
most power are, sea water, or certain mineral
waters; but these have generally proved hurt-
ful in the case of tubercles of the lungs. I
have known several instances of mercury very
fully employed for certain diseases, in persons
who were supposed at the time to have tuber-
cles formed, or forming, in their lungs; but
though the mercury proved a cure for those
other diseases, it was of no service in prevent-
ing phthisis, and in some cases seemed to hur-
ry it on.
DCCCCVIII. 

198 PRACTICE
DCCCCVIII.
Such appears to me to be the present state
of our art, with respect to the cure of tuber-
cles; but I do not despair of a remedy for the
purpose being found hereafter. In the mean
time, all that at present seems to be within
the reach of our art, is to take the measures
proper for avoiding the inflammation of tu-
bercles. It is probable that tubercles may
subsist long without producing any disorder;
and I am disposed to think, that nature some-
times resolves and discusses tubercles which
have been formed; but that nature does this
only when the tubercles remain in an unin-
flamed state; and therefore, that the measures
necessary to be taken are chiefly those for a-
voiding the inflammation of the tubercles.
DCCCCIX.
The inflammation of a tubercle of the lungs-
is to be avoided upon the general plan of a-
voiding inflammation, by bloodletting, and
by an antiphlogistic regimen; the chief part of
which, in this case, is the use of a low diet.
This supposes a total abstinence from animal
food, and the using of vegetable food almost 
alone; but it has been found, that it is not
necessary for the patient to be confined to
vegetables of the weakest nourishment, it be-
ing

199 OF PHYSIC.
ing sufficient that the farinacea be employed,
and together with these, milk.
DCCCCX.
Milk has been generally considered as the
chief remedy in phthisis, and in the case of
every tendency to it; but whether from its
peculiar qualities, or from its being of a lower
quality, with respect to nourishment, than any
food entirely animal, is not certainly deter-
mined. The choice and administration of
milk will be properly directed, by considering
the nature of the milk of the several animals
from which it may be taken, and the particu-
lar state of the patient with respect to the pe-
riod and circumstances of the disease, and to
the habits of his stomach with respect to milk.
DCCCCXI.
A second means of preventing the inflam-
mation of the tubercles of the lungs, is, by a-
voiding any particular irritation of the affect-
ed part, which may arise from any violent ex-
ercise of respiration; from any considerable
degree of bodily exercise; from any position
of the body which straitens the capacity of
the thorax; and, lastly, from cold applied to
the surface of the body, which determines the
blood in greater quantity to the internal parts,
and particularly to the lungs.
DCCCCXII. 

200 PRACTICE
DCCCCXII.
From the last mentioned consideration, the
application of cold in general, and therefore
the winter season, in cold climates, as dimin-
ishing the cutaneous perspiration, is to be a-
voided; but more particularly, that applica-
tion of cold is to be shunned that may sup-
press perspiration, to the degree of occasioning
a catarrh, which consists in an inflammatory
determination to the lungs, and may therefore
most certainly produce an inflammation of
the tubercles there.
By considering, that the avoiding heat is a
part of the antiphlogistic regimen above rec-
ommended, and by comparing this with what
has been just now said respecting the avoiding
cold, the proper choice of climates and sea-
sons for phthisical patients will be readily un-
derstood.
DCCCCXIII.
A third means of avoiding the inflamma-
tion of the tubercles of the lungs consists, in
diminishing the determination of the blood to
the lungs, by supporting and increasing the
determination to the surface of the body;
which is to be chiefly and most safely done
by warm clothing, and the frequent use of the
exercises of gestation.
DCCCCXIV. 

201 OF PHYSIC.
DCCCCXIV.
Every mode of gestation has been found of
use in phthisical cases; but riding on horse-
back, as being accompanied with a great deal
of bodily exercise, is less safe in persons liable
to an hemoptysis. Travelling in a carriage,
unless upon very smooth roads, may also be
of doubtful effect; and all the modes of ges-
tation that are employed on land, may fall
short of the effects expected from them, be-
cause they cannot be rendered sufficiently
constant: And therefore it is that sailing, of
all other modes of gestation, is the most effec-
tual in pneumonic cases, as being both the
smoothest and most constant.
It has been imagined, that some benefit is
derived from the state of the atmosphere upon
the sea: But I cannot find that any impreg-
nation of this which can be supposed to take
place, can be of service to phthisical persons.
It is however probable, that frequently some
benefit may be derived from the more mode-
rate temperature and greater purity of the air
upon the sea.
DCCCCXV.
In order to take off any inflammatory de-
termination of the blood into the vessels of the
lungs, blisters applied to some part of the
thorax may often be of service; and for the
same 

202 PRACTICE
same purpose, as well as for moderating the
general inflammatory state of the body, issues
of various kinds may be employed with ad-
vantage.
DCCCCXVI.
The several measures to be pursued in the
case of what is properly called an Incipient
Phthisis, have now been mentioned; but they
have seldom been employed in such cases in
due time, and have therefore, perhaps, seldom
proved effectual. It has more commonly
happened, that after some time, an inflam-
mation has come upon the tubercle, and an
abscess has been formed, which opening into
the cavity of the bronchiæ, has produced an
ulcer, and a confirmed phthisis.
DCCCCXVII.
In this state of matters, some new indica-
tions different from the former may be sup-
posed to arise; and indications for preventing
absorption, for preventing the effects of
the absorbed matter upon the blood, and
for healing the ulcer, have been actually
proposed. I cannot find, however, that
any of the means proposed for executing
these indications, are either probable or have
proved effectual. If, upon some occasions,
they have appeared to be useful, it has been
probably by answering some other intention.
While 

203 OF PHYSIC.
While no antidote against the poison which
especially operates here, seems to have been
as yet found out, it appears to me, that too
great a degree of inflammation has a great
share in preventing the healing of the ulcer
which occurs; and such inflammation is cer-
tainly what has a great share in urging on its
fatal consequences. The only practice, there-
fore, which I can venture to propose, is the
same in the ulcerated as in the crude state of
a tubercle; that is, the employment of means
for moderating inflammation, which have
been already mentioned DCCCCIX et seq.
DCCCCXVIII.
The balsamics, whether natural or artificial,
which have been so commonly advised in
cases of phthisis, appear to me to have been
proposed upon no sufficient grounds, and to
have proved commonly hurtful. The resin-
ous and acrid substance of myrrh, lately rec-
ommended, has not appeared to me to be of
any service, and in some cases to have proved
hurtful.
DCCCCXIX.
Mercury, so often useful in healing ulcers,
has been speciously enough proposed in this
disease; but whether that it be not adapted to
the particular nature of the ulcers of the lungs
occurring in phthisis, or that it proved hurt-
ful 

204 PRACTICE
ful because it cannot have effect without ex-
citing such an inflammatory state of the whole
system, as, in a hectic state, must prove very
hurtful, I cannot determine. Upon many
trials which I have seen made, it has proved
of no service, and commonly has appeared to
be manifestly pernicious.
DCCCCXX.
The Peruvian bark has been recommended
for several purposes in phthisical cases; and
is said, upon some occasions, to have been use-
ful: But I have seldom found it to be so;
and as by its tonic power it increases the
phlogistic diathesis of the system, I have fre-
quently found it hurtful. In some cases,
where the morning remissions of the fever
were considerable, and the noon exacerbations
well marked, I have observed the Peruvian
bark given in large quantities, have the effect
of stopping these exacerbations, and at the
same time of relieving the whole of the phthis-
ical symptoms; but in the cases in which I
observed this, the fever showed a constant
tendency to recur; and at length the phthis-
ical symptoms also returned, and proved
quickly fatal.
DCCCCXXI.
Acids of all kinds, as antiseptic and refrig-
erant, are useful in cases of phthisis; but the
native 

205 OF PHYSIC.
native acid of vegetables is more useful than
the fossil acids, as it can be given in much larger
quantities and may also be given more safely
than vinegar, being less liable to excite cough-
ing.
DCCCCXXII.
Though our art can do so little towards the
cure of this disease, we must, however palli-
ate the uneasy symptoms of it as well as we
can. The symptoms especially urgent, are
the cough and diarrhœa. The cough may
be in some measure relieved by demulcents
(DCCCLXXIII): But the relief obtained
by these is imperfect and transitory; and very
often the stomach is disturbed by the quanti-
ty of oily, mucilaginous, and sweet substances,
which are on these occasions taken into it.
DCCCCXXIII.
The only certain means of relieving the
cough, is by employing opiates. These, in-
deed, certainly increase the phlogistic diathesis
of the system; but commonly they do not
so much harm in this way, as they do service
by quieting the cough, and giving sleep.
They are supposed to be hurtful by checking
expectoration: But they do it for a short time
only; and, after a sound sleep, the expecto-
ration in the morning is more easy than usual.
In the advanced state of the disease, opiates
VOL. II. K seem 

206 PRACTICE
seem to increase the sweatings that occur; but
they compensate this, by the ease they afford
in a disease which cannot be cured.
DCCCCXXIV.
The diarrhœa which happens in the ad-
vanced state of this disease, is to be palliated
by moderate astringents, mucilages, and o-
piates.
Rhubarb, so commonly prescribed in every
diarrhœa, and all other purgatives, are ex-
tremely dangerous in the colliquative diar-
rhœa of hectics.
Fresh subacid fruits, supposed to be always
laxative, are often, in the diarrhœa of hectics,
by their antiseptic quality, very useful.
CHAP. 

207 OF PHYSIC.
CHAP. V.
OF THE HEMORRHOIS; OR OF THE
HEMORRHOIDAL SWELLING
AND FLUX.
SECT. I.
Of the PHENOMENA and CAUSES of the
HEMORRHOIS.
DCCCCXXV.
A DISCHARGE of blood
from small tumours on the verge of the anus,
is the symptom which generally constitutes the
Hemorrhoids; or, as it is vulgarly called, the
Hemorrhoidal Flux. But a discharge of
blood from within the anus, when the blood
is of a florid colour, showing it to have come
from no great distance, is also considered as
the same disease; and physicians have agreed
in making two cases or varieties of it, under
K2 the 

208 PRACTICE
the names of External and Internal Hem-
orrhoids.
DCCCCXXVI.
In both cases it is supposed that the flow of
blood is from tumours previously formed,
which are named Hemorrhoids, or Piles; and
it frequently happens, that the tumours exist
without any discharge of blood; in which
case, however, they are supposed to be a part
of the same disease, and are named Hemor-
rhoids Cæcæ, or Blind Piles.
DCCCCXXVII.
These tumours, as they appear without the
anus, are sometimes separate, round, and
prominent, on the verge of the anus; but
frequently the tumour is only one tumid ring,
forming, as it were, the anus pushed without
the body.
DCCCCXXVIII.
These tumours, and the discharge of blood
from them, sometimes come on as an affection
purely topical, and without any previous dis-
order in other parts of the body; but it fre-
quently happens, even before the tumours
are formed, and more especially before the
blood flows, that various disorders are felt in
different parts of the body, as headach, verti-
go, 

209 OF PHYSIC.
go, stupor, difficulty of breathing, sickness,
colic pains, pain of the back and loins; and
often, together with more or fewer of these
symptoms, there occurs a considerable degree
of pyrexia.
The coming one of the disease with these
symptoms, is usually attended with a sense of
fullness, heat, itching, and pain in and about
the anus.
Sometimes the disease is preceded by a dis-
charge of serious matter from the anus; and
sometimes this serous discharge, accompanied
with some swelling, seems to be in place of
the discharge of blood, and to relieve those
disorders of the system which we have men-
tioned. This serous discharge, therefore, has
been named the Hemorrhoids Alba.
DCCCCXXIX.
In the hemorrhoids, the quantity of blood
discharged is different upon different occa-
sions. Sometimes the blood flows only upon
the person's going to stool; and commonly in
larger or lesser quantity, follows the discharge
of the fæces. In other cases, the blood flows
without any discharge of fæces; and then,
generally, it is after having been preceded by
the disorders abovementioned, when it is also
commonly in larger quantity. This discharge
of blood is often very considerable; and, by
the repetition, it is often so great, as we could
hardly suppose the body to bear but with the
K3 hazard 

210 PRACTICE
hazard of life. Indeed, though rarely, it has
been so great as to prove suddenly fatal.
These considerable discharges occur especially
to persons who have been frequently liable to
the disease. They often induce great debili-
ty; and frequently a leucophlegmatia, or
dropsy, which proves fatal.
The tumours and discharges of blood in
this disease, often recur at exactly stated
periods.
DCCCCXXX.
It often happens, in the decline of life, that
the hemorrhoidal flux, formerly frequent,
ceases to flow; and, upon that event, it gen-
erally happens that the persons are affected
with apoplexy or palsy.
DCCCCXXXI.
Sometimes hemorrhoidal tumours are af-
fected with considerable inflammation; which,
ending in suppuration, gives occasion to the
formation of fistulous ulcers in those parts.
DCCCCXXXII.
The hemorrhoidal tumours have been often
considered as varicous tumours, or dilatations
of veins; and it is true, that in some cases va-
ricous dilatations have appeared upon dissec-
tion. These, however, do not always appear;
and 

211 OF PHYSIC.
and I presume it is not the ordinary case, but
that the tumours are formed by an effusion of
blood into the cellular texture of the intestine
near to its extremity. These tumours, es-
pecially when recently formed, frequently
contain fluid blood; but, after they have re-
mained for some time, they are commonly of
a firmer substance.
DCCCCXXXIII.
From a consideration of their causes, to be
hereafter mentioned, it is sufficiently proba-
ble, that hemorrhoidal tumours are produced
by some interruption of the free return of
blood from the veins of the lower extremity
of the rectum; and it is possible, that a con-
siderable accumulation of blood in these veins,
may occasion a rupture of their extremities,
and thus produce the hemorrhagy or tumours
I have mentioned. But, considering that the
hemorrhagy occurring here, is often preceded
by pain, inflammation, and a febrile state, as
well as by many other symptoms which show
a connexion between the topical affection and
the state of the whole system, it seems proba-
ble that the interruption of the venous blood,
which we have supposed to take place, operates
in the manner explained in DCCLXIX; and
therefore, that the discharge of blood here is
commonly from arteries.
K4 DCCCCXXXIV. 

212 PRACTICE
DCCCCXXXIV.
Some physicians have been of opinion, that
a difference in the nature of the hemorrhois,
and of its effects upon the system, might a-
rise from the difference of the hemorrhoidal
vessels from which the blood issued. But it ap-
pears to me, that hardly in any case we can dis-
tinguish the vessels from which the blood flows;
and that the frequent inoculations of both
the arteries and veins which belong to the
lower extremity of the rectum, will render the
effects of the hemorrhagy nearly the same,
from which so ever of these vessels the blood
proceed.
DCCCCXXXV.
In DCCLXIX, I have endeavoured to ex-
plain the manner in which a certain state of
the sanguiferous system might give occasion
to an hemorrhoidal flux; and I have no doubt,
that this flux may be produced in that man-
ner. I cannot, however, by any means admit,
that the disease is so often produced in that
manner, or that, on its first appearance, it is
so frequently a systematic affection, as the
Stahlians have imagined, and would have us
to believe. It occurs in many persons before
the period of life at which the venous pletho-
ra takes place; it happens to females, in
whom a venous plethora, determined to the
hemorrhoidal 

213 OF PHYSIC.
hemorrhoidal vessels, cannot be supposed; and
it happens to both sexes, and to persons of all
ages, from causes which do not affect the sys-
tem, and are manifestly suited to produce a
topical affection only.
DCCCCXXXVI.
These causes of a topical affection are, in the
first place, the frequent voiding of hard and
bulky fæces, which, not only by their long
stagnation in the rectum, but especially when
voided, must press upon the veins of the anus,
and interrupt the course of the blood in them.
It is for this reason that the disease happens so
often to persons of a slow and bound belly.
DCCCCXXXVII.
From the causes just now mentioned, the
disease happens especially to persons liable to
some degree of a prolapsus ani. Almost eve-
ry person in voiding fæces has the internal
coat of the rectum more or less protruded
without the body; and this will be to a great-
er or lesser degree, according as the hardness
and bulk of the fæces occasion a greater or
lesser effort or pressure upon the anus. While
the gut is thus pushed out, it often happens,
that the sphincter ani is contracted before the
gut is replaced; and, in consequence thereof,
a strong constriction is made, which preventing
the fallen out gut from being replaced, and at
VOL. 2. K5 the 

214 PRACTICE
the same time preventing the return of blood
from it, occasions its being considerably swell-
ed, and its forming a tumid ring round the
anus.
DCCCCXXXVIII.
Upon the sphincter's being a little relaxed,
as it is immediately after its strong contrac-
tion, the fallen out portion of the gut is com-
monly again taken within the body; but, by
the frequent repetition of such an accident,
the size and fullness of the ring formed by the
fallen out gut, is much increased. It is there-
fore more slowly and difficultly replaced; and
in this consists the chief uneasiness of hemor-
rhoidal persons.
DCCCCXXXIX.
As the internal edge of the ring mentioned,
is necessarily divided by clefts, the whole often
assumes the appearance of a number of dis-
tinct swellings; and it also frequently happens,
that some portions of it, more considerably
swelled than others, become more protube-
rant, and form those small tumours more
strictly called Hemorrhoids, or Piles.
DCCCCXL.
From considering that the pressure of fæces,
and other causes interrupting the return of
venous 

215 OF PHYSIC.
venous blood from the lower extremity of the
rectum, may operate a good deal higher up in
the gut than that extremity, it may be easily
understood that tumours may be formed
within the anus; and probably it also hap-
pens, that some of the tumours formed with-
out the anus, as in DCCCCXXXIX, may
continue when taken within the body, and
even be increased by the causes just now men-
tioned. It is thus that I would explain the
production of internal piles, which, on account
of their situation and bulk, are not protruded
on the person's going to stool, and are often,
therefore, more painful. The same internal
piles are more especially painful, when af-
fected by the hemorrhagic effort described in
DCCXLV and DCCLXIX.
DCCCCXLI. 
The production of piles is particularly il- 
lustrated by this, that pregnant women are
frequently affected with them. This is to
be accounted for partly from the pressure of
the uterus upon the rectum, and partly from
the costive habit to which pregnant women
are usually liable. I have known many in-
stances of piles occurring for the first time
during the state of pregnancy; and there are
few women that have born children who are
afterwards entirely free from piles. The
Stahlians have commonly asserted, that the
male sex is more frequently affected with this
K6 disease 

216 PRACTICE
disease than the female; but in this country I
have constantly found it otherwise.
DCCCCXLII.
It is commonly supposed, that the frequently
use of purgatives, especially of those of the
more acrid kind, and more particularly of al-
oetics, is apt to produce the hemorrhoidal af-
fection; and as these purgatives stimulate
chiefly the great guts, it seems sufficiently
probable that they may excite this disease.
DCCCCXLIII.
I have now mentioned several causes which
may produce the hemorrhoidal tumours and
flux as a topical affection only; but must ob-
serve farther, that although the disease appears
first as a purely topical affection, it may, by
frequent repetition, become habitual; and
therefore may become connected with the
whole system, in the manner already explain-
ed, with respect to hemorrhagy in general, in
DCCXLVIII.
DCCCCXLIV.
The doctrine now referred to will, it is ap-
prehended, apply very fully to the case of
the hemorrhoidal flux; and will the more
readily apply, from the person who has been
once affected being much exposed to a re-
newal 

217 OF PHYSIC.
newal of the causes which first occasioned the
disease; and from many persons being much
exposed to a congestion in the hemorrhoidal
vessels, in consequence of their being often in
an erect position of the body, and in an exer-
cise which pushes the blood into the depend-
ing vessels, while at the same time the effects
of these circumstances are much favoured by
the abundance and laxity of the cellular tex-
ture about the rectum.
DCCCCXLV.
It is thus that the hemorrhoidal flux is so
often artificially rendered an habitual and sys-
tematic affection; and I am persuaded, that
it is this which has given occasion to the
Stahlians to consider the disease as almost
universally such.
DCCCCXLVI.
It is to be particularly observed here, that
when the hemorrhoidal disease has either been
originally, or has become, in the manner just
now explained, a systematic affection, it then
acquires a particular connexion with the
stomach, so that certain affections there ex-
cite the hemorrhoidal disease, and certain
states of the hemorrhoidal affection excite dis-
orders of the stomach.
It 

218 PRACTICE
It is perhaps owing to this connexion that
the gout sometimes affects the rectum. See
DXXV.
SECT. II.
Of the CURE of HEMORRHOIDAL AFFEC-
TIONS.
DCCCCXLVII.
ALMOST at all times it has been an opin-
ion amongst physicians, and from them spread
amongst the people, that the hemorrhoidal
flux is a salutary evacuation which prevents
many diseases that would otherwise have hap-
pened; and that it even contributes to give
long life. This opinion, in later times, has
been especially maintained by Dr. Stahl and
his followers; and has had a great deal of in-
fluence upon the practice of physic in Ger-
many.
DCCCCXLVIII.
The question arises with respect to hemor-
rhagy in general, and indeed it has been ex-
tended so far by the Stahlians. I have ac-
cordingly considered it as a general question,
(DCCLXVII——DCCLXXX); but it has
been 

219 OF PHYSIC.
been more especially agitated with regard to
the disease now under our consideration:
And as to this, although I am clearly of opin-
ion, that the hemorrhois may take place in
consequence of the general state of the system
(DCCLXIX); or, what is still more frequent,
that by repetition it may become connected
with that general state (DCCCCXLIII), and
in either case cannot be suppressed without
great caution; I must beg leave, notwithstand-
ing this, to maintain, that the first is a rare
case, that generally the disease first appears as
an affection purely topical (DCCCCXXXV,
DCCCCXLII), and that the allowing it to
become habitual is never proper. It is a nasty
disagreeable disease, ready to go to excess,
and to be thereby very hurtful, as well as
sometimes fatal. At best it is liable to acci-
dents, and thereby to unhappy consequences.
I am therefore of opinion, that not only the
first approaches of the disease are to be guard-
ed against; but even that when it has taken
place for some time, from whatever cause it
may have proceeded, the flux is always to be
moderated, and the necessity of it, if possible,
superseded.
DCCCCXLIX.
Having delivered these general rules, I
proceed to mention more particularly, how
the disease is to be treated, according to the
different 

220 PRACTICE
different circumstances under which it may
appear.
When we can manifestly discern the first
appearance of the disease to arise from causes
acting upon the part only, the strictest atten-
tion should be employed in guarding against
the renewal of these causes.
DCCCCL.
One of the most frequent of the remote
causes of the hemorrhoidal affection, is a slow
and bound belly, (DCCCCXXXVI): And
this is to be constantly obviated by a proper
diet, which each individual's own experience
must direct; or, if the management of diet be
not effectual, the belly must be kept regular
by such medicines as may prove gently laxa-
tive, without irritating the rectum. In most
cases it will be of advantage to acquire a hab-
it with respect to time, and to observe it
exactly.
DCCCCLI.
Another cause of hemorrhois to be espec-
ially attended to, is the prolapsus or protru-
sion of the anus, which is apt to happen on a
person's having a stool (DCCCCXXXVII.)
If it shall occur to any considerable degree,
and at the same time be not easily and imme-
diately replaced, it most certainly produces
piles, or increases them when otherwise pro-
duced. 

221 OF PHYSIC.
duced. Persons therefore liable to this pro-
lapsus, should, upon their having been at stool,
make great pains to have the gut immediately
replaced, by lying down in a horizontal pos-
ture, and pressing gently upon the anus, till
the reduction shall be completely obtained.
DCCCCLII.
When the prolapsus of which I speak is
occasioned only by voiding hard and bulky
fæces, it should be obviated by the means
mentioned in DCCCCL, and may be thereby
avoided. But in some persons it is owing to
a laxity of the rectum; in which case it is
often most considerable upon occasion of a
loose stool; and then the disease is to be treat-
ed by astringents, as well as by proper arti-
fices for preventing the falling down of the
gut.
DCCCCLIII.
These are the means to be employed upon
the first approaches of the hemorrhoidal af-
fection; and when from neglect it shall have
frequently recurred, and has become in some
measure established, they are no less proper.
In the latter case, however, some other means
are also necessary. It is particularly proper
to guard against a plethoric state of the body;
consequently, to avoid a sedentary life, a full
diet, and particularly intemperance in the use
of 

222 PRACTICE
of strong liquor; which, as I should have ob-
served before, is, in all cases of hemorrhagy,
of the greatest influence in increasing the dis-
position to the disease.
DCCCCLIV.
I need hardly repeat here, that exercise of
all kinds must be a chief means of obviating
and removing a plethoric state of the body;
but upon occasion of the hemorrhoidal flux
immediately approaching, both walking and
riding, as increasing the determination of the
blood into the hemorrhoidal vessels, are to
be avoided. At other times, when no such
determination has been already formed, those
modes of exercise may be very properly em-
ployed.
DCCCCLV.
Cold bathing is another remedy that may
be employed to obviate plethora, and prevent
hemorrhagy; but it is to be used with cau-
tion. When the hemorrhoidal flux is ap-
proaching, it may be dangerous to turn it
suddenly aside by cold bathing: But during
the intervals of the disease, this remedy may
be employed with advantage; and in persons
liable to a prolapsus ani, the frequent washing
of the anus with cold water may be very
useful.
DCCCCLVI. 

223 OF PHYSIC.
DCCCCLVI.
These are the means for preventing the re-
currence of the hemorrhoidal flux; and in all
cases, when it is not immediately approaching,
they are to be employed. When it has actu-
ally come on, means are to be employed for
moderating it as much as possible, by the
persons lying in a horizontal position upon a
hard bed; by avoiding exercise in an erect
posture; by using a cool diet; by avoiding
external heat; and by obviating the irritation
of hardened fæces by the use of proper laxa-
tives, (DCCCCL). From what has been
said above, as to the being careful not to in-
crease the determination of the blood into the
hemorrhoidal vessels, the propriety of these
measures must sufficiently appear; and if they
were not so generally neglected, many persons
would escape the great trouble, and the va-
rious bad consequences which so frequently
result from this disease.
DCCCCLVII.
With respect to the further cure of this
disease, it is almost in two cases only, that
hemorrhoidal persons call for the assistance of
the physician. The one is when the affec-
tion is accompanied with much pain; and of
this there are two cases, according as the pain
happens 

224 PRACTICE
happens to attend the external or the inter-
nal piles.
DCCCCLVIII.
The pain of the external piles arises espec-
ially when a considerable protrusion of the
rectum has happened; and when, continuing
unreduced, it is strangled by the constriction
of the sphincter; while, at the same time, no
bleeding happens, to take off the swelling of
the protruded portion of the intestine. Some-
times an inflammation supervenes, and greatly
aggravates the pain. To relieve the pain in
this case, emollient fomentations and poultices
are sometimes of service; but a more effectual
relief is to be obtained by applying leeches
to the tumid parts.
DCCCCLIX.
The other case in which hemorrhoidal per-
sons seek assistance, is that of excessive bleed-
ing. Upon the opinion so generally received
of this discharge being salutary, and from the
observation that upon the discharge occurring
persons have sometimes found relief from va-
rious disorders, the most part of persons liable
to it are ready to let it go too far; and indeed
the Stahlians will not allow it to be a disease,
unless when it has actually gone to excess. I
am, however, well persuaded, that this flux
ought always to be cured as soon as possible.
DCCCCLX. 

225 OF PHYSIC.
DCCCCLX.
When the disease occurs as a purely topical
affection, there can be no doubt of the pro-
priety of this rule; and, even when it has oc-
curred as a critical discharge in the case of a
particular disease, yet when this disease shall
have been entirely cured and removed, the
preventing any return of the hemorrhois seems
to be both safe and proper.
DCCCCLXI.
It is only when the disease arises from a
plethoric state of the body, and from a stag-
nation of blood in the hypochondriac region;
or when, though originally topical, the disease,
by frequent repetition, has become habitual,
and has thereby acquired a connexion with
the whole system, that any doubt can arise as to
the safety of curing it entirely. Even in these
cases, however, I apprehend it will be always
proper to moderate the bleeding; left by its
continuance or repetition, the plethoric state
of the body, and the particular determination
of the blood into the hemorrhoidal vessels, be
increased, and the recurrence of the disease,
with all its inconveniences and danger, be too
much favoured.
DCCCCLXII. 

226 PRACTICE
DCCCCLXII.
Further, even in the cases stated
(DCCCCLXI), in so far as the plethoric state
of the body, and the tendency to that state,
can be obviated and removed, this is always
to be diligently attempted; and if it can be
executed with success, the flux may be entire-
ly suppressed.
DCCCCLXIII.
The Stahlian opinion, that the hemorrhoi-
dal flux is only in excess when it occasions
great debility, or a leucophlegmatia, is by no
means just; and it appears to me, that the
smallest approach towards producing either of
these, should be considered as an excess, which
ought to be prevented from going farther.
DCCCCLXIV.
In all cases therefore of excess, or of any
approach towards it, and particularly when
the disease depends upon a prolapsus ani
(DCCCCLI), I am of opinion that astringents,
both internal and external, may be safely and
properly employed; not indeed to induce an
immediate and total suppression, but to mod-
erate the hemorrhagy, and by degrees to sup-
press it altogether, while at the same time
measures 

227 OF PHYSIC. 
measures are taken for removing the necessity
of its recurrence.
DCCCCLXV.
When the circumstances (DCCCCXLVI)
marking a connexion between the hemorrhoi-
dal affection and the state of the stomach oc-
cur, the measures necessary are the same as in
the case of atonic gout.
CHAP. 

228 PRACTICE
CHAP. VI.
OF THE MENORRHAGIA, OR THE
IMMODERATE FLOW OF THE
MENSES.
DCCCCLXVI.
BLOOD discharged from the
vagina may proceed from different sources in
the internal parts: But I here mean to treat
of those discharges only, in which the blood
may be presumed to flow from the same sourc-
es that the menses in their natural state pro-
ceed from; and which discharges alone, are
those properly comprehended under the pres-
ent title. The title of Metrorrhagia, or
hæmorrhagia uteri, might comprehend a great
deal more. 
DCCCCLXVII.
The menorrhagia may be considered as of
two kinds; either as it happens to pregnant
and lying in women, or as it happens to
women neither pregnant nor having recently
born children. The first kind, as connected
with 

229 OF PHYSIC.
with the circumstances of pregnancy and
childbearing, (which are not to be treated of
in the present course), I am not to consider
here, but shall confine myself to the second
kind of menorrhagia only.
DCCCCLXVIII.
The flow of the menses is considered as im-
moderate, when it recurs more frequently,
when it continues longer, or when, during the
ordinary continuance, it is more abundant
than is usual with the same person at other
times.
DCCCCLXIX.
As the most part of women are liable to
some inequality with respect to the period,
the duration, and the quantity of their mens-
es; so it is not every inequality in these re-
spects that is to be considered as a disease;
but only those deviations, which are excessive
in degree, which are permanent, and which
induce a manifest state of debility.
DCCCCLXX.
The circumstances (DCCCCLXVIII,
DCCCCLXIX) are those which chiefly con-
stitute the menorrhagia: But it is proper to
observe, that although I allow the frequency,
duration, and quantity of the menses to be
VOL. II. L judged 

230 PRACTICE
judged of by what is usual with the same in-
dividual at other times; yet there is, in these
particulars, so much uniformity observable in
the whole of the sex, that in any individual
in whom there occurs a considerable devia-
tion from the common measure, such a devia-
tion, if constantly recurring, may be consider-
ed as at least approaching to a morbid state,
and as requiring most of the precautions which
I shall hereafter mention as necessary to be
attended to by those who are actually in such
a state.
DCCCCLXXI.
However we may determine with respect
to the circumstances DCCCCLXVIII,
DCCCCLXIX, it must still be allowed, that
the immoderate flow of the menses is especial-
ly to be determined by those symptoms af-
fecting other functions of the body, which ac-
company and follow the discharge.
When a larger flow than usual of the
menses has been preceded by headach, giddi-
ness, or dyspnœa, and has been ushered in by
a cold stage, and is attended with much pain
of the back and loins, with a frequent pulse,
heat, and thirst, it may then be considered as
preternaturally large.
DCCCCLXXII.
When, in consequence of the circum-
stances DCCCCLXVIII——DCCCCLXXI,
and 

231 OF PHYSIC.
and the repetition of these, the face becomes
pale; the pulse grows weak; an unusual
debility is felt in exercise; the breathing is
hurried by moderate exercise; when, also, the
back becomes pained from any continuance
in an erect posture; when the extremities be-
come frequently cold; and when in the even-
ing the feet appear affected with œdematous
swelling; we may from these symptoms cer-
tainly conclude, that the flow of the menses
has been immoderate, and has already induc-
ed a dangerous state of debility.
DCCCCLXXIII.
The debility thus induced, does often dis-
cover itself also by affections of the stomach,
as anorexia and other symptoms of dyspepsia;
by a palpitation of the heart, and frequent
faintings; by a weakness of mind liable to
strong emotions from slight causes, especially
when suddenly presented.
DCCCCLXXIV.
That flow of the menses, which is attended
with barrenness in married women, may be
generally considered as immoderate and mor-
bid.
L2 DCCCCLXXV. 

232 PRACTICE
DCCCCLXXV.
Generally, also, that flow of the mens-
es may be considered as immoderate, which
is preceded and followed by a leucorrhœa.
DCCCCLXXVI.
I treat of menorrhagia here as an active
hemorrhagy, because I consider menstruation,
in its natural state, to be always of that kind;
and although there should be cases of menor-
rhagia which might be considered as purely
passive, it appears to me that they cannot be
so properly treated of in any other place.
DCCCCLXXVII.
The menorrhagia (DCCCCLXVIII, et seq.)
has for its proximate cause, either the hemor-
rhagic effort of the uterine vessels preternatu-
rally increased, or a preternatural laxity of the
extremities of the uterine arteries, the hemor-
rhagic effort remaining as in the natural state.
DCCCCLXXVIII.
The remote causes of the menorrhagia
may be, 1st, Those which increase the plethor-
ic state of the uterine vessels; such as a full
and nourishing diet, much strong liquor, and
frequent intoxication. 2dly, Those which
determine the blood more copiously and for- 
cibly

233 OF PHYSIC.
cibly into the uterine vessels; as violent strain-
ings of the whole body; violent shocks of the
whole body from falls; violent strokes or con-
tusions on the lower belly; violent exercise,
particularly in dancing; and violent passions
of the mind. 3dly, Those which particularly
irritate the vessels of the uterus; as excess in
venery; the exercise of venery in the time of
menstruation; a costive habit, giving occasion
to violent straining at stool; and cold applied
to the feet. 4thly, Those which have forcibly
overstrained the extremities of the uterine ves-
sels; as frequent abortions; frequent child-
bearing without nursing; and difficult tedious
labours. Or, lastly, Those which induce a
general laxity; as living much in warm cham-
bers, and drinking much of warm enervating
liquors, such as tea and coffee.
DCCCCLXXIX.
The effects of the menorrhagia are pointed
out in DCCCCLXXII, DCCCCLXXIII,
where I have mentioned the several symp-
toms accompanying the disease, and from
these the consequences to be apprehended will
also readily appear.
DCCCCLXXX.
The treatment and cure of the menorrha-
gia must be different, according to the differ-
ent causes of the disease.
L3 In 

234 PRACTICE
In all cases, the first attention ought to be
given to avoiding the remote causes, whenever
that can be done; and by that means the dis-
ease may be often entirely avoided.
When the remote causes cannot be avoided,
or when the avoiding them has been neglect-
ed, and therefore a copious menstruation has
come on, it should be moderated as much as
possible, by abstaining from all exercise, either
at the coming on or during the continuance of
the menstruation; by avoiding even an erect
posture as much as possible; by shunning
external heat, and therefore warm chambers
and soft beds; by using a light and cool diet;
by taking cold drink, at least as far as former
habits will allow; by avoiding venery; by
obviating costiveness, or removing it by laxa-
tives that give little stimulus.
The sex are commonly negligent, either in
avoiding the remote causes or in moderating
the first beginnings of this disease. It is by
such neglect that it so frequently becomes vi-
olent, and of difficult cure; and the frequent
repetition of a copious menstruation, may be
considered as a cause of great laxity in the ex-
treme vessels of the uterus.
DCCCCLXXXI.
When the coming one of the menstruation
has been preceded by some disorder in other
parts of the body, and is accompanied with
pains of the back, resembling parturient pains,
together 

235 OF PHYSIC.
together with febrile symptoms, and when at
the same time the flow seems to be copious,
then a bleeding at the arm may be proper,
but it is not often necessary: and it will in
most cases be sufficient to employ, with great
attention and diligence, those means for mod-
erating the discharge which have been men-
tioned in the last paragraph.
DCCCCLXXXII.
When the immoderate flow of the menses
shall seem to be owing to a laxity of the vessels
of the uterus, as may be concluded from the
general debility and laxity of the person's
habit; from the remote causes that have occa-
sioned the disease (DCCCCLXXVIII);
from the absence of the symptoms which de-
note increased action in the vessels of the ute-
rus (DCCCCLXXI); from the frequent re-
currence of the disease; and particularly from
this, that in the intervals of menstruation the
person is liable to a leucorrhœa; then in such
case the disease is to be treated, not only by
employing all the means mentioned in
DCCCCLXXX, for moderating the hemor-
rhagy, but also by avoiding all irritation, eve-
ry irritation having the greater effect in pro-
portion as the vessels have been more lax and
yielding. If, in such a case of laxity, it shall
appear that some degree of irritation concurs,
opiates may be employed to moderate the dis-
L4 charge; 

236 PRACTICE
charge; but in using these, much caution is
requisite.
If, notwithstanding these measures having
been taken, the discharge shall prove very
large, astringents both external and internal
may be employed. In such cases, may small
doses of emetics be of service?
DCCCCLXXXIII.
When the menorrhagia depends on the lax-
ity of the uterine vessels, it will be proper, in
the intervals of menstruation, to employ tonic
remedies; as cold bathing and chalybeates.
The exercises of gestation, also, may be very
useful, both for strengthening the whole sys-
tem, and for taking off the determination of
the blood to the internal parts.
DCCCCLXXXIV.
The remedies mentioned in these two last
paragraphs, may be employed in all cases of
menorrhagia, from whatever cause it may
have proceeded, if the disease shall have al-
ready induced a considerable degree of debil-
ity in the body.
CHAP.

237 OF PHYSIC.
CHAP. VII.
OF THE LEUCORRHŒA, FLUOR AL-
BUS, OR WHITES.
DCCCCLXXXV.
EVERY serous or puriform
discharge from the vagina, may be, and has
been comprehended under one or other of the
appellations I have prefixed to this chapter.
Such discharges, however, may be various;
and may proceed from various sources, not
yet well ascertained; but I confine myself here
to treat of that discharge alone which may be
presumed to proceed from the same vessels,
which, in their natural state, pour out the
menses.
DCCCCLXXXVI.
I conclude a discharge from the vagina to
be of this kind; 1. From its happening to
women who are subject to an immoderate
flow of the menses, and liable to this from
VOL. 2. L5 causes

238 PRACTICE
causes weakening the vessels of the uterus.
2. From its appearing chiefly, and often only,
a little before, as well as immediately after, the
flow of the menses. 3. From the flow of the
menses being diminished, in proportion as the
leucorrhœa is increased. 4. From the leu-
corrhœa continuing after the menses have en-
tirely ceased, and with some appearance of its
observing a periodical recurrence. 5. From
the leucorrhœa being accompanied with the
effects of the menorrhagia (DCCCCLXXII,
DCCCCLXXIII.) 6. From the discharge
having been neither preceded by, nor accom-
panied with, symptoms of any topical affec-
tions of the uterus. 7. From the leucorrhœa
not having appeared soon after communica-
tion with a person who might be suspected of
communicating infection, and from the first
appearance of the disease not being accom-
panied with any inflammatory affection of the
pudenda.
DCCCCLXXXVII.
The appearance of the matter discharged
in the leucorrhœa, is very various with re-
spect to consistence and colour; but from
these appearances, it is not always possible to
determine concerning its nature, or the partic-
ular source from whence it proceeds.
DCCCCLXXXVIII. 

239 OF PHYSIC. 
DCCCCLXXXVIII.
The leucorrhœa, of which I am to treat, as
ascertained by the several circumstances
(DCCCCLXXXVI) seems to proceed from
the same causes as that species of menorrha-
gia which I suppose to arise from the laxity
of the extreme vessels of the uterus. It ac-
cordingly often follows or accompanies such
a menorrhagia; but though the leucorrhœa
depends chiefly upon the laxity mentioned,
it may have proceeded from irritations induc-
ing that laxity, and seems to be always in-
creased by any irritations applied to the
uterus.
DCCCCLXXXIX.
Some authors have alleged, that a variety
of circumstances in other parts of the body
may have a share in bringing on and in con-
tinuing this affection of the uterus now under
consideration; but I cannot discover the real-
ity of those causes; and it seems to me, that
this leucorrhœa, excepting in so far as it de-
pends upon a general debility of the system, is
always primarily an affection of the uterus;
and the affections of other parts of the body
which may happen to accompany it, are for
the most part to be considered as effects, rath-
er than as causes.
L6 DCCCCXC. 

240 PRACTICE
DCCCCXC.
The effects of the leucorrhœa are much the
same with those of menorrhagia; inducing a
general debility, and in particular, a debility
in the functions of the stomach. If, however,
the leucorrhœa be moderate, and be not ac-
companied with any considerable degree of
menorrhagia, it may often continue long
without inducing any great degree of debility,
and it is only when the discharge has been
very copious as well as constant, that its effects
in that way are very remarkable.
DCCCCXCI.
But, even when its effects upon the whole
body are not very considerable, it may still be
supposed to weaken the genital system; and it
seems sufficiently probable that this discharge
may often have a share in occasioning barren-
ness.
DCCCCXCII.
The matter discharged in the leucorrhœa,
is at first generally mild; but after some con-
tinuance of the disease, it sometimes becomes
acrid; and by irritating, or perhaps eroding,
the surfaces over which it passes, induces vari-
ous painful disorders.
DCCCCXCIII. 

241 OF PHYSIC.
DCCCCXCIII.
As I have supposed that the leucorrhœa
proceeds from the same causes as that species
of menorrhagia which is chiefly owing to a
laxity of the uterine vessels, it must be treated,
and the cure attempted, by the same means
as delivered in DCCCCLXXXII, for the
cure of menorrhagia, and with less reserve in
respect of the use of astringents.
DCCCCXCIV.
As the leucorrhœa generally depends upon
a great loss of tone in the vessels of the uterus,
the disease has been relieved, and sometimes
cured by certain stimulant medicines, which
are commonly determined, to the urinary pas-
sages, and from the vicinity of these are often
communicated to the uterus. Such, for ex-
ample, are cantharides, turpentine, and other
balsams of a similar nature.
CHAP. 

242 PRACTICE
CHAP. VIII.
OF THE AMENORRHŒA, OR IN-
TERRUPTION OF THE MENSTRU-
AL FLUX.
DCCCCXCV.
WHATEVER, in a system
of methodical nosology, may be the fittest
place for the amenorrhœa, it cannot be im-
proper to treat of it here as an object of prac-
tice, immediately after having considered the
menorrhagia.
DCCCCXCVI.
The interruption of the menstrual flux is to-
be considered as of two different kinds; the
one being when the menses do not begin to
flow at that period of life at which they usual-
ly appear; and the other being that when, af-
ter they have repeatedly taken place for some
time, they do, from other causes than concep-
tion, cease to return at their usual periods:
The 

243 OF PHYSIC.
The former of these cases is named the retention,
and the latter the suppression, of the menses.
DCCCCXCVII.
As the flowing of the menses depends upon
the force of the uterine arteries impelling the
blood into their extremities, and opening
these so as to pour out red blood; so the in-
terruption of the menstrual flux must depend,
either upon the want of due force in the action
of the uterine arteries, or upon some preter-
natural resistance in their extremities. The
former I suppose to be the most usual cause
of retention, the latter the most common cause
of suppression; and of each of these I shall
now treat more particularly.
DCCCCXCVIII. 
The retention of the menses, the emansio
mensium of Latin writers, is not to be consid-
ered as a disease merely from the menses not
flowing at that period which is usual with
most other women. This period is so differ-
ent in different women, that no time can be
precisely assigned as proper to the sex in gen-
eral. In this climate, the menses usually ap-
pear about the age of fourteen; but in many
they appear more early, and in many not till
the sixteenth year; in which last case it is oft-
en without any disorder being thereby occa-
sioned. It is not therefore from the age of 
the

244 PRACTICE
the person, that the retention is to be consid-
ered as a disease; and it is only to be consider-
ed as such, when, about the time the menses
usually appear, some disorders arise in other
parts of the body which may be imputed to
their retention; being such as, when arising
at this period, are known from experience to
be removed by the flowing of the menses.
DCCCCXCIX.
These disorders are, a sluggishness and fre-
quent sense of lassitude and debility, with va-
rious symptoms of dyspepsia; and sometimes
with a preternatural appetite. At the same
time the face loses its vivid colour, becomes
pale, and sometimes of a yellowish hue; the
whole body becomes pale and flaccid; and
the feet, and perhaps also a great part of the
body, become affected with œdematous swell-
ing. The breathing is hurried by any quick
or laborious motion of the body, and the heart
is liable to palpitation and syncope. A head-
ach sometimes occurs; but more certainly
pains of the back, loins, and haunches.
M.
These symptoms, when occurring in a high
degree, constitute the chlorosis of authors, hard-
ly ever appearing separate from the retention
of the menses; and, attending to these symp-
toms, 

245 OF PHYSIC. 
toms, the cause of this retention may, I think,
be perceived.
These symptoms manifestly show a consid-
erable laxity and flaccidity of the whole sys-
tem; and therefore give reason to conclude,
that the retention of the menses accompany-
ing them, is owing to a weaker action of the
vessels of the uterus; which therefore do not
impel the blood into their extremities with a
force sufficient to open these, and pour out
blood by them.
MI.
How it happens that at a certain period of
life a flaccidity of the system arises in young
women not originally affected with any such
weakness or laxity, and of which, but a little
time before, they had given no indication,
may be difficult to explain; but I would at-
tempt it in this way.
As a certain state of the ovaria in females,
prepares and disposes them to the exercise of
venery, about the very period at which the
menses first appear, it is to be presumed that
the state of the ovaria and that of the uterine
vessels are in some measure connected togeth-
er; and as generally symptoms of a change in
the state of the former appear before those of
the latter, it may be inferred, that the state of
the ovarian has a great share in exciting the ac-
tion of the uterine vessels, and producing the
menstrual flux. But, analogous to what hap-
pens 

246 PRACTICE
pens in the male sex, it may be presumed,
that in females a certain state of the genitals is
necessary to give tone and tension to the
whole system; and therefore that, if the stim-
ulus arising from the genitals be wanting, the
whole system may fall into a torpid and flac-
cid state, and from thence the chlorosis and
retention of the menses may arise.
MII.
It appears to me, therefore, that the reten-
tion of the menses is to be referred to a certain
state or affection of the ovaria: But what is
precisely the nature of this affection, or what
are the causes of it, I will not pretend to ex-
plain; nor can I explain in what manner that
primary cause of retention is to be removed.
In this, therefore, as in many other cases,
where we cannot assign the proximate cause of
diseases, our indications of cure must be form-
ed for obviating and removing the morbid ef-
fects or symptoms which appear.
MIII.
The effects, as has been said in M, consist
in a general flaccidity of the system, and con-
sequently in a weaker action of the vessels of
the uterus; so that this debility may be con-
sidered as the more immediate cause of the re-
tention. This, therefore, is to be cured by
restoring the tone of the system in general,
and 

247 OF PHYSIC.
and by exciting the action of the uterine ves-
sels in particular.
MIV.
The tone of the system in general is to be
restored by exercise, and, in the beginning
of the disease, by cold bathing. At the same
time, tonic medicines may be employed; and
of these the chalybeates have been chiefly rec-
ommended.
MV.
The action of the vessels of the uterus may
be excited:
1st, By determining the blood into them
more copiously; which is to be done by de-
termining the blood into the descending aor-
ta, by purging, by the exercise of walking, by
friction, and by warm bathing of the lower
extremities. It is also probable that the blood
may be determined more copiously into the
hypogastric arteries which go to the uterus, by
a compression of the iliacs; but the trials of
this kind hitherto made have seldom suc-
ceeded.
MVI.
2dly, The action of the uterine vessels may
be excited by stimulants applied to them.
Thus those purgatives which particularly
stimulate the intestinum rectum, may also
prove 

248 PRACTICE
prove stimulant to the uterine vessels con-
nected with those of the rectum. The exer-
cise of venery certainly proves a stimulus to
the vessels of the uterus; and therefore may
be useful when, with propriety, it can be em-
ployed. The various medicines recommend-
ed as stimulants of the uterine vessels, under
the title of Emmenagogues, have never ap-
peared to me to be effectual; and I cannot
perceive that any of them are possessed of a
specific power in this respect. Mercury, as
an universal stimulant, may act upon the ute-
rus, but cannot be very safely employed in
chlorotic persons. One of the most powerful
means of exciting the action of the vessels in
every part of the system is, the electrical shock;
and it has often been employed with success
for exciting the vessels of the uterus.
MVII.
The remedies (MIII——MVI) now men-
tioned, are those adapted to the retention of
the menses; and I am next to consider the
case of suppression. In entering upon this, I
must observe, that every interruption of the
flux, after it has once taken place, is not to be
considered as a case of suppression. For the
flux, upon its first appearance, is not always
immediately established in its regular course;
and therefore, if an interruption happen soon
after the first appearance, or even in the course
of the first, or perhaps second year after, it
may 

249 OF PHYSIC.
may often be considered as a case of retention,
especially when the disease appears with the
symptoms peculiar to that state.
MVIII.
Those which may be properly considered
as cases of suppression, are such as occur after
the flux has been for some time established in
its regular course, and in which the interrup-
tion cannot be referred to the causes of re-
tention (MII, MIII) but must be imputed to
some resistance in the extremities of the ves-
sels of the uterus. Accordingly, we often
find the suppression induced by cold, fear, and
other causes which may produce a constric-
tion of these extreme vessels. Some physi-
cians have supposed an obstructing lentor of
the fluids to occasion the resistance now men-
tioned: But this is purely hypothetical, with-
out any proper evidence of the fact; and it is
besides, from other considerations, improba-
ble.
MIX.
There are indeed some cases of suppression
that seem to depend upon a general debility
of the system, and consequently of the vessels
of the uterus. But in such cases, the suppres-
sion always appears as symptomatic of other
affections, and is therefore not to be consider- 
ed here.
MX.

250 PRACTICE
MX.
The idiopathic cases of suppression (MVIII)
seldom continue long without being attended
with various symptoms or disorders in differ-
ent parts of the body; very commonly aris-
ing from the blood which should have passed
by the uterus, being determined more copious- 
ly into other parts, and very often with such
force as to produce hemorrhagies in these.
Hence hemorrhagies from the nose, lungs, 
stomach, and other parts, have appeared in
consequence of suppressed menses. Besides
these, there are commonly hysteric and dys-
peptic symptoms produced by the same cause;
and frequently colic pains, with a bound
belly.
MXI.
In the idiopathic cases of suppression,
(MVIII) the indication of cure is to remove
the constriction affecting the extreme vessels
of the uterus; and for this purpose, the chief
remedy is warm bathing applied to the region
of the uterus. This, however, is not always
effectual, and I do not know of any other
remedy adapted to the indication. Besides
this, we have perhaps no other means of re-
moving the constriction in fault, but that of
increasing the action and force of the vessels
of the uterus, so as thereby to overcome the
resistance 

251 OF PHYSIC.
resistance or constriction of their extremities.
This therefore is to be attempted by the same
remedies in the case of suppression, as those
prescribed in the cases of retention (MIV——
MVI). The tonics, however, and cold bath-
ing (MIV) seems to be less properly adapted
to the cases of suppression, and have appeared
to me of ambiguous effect.
MXII. 
It commonly happens in the cases of sup-
pression, that though the menses do not flow
at their usual periods, there are often at those
periods some marks of an effort having a ten-
dency to produce the discharge. It is there-
fore at those times especially when the efforts
of the system are concurring, that we ought to
employ the remedies for curing a suppression;
and it is commonly fruitless to employ them
at other times, unless they be such as require
some continuance in their use to produce
their effects.
MXIII.
Nearly similar to the cases of suppression,
are those cases in which the menses flow after
longer intervals and in lesser quantity than u-
sual; and when these cases are attended with
the disorders in the system (MX) they are to
be cured by the same remedies as the cases of
entire suppression.
MXIV. 

252 PRACTICE
MXIV.
It may be proper in this place to take no-
tice of the dysmenorrhea, or cases of menstru-
ation in which the menses seem to flow with
difficulty, and are accompanied with much
pain in the back, loins, and lower belly. We
impute this disorder partly to some weaker
action of the vessels of the uterus, and partly,
perhaps more especially, to a spasm of its ex-
treme vessels. We have commonly found
the disease relieved by employing some of the
remedies of suppression immediately before
the approach of the period, and at the same
time employing opiates.
CHAP.

253 OF PHYSIC. 
CHAP. IX.
OF SYMPTOMATIC HEMORRHA-
GIES.
MXV.
I HAVE thought it very im-
proper in this work, to treat of those morbid
affections that are almost always symptomatic
of other more primary diseases; and this for sev-
eral reasons, particularly because it introduces a
great deal of confusion in directing practice,
and leads physicians to employ palliative
measures only. I shall here, however, devi-
ate a little from my general plan, to make
some reflections upon symptomatic hemor-
rhagies.
MXVI.
The hemorrhagies of this kind that especial-
ly deserve our notice, are the Hematemesis, or
Vomiting of Blood; and the Hematuria, or
the Voiding of Blood from the urinary pas-
sage. Upon these I am here to make some re-
VOL. II. M marks; 

254 PRACTICE
marks; because, though they are very gener-
ally symptomatic, it is possible they may be
sometimes primary and idiopathic affections;
and because they have been treated of as pri-
mary diseases in almost every system of the
practice of physic.
SECT. I.
Of the HEMATEMESIS, or VOMITING of
BLOOD.
MXVII.
I HAVE said above (in DCCCCXLV)in
what manner blood thrown out from the
mouth may be known to proceed from the
stomach, and not from the lungs; but it may
be proper here to say more particularly, that
this may be certainly known, when the
blood is brought up manifestly by vomiting
without any coughing; when this vomiting
has been preceded by some sense of weight,
anxiety, and pain, in the region of the stomach;
when the blood brought up is of a black and
grumous appearance, and when it is manifest-
ly mixed with other contents of the stomach;
we can seldom have any doubt of the source
from whence the blood proceeds, and there-
fore of the existence of the disease we treat of.
MXVIII. 

255 OF PHYSIC. 
MXVIII.
We must allow it to be possible that a
plethoric state of the body from general causes
may be accompanied with causes of a peculiar
determination and afflux of blood to the
stomach, so as to occasion an hemorrhagy
there, and thence a vomiting of blood; and
in such a case this appearance might be con-
sidered as a primary disease. But the history
of diseases in the records of physic, afford lit—
tle foundation for such a supposition; and on
the contrary, the whole of the instances of a
vomiting of blood which have been recorded,
are pretty manifestly symptomatic of a more
primary affection.
Of such symptomatic vomitings of blood,
the chief instances are the following.
MXIX.
One of the most frequent is that which ap-
pears in consequence of a suppression of an e-
vacuation of blood which had been for some
time before established in another part of the
body, particularly that of the menstrual flux
in women.
MXX.
There are instances of a vomiting of blood
happening from the retention of the menses:
M2 But 

256 PRACTICE
But such instances are very uncommon; as a
retention of the menses rarely happens in con-
sequence of, or even with, a plethoric state of
the body; and as rarely does it produce that,
or the hemorrhagy in question.
There are instances of a vomiting of blood
happening to pregnant women; that might
therefore also be imputed to the suppression
of the menses, which happens to women in
that state. There have indeed been more in-
stances of this than of the former case; but
the latter are still very rare; for although the
blood which used to flow monthly before im-
pregnation, is, upon this taking place, retain-
ed, it is commonly so entirely employed in
dilating the uterine vessels, and in the growth
of the fœtus, that it is seldom found to pro-
duce a plethoric state of the body, requiring
a vicarious outlet.
The vomiting of blood, therefore, that is
vicarious of the menstrual flux, is that which
commonly and almost only happens upon a
suppression of that flux, after it had been for
some time established.
MXXI.
When such a suppression happens, it may
be supposed to operate by inducing a plethor-
ic state of the whole body, and thereby occa-
sioning hemorrhagy from other parts of it;
and hemorrhagies from many different parts
of the body have been observed by physicians
as 

257 OF PHYSIC.
as occurring in consequence of the suppression
we speak of. It is however the great variety
of such hemorrhagies, that leads me to think,
that with the plethoric state of the whole body
there must be always some peculiar circum-
stances in the part from which the blood flows,
that determines its afflux to that particular,
often singularly odd, part; and therefore, that
such hemorrhagies may from these circum-
stances occur without any considerable pleth-
ora at the same time prevailing in the whole
system.
MXXII.
It is to be observed, that if we are to expect
an hemorrhagy in consequence of a suppres-
sion of the menses inducing a plethoric state
of the system, we should expect especially an
hemoptysis, or hemorrhagy from the lungs,
as a plethora might be expected to show its ef-
fects especially there; and accordingly, upon
occasion of suppressed menses, that hemorrha-
gy occurs more frequently than any other:
But even this, when it does happen, neither
in its circumstances nor its consequences, leads
us to suppose, that at the same time any con-
siderable or dangerous plethora prevails in the
body.
MXXIII.
These considerations in MXXI, MXXII,
will, I apprehend, apply to our present sub-
M3 ject;

258 PRACTICE
ject; and I would therefore allege, that a
hematemesis may perhaps depend upon par-
ticular circumstances of the stomach deter-
mining an afflux of blood to that organ, and
may therefore occur without any considerable
or dangerous plethora prevailing in the sys-
tem. What are the circumstances of the
stomach, which, upon the occasion mentioned,
may determine an afflux of blood to it, I can-
not certainly or clearly explain; but presume
that it depends upon the connexion and con-
sent which we know to subsist between the u-
terus and the whole of the alimentary canal,
and especially that principal part of it the
stomach.
MXXIV.
From these reflections, we may, I think,
draw the following conclusions.
I. That the hematemesis we speak of is
hardly ever a dangerous disease.
II. That it will hardly ever require the
remedies suited to the cure of active hemor-
rhagy; and at least that it will require these
only in those unusual cases in which there ap-
pear strong marks of a general plethora, and
in which the vomiting of blood appears to be
considerably active, very profuse, and fre-
quently recurring.
III. That a vomiting of blood from sup-
pressed menses, ought seldom to prevent the
use of these remedies of amenorrhœa, which
might 

259 OF PHYSIC.
might be improper in the case of an active id-
iopathic hemorrhagy.
MXXV.
Another case of symptomatic, hematemesis
quite analogous to that already mentioned, is
the hematemesis following, and seemingly
depending upon, the suppression of an hemor-
rhoidal flux, which had been established and
frequent for some time before.
This may perhaps be explained by a gen-
eral plethoric state induced by such a sup-
pression; and indeed some degree of a ple-
thoric state must in such a case be supposed to
take place; but that supposition alone will
not explain the whole of the case; for a gen-
eral plethora would lead us to expect an he-
moptyis (MXXII) rather than an hemateme-
sis; and there is therefore something still
wanting, as in the former case, to explain the
particular determination to the stomach.
Whether such an explanation can be got
from the connexion between the different parts
of the sanguiferous vessels of the alimentary
canal, or from the connexion of the whole of
these vessels with the vena portarum, I shall
not venture to determine. But in the mean
time I imagine, that the explanation required
is rather to be obtained from that connexion
of the stomach with the hemorrhoidal affection
that I have taken notice of in DCCCCXLVI.
M4 MXXVI.

260 PRACTICE
MXXVI.
However we may explain the hematemesis
occasioned by a suppression of the hemorrhois,
the considerations in MXXI, MXXII, will
apply here as in the analogous case of hemat-
emesis from suppressed menses; and will
therefore allow us also to conclude here, that
the disease we now treat of will seldom be
dangerous, and will seldom require the same
remedies that idiopathic and active hemorrha-
gy does.
MXXVII.
The cases of hematemesis already mention-
ed, may be properly supposed to be hemor-
rhagies of the arterial kind; but it is probable
that the stomach is also liable to hemorrhagies
of the venous kind. (DCCLXVIII).
In the records of physic there are many in-
stances of vomitings of blood, which were ac-
companied with a tumefied spleen, which had
compressed the vas breve, and thereby pre-
vented the free return of venous blood from
the stomach. How such an interruption of
the venous blood may occasion an hemorrha-
gy from either the extremities of the veins
themselves, or from the extremities of their cor-
respondent arteries, we have explained above
in DCCLXIX, and the histories of tumefied
spleens compressing the vasa brevia, afford an
excellent 

261 OF PHYSIC. 
excellent illustration and confirmation of our
doctrine on that subject, and render it suf-
ficiently probable that vomitings of blood
often arise from such a cause.
MXXVIII.
It is also possible, that an obstruction of the
liver resisting the free motion of the blood in
the vena portarum, may sometimes interrupt
the free return of the venous blood from the
vessels of the stomach, and thereby occasion a
vomiting of blood; but the instances of this
are neither so frequent nor so clearly explain-
ed as those of the former case.
MXXIX.
Beside these cases depending on the state of
the liver or spleen, it is very probable that
other hemorrhagies of the stomach are fre-
quently of the venous kind.
The disease named by Sauvages Melæna,
and by other writers commonly termed the
Morbus Niger (DCCLXXII), consisting in
an evacuation either by vomiting or by stool,
and sometimes in both ways, of a black and
grumous blood, can hardly be otherwise oc-
casioned, than by a venous hemorrhagy from
some part of the internal surface of the ali-
mentary canal.
It is, indeed, possible, that the bile may
sometimes put on a black and viscid appear-
VOL. 2. M5 ance, 

262 PRACTICE
ance, and give a real foundation for the appel-
lation of an Atra Bilis: But it is certain, that
instances of this are very rare; and it is high-
ly probable, that what gave occasion to the
notion of an atra bilis among the ancients, was
truly the appearance of blood poured into the
alimentary canal in the manner I have men-
tioned; and which appearance, we know, the
blood always puts on when it has stagnated
there for any length of time. I suppose it is
now generally thought, that Boerhaave's no-
tion of such a matter existing in the mass of
blood, is without any foundation; whilst, by
dissections in modern times, it appears very
clearly, that the morbus niger presenting such
an appearance of blood, always depends upon
the effusion and stagnation I have mentioned.
MXXX.
From this account of the melæna it will
appear, that vomitings of blood may arise in
consequence of blood being poured out in the
manner I have mentioned, either into the cav-
ity of the stomach itself, or into the superior
portions of the intestines, from whence mat-
ters often pass into the stomach.
MXXXI.
Both in the case of the malæna, and in the
analogous cases from affections of the spleen or
liver, it will appear, that the vomitings of
blood 

263 OF PHYSIC.
blood occurring must be considered as symp-
tomatic affections, not at all to be treated as a
primary active hemorrhagy, but by remedies,
if any such be known, that may resolve the
primary obstructions.
MXXXII.
I believe I have now mentioned almost the
whole of the causes producing an hematemesis;
and certainly the causes mentioned, are those
which most commonly give occasion to that
symptom. Possibly, however, there may be
some other causes of it, such as that singular
one mentioned by Sauvage of an aneurism of
the aorta bursting into the stomach; and it is
possible, that some diseases of other contiguous
parts, which have become closely adhering to
the stomach, may sometimes, by a rupture in-
to the cavity of the stomach, pour blood into
it, which is afterwards rejected by vomiting.
It is possible also, that abscesses and ulcera-
tions of the stomach itself, may sometimes
pour blood into its cavity to be thrown up by
vomiting.
I did not think it necessary, among the
symptomatic vomitings of blood, to enumerate
those from external violence, nor, what is an-
alogous to it, that which arises from violent
straining to vomit; which last, however, is
much more rare than might be expected. In
either of these cases the nature of the disease
cannot be doubtful, and the management of it
M6 will 

264 PRACTICE
will be readily understood from what has been
delivered above with respect to moderating
and restraining hemorrhagy in general. 
SECT. II.
Of the HEMATURIA, or the VOIDING of
BLOOD from the URINARY PASSAGE.
MXXXIII.
IT is alleged, that an hematuria has occur-
red without any other symptom of an affec-
tion of the kidneys or urinary passages being
present at the same time; and as this happen-
ed to plethoric persons, and recurred at fixed
periods, such a case has been supposed to be
an instance of idiopathic hematuria, and of the
nature of those active hemorrhagies I have
treated of before. 
MXXXIV.
I cannot positively deny the existence of
such a case; but must observe, that there are
very few instances of such upon the records
of physic; that none have ever occurred to
my observation, or to that of my friends; and
that the observations adduced may be falla-
cious, as I have frequently observed an hema-
turia 

265 OF PHYSIC.
turia without symptoms of other affection of
the kidney or urinary passages being, for the
time, present; whilst, however, fits of a neph-
ralgia calculosa having, before or soon after,
happened, rendered it to me sufficiently prob-
able, that the hematuria was owing to a wound
made by a stone present in some part of the
urinary passages.
MXXXV.
The existence of an idiopathic hematuria
is further improbable, as a general plethora is
more likely to produce an hemoptysis
(MXXII), and as we do not well known of
any circumstances which might determine
more particularly to the kidneys. An idio-
pathic hematuria, therefore, must certainly be
a rare occurrence; and instances of sympto-
matic affections of the same kind are very
frequent.
MXXXVI.
One of the most frequent is, that hematuria
which attends the nephralgia calculosa, and
seems manifestly to be owing, to a stone
wounding the internal surface of the pelvis of
the kidney or of the ureter. In such cases,
the blood discharged with the urine is some-
times of a pretty florid colour, but for the
most part is of a dark hue; the whole of it is
sometimes diffused or dissolved, and therefore
entirely 

266 PRACTICE
entirely suspended in the urine; but if it is in
any large quantity, a portion of it is deposited
to the bottom of the vessel containing the
voided blood and urine. On different occa-
sions the blood voided puts on different ap-
pearances. If the blood poured out in the
kidney has happened to stagnate for some
time in the ureters or bladder, it is sometimes
coagulated, and the coagulated part is after-
wards broken down into a grumous mass of a
black or dark colour, and therefore gives the
same colour to the urine voided; or if the
quantity of broken down blood is small, it
gives only a brownish urine resembling coffee.
It sometimes also happens, that the blood
stagnating and coagulating in the ureters, takes
the form of these vessels, and is therefore voided
under the appearance of a worm; and if the
coagulated blood happens to have, as it may
sometimes have, the gluten separated from the
red globules, these wormlike appearances
have their external surface whitish, and the
whole seemingly forming a tube containing a
red liquor. I have sometimes observed the
blood which had seemingly been coagulated
in the ureter, come away in an almost dry
state, resembling the half burnt wick of a
candle.
MXXXVII.
These are the several appearances of the
blood voided in the hematuria calculosa, when
it 

267 OF PHYSIC.
it proceeds especially from the kidneys or u-
reter; and many of the same appearances are
observed when the blood proceeds only from
the bladder when a stone is lodged there; but
the attending symptoms will commonly point
out the different seat of the disease.
In one case, when a quantify of blood from
the kidney or ureter is coagulated in the blad-
der, and is therefore difficultly thrown out
from this, the pain and uneasiness on such an
occasion may appear chiefly to be in the blad-
der, though it contains no stone; but the an-
tecedent symptoms will commonly discover
the nature of the disease.
MXXXVIII.
In any of the cases of the hematuria calcu-
losa it will hardly be necessary to employ the
remedies suited to an active hemorrhagy. It
will be proper only to employ the regimen fit
for moderating hemorrhagy in general, and
particularly here to avoid every thing or cir- 
cumstance that might irritate the kidneys or
ureters. Of such cases of irritation there is
none more frequent or more considerable than
the presence of hardened fæces in the colon;
and these therefore are to be frequently remov-
ed, by the frequent use of gentle laxatives.
MXXXIX.
The hematuria calculosa may be properly
considered as a case of the hematuria violenta;
and 

268 PRACTICE
and therefore I subjoin to that the other in-
stances of hematuria from external violence;
such as that from external contusion on the
region of the kidney, and that from the vio-
lent or long continued exercise of the muscles
incumbent on the kidneys. An instance of
the latter cause occurs especially in riding.
MXL.
It may also be considered as a case of the
hematuria violenta, when the disease occurs
in consequence of the taking in of certain ac-
rid substances, which pass again especially by
the urinary passages; and, by inflaming and
swelling the neck of the bladder, bring on a
rupture of the over distended blood vessels,
and give occasion to a bloody urine. The
most noted instance of this is in the effect of
cantharides in a certain quantity, any way in-
troduced into the body. And possibly some
other acrids may have the same effect.
MXLI.
Beside these most frequent instances of
hematuria, which cannot be considered as id-
iopathic hemorrhagies, there are some other
instances of hematuria mentioned by authors,
that are still however manifestly symptomat-
ic; such as a discharge of blood from the u-
rinary passages, in consequence of a suppres-
sion of either the menstrual or hemorrhoidal
flux. 

269 OF PHYSIC.
flux. These may be considered as analogous
to the hematemesis produced by the like caus-
es; and the several reflections made above on
that subject, will, I think, apply here, and
particularly the conclusions formed in
MXXIV. Instances, however, of either of
these cases, and especially of the first, have
been extremely rare.
MXLII.
Of such symptomatic hematuria there is
however one instance deserving notice; and
that is, when a suppression of the hemorrhoi-
dal flux, either by a communication of ves-
sels, or merely by the vicinity of parts, occa-
sions a determination of the blood into the
vessels of the neck of the bladder, which in
consequence of a rixis or anastomosis, pour
out blood to be voided either with or without
the urine. This case is what has been named
the Hemorrhoides Vesicæ; and with some
propriety, when it is manifestly an evacuation
vicarious of what had before been usually
made from the rectum. With respect to the
management of the hemorrhoides vesicæ, I
would apply the whole of the doctrines that
I have delivered above, with respect to the
cure of the proper hemorrhoidal affection.
MXLIII.
There remains still to be mentioned one
other instance of symptomatic hematuria,
which 

270 PRACTICE
which is that which happens in the case of con-
fluent and putrid small pox, as well as in several
other instances of putrid diseases. The blood,
in such cases, may be presumed to come from
the kidneys; and I apprehend that it comes
from thence in consequence of that fluidity
which is always produced in the blood ap-
proaching to a putrid state. Such hematuria,
therefore, is not to be considered as a symp-
tom of any affection of the kidneys, but merely
as a mark of the putrescent state of the blood.
MXLIV.
In certain diseases the urine is discharged
of such a deep red colour, as to give a sus-
picion of its being tinged by blood present in
it; and this has given occasion to Sauvages,
amongst the other species of hematuria, to mark
the hematuria spuria, and the hematuria lateri-
tia; both of which, however, he supposes to be
without any blood present in the urine. In
many cases it is of importance, in ascertaining
the nature of a disease, to determine whether
the red colour of urine be from blood present
in it, or from a certain state of the salts and
oils which are always in greater or lesser pro-
portion constituent parts of the urine; and
the question may be commonly determined
by the following considerations.
It has been observed above, that when any
considerable quantity of blood is voided with
the urine, there is always a portion of it de-
posited 

271 OF PHYSIC.
posited at the bottom of the vessel containing
the voided blood and urine; and in such a
case there will be no doubt in attributing the
colour of the urine floating above to some
part of the blood diffused in it. The ques-
tion, therefore, with respect to the presence
of blood in the urine can only occur when no
such deposition as I have mentioned appears;
and when the blood that may be supposed to
be present is dissolved or diffused, and there-
fore entirely suspended in the urine. In this
case the presence of the blood may be com-
monly known, 1st, By the colour which blood
gives, different from any urine without blood
that I have ever seen; and I think a little ex-
perience will enable most persons to make
this distinction. 2dly, By this, that the pres-
ence of blood always diminishes the transpar-
ency of the urine with which it is mixed; and
it is very seldom that urine, though very
high coloured, loses its transparency; at least
this hardly ever appears, if the urine is
examined when recently voided. 3dly, When
urine has blood mixed with it, it tinges a
piece of linen dipped into it with a red colour,
which the highest coloured urine without
blood, never does. 4thly, High coloured urine
without blood, upon cooling, and remaining
at rest in a vessel, almost always deposites a
lateritious sediment; and if upon any occasion
bloody urine should deposite a sediment that
may be of a portion of the blood formerly dif-
fused in it, the difference, however, may be
discerned 

272 PRACTICE
discerned by this, that the sediment deposited
by urine without blood, upon the urine's be-
ing again heated, will be entirely redissolved,
which will not happen to any sediment from
blood. Lastly, we know no state of urine
without blood, which shews any portion of it
coagulable by a heat equal to that of boiling
water; but blood diffused in urine is still co-
agulable by such a heat; and by this test,
therefore, the presence of blood in urine may
be commonly ascertained.
BOOK 

273
BOOK V.
OF PROFLUVIA, OR FLUXES,
WITH PYREXIA.
MXLV.
FORMER nosologists have
established a class of diseases under the title of
Fluxes, or Profluvia; but as in this class they
have brought together a great number of dis-
eases, which have nothing in common, ex-
cepting the single circumstance of an increas-
ed discharge of fluids, and which also are, in
other respects, very different from one anoth-
er; I have avoided so improper an arrange-
ment, and have distributed most of the dis-
eases comprehended in such a class by the nos-
ologists, into places more natural and proper
for them. I have, indeed, still employed
here the general title; but I confine it to
such 

274 PRACTICE
such fluxes only as are constantly attended
with pyrexia, and which therefore necessarily
belong to the class of diseases of which I am
now treating.
Of the fluxes which may be considered as
being very constantly febrile diseases, there
are only two, the catarrh and dysentery; and
of these therefore I now proceed to treat.
CHAP. 

275 OF PHYSIC.
CHAP. I.
OF THE CATARRH.
MXLVI.
THE catarrh is an increased
excretion of mucus from the mucous mem-
brane of the nose, fauces, and bronchiæ, at-
tended with pyrexia.
Practical writers and nosologists have dis-
tinguished the disease by different appella-
tions, according as it happens to affect those
different parts of the mucous membrane, the
one part more or less than the other: But I
am of opinion, that the disease, although af-
fecting different parts, is always of the same
nature, and proceeds from the same cause.
Very commonly, indeed, those different parts
are affected at the same time; and therefore
there can be little room for the distinction
mentioned.
The disease has been frequently treated of
under the title of Tussis, or Cough; and a
cough, 

276 PRACTICE
cough, indeed, always attends the chief form
of catarrh, that is, the increased excretion
from the bronchiæ; but a cough is so often a
symptom of many other affections, which are
very different from one another, that it is im-
properly employed as a generic title.
MXLVII.
The remote cause of catarrh is most com-
monly cold applied to the body. This ap-
plication of cold producing catarrh, can in
many cases be distinctly observed; and I be-
lieve it would always be so, were men ac-
quainted with, and attentive to, the circum-
stances which determine cold to act upon the
body. See XCIV——XCVI.
From the same paragraphs we may learn
what in some persons gives a predisposition to
catarrh.
MXLVIII.
The disease, of which I am now to treat,
generally begins with some difficulty of breath-
ing through the nose, and with a sense of
some fulness stopping up that passage. This
is also often attended with some dull pain and
a sense of weight in the forehead, as well as
some stiffness in the motion of the eyes. These
feelings, sometimes at their very first begin-
ning, and always soon after, are attended with
the distillation from the nose; and sometimes
from 

277 OF PHYSIC.
from the eyes, of a thin fluid, which is often
found to be somewhat acrid, both by its taste,
and by its fretting the parts over which it
passes.
MXLIX.
These symptoms constitute the coryza and
gravedo of medical authors, and are common-
ly attended with a sense of lassitude over the
whole body. Sometimes cold shiverings are
felt, at least the body is more sensible than u-
sual to the coldness of the air; and with all
this the pulse becomes, especially in the even-
ings, more frequent than ordinary.
ML.
These symptoms seldom continue long be-
fore they are accompanied with some hoarse-
ness, and a sense of roughness and soreness in
the trachea, and with some difficulty of breath-
ing, attributed to a sense of straightness of the
chest, and attended with a cough, which
seems to arise from some irritation felt at the
glottis. The cough is generally at first dry,
occasioning pains about the chest, and more
especially in the breast. Sometimes, togeth-
er with these symptoms, pains resembling
those of the rheumatism are felt in several
parts of the body, particularly about the neck
and head. While these symptoms take place,
VOL. II. N the 

278 PRACTICE
the appetite is impaired, some thirst arises,
and a general lassitude is felt over all the body.
MLI.
These symptoms (MXLVIII——ML) mark
the violence and height of the disease; which,
however, does not commonly continue long.
By degrees the cough becomes attended with
a copious excretion of mucus; which is at
first thin, but gradually becoming thicker, is
brought up with less frequent and less labori-
ous coughing. The hoarseness and soreness
of the trachea likewise going off, the febrile
symptoms abating, the cough becoming less
frequent, and with less expectoration, the dis-
ease soon after ceases altogether.
MLII.
Such is generally the course of this disease,
which is commonly neither tedious nor dan-
gerous; but, upon some occasions, it is in both
respects otherwise. A person affected with
catarrh seems to be more than usually liable
to be affected by cold air; and in that condi-
tion, if exposed to cold, the disease, which
seemed to be yielding, is often brought back
with greater violence than before; and is ren-
dered not only more tedious than otherwise
it would have been, but also more dangerous
by the supervening of other diseases.
MLIII. 

279 OF PHYSIC. 
MLIII.
Some degree of the cynanche tonsillaris
often accompanies the catarrh; and, when the
latter is aggravated by a fresh application of
cold, the cynanche also becomes more violent
and dangerous, in consequence of the cough
which is present at the same time.
MLIV.
When a catarrh has been occasioned by a
violent cause; when it has been aggravated
by improper management; and especially
when it has been rendered more violent by
fresh and repeated applications of cold, it oft-
en passes into a pneumonic inflammation at-
tended with the utmost danger.
MLV.
Unless, however, such accidents as those of
MLII——MLIV, happen, a catarrh, in sound
persons not far advanced in life, is, I think,
always a slight disease, and attended with
little danger. But, in persons of a phthisical
disposition, a catarrh may readily produce an
hemoptysis, or perhaps form tubercles in the
lungs; and more certainly, in persons who
have tubercles already formed in the lungs,
an accidental catarrh may occasion the inflam-
N2 mation

280 PRACTICE
mation of these tubercles, and in consequence
produce a phthisis pulmonalis.
MLVI.
In elderly persons, a catarrh sometimes
proves a dangerous disease. Many persons,
as they advance in life, and especially after
they have arrived at old age, have the natur-
al mucus of the lungs poured out in greater
quantity, and consequently requiring a fre-
quent expectoration. If therefore a catarrh
happen to such persons, and increase the af-
flux of fluids to the lungs, with some degree
of inflammation, it may produce the peri-
pneumonia notha, which in such cases is
very often fatal. See CCCLXXVI——
CCCLXXXII.
MLVII.
The proximate cause of catarrh seems to be
an increased afflux of fluids to the mucous
membrane of the nose, fauces, and bronchiæ,
along with some degree of inflammation af-
fecting these parts. The latter circumstance
is confirmed by this, that in the case of ca-
tarrh, the blood drawn from a vein, common-
ly exhibits the same inflammatory crust which
appears in the case of phlegmasiæ.
MLVIII. 

281 OF PHYSIC. 
MLVIII.
The application of cold which occasions a
catarrh, probably operates by diminishing the
perspiration usually made by the skin, and
which is therefore determined to the mucous
membrane of the parts above mentioned. As
a part of the weight which the body daily
loses by insensible evacuation, is owing to
an exhalation from the lungs, there is proba-
bly a connexion between this exhalation and
the cutaneous perspiration, so that the one
may be increased in proportion as the other
is diminished: And therefore we may under-
stand how the diminution of cutaneous per-
spiration, in consequence of the application of
cold, may increase the afflux of fluids to the
lungs, and thereby produce a catarrh.
MLIX.
There are some observations made by Dr.
James Keil which may seem to render this
matter doubtful; but there is a fallacy in his
observations. The evident effects of cold in
producing coryza, leave the matter in general
without doubt; and there are several other
circumstances which show a connexion be-
tween the lungs and the surface of the body.
N3 MLX. 

282 PRACTICE
MLX.
Whether, from the suppression of perspira-
tion, a catarrh be produced merely by an in-
creased afflux of fluids, or whether the matter
of perspiration be at the same time determin-
ed to the mucous glands, and there excite a
particular irritation, may be uncertain; but
the latter supposition is sufficiently probable.
MLXI.
Although, in the case of a common catarrh,
which is in many instances sporadic, it may be
doubtful whether any morbific matter be ap-
plied to the mucous glands; it is, however,
certain, that the symptoms of a catarrh do
frequently depend upon such a matter being
applied to these glands; as appears from the
case of measles, chincough, and especially
from the frequent occurrence of contagious
and epidemical catarrh.
MLXII.
The mention of this last leads me to ob-
serve, that there are two species of catarrh, as
I have marked in my Synopsis of Nosology.
One of these, as I suppose, is produced by
cold alone, as has been explained above; and
the other seems manifestly to be produced by
a specific contagion. 
Of 

283 OF PHYSIC.
Of such contagious catarrhs, I have point-
ed out in the Synopsis many instances occur-
ring from the 14th century down to the pres-
ent day. In all these instances the phenom-
ena have been much the same; and the dis-
ease has always been particularly remarkable
in this, that it has been the most widely and
generally spreading epidemic known. It has
seldom appeared in any one country of Eu-
rope, without appearing successively in every
other part of it; and in some instances, it has
been even transferred to America, and has
been spread over that continent, so far as we
have had opportunities of being informed.
MLXIII.
The catarrh from contagion appears with
nearly the same symptoms as those mentioned
MXLVIII——ML. It seems often to come
on in consequence of the application of cold. 
It comes on with more cold shivering than
the catarrh arising from cold alone, and soon-
er shows febrile symptoms, and these likewise
in a more considerable degree. Accordingly, 
it more speedily runs its course, which is com-
monly finished in a few days. It sometimes
terminates by a spontaneous sweat; and this,
in some persons, produces a miliary eruption. 
It is, however, the febrile state of this disease
especially, that is finished in a few days; for
the cough, and other catarrhal symptoms, do
frequently continue longer; and often, when
N4 they 

284 PRACTICE
they appear to be going off, they are renewed
by any fresh application of cold.
MLXIV.
Considering the number of persons who
are affected with catarrh, of either the one
species or the other, and escape from it quick-
ly without any hurt, it may be allowed to be
a disease very free from danger; but it is not
always to be considered as such; for in some
persons it is accompanied with pneumonic in-
flammation. In the phthisically disposed, it
often accelerates the coming on of phthisis;
and in elderly persons, it frequently proves
fatal in the manner explained above, MLIV
and MLVI.
MLXV.
The cure of catarrh is nearly the same,
whether it proceed from cold or contagion;
with this difference, that in the latter case,
remedies are commonly more necessary than
in the former.
In the cases of a moderate disease, it is
commonly sufficient to avoid cold, and to ab-
stain from animal food for some days; or per-
haps to lie a bed, and, by taking frequently
of some mild and diluent drink a little warm-
ed, to promote a very gentle sweat; and af-
ter these to take care to return very gradually
only, to the use of the free air.
MLXVI. 

285 OF PHYSIC.
MLXVI.
When the disease is more violent, not only
the antiphlogistic regimen must be exactly
observed, but various remedies also become
necessary. 
To take off the phlogistic diathesis which
always attends this disease, bloodletting, in a
larger or smaller quantity, and repeated ac-
cording as the symptoms shall require, is the
proper remedy.
For restoring the determination of the flu-
ids to the surface of the body, and at the same
time for expending the secretion of mucus in
the lungs, which may take off the inflamma-
tion of its membrane, vomiting is the most ef-
fectual means.
For the latter purpose, it has been suppos-
ed, that squills, gum ammoniac, the volatile
alkali, and some other medicines, might be
useful: But their efficacy has never appeared
to me to be considerable; and, if squills have
ever been very useful, it seems to have been
rather by their emetic, than by their expecto-
rant powers.
When the inflammatory affections of the
lungs seem to be considerable, it is proper,
besides bloodletting, to apply blisters on some
part of the thorax.
As a cough is often the most troublesome
circumstance of this disease, so demulcents
VOL. 2. N5 may 

286 PRACTICE
may be employed to alleviate it. See
CCCLXXIII.
But, after the inflammatory symptoms have
much abated, if the cough should still contin-
ue, opiates afford the most effectual means of
relieving it; and, in the circumstances just
now mentioned, they may be very safely em-
ployed. See CCCLXXV.
After the inflammatory and febrile states
of this disease are almost entirely gone, the
most effectual means of discussing all remains
of the catarrhal affection, is by some exercise
of gestation diligently employed.
CHAP. 

287 OF PHYSIC.
CHAP. II.
OF THE DYSENTERY.
MLXVII.
THE dysentery is a disease in
which the patient has frequent stools, accom-
panied with much griping, and followed by a
tenesmus. The stools, though frequent, are
generally in small quantity; and the matter
voided is chiefly mucus, sometimes mixed
with blood. At the same time, the natural
fæces seldom appear; and, when they do, it
is generally in a compact and hardened form.
MLXVIII.
This disease occurs especially in summer
and autumn, at the same time with autumnal
intermittent and remittent fevers; and with
these it is sometimes combined or complicat-
ed.
N6 MLXIX. 

288 PRACTICE
MLXIX.
The disease comes on sometimes with cold
shiverings, and other symptoms of pyrexia;
but more commonly the symptoms of the top-
ical affection appears first. The belly is cos-
tive, with an unusual flatulence in the bowels.
Sometimes, though more rarely, some degree
of diarrhœa is the first appearance. In most
cases the disease begins with griping, and a
frequent inclination to go to stool. In indulg-
ing this, little is voided; but some tenesmus
attends it. By degrees the stools become more
frequent, the griping more severe, and the te-
nesmus more considerable. Along with these
symptoms there is a loss of appetite; and fre-
quently sickness, nausea, and vomiting, also
affecting the patient. At the same time there
is always more or less of pyrexia present, which
is sometimes of the remittent kind, and ob-
serves a tertian period. Sometimes the fever
is manifestly inflammatory, and very often of
a putrid kind. These febrile states continue
to accompany the disease during its whole
course, especially when it terminates soon in
a fatal manner. In other cases, the febrile
state almost entirely disappears, while the
proper dysenteric symptoms remain for a long
time after.
MLXX. 

289 OF PHYSIC.
MLXX.
In the course of the disease, whether of a
shorter or longer duration, the matter voided
by stool is very various. Sometimes it is
merely a mucous matter, without any blood,
exhibiting that disease which Dr. Roderer has
named the morbus mucosus, and others the
dysenteria alba. For the most part, however,
the mucus discharged is more or less mixed
with blood. This sometimes appears only in
streaks amongst the mucus; but at other times
is more copious, tinging the whole of the
matter discharged; and upon some occasions
a pure and unmixed blood is voided in con-
siderable quantity. In other respects, the
matter voided is variously changed in colour
and consistence, and is commonly of a strong
and unusually fetid odour. It is probable,
that sometimes a genuine pus is voided; and
frequently a putrid sanies, proceeding from
gangrenous parts. There are very often
mixed with the liquid matter some films of a
membranous appearance, and frequently some
small masses of a seemingly sebaceous matter.
MLXXI.
While the stools consisting of these various
matters, are, in many instances, exceedingly
frequent, it is seldom that natural fæces ap-
pear in them; and when they do appear, it
is, 

290 PRACTICE
is, as I have mentioned, in the form of scyba-
la, that is, in somewhat hardened, separate
balls. When these are voided, whether by
the efforts of nature, or as solicited by art,
they procure a remission of all the symptoms,
and more especially of the frequent stools,
griping, and tenesmus.
MLXXII.
Accompanied with these circumstances, the
disease proceeds for a longer or a shorter time.
When the pyrexia attending it is of a violent
inflammatory kind, and more especially when
it is of a very putrid nature, the disease often
terminates fatally in a very few days, with all
the marks of a supervening gangrene. When
the febrile state is more moderate, or disap-
pears altogether, the disease is often protract-
ed for weeks, and even for months; but, even
then, after a various duration, it often termin-
ates fatally, and generally in consequence of
a return and considerable aggravation of the
inflammatory and putrid states. In some
cases, the disease ceases spontaneously; the
frequency of stools, the griping, and tenesmus,
gradually diminishing, while natural stools
return. In other cases, the disease, with mod-
erate symptoms, continues long, and ends in a
diarrhoea, sometimes accompanied with lien-
teric symptoms.
MLXXIII. 

291 OF PHYSIC.
MLXXIII.
The remote causes of this disease have been
variously judged of. It generally arises in
summer or autumn, after considerable heats
have prevailed for some time, and especially
after very warm and at the same time very dry
states of the weather; and the disease is much
more frequent in warm, than in cooler cli-
mates. It happens, therefore, in the same
circumstances and seasons which considerably
affect the state of the bile in the human body;
but as the cholera is often without any dysen-
teric symptoms, and copious discharges of bile
have been found to relieve the symptoms of
dysentery, it is difficult to determine what
connexion the disease has with the state of the
bile.
MLXXIV.
It has been observed, that the effluvia from
very putrid animal substances, readily affect
the alimentary canal; and upon some occa-
sions they certainly produce a diarrhœa; but,
whether they ever produce a genuine dysen-
tery, I have not been able to learn with cer-
tainty.
MLXXV.
The dysentery does often manifestly arise
from the application of cold, but the disease
is 

292 PRACTICE
is always contagious; and, by the propagation
of such contagion, independent of cold, or
other exciting causes, it becomes epidemic in
camps and other places. It is, therefore, to
be doubted, if the application of cold does
ever produce the disease, unless where the
specific contagion has been previously receiv-
ed into the body: And upon the whole, it is
probable, that a specific contagion is to be
considered as always the remote cause of this
disease.
MLXXVI.
Whether this contagion, like many others,
be of a permanent nature, and only shows its
effects in certain circumstances which render
it active, or if it be occasionally produced, I
cannot determine. Neither, if the latter sup-
position be received, can I say by what means
it may be generated. As little do we know
any thing of its nature, considered in itself;
or at most this only, that, in common with
many other contagions, it appears to be com-
monly of a putrid nature, and capable of in- 
ducing a putrescent tendency in the human
body. This, however, does not at all explain
its peculiar power in inducing those symptoms
which properly and essentially constitute the
disease of dysentery. (MLXVII).
MLXXVII. 

293 OF PHYSIC.
MLXXVII.
Of these symptoms the proximate cause is
still obscure. The common opinion has been,
that the disease depends upon an acrid matter
received into, or generated in the intestines
themselves, exciting their peristaltic motion,
and thereby producing the frequent stools
which occur in this disease. But this suppo-
sition cannot be admitted; for, in all the in-
stances known of acrid substances applied to
the intestines and producing frequent stools,
they at the same time produce copious stools,
as might be expected from acrid substances
applied to any length of the intestines. This,
however, is not the case in dysentery; in
which the stools, however frequent, are gen-
erally in very small quantity, and such as may
be supposed to proceed from the lower parts
of the rectum only. With respect to the su-
perior portions of the intestines, and particu-
larly those of the colon, it is probable they
are under a preternatural and considerable
degree of constriction: For, as I have observ-
ed above, the natural fæces are seldom void-
ed; and when they are, it is in a form which
gives reason to suppose, they have been long
retained in the cells of the colon, and conse-
quently that the colon had been affected with
a preternatural constriction. This is confirm-
ed by almost all the dissections which have
been made of the bodies of dysenteric patients,
in

294 PRACTICE
in which, when gangrene had not entirely
destroyed the texture and form of the parts,
considerable portions of the great guts have
been found affected with a very considerable
constriction.
MLXXVIII.
I apprehend, therefore, that the proximate
cause of dysentery, or at least the chief part
of the proximate cause, consists in a preternat-
ural constriction of the colon, occasioning at
the same time those spasmodic efforts which
are felt in severe gripings, and which efforts,
propagated downwards to the rectum, occa-
sion there the frequent mucous stools and te-
nesmus. But, whether this explanation shall
be admitted or not, it will still remain certain,
that hardened fæces retained in the colon are
the cause of the griping, frequent stools, and
tenesmus; for the evacuation of these fæces,
whether by nature or by art, gives relief from
the symptoms mentioned; and it will be more
fully and usefully confirmed by this, that the
most immediate and successful cure of dysen-
tery is obtained by an early and constant at-
tention to the preventing the constriction, and
the frequent stagnation of fæces in the colon.
MLXXIX.
In this manner I have endeavoured to as-
certain the proximate cause of dysentery, and
therefore 

295 OF PHYSIC.
therefore to point out also the principal part
of the cure, which, from want of the proper
view of the nature of the disease, seems to
have been in several respects fluctuating and
undetermined among practitioners.
MLXXX.
The most eminent of our late practition-
ers, and of greatest experience in this disease,
seem to be of opinion, that the disease is to
be cured most effectually by purging assidu-
ously employed. The means may be vari-
ous; but the most gentle laxatives are usually
sufficient; and as they must be frequently re-
peated, the most gentle are the most safe; the
more especially as an inflammatory state so
frequently accompanies the disease. What-
ever laxatives produce an evacuation of nat-
ural fæces, and a consequent remission of the
symptoms, will be sufficient to effectuate the
cure. But if gentle laxatives shall not pro-
duce the evacuation now mentioned, some
more powerful medicines must be employed;
and I have found nothing more proper or
convenient than tartar emetic, given in small
doses, and at such intervals as may determine
their operation to be chiefly by stool. Rhu-
barb, so frequently employed, is in several re-
spects amongst the most improper purga-
tives.
MLXXXI. 

296 PRACTICE
MLXXXI.
Vomiting has been held a principal remedy
in this disease; and may be usefully employ-
ed in the beginning of it, with a view to both
the state of the stomach and of the fever; but
it is not necessary to repeat it often; and un-
less the emetics employed operate also by stool,
they are of little service. Ipecacuanha seems
to possess no specific power; and it proves
only useful when so managed as to operate
chiefly by stool.
MLXXXII.
For relieving the constriction of the colon,
and evacuating the retained fæces, glysters may
sometimes be useful; but they are seldom so
effectual as laxatives given by the mouth; and
acrid glysters, if they be not effectual in evac-
uating the colon, may prove hurtful by stim-
ulating the rectum too much.
MLXXXIII.
The frequent and severe griping attending
this disease, leads almost necessarily to the use
of opiates, and they are very effectual for the
purpose of relieving from the gripes; but by
occasioning an interruption of the action of
the small guts, they favour the constriction
of the colon, and thereby sometimes aggravate
the

297 OF PHYSIC.
the disease; and if at the same time the use
of them supersede in any measure the em-
ploying of purgatives, it commonly does much
mischief; I believe it indeed to be only the
neglect of purging that renders the use of o-
piates very necessary.
MLXXXIV.
When the gripes are both frequent and se-
vere, they may sometimes be relieved by the
employment of a semicupium, or by a fomen-
tation of the abdomen, continued for some
time. In the same case, the pains may be
relieved, and, as I think, the constriction of
the colon may be taken off, by blisters applied
to the lower belly.
MLXXXV.
At the beginning of this disease, when the
fever is any way considerable, bloodletting, in
patients of tolerable vigour, may be proper
and necessary; and, when the pulse is full
and hard, with other symptoms of an inflam-
matory disposition, bloodletting ought to be
repeated. But, as the fever attending dysen-
tery is often of a putrid kind, or does, in the
course of the disease, become soon of that na-
ture, bloodletting must be employed with
great caution.
MLXXXVI. 

298 PRACTICE
MLXXXVI.
From the account now given of the nature
of this disease, it will be sufficiently obvious,
that the use of astringents in the beginning of
it must be absolutely pernicious.
MLXXXVII.
Whether an acrid matter be the original
cause of this disease, may be uncertain; but
from the indigestion and the stagnation of flu-
ids in the stomach which attend the disease, it
may be presumed, that some acrid matters
are constantly present in the stomach and in-
testines, and therefore that demulcents may
be always usefully employed. At the same
time, from this consideration that mild oily
matters thrown into the intestines in consider-
able quantity always prove laxative, I am of
opinion that the oleaginous demulcents are
the most useful.
MLXXXVIII.
As this disease is so often of an inflammato-
ry or of a putrid nature, it is evident that the
diet employed in it should be vegetable and
acescent. Milk in its entire state is of doubt-
ful quality in many cases; but some portion
of the cream is often allowable, and whey is
always proper.
In 

299 OF PHYSIC.
In the first stages of the disease, the sweet
and subacid fruits are allowable, and even
proper. It is in the more advanced stages
only that any morbid acidity seems to prevail
in the stomach, and to require some reserve
in the use of acescents. At the beginning of
the disease, absorbents seem to be superfluous;
and by their astringent and septic powers they
may be hurtful.
MLXXXIX.
When this disease is complicated with an
intermittent fever, and is protracted from that
circumstance chiefly, it is to be treated as an
intermittent, by administering the Peruvian
bark, which, however, in the earlier periods
of the disease, is hardly to be admitted.
PART 



PART II.
Of Neuroses, or Nervous Disease.
MXC.
IN a certain view, almost the
whole of the diseases of the hu-
man body might be called
NERVOUS: But there would
be no use for such a general
appellation; and, on the other
hand, it seems improper to limit the term, in
the loose inaccurate manner in which it has
been hitherto applied, to hysteric or hypo-
chondriacal disorders, which are themselves
hardly to be defined with sufficient precision.
MXCI.
In this place I propose to comprehend,
under the title of NEUROSES, all those pre-
VOL. II. O ternatural 

302 PRACTICE
ternatural affections of sense or motion which
are without pyrexia, as a part of the primary
disease; and all those which do not depend
upon a topical affection of the organs, but
upon a more general affection of the nervous
system, and of those powers of the system up-
on which sense and motion more especially
depend.
MXCII.
Of such diseases I have established a class,
under the title of NEUROSIS, or NERVOUS
DISEASES. These I again distinguish, as
they consist, either in the interruption and de-
bility of the powers of sense and motion, or
in the irregularity with which these powers
are exercised; and have accordingly arranged
them under the four orders of Comata, Adyna-
miæ, Spasmi, and Vesaniæ, to be defined as we
proceed to treat of them more particularly.
BOOK 

303
BOOK I.
OF COMATA; OR, OF THE LOSS OF
VOLUNTARY MOTION.
MXCIII.
UNDER this title are com-
prehended those affections which have been
commonly called the Soporose diseases; but
they are most properly distinguished by their
consisting in some interruption or suppression
of the powers of sense and voluntary motion,
or of what are called the animal functions.
These are indeed usually suspended in the
time of natural sleep: But of all the diseases
to be comprehended under our title, sleep, or
even the appearance of it, is not constantly a
symptom. Of such diseases I can mark and
properly explain two genera only, which come
under the titles of Apoplexy and Palsy.
O2 CHAP.

304 PRACTICE
CHAP. I.
OF APOPLEXY.
MXCIV.
APOPLEXY is that disease
in which the whole of the external and inter-
nal senses, and the whole of the voluntary
motions, are in some degree abolished; while
respiration and the action of the heart contin-
ue to be performed. By its being an affec-
tion of the whole of the powers of sense and
of voluntary motion, we distinguish it from
Palsy; and by its being with the continuance
of respiration and the action of the heart, it is
distinguished from Syncope. I have further
added to the ordinary definition of apoplexy,
that the abolition of the powers of sense and
motion is in some degree only; meaning by
this to imply, that, under the title of Apo-
plexy, are here comprehended those diseases
which, as differing from it in degree only,
cannot, with a view either to pathology or
practice, be properly distinguished from it:
Such 

305 OF PHYSIC.
Such are the diseases sometimes treated of un-
der the names of Carus, Cataphora, Coma, and
Lethargus.
MXCV.
Apoplexy, in all its different degrees, most
commonly affects persons advanced in life,
and especially those above sixty years of age.
It most usually affects persons of large heads
and short necks, persons of a corpulent habit,
persons who have passed an indolent life and
used a full diet, and especially those who have
indulged in frequent intoxication. Men who
have long laboured under a frequent and co-
pious discharge of blood from the hemorrhoi-
dal vessels, upon either the suppression or
spontaneous ceasing of that discharge, are par-
ticularly liable to be affected with apoplexy.
MXCVI.
This disease frequently comes on very sud-
denly: But in many cases it is preceded by
various symptoms, such as frequent fits of gid-
diness, frequent headachs, a hemorrhagy from
the nose, some transitory interruptions of see-
ing and hearing, some false vision and hear-
ing, some transitory degree of numbness or loss
of motion in the extremities, some faltering of
the tongue in speaking, a loss of memory, a
frequent drowsiness, and frequent fits of in-
cubus.
O3 MXCVII. 

306 PRACTICE
MXCVII.
An attention to these symptoms, and to the
predisponent circumstances (MXCV), will
often enable us to foresee the more violent at-
tacks of this disease.
MXCVIII.
When the disease comes on suddenly to a
considerable degree, it has been frequently
observed to have been immediately induced
by violent exercise; by a full and long con-
tinued inspiration; by a fit of anger; by much
external heat, especially that arising from a
crowded assembly of people; by warm bath-
ing; by intoxication; by long stooping with
the head down; and by a tight ligature about
the neck. The disease has been remarked to
make its attacks most frequently in the spring
season, and especially when the vernal heat
suddenly succeeds to the winter cold.
MXCIX.
The symptoms denoting the presence of
this disease will be sufficiently known from
the definition given MXCIV. Although the
whole of the body is affected with the loss of
sense and motion, it sometimes takes place
more upon one side of the body than the oth-
er; and, in that case, the side least affected
with 

307 OF PHYSIC.
with palsy is sometimes affected with convul-
sions. In this disease there is often a stertor-
ous breathing; and this has been said to be a
mark of the most violent state of the disease:
But it is not always present even in the most
complete form or most violent degree of the
disease.
MC.
The proximate cause of this disease may be
in general, whatever interrupts the motion of
the nervous power from the brain to the mus-
cles of voluntary motion; or, in so far a sense
is affected whatever interrupts the motion of
the nervous power from the sentient extrem-
ities of the nerves to the brain.
MCI.
Such an interruption of the motion of the
nervous power may be occasioned, either by
some compression of the origin of the nerves, or
by something destroying the mobility of the
nervous power. Both these causes we must
treat of more particularly; and, first, of that
of compression, seemingly the most frequent
occasion of apoplexy, and perhaps the occa-
sion of all those apoplexies arising from inter-
nal causes.
O4 MCII.

308 PRACTICE
MCII.
The loss of sense and motion in particular
parts of the body, may be occasioned by a
compression, either of the origin of certain
nerves only, or of the same nerves in some
part of their course from the brain to the or-
gans of sense and motion. Such cases of par-
tial compression will be more properly con-
sidered hereafter; and the affection I am
now to treat of being general, it must depend
upon a very general compression of the origin
of the nerves, or medullary portion of the
brain; and therefore, this more general com-
pression only is to be considered here.
MCIII.
This compression of the origin of the
nerves, or medullary portion of the brain,
may be produced in different ways; as,
1. By external violence fracturing and
pressing in a part of the cranium.
2. By tumours, sometimes soft, sometimes
bony, formed in different parts of the brain,
or in its membranes, and becoming of such a
bulk as to compress the medullary substance
of the brain.
3. By the blood accumulated in the blood-
vessels of the brain, and distending them to
such a degree as to compress the medullary
portion of the same.
4. By 

309 OF PHYSIC.
4. By fluids effused in different parts of
the brain, or into the cavity of the cranium,
and accumulated in such quantity as to occa-
sion the compression we treat of. 
And, as to this last, it is to be remarked
here, that the fluids effused may be of two
kinds; that is, they may be either a portion
of the common mass of blood, poured out
from red vessels; or a portion of serum or
colourless fluid, poured out chiefly by exha-
lants. 
MCIV. 
Of these several causes of compression, the
first is not to be considered here, because the
removing it does not belong to our province;
and the consideration of the second may be
omitted, as in most instances it is neither to
be discerned nor cured by any means yet
known. The third and fourth causes of
compression, as they are the most frequent,
and are also most properly the subjects of our
art, so they are those which deserve our par-
ticular attention; and we shall therefore en-
deavour to trace them further back in the se-
ries of causes which may produce them.
MCV.
Both the states of over distention and of
effusion, may be produced by whatever in-
creases the afflux and impetus of the blood in
VOL. 2. O5 the 

310 PRACTICE
the arteries of the head; such as violent exer-
cise, a violent fit of anger, external heat ap-
plied, or any strong pressure upon the de-
scending aorta.
MCVI.
But both these states of over distention and
of effusion, may also and seem to be more
frequently produced by causes that operate
by preventing the free return of the venous
blood from the vessels of the head to the right
ventricle of the heart.
MCVII.
The venous vessels of the brain are of a
conformation and distribution so peculiar, as
lead us to believe, that Nature intended to
retard the motion of the blood, and accumu-
late it in these vessels; and therefore, even very
small additional resistances to the motion of
the blood from these towards the right ventri-
cle of the heart, may still more readily accu-
mulate the blood in them. Such accumula-
tion will most readily happen in advanced
life, when the venous system in general is in
a plethoric state, and when this plethora takes
place especially in the venous vessels of the
brain. It will, in like manner, be most apt
to occur in persons whose heads are large
with respect to the rest of the body; and in
persons of a short neck, which is unfavourable
to 

311 OF PHYSIC.
to the return of the venous blood from the
head. The accumulation of blood in the
venous vessels of the brain, will also be most
likely to occur in persons of a corpulent habit,
either because these may be considered to be
in a plethoric state, or because obesity, by oc-
casioning a compression of the blood vessels
in other parts of the body, more readily fills
those of the brain, which are entirely free
from any such compression.
MCVIII.
These are the circumstances in the consti-
tution of the body, which, producing a slow-
er motion and return of the venous blood
from the vessels of the head, favour an accu-
mulation and distention in them; and we now
proceed to mention the several occasional
causes, which, in every person, may directly
prevent the free return or the blood from the
vessels of the head towards the heart. Such
are,
1. Stooping down with the head, or other
situations of the body in which the head is
long kept in a depending state, and in which
the gravity of the blood increases the afflux of
it by the arteries, and opposes the return of it
by the veins.
2. A tight ligature about the neck, which
compresses the veins more strongly than the
arteries.
O6 3. Any

312 PRACTICE
3. Any obstruction of a considerable num-
ber of the veins carrying the blood from the
head, and more especially any considerable
obstruction of the ascending vena cava.
4. Any considerable impediment of the
free passage of the blood from the veins into
the right ventricle of the heart; and it is com-
monly by this, and the immediately preceding
circumstance, that polypous concretions in
the cava, or right ventricle, are found to occa-
sion apoplexy. 
5. The return of blood from the veins of
the head towards the heart, is especially inter-
rupted by every circumstance that produces a
more difficult transmission of the blood through
the vessels of the lungs. It is well known,
that, at the end of every expiration, some in-
terruption is given to the free transmission of
the blood through the lungs; and that this at
the same time gives an interruption to the
motion of the blood from the veins into the
right ventricle of the heart. This clearly ap-
pears from that regurgitation of the blood in
the veins which occasions the alternate heav-
ing and subsiding that is perceived in the
brain of living animals when the cranium is
removed, and which is observed to be syn-
chronous with the alternate motions of respi-
ration. From this we readily perceive, that
whatever occasions a difficulty in the trans-
mission of the blood through the lungs, must
also interrupt the free return of the venous
blood from the vessels of the head; and must
therefore 

313 OF PHYSIC. 
therefore favour, and perhaps produce, an ac-
cumulation of blood, and an over distention
in these vessels.
It is further to be observed, that as a very
full inspiration, continued for any length of
time, occasions such an interruption of the
free transmission of the blood through the
lungs, as produces a suffusion of face, and a
manifest turgescence of the blood vessels of
the head and neck; so every full and long
continued inspiration may occasion an accu-
mulation of blood in the vessels of the head,
to a very considerable degree. Thus, as ev-
ery strong exertion of the muscular force of
the body requires, and is attended with, a
very full and long continued inspiration, we
thence learn why the violent exertions of
muscular force have been so often the imme-
diate or exciting causes of apoplexy.
It may also be remarked, that corpulency
and obesity seem to operate very much, by
occasioning a more difficult transmission of
the blood through the vessels of the lungs. It
appears, that in fat persons, from the compres-
sion of the bloodvessels in many parts of the
body, the vessels of the lungs are thereby
kept very full; so that upon the least increase
of bodily motion, which sends the blood faster
into the lungs, a more frequent and laborious
respiration becomes in such persons imme-
diately necessary. This shows, that, in such
persons, the blood is not freely transmitted
through the lungs; a circumstance which, as 
in

314 PRACTICE
in other instances, must give a constant resist-
ance to the return of blood from the vessels
of the head, and therefore favour or occasion
an accumulation of blood in them.
Is the motion of the blood in the vessels of
the head, rendered slower by study, care, and
anxiety?
MCIX.
It is to be observed further, that these sev-
eral causes (MCV——MCVIII) of a preter-
natural fulness in the bloodvessels of the brain,
may produce apoplexy in different ways, ac-
cording as the fulness takes place in the arte-
ries or in the veins.
MCX.
Accordingly, first, the increased afflux of
blood into the arteries of the brain, and an in-
creased action in these, may either occasion a
rupture of their extremities, and thereby an
effusion of red blood producing compression;
or the same afflux and increased action may
occasion an increased exhalation from their
extremities, of a serous fluid, which, if not as
quickly reabsorbed, may soon accumulate in
such quantity as to produce compression.
MCXI. 

315 OF PHYSIC.
MCXI.
Secondly, The plethoric state of the venous
vessels of the brain, may operate in three dif-
ferent ways.
1. The fulness of the veins may give such
resistance to the blood flowing into them from
the arteries, as to determine the impetus of
the blood to be so much greater upon the ex-
tremities of the arteries as to occasion a rup-
ture of these, and consequently an effusion of
red blood, or the Hæmorrhagia cerebri, which
HOFFMAN considers as a frequent cause of
apoplexy, and which we have before explain-
ed in DCCLXXII.
2. Whilst the same resistance to the blood
flowing from the arteries into the veins, in-
creases the impetus of the blood in the former,
this may, without occasioning rupture, in-
crease the exhalation from their exhalant ex-
tremities, and produce an effusion of a serous
fluid; in the same manner as such resistance
in the veins produces hydropic effusions in
other parts of the body.
3. If we may suppose, as no lymphatics
have been yet discovered in the brain, that
the ordinary absorbents are not present there,
and that the exhaled fluids are absorbed or
taken up by the extremities of the veins;
this will show still more clearly that a resist-
ance to the motion of the blood in the veins
of the brain, may readily produce an accumu-
lation 

316 PRACTICE
lation of serous fluid in its cavities, and con-
sequently a compression producing apoplexy.
MCXII.
Besides these cases of apoplexy from af-
flux in the arteries, or resistance in the veins,
an effusion of serum may happen from two
other causes. The one is a relaxation of the
exhalants, as in other cases of hydropic dia-
thesis prevailing in the body; and it is not
unusual for a general dropsy to end in apo-
plexy. The second is an over proportion of
watery parts in the mass of blood, which is
therefore ready to run off by the exhalants, as
in the case of an ischuria renalis; which when
it proves incurable, very commonly termin-
ates in apoplexy.
MCXIII.
We have now mentioned the several causes
of apoplexy depending upon compression;
and from the whole it will appear, that the
most frequent of all these causes is a plethoric
state, or an accumulation and congestion of
blood in the venous vessels of the head, ope-
rating, according to its degree, in producing
over distention or effusion. The frequent
operation of such a cause will especially ap-
pear from a consideration of the predisponent
circumstances (MXCV), and from the ante-
cedent symptoms (MXCVI).
MCXIV. 

317 OF PHYSIC.
MCXIV.
From the view I have now given of the
causes of apoplexy arising from compression,
it will readily appear that there is a founda-
tion for the common distinction of this dis-
ease into the two kinds of Sanguine and Se-
rous. But this distinction cannot be very
usefully applied in practice, as both kinds
may often depend on the same cause, that is,
a venous plethora, and therefore requiring
very nearly the same method of cure. The
only distinction that can be properly made of
apoplexies from compression, is perhaps the
distinction of serous apoplexy, into that de-
pending on the plethora mentioned MCXIII,
and that depending upon hydropic diathesis
or an over proportion of water in the blood
(MCXII); the former causes giving a prop-
er idiopathic, the latter only a symptomatic,
disease.
MCXV.
Beside the causes now mentioned, occa-
sioning apoplexy by compression, I allege
there are other causes producing the same
disease, by directly destroying the mobility
of the nervous power. Such causes seem to
be the mephitic air arising from fermenting
liquors, and from many other sources; the
fumes arising from burning charcoal; the
fumes 

318 PRACTICE
fumes of mercury, of lead, and of some other
metallic substances; opium, alcohol, and
many other narcotic poisons: To all which I
would add the power of cold, of concussion,
of electricity, and of certain passions of the
mind.
MCXVI.
None of these poisons or noxious powers
seem to kill by acting first upon the organs of
respiration, or upon the sanguiferous system;
and I believe their immediate and direct ac-
tion to be upon the nervous power, destroying
its mobility, because the same poisons show
their power in destroying the irritability of
muscles and of the nerves connected with
them, when both these are entirely separated
from the rest of the body.
MCXVII.
It appears to me probable, that the apo-
plectic state in some degree accompanying,
and almost always succeeding, an epileptic
paroxysm, does not depend upon compres-
sion, but upon a certain state of immobility
of the nervous power, produced by certain
circumstances in the nervous system itself,
which sometimes seem to be communicated
from one part of the body to another, and
at length to the brain.
MCXVIII. 

319 OF PHYSIC.
MCXVIII.
The same observation may be made with
respect to many instances of hysteric parox-
ysm; and the circumstances, both of epilep-
tic and hysteric paroxysms, ending in coma,
or a degree of apoplexy, lead me to think,
that also the apoplexy proceeding from retro-
cedent or atonic gout is of the same kind, or
that it depends upon an immobility of the
nervous power, rather than upon compression.
MCXIX. 
It may indeed happen, that as the apo-
plectic and gouty predispositions do often
concur in the same person; so it may conse-
quently happen, that the apoplexy coming
upon gouty persons, may sometimes depend
upon compression; and dissections may, ac-
cordingly, discover that the circumstances of
such a cause had preceded.
But, in many cases of apoplexy following a
retrocedent or atonic gout, no such antecedent
or concomitant circumstances, as commonly
occur in cases of compression, do distinctly or
clearly appear; while others present them-
selves, which point out an affection of the
nervous power alone.
MCXX. 

320 PRACTICE
MCXX.
With respect, however, to the circum-
stances which may appear upon the dissection
of persons dead of apoplexy, there may be
some fallacy in judging, from those circum-
stances, of the cause of the disease. What-
ever takes off or diminishes the mobility of
the nervous power, may very much retard
the motion of the blood in the vessels of the
brain; and that perhaps to the degree of in-
creasing exhalation, or even of occasioning
rupture and effusion; so that, in such cases,
the marks of compression may appear, upon
dissection, though the disease had truly de-
pended on causes destroying the mobility of
the nervous power. This seems to be illus-
trated and confirmed from what occurs in
many cases of epilepsy. In some of these,
after a repetition of fits, recovered from in
the usual manner, a fatuity is induced, which
commonly depends upon a watery inunda-
tion of the brain: And in other cases of epi-
lepsy, when fits have been often repeated
without any permanent consequence, there
happens at length a fatal paroxysm; and up-
on dissection it appears, that an effusion of
blood had happened. This, I think, is
to be considered as a cause of death, not
as a cause of the disease; for in such cases,
I suppose that the disease had diminish-
ed the action of the vessels of the brain,
and thereby given occasion to a stagnation,
which 

321 OF PHYSIC.
which produced the appearances mentioned.
And I apprehend the same reasoning will ap-
ply to the cases of retrocedent gout, which,
by destroying the energy of the brain, may
occasion such a stagnation as will produce
rupture, effusion, and death; and in such a
case, the appearances upon dissection might
lead us to think that the apoplexy had de-
pended entirely upon compression.
MCXXI.
The several causes mentioned in MCXV,
are often of such power as to occasion imme-
diate death; and therefore have not com-
monly been taken notice of as affording in-
stances of apoplexy; but, as the operation of
the whole of these causes is similar and anal-
ogous, and as in most instances of the opera-
tion of these causes an apoplectic state is man-
ifestly produced, there can be little doubt in
considering most of the instances of their ef-
fects as cases of apoplexy, and therefore such
as fall properly under our consideration here.
MCXXII.
This disease of apoplexy is sometimes en-
tirely recovered from; but more frequently
it ends in death, or in a hemiplegia. Even
when an attack of the disease is recovered
from, we generally find it disposed to return;
and the repeated attacks of it almost always,
sooner 

322 PRACTICE
sooner or later, bring on the events we have
mentioned.
MCXXIII.
The several events of this disease, in health,
death, or another disease, may be expected
and foreseen from a consideration of the pre-
disponent circumstances (MXCV); of the
antecedent symptoms (MXCVI); of the ex-
citing causes (MXCVIII); of the violence
and degree of the symptoms when the disease
has come on (MXCIV); of the duration of
the disease; and of the effects of the reme-
dies employed.
MCXXIV.
From the great danger attending this dis-
ease when it has come on (MCXXII), it will
readily appear, that our care should be chief-
ly directed to the prevention of it. This, I
think, may be often done by avoiding the re-
mote and exciting causes; and how this may
be accomplished, will be obvious from the
enumeration of those causes given above
(MXCVIII.) But it will also appear from
what is said above, that the prevention of this
disease will especially depend upon obviating
the predisponent cause; which, in most cases,
seems to be a plethoric state of the bloodves-
sels of the brain. This, I think, may be ob-
viated by different means; and, in the first
place, 

323 OF PHYSIC.
place, by a proper management of exercise
and diet.
MCXXV.
The exercise ought to be such as may sup-
port the perspiration, without heating the
body or hurrying respiration; and, therefore,
commonly by some mode of gestation. In
persons not liable to frequent fits of giddi-
ness, and who are accustomed to riding on
horseback, this exercise is, of all others, the
best. Walking, and some other modes of
bodily exercise, may be employed with the
restrictions just now mentioned; but in old
men, and in men of corpulent habits, bodily
exercise ought always to be very moderate.
MCXXVI.
In persons who pretty early in life show
the predisposition to apoplexy, it is probable
that a low diet, with a good deal of exercise,
might entirely prevent the disease; but, in
persons who are advanced in life before they
think of taking precautions, and are at the
same time of a corpulent habit, which gen-
erally supposes their having, been accustom-
ed to full living, it might not be safe to put
them upon a low diet; and it may be enough
that their diet be rendered more moderate
than usual, especially with respect to animal
food; 

324 PRACTICE
food; and that, at supper, such food should
be abstained from altogether.
In drinking, all heating liquors are to be
abstained from, as much as former habits will
allow; and the smallest approach to intoxi-
cation is to be carefully shunned. For ordi-
nary draught, small beer is to be preferred to
plain water, as the latter is more ready to oc-
casion costiveness, which in apoplectic hab-
its is to be carefully avoided. The large use
of tobacco in any shape, may be hurtful; and
except in cases where it has been accustomed
to occasion a copious excretion from the head,
the interruption of which might not be safe,
the use of tobacco should be avoided; and
even in the circumstance mentioned, where
it may be in some measure necessary, the use
of it should at least be rendered as moderate
as possible.
MCXXVII.
Evacuations by stood may certainly con-
tribute to relieve the plethoric state of the
vessels of the head; and, upon an appear-
ance of any unusual turgescence in these,
purging will be very properly employed:
But, when no such turgescence appears, the
frequent repetition of large purging might
weaken the body too much; and, for pre-
venting apoplexy, it may for the most part
be enough to keep the belly regular, and
rather open, by gentle laxatives. In the
summer 

325 OF PHYSIC.
summer season, it may be useful to drink, ev-
ery morning, of a gentle laxative mineral
water, but never in large quantity.
MCXXVIII.
In the case of a plethoric state of the sys-
tem, it might be supposed that bloodletting
would be the most effectual means of dimin-
ishing the plethora, and of preventing its con-
sequences: And, when an attack of apoplexy
is immediately threatened, bloodletting is cer-
tainly the remedy to be depended upon; and
blood should be taken largely, if it can be
done, from the jugular vein, or temporal ar-
tery. But, when no threatening turgescence
appears, the obviating plethora is not ju-
diciously attempted by bloodletting, as we
have endeavoured, to demonstrate above,
DCCLXXXVII. In doubtful circum-
stances, leeches applied to the temples, or
scarifications of the hind head, may be more
safe than general bleedings.
MCXXIX.
When there are manifest symptoms of a
plethoric state in the vessels of the head, a se-
ton, or pea issue, near the head, may be very
useful in obviating any turgescence of the
blood.
VOL. II. P MCXXX 

326 PRACTICE
MCXXX.
These are the means to be employed for pre-
venting the apoplexy which might arise from
a plethoric state of the vessels of the brain;
and if, at the same time, great care is taken to
avoid the exciting causes (MXCVIII), these
means will be generally successful.
In the cases proceeding from other causes
(MCXV), as their application is so imme-
diately succeeded by the disease, they hardly
allow any opportunity for prevention.
MCXXXI.
For the CURE of apoplexies from internal
causes, and which I suppose to be chiefly
those from compression, the usual violence
and fatality of it require that the proper rem-
edies be immediately and largely employed.
The patient is to be kept as much as pos-
sible in somewhat of an erect posture, and in
cool air; and therefore neither in a warm
chamber, nor covered with bed clothes, nor
surrounded with a crowd of people.
MCXXXII.
In all cases of a full habit, and where the
disease has been preceded by marks of a ple-
thoric state, bloodletting is to be immediately
employed, and very largely. In my opin-
ion, 

327 OF PHYSIC
ion, it will be most effectual when the blood
is taken from the jugular vein; but, if that
cannot be properly done, it may be taken
from the arm. The opening of the temporal
artery, when a large branch can be opened,
so as suddenly to pour out a considerable
quantity of blood, may also be an effectual
remedy; but, in execution, it is more uncer-
tain, and may be inconvenient. It may be
in some measure supplied, by cupping and
scarifying on the temples or hind head.
This, indeed, should seldom be omitted; and
these scarifications are always preferable to
the application of leeches.
With respect to every mode of bloodlet-
ting, this is to be observed, that when in any
case of apoplexy, it can be perceived that one
side of the body is more affected with the loss
of motion than the other, the bloodletting, if
possible, should be made on the side opposite
to that most affected.
MCXXXIII.
Another remedy to be employed is purg-
ing, to be immediately attempted by acrid
glysters; and at the same time, if any power
of swallowing remain, by drastic purgatives
given by the mouth. These, however, lest
they may excite vomiting, should be given
in divided portions at proper intervals.
P2 MCXXXIV. 

328 PRACTICE
MCXXXIV.
Vomiting has been commended by some
practitioners and writers: But, apprehending
that this might impel the blood with too
much violence into the vessels of the head, I
have never employed it.
MCXXXV.
Another remedy to be immediately em-
ployed is blistering; and I judge that this is
more effectual when applied to the head, or
near to it, than when it is applied to the low-
er extremities. This remedy I do not con-
sider as a stimulant, or capable of making
any considerable revulsion: But, applied to
the head, I suppose it useful in taking off the
hemorrhagic disposition so often prevailing
there.
MCXXXVI.
It has been usual with practitioners, to-
gether with the remedies already mention-
ed, to employ stimulants of various kinds:
But I am disposed to think them generally
hurtful; and they must be so, wherever the
fulness of the vessels, and the impetus of the
blood in these, is to be diminished. Upon
this principle it is therefore agreed, that stim-
ulants are absolutely improper in what is sup-
posed

329 OF PHYSIC.
posed to be a sanguine apoplexy; but they
are commonly supposed to be proper in the
serous. If, however, we be right in alleging
that this also commonly depends upon a ple-
thoric state of the bloodvessels of the brain,
stimulants must be equally improper in the
one case as in the other.
MCXXXVII.
It may be argued from the almost universal
employment of stimulants, and sometimes
with seeming advantage, that they may not
be so hurtful as my notions of the causes of
apoplexy lead me to suppose. But this ar-
gument is, in several respects, fallacious; and
particularly in this, that in a disease which,
under every management, often proceeds so
quickly to a fatal termination, the effects of
remedies are not to be easily ascertained.
MCXXXVIII.
I have now mentioned the several remedies
which I think adapted to the cure of apo-
plexy arising from compression, and should
next proceed to treat of the cure of apoplexy
arising from those causes that directly destroy
the mobility of the nervous power. But
many of those causes are often so powerful,
and thereby so suddenly fatal in their effects,
as hardly to allow of time for the use of rem-
edies; and such cases therefore have been so
P3 seldom 

330 PRACTICE
seldom the subjects of practice, that the prop-
er remedies are not so well ascertained as to
enable me to say much of them here.
MCXXXIX.
When, however, the application of the
causes (MCXV) is not so powerful as imme-
diately to kill, and induces only an apoplectic
state, some efforts are to be made to obviate
the consequences, and to recover the patient;
and even in some cases where the causes re-
ferred to, from the ceasing of the pulse and of
respiration, and from a coldness coming upon
the body, have induced an appearance of
death; yet, if these appearances have not
continued long, there may be means of re-
covering the persons to life and health. I
cannot, indeed, treat this subject completely;
but for the cure of apoplexy from several
of the causes mentioned MCXV, shall offer
the following general directions.
1. When a poison capable of producing
apoplexy has been recently taken into the
stomach, if a vomiting spontaneously arises, it
is to be encouraged; or, if it does not spon-
taneously come on, a vomiting is to be imme-
diately excited by art, in order that the poison
may be thrown out as quickly as possible.
If, however, the poison has been taken into
the stomach long before its effects have ap-
peared, we judge that, upon their appear-
ance, 

331 OF PHYSIC.
ance, the exciting of vomiting will be useless,
and may perhaps be hurtful.
2. When the poison taken into the stom-
ach, or otherwise applied to the body, has al-
ready induced an apoplectic state, as those
causes do commonly at the same time occa-
sion a stagnation or slower motion of the
blood in the vessels of the brain and of the
lungs, so it will generally be proper to relieve
this congestion by taking some blood from
the jugular vein, or from the veins of the
arm.
3. Upon the same supposition of a con-
gestion in the brain or lungs, it will generally
be proper to relieve if by means of acrid
glysters producing some evacuation from the
intestines.
4. When these evacuations by bloodletting
and purging have been made, the various
stimulants which have been commonly pro-
posed in other cases of apoplexy, may be em-
ployed here with more probability and safe-
ty. One of the most effectual means of
rousing apoplectics of this kind seems to
be throwing cold water on several parts of
the body, or washing the body all over with
it.
5. Although the poison producing apo-
plexy happens to be so powerful as very soon
to occasion the appearances of death above
mentioned; yet if this state has not contin-
ued long, the patient may often be recover-
able; and the recovery is to be attempted
P4 by

332 PRACTICE
by the same means that are directed to
be employed for the recovery of drowned
persons, and which are now commonly
known. 
CHAP.

333 OF PHYSIC.
CHAP. II.
OF PALSY.
MCXL.
PALSY is a disease consist-
ing in a loss of the power of voluntary mo-
tion, but affecting certain parts of the body
only, and by this it is distinguished from ap-
oplexy (MXCIV). One of the most fre-
quent forms of palsy is when it affects the
whole of the muscles on one side of the
body; and then the disease is named a He-
miplegia.
MCXLI.
The loss of the power of voluntary motion
may be owing either to a morbid affection of
the muscles or organs of motion, by which they
are rendered unfit for motion; or to an inter-
ruption of the influx of the nervous power in-
VOL. 2. P5 to

334 PRACTICE
to them, which is always necessary to the mo-
tions of those that are under the power of
the will. The disease, from the first of these
causes, as consisting in an organic and local
affection, we refer entirely to the class of lo-
cal diseases. I am here to consider that dis-
ease only which depends upon the interrupt-
ed influx of the nervous power; and it is to
this disease alone I would give the appella-
tion of Palsy. A disease depending on an
interrupted influx of the nervous power, may
indeed often appear as merely a local affec-
tion; but as it depends upon an affection of
the most general powers of the system, it
cannot be properly separated from the syste-
matic affections.
MCXLII.
In palsy, the loss of motion is often ac-
companied with a loss of sense: But as this
is not constantly the case, and as therefore the
loss of sense is not an essential symptom of
palsy, I have not taken it into my definition
(MCXL); and I shall not think it necessary
to take any further notice of it in this treatise;
because, in so far as it is in any case a part of
the paralytic affection, it must depend upon
the same causes, and will be cured also by the
very same remedies, as the loss of motion. 
MCXLIII. 

335 OF PHYSIC.
MCXLIII.
The palsy then, or loss of motion, which
is to be treated of here, may be distinguished
as of two kinds; one of them depending up-
on an affection of the origin of the nerves in
the brain, and the other depending upon an
affection of the nerves in some part of their
course between the brain and the organs of
motion. Of the latter, as appearing in a very
partial affection, I am not to speak particu-
larly here; I shall only treat of the more
general paralytic affections, and especially of
the hemiplegia (MCXL). At the same time
I expect, that what I shall say upon this sub-
ject will readily apply to both the pathology
and practice in the cases of affections more
limited.
MCXLIV.
The hemiplegia (MCXL) usually begins
with, or follows, a paroxysm of apoplexy;
and when the hemiplegia, after subsisting for
some time, becomes fatal, it is commonly by
passing again into the state of apoplexy. The
relation therefore or affinity between the two
diseases, is sufficiently evident; and is further
strongly confirmed by this, that the hemi-
plegia comes upon persons of the same con- 
stitution (MXCV), and is preceded by the
P6 same 

336 PRACTICE
same symptoms (MXCVIII), that have been
taken notice of with respect to apoplexy.
MCXLV.
When a fit of apoplexy has gone off, and
there remains a state of palsy appearing as a
partial affection only, it might perhaps be
supposed that the origin of the nerves is in a
great measure relieved; but in so far as com-
monly there still remain the symptoms of the
loss of memory, and of some degree of fatu-
ity, these, I think, show that the organ of in-
tellect, or the common origin of the nerves,
is still considerably affected.
MCXLVI.
Thus, the hemiplegia, from its evident
connexion with, and near relation to apo-
plexy, may be properly considered as de-
pending upon like causes; and consequently,
either upon a compression preventing the
flow of the nervous power from the brain in-
to the organs of motion, or upon the applica-
tion of narcotic or other powers (MCXV)
rendering the nervous power unfit to flow in
the usual and proper manner.
MCXLVII.
We begin with considering the cases de-
pending upon compression.
The 

337 OF PHYSIC.
The compression occasioning hemiplegia
may be of the same kind, and of all the dif-
ferent kinds that produce apoplexy; and
therefore either from tumour, over distention,
or effusion. The existence of tumour giving
compression, may often be better discerned in
the case of palsy than in that of apoplexy, as
its effects often appear at first in a very par-
tial affection.
MCXLVIII.
The other modes of compression, that is, of
over distention and effusion, may, and com-
monly do, take place, in hemiplegia; and
when they do, their operation here differs
from that producing apoplexy, by its effects
being partial, and on one side of the body
only.
It may seem difficult to conceive that an
over distention can take place in the vessels
on one side of the brain only; but it may be
understood: And in the case of a palsy
which is both partial and transitory, it is per-
haps the only condition of the vessels of the
brain that can be supposed. In a hemiple-
gia, indeed, which subsists for any length of
time, there is probably always an effusion,
either sanguine or serous: But it is likely that
even the latter must be supported by a re-
maining congestion in the bloodvessels.
MCXLIX. 

338 PRACTICE
MCXLIX.
That a sanguine effusion can happen with-
out becoming very soon general, and thereby
occasioning apoplexy and death, may also
seem doubtful: But dissections prove that in
fact it does happen occasioning palsy only;
though it is true, that this mare commonly
depends upon an effusion of serous fluid, and
of this only.
MCL.
Can a palsy occasioned by a compres-
sion remain, though the compression be re-
moved?
MCLI.
From what has been said MCXLIV, it
will be obvious, that the hemiplegia may be
prevented by all the several means proposed
MCXXV et seq. for the prevention of apo-
plexy.
MCLII.
Upon the same grounds, the CURE of pal-
sy must be very much the same with that of
apoplexy (MCXXX et seq.); and when
palsy has begun as an apoplexy, it is presum-
ed, that, before it is to be considered as palsy,
all 

339 OF PHYSIC.
all those several remedies have been employ-
ed. Indeed, even when it happens that on
the first attack of the disease the apoplectic
state is not very complete, and that the very
first appearance of the disease is as a hemi-
plegia, the affinity between the two diseases.
(MCXLIV) is such as to lead to the same
remedies in both cases. This is certainly
proper in all those cases in which we can with
much probability imputes the disease to com-
pression; and it is indeed seldom that a
hemiplegia from internal causes comes on but
with a considerable affection of the internal
and even of the external senses, together with
other marks of a compression of the origin of
the nerves.
MCLIII.
Not only, however, where the disease can
be imputed to compression, but even where
it can be imputed to the application of nar-
cotic powers, if the disease come on with
the appearances mentioned at the end of last
paragraph, it is to be treated in the same
manner as an apoplexy by MCXXXI——
MCXXXIX.
MCLIV.
The cure of hemiplegia, therefore, on its
first attack, is the same, or very nearly the
same, 

340 PRACTICE
same, with that of apoplexy: And it seems
requisite that it should be different only, 1.
When the disease has subsisted for some
time; 2. When the apoplectic symptoms, or
those marking a considerable compression of
the origin of the nerves, are removed; and
particularly, 3. When there are no evident
marks of compression, and it is at the same
time known that narcotic powers have been
applied.
MCLV.
In all these cases, the question arises,
Whether stimulants may be employed, or
how far the cure may be entirely trusted to
such remedies? Upon this question, with
respect to apoplexy, I have offered my opin-
ion in MCXXXVI. And, with respect to
hemiplegia, I am of opinion, that stimulants
are almost always equally dangerous as in the
cases of complete apoplexy; and particular-
ly, 1. In all the cases of hemiplegia succeed-
ing to a paroxysm of complete apoplexy; 2.
In all the cases coming upon persons of the
temperament mentioned in MXCV, and after
the same antecedents as those of apoplexy
(MCXVI); and, 3. In all the cases coming
on with symptoms of apoplexy from com-
pression.
MCLVI. 

341 OF PHYSIC.
MCLVI.
It is, therefore, in the cases MCLIV only,
that stimulants are properly admissible: And
even in the two first of these cases, in which a
plethoric state of the bloodvessels of the brain
may have brought on the disease, in which a
disposition to that state may still continue, and
in which even some degree of congestion may
still remain, the use of stimulants must be
an ambiguous remedy; so that perhaps it is
in the third of these cases only that stimulants
are clearly indicated and admissible.
MCLVII.
These doubts with respect to the use of
stimulants, may perhaps be overlooked or
disregarded by those who allege that stimu-
lants have been employed with advantage
even in those cases (MCLV) in which I have
said they ought to be avoided.
MCLVIII.
To compromise this contrariety of opinion,
I must observe, that even in the cases of hemi-
plegia depending upon compression, although
the origin of the nerves be so much compress-
ed as to prevent so full a flow of the nervous
power as is necessary to muscular motion, yet
it 

342 PRACTICE
it appears from the power of sense still re-
maining, that the nerves are, to a certain de-
gree, still pervious; and therefore it is pos-
sible that stimulants applied, may excite the
energy of the brain so much, as in some meas-
ure to force open the compressed nerves, and
to show some return of motion in paralytic
muscles. Nay, further, it may be allowed,
that if these stimulants be such as act more
upon the nervous than upon the sanguiferous
system, they may possibly be employed with-
out any very hurtful consequence.
MCLIX.
But still it will be obvious, that although
certain stimulants act chiefly upon the ner-
vous system, yet they also act always in some
measure upon the sanguiferous; so that, when
they happen to have the latter effect in any
considerable degree, they may certainly do
much harm; and in a disease which they do
not entirely cure, the mischief arising from
them may not be discerned.
MCLX.
Whilst the employment of stimulants is so
often an ambiguous practice, we may perhaps
go some length towards ascertaining the mat-
ter, by considering the nature of the several
stimulants which may be employed, and some
of 

343 OF PHYSIC.
of the circumstances of their administration.
With this view, therefore, I shall now men-
tion the several stimulants that have been
commonly employed, and offer some remarks
upon their nature and use.
MCLXI.
They are in the first place to be distin-
guished as external or internal. Of the first
kind, we again distinguish them as they are
applied to particular parts of the body only,
or as they are more generally applied to the
whole system. Of the first kind are,
1. The concentrated acids of vitriol or ni-
tre; involved, however, in oily or unctuous
substances, which may obviate their cor-
rosive, without destroying their stimulant
power.
2. The volatile alkaline spirits, especially
in their caustic state; but involved also in
oils, for the purpose just now mentioned.
3. The same volatile spirits are frequently
employed by being held to the nose, when
they prove a powerful stimulus to the nervous
system; but it is at the same time probable,
that they may also prove a strong stimulant
to the bloodvessels of the brain.
4. A brine, or strong solution of sea salt.
5. The essential oils of aromatic plants, or
of their parts. 
6. The essential oils of turpentine, or of
other such resinous substances.
7. The 

344 PRACTICE
7. The distilled oils of amber, or of other
bituminous fossils.
8. The rectified empyreumatic oils of an-
imal or vegetable substances.
9. Various vegetable acrids, particularly
mustard.
10. The acrid matter found in several in-
sects, particularly cantharides.
Some of these stimulants may be either ap-
plied in substance; or may be dissolved in
ardent spirits, by which their stimulant pow-
er may be increased, or more conveniently
applied.
MCLXII.
The greater part of the substances now
enumerated show their stimulant power by
inflaming the skin of the part to which they
are applied; and when their application is
so long continued as to produce this effect,
it interrupts the continuance of their use;
and the inflammation of the part does not
seem to do so much good as the frequent
repetition of a more moderate stimulus.
MCLXIII.
Analogous to these stimulants is the sting-
ing of nettles, which has been frequently
commended.
Among the external stimulants, the me-
chanical one of friction with the naked hand,
the 

345 OF PHYSIC.
the flesh brush, or flannel, is justly to be
reckoned. Can the impregnation of the
flannels to be employed, with the fumes of
burning mastic, olibanum, &c. be of any
service?
MCLXIV.
With respect to the whole of these external
stimulants, it is to be observed, that they af-
fect the part to which they are applied much
more than they do the whole system, and
they are therefore indeed safer in ambiguous
cases; but, for the same reason, they are of
less efficacy in curing a general affection.
MCLXV.
The external applications which may be
applied to affect the whole system, are the
powers of heat and cold, and of electricity.
Heat, as one of the most powerful stimu-
lants of the animal economy, has been often
employed in palsies, especially by warm bath-
ing. But as, both by stimulating the solids
and rarefying the fluids, this proves a strong
stimulus to the sanguiferous system, it is often
an ambiguous remedy; and has frequently
been manifestly hurtful in palsies depending
upon a congestion of blood in the vessels of
the brain. The most certain, and therefore
the most proper use of warm bathing in pal-
sies, seems to be in those that have been oc-
casioned 

346 PRACTICE
casioned by the application of narcotic pow-
ers. Are the natural baths more useful by
the matters with which they may be naturally
impregnated?
MCLXVI.
Cold applied to the body for any length
of time, is always hurtful to paralytic per-
sons; but if it be not very intense, nor the
application long continued, and if at the same
time the body be capable of a brisk reaction,
such an application of cold is a powerful
stimulant of the whole system, and has often
been useful in curing palsy. But, if the
power of reaction in the body be weak, any
application of cold may prove very hurtful.
MCLXVII.
Electricity, in a certain manner applied, is
certainly one of the most powerful stimulants
that can be employed to act upon the ner-
vous system of animals; and therefore much
has been expected from it in the cure of pal-
sy. But, as it stimulates the sanguiferous as
well as the nervous system, it has been often
hurtful in palsies depending upon a compres-
sion of the brain; and especially when it has
been so applied as to act upon the vessels of
the head. It is safer when its operation is
confined to particular parts somewhat remote
from the head; and, further, as the operation 
of

347 OF PHYSIC.
of electricity, when very strong, can destroy
the mobility of the nervous power, I am of
opinion, that it is always to be employed with
caution, and that it is only safe when applied
with moderate force, and when confined to
certain parts of the body remote from the
head. It is also my opinion, that its good
effects are to be expected from its repetition
rather than from its force, and that it is par-
ticularly suited to the cure of those palsies
which have been produced by the application
of narcotic powers.
MCLXVIII.
Amongst the remedies of palsy, the use of
exercise is not to be omitted. In a hemiple-
gia, bodily exercise cannot be employed; and
in a more limited affection, if depending up-
on a compression of some part of the brain, it
would be an ambiguous remedy: But, in all
cases where the exercises of gestation can be
employed, they are proper; as, even in cases
of compression, the stimulus of such exercise
is moderate, and therefore safe; and, as it al-
ways determines to the surface of the body, it
is a remedy in all cases of internal congestion.
MCLXIX.
The internal stimulants employed in palsy
are various, but chiefly the following.
1. The 

348 PRACTICE
1. The volatile alkaline salts, or spirits, as
they are called, are very powerful and diffu-
sive stimulants, operating especially on the
nervous system; and even although they op-
erate on the sanguiferous, yet, if given in fre-
quently repeated small rather than in large
doses, their operation being transitory, is tol-
erably safe.
2. The vegetables of the class named Te-
tradynamia, are many of them powerful dif-
fusive stimulants; and at the same time, as
quickly passing out of the body, and therefore
of transitory operation, they are often em-
ployed with safety. As they commonly prove
diuretic, they may in this way also be of ser-
vice in some cases of serous palsy.
3. The various aromatics, whether em-
ployed in substance, in tincture, or in their
essential oils, are often powerful stimulants;
but being more adhesive and inflammatory
than those last mentioned, they are therefore,
in all ambiguous cases, less safe.
4. Some other acrid vegetables have been
employed; but we are not well acquainted
with their peculiar virtues, or proper use.
5. Some resinous substances, as guaiacum,
and the terebinthinate substances, or their es-
sential oils, have been, with some probability,
employed; but they are apt to become in-
flammatory. Decoctions of guaiacum, and
some other sudorifics, have been directed to
excite sweating by the application of the
fumes of burning spirit of wine in the la-
conicum, 

349 OF PHYSIC.
conicum, and have in that way been found
useful.
6. Many of the fetid antispasmodic medi-
cines have been frequently employed in pal-
sy; but I do not perceive in what manner
they are adapted to the cure of this disease,
and I have not observed their good effects in
any cases of it.
7. Bitters, and the Peruvian bark, have
also been employed; but with no propriety
or advantage that I can perceive. 
MCLXX.
With respect to the whole of these internal
stimulants, it is to be observed, that they sel-
dom prove very powerful; and wherever
there is any doubt concerning the nature or
state of the disease, they may readily do
harm, and are often therefore of ambiguous
use.
VOL. II. Q BOOK 

350
BOOK II.
OF ADYNAMIÆ, OR DISEASES CON-
SISTING IN A WEAKNESS OR LOSS
OF MOTION IN EITHER THE VITAL
OR NATURAL FUNCTIONS.
CHAP. I.
OF SYNCOPE, OR FAINTING.
MCLXXI.
THIS is a disease in which
the action of the heart and respiration be-
come considerably weaker than usual, or in
which for a certain time these functions cease
altogether.
MCLXXII. 

351 OF PHYSIC. 
MCLXXII.
Physicians having observed that this affec-
tion occurs in different degrees, have endeav-
oured to distinguish these by different appel-
lations: But as it is not possible to ascertain
these different degrees with any precision, so
there can be no strict propriety in employing
those different names; and I shall here com-
prehend the whole of the affections of this
kind under the title of Syncope.
MCLXXIII.
This disease sometimes comes on suddenly
to a considerable degree, but sometimes also
it comes on gradually; and in the latter case,
it usually comes on with a sense of languor,
and of anxiety about the heart, accompanied
at the same time, or immediately after, with
some giddiness, dimness of sight, and sound-
ing in the ears. Together with these symp-
toms, the pulse and respiration become weak;
and often so weak, that the pulse is scarcely
to be felt, or the respiration to be perceived;
and sometimes these motions, for a certain
time, cease altogether. While these symp-
toms take place, the face and whole surface of
the body become pale, and more or less cold
according to the degree and duration of the
paroxysm. Very commonly, at the begin-
ning of this, and during its continuance, a
Q2 cold 

352 PRACTICE
cold sweat appears, and perhaps continues,
on the forehead, as well as on some other
parts of the body. During the paroxysm,
the animal functions, both of sense and mo-
tion, are always in some degree impaired, and
very often entirely suspended. A paroxysm
of syncope is often, after some time, sponta-
neously recovered from; and this recovery
is generally attended with a sense of much
anxiety about the heart.
Fits of syncope are frequently attended
with, or end in, vomiting; and sometimes
with convulsions, or an epileptic fit.
MCLXXIV.
These are the phenomena in this disease;
and from every view of the greatest part of
them, there cannot be a doubt that the prox-
imate cause of this disease is a very weak or a
total ceasing of the action of the heart. But
it will be a very difficult matter to explain in
what manner the several remote causes ope-
rate in producing the proximate cause. This,
however, I shall attempt, though with that
diffidence which becomes me in attempting a
subject that has not hitherto been treated with
much success.
*MCLXXIV.
The remote cause of syncope may, in the
first place, be referred to two general heads.
The 

353 OF PHYSIC.
The one is, of those causes existing and act-
ing in the brain, or in parts of the body re-
mote from the heart, but acting upon it by
the intervention of the brain. The other
general head of the remote causes of syncope,
is of those existing in the heart itself, or in
parts very immediately connected with it, and
thereby acting more directly upon it in pro-
ducing this disease.
MCLXXV.
In entering upon the consideration of the
first set of those causes (MCLXXIV), I must
assume a proposition which I suppose to be
fully established in Physiology. It is this:
That, though the muscular fibres of the heart
be endowed with a certain degree of inherent
power, they are still, for such action as is nec-
essary to the motion of the blood, very con-
stantly dependent upon a nervous power sent
into them from the brain. At least this is
evident, that there are certain powers acting
primarily, and perhaps only in the brain,
which influence and variously modify the ac-
tion of the heart. I suppose, therefore, a
force very constantly during life exerted in
the brain, with respect to the moving fibres
of the heart, as well as of every part of the
body; which force I shall call the Energy of
the Brain; and which I suppose may be, on
Q3 different 

354 PRACTICE
different occasions, stronger or weaker with
respect to the heart.
MCLXXVI.
Admitting these propositions, it will be ob-
vious, that if I can explain in what manner
the first set of remote causes (MCLXXIV)
diminish the energy of the brain, I shall at the
same time explain in what manner these caus-
es occasion a syncope.
MCLXXVII.
To do this, I observe, that one of the most
evident of the remote causes of syncope is a
hemorrhagy, or an evacuation of blood,
whether spontaneous or artificial. And as it
is very manifest that the energy of the brain
depends upon a certain fulness and tension of
its bloodvessels, for which nature seems to
have industriously provided by such a con-
formation of those bloodvessels as retards the
motion of the blood both in the arteries and
veins of the brain; so we can readily per-
ceive, that evacuations of blood, by taking off
the fulness and tension of the bloodvessels of
the brain, and thereby diminishing its energy
with respect to the heart, may occasion a syn-
cope. In many persons, a small evacuation
of blood will have this effect; and in such
cases there is often a clear proof of the man-
ner in which the cause operates, from this cir-
cumstance, 

355 OF PHYSIC.
cumstance, that the effect can be prevented
by laying the body in a horizontal posture;
which, by favouring the afflux of the blood
by the arteries, and retarding the return of it
by the veins, preserves the necessary fulness
of the vessels of the brain. 
It is farther to be remarked here, that not
only an evacuation of blood occasions syn-
cope, but that even a change in the distribu-
tion of the blood, whereby a larger portion of
it flows into one part of the system of blood-
vessels, and consequently less into others, may
occasion a syncope. It is thus I explain the
syncope that readily occurs upon the evacu-
ation of hydropic waters, which had before
filled the cavities of the abdomen or thorax.
It is thus also I explain the syncope that
sometimes happens on bloodletting, but, which
does not happen till the ligature which had
been employed is untied, and admits a larger
afflux of blood into the bloodvessels of the
arm. Both these cases, of syncope show, that
an evacuation of blood does not always occa-
sion the disease by any general effect on the
whole system, but often merely by taking off
the requisite fulness of the bloodvessels of the
brain.
MCLXXVIII.
The operation of some others of the remote
causes of syncope, may be explained on the
following principles. Whilst the energy of
Q4 the 

356 PRACTICE
the brain is, upon different occasions, mani-
festly stronger or weaker, it seems to be with
this condition, that a stronger exertion of it is
necessarily followed by a weaker state of the
same. It seems to depend upon this law in
the constitution of the nervous power, that
the ordinary contraction of a muscle is always
alternated with a relaxation of the same; that,
unless a contraction proceeds to the degree of
spasm, the contracted state cannot be long
continued: And it seems to depend upon
the same cause that the voluntary motions,
which always require an unusual increase of
exertion, occasion fatigue, debility, and at
length irresistible sleep.
From this law, therefore, of the nervous
power, we may understand, why a sudden
and violent exertion of the energy of the
brain is sometimes followed by such a dimi-
nution of it as to occasion a syncope; and it
is thus I suppose that a violent fit of joy pro-
duces syncope, and even death. It is upon
the same principle also, I suppose, that an ex-
quisite pain may sometimes excite the energy
of the brain more strongly than can be sup-
ported, and is therefore followed by such a
diminution as must occasion fainting. But
the effect of this principle appears more clear-
ly in this, that a fainting readily happens up-
on the sudden remission of a considerable
pain; and thus I have seen a fainting occur
upon the reduction of a painful dislocation.
MCLXXIX. 

357 OF PHYSIC.
MCLXXIX.
It seems to be quite analogous when a syn-
cope immediately happens on the finishing of
any great and long continued effort, whether
depending on the will, or upon a propensity;
and in this way a fainting sometimes happens
to a woman on the bearing of a child. This
may be well illustrated by observing, that in
persons already much weakened, even a very
moderate effort will sometimes occasion faint-
ing.
MCLXXX.
To explain the operation of some other
causes of syncope, it may be observed, that as
the exertions of the energy of the brain are
especially under the influence of the will, so
it is well known that those modifications of
the will which are named Passions and Emo-
tions, have a powerful influence on the ener-
gy of the brain in its actions upon the heart,
either in increasing or diminishing the force
of that energy. Thus, anger has the former,
and fear the latter effect; and thence it may
be understood how terror often occasions a
syncope sometimes of the most violent kind,
named Asphyxia, and sometimes death itself.
VOL. 2. Q5 MCLXXXI. 

358 PRACTICE
MCLXXXI.
As, from what I have just mentioned, it
appears, that the emotions of desire increase,
and those of aversion diminish, the energy of
the brain; so it may be understood, how a
strong aversion, a horror, or the feeling which
arises upon the sight of a very disagreeable ob-
ject, may occasion fainting. As an example
of this, I have known more than one instance
of a person's fainting at the sight of a sore in
another person.
MCLXXXII.
To this head of horror and disgust, I refer
the operation of those odours which in certain
persons occasion syncope. It may be sup-
posed, that those odours are endowed with a
directly sedative power, and may thereby oc-
casion syncope; but they are, many of them,
with respect to other persons, evidently of a
contrary quality: And it appears to me, that
those odours occasion syncope only in those
persons to whom they are extremely disa-
greeable.
MCLXXXIII.
It is, however, very probable, that among
the causes of syncope, there are some which,
analogous to all those we have already men-
tioned, 

359 OF PHYSIC.
tioned, act by a directly sedative power: And
such may either be diffused in the mass of
blood, and thereby communicated to the
brain; or may be only taken into the stom-
ach, which so readily and frequently commu-
nicates its affections to the brain.
MCLXXXIV.
Having now enumerated, and, as I hope,
explained, the most part of the remote causes
of syncope, that either operate immediately
upon the brain, or whose operation upon
other parts of the body is communicated to
the brain, it is proper to observe, that the
most part of these causes operate upon certain
persons more readily and more powerfully
than upon others; and this circumstance,
which may be considered as the predisponent
cause of syncope, deserves to be inquired
into.
It is, in the first place, obvious, that the
operation of some of those causes depends en-
tirely upon an idiosyncrasy in the persons
upon whom they operate; which, however,
I cannot pretend to explain. But, in the
next place, with respect to the greater part of
the other causes, their effects seem to depend
upon a temperament which is in one degree
or other in common to many persons. This
temperament seems to consist in a great de-
gree of sensibility and mobility, arising from
a state of debility, sometimes depending upon
Q6 original

360 PRACTICE
original conformation, and sometimes pro-
duced by accidental occurrences in the course
of life.
MCLXXXV.
The second set of the remote causes of syn-
cope (MCLXXIV), or those acting directly
upon the heart itself, are certain organic af-
fections of the heart itself, or of the parts im-
mediately connected with it, particularly the
great vessels which pour blood into or imme-
diately receive it from the cavities of the
heart. Thus a dilatation or aneurism of the
heart, a polypus in its cavities, abscesses or
ulcerations in its substance, a close adherence
of the pericardium to the surface of the heart,
aneurisms of the great vessels near to the
heart, polypus in these, and ossifications in
these or in the valves of the heart, are one or
other of them conditions which, upon dissec-
tion, have been discovered in those persons
who had before laboured under frequent
syncope.
MCLXXXVI.
It is obvious, that these conditions are all
of them, either such as may, upon occasion,
disturb the free and regular influx into, or
the free egress of the blood from, the cavities
of the heart; or such as may otherwise dis-
turb its regular action, by sometimes inter-
rupting 

361 OF PHYSIC. 
rupting it, or sometimes exciting it to more
violent and convulsive action. The latter is
what is named the Palpitation of the Heart,
and it commonly occurs in the same persons
who are liable to syncope.
MCLXXXVII.
It is this, as I judge, that leads us to per-
ceive in what manner these organic affections
of the heart and great vessels may occasion
syncope: For it may be supposed, that the
violent exertions made in palpitations may
either give occasion to an alternate great re-
laxation (MCLXXVIII), or to a spasmodic
contraction; and in either way suspend the
action of the heart, and occasion syncope. It
seems to me probable, that it is a spasmodic
contraction of the heart that occasions the in-
termission of the pulse so frequently accom-
panying palpitation and syncope.
MCLXXXVIII.
Though it frequently happens that palpi-
tation and syncope arise, as we have said, from
the organic affections above mentioned, it is
proper to observe, that these diseases, even
when in a violent degree, do not always de-
pend on such causes acting directly on the
heart, but are often dependent on some of
those 

362 PRACTICE
those causes which we have mentioned above
as acting primarily on the brain.
MCLXXXIX.
I have thus endeavoured to give the pa-
thology of syncope; and of the cure I can
treat very shortly.
The cases of syncope depending on the
second set of causes (MCLXXIV), and fully
recited in MCLXXXV, I suppose to be gen-
erally incurable; as our art, so far as I know,
has not yet taught us to cure any one of those
several causes of syncope (MCLXXXV).
The cases of syncope depending on the
first set of causes (MCLXXIV), and whose
operation I have endeavoured to explain in
MCLXXVII et seq. I hold to be generally
curable, either by avoiding the several occa-
sional causes there pointed out, or by correct-
ing the predisponent causes (MCLXXXIV).
The latter, I think, may generally be done
by correcting the debility or mobility of the
system, by the means which I have already
had occasion to point out in another place.
CHAP. 

363 OF PHYSIC.
CHAP. II.
OF DYSPEPSIA, OR INDIGESTION.
MCXC.
A WANT of appetite, a
squeamishness, sometimes a vomiting, sudden
and transient distentions of the stomach, eruc-
tations of various kinds, heartburn, pains in
the region of the stomach, and a bound belly,
are symptoms which frequently concur in the
same person, and therefore may be presumed
to depend upon one and the same proximate
cause. In both views, therefore they may be
considered as forming one and the same dis-
ease to which we have given the appellation
of Dyspepsia, set at the head of this chapter.
MCXCI.
But as this disease is also frequently a sec-
ondary and sympathic affection, so the symp-
toms above mentioned are often joined with 
many

364 PRACTICE
many others; and this has given occasion to
a very confused and undetermined descrip-
tion of it, under the general title of Nervous
Diseases, or under that of Chronic Weakness.
It is proper, however, to distinguish; and I
apprehend the symptoms enumerated above
are those essential to the idiopathic affection
I am now to treat of.
MCXCII.
It is indeed to be particularly observed,
that these symptoms are often truly accom-
panied with a certain state of mind which
may be considered as a part of the idiopathic
affection: But I shall take no further notice
of this symptom in the present chapter, as it
will be fully and more properly considered
in the next, under the title of Hypochon-
driasis.
MCXCIII.
That there is a distinct disease attended al-
ways with the greater part of the above symp-
toms, is rendered very probable by this, that
all these several symptoms may arise from one
and the same cause; that is, from an imbe-
cility, loss of tone, and weaker action in the
muscular fibres of the stomach: And I con-
clude therefore, that this imbecility may be
considered as the proximate cause of the
disease 

365 OF PHYSIC.
disease I am to treat of under the name of
Dyspepsia.
MCXCIV.
The imbecility of the stomach, and the
consequent symptoms (MCXC), may, how-
ever, frequently depend upon some organic
affection of the stomach itself, as tumour,
ulcer, or scirrhosity; or upon some affection
of other parts of the body communicated to
the stomach, as in gout, amenorrhœa, and
some others. In all these cases, however, the
dyspeptic symptoms are to be considered as
secondary or sympathic affections, to be cur-
ed only by curing the primary disease. Such
secondary and sympathic cases cannot, in-
deed, be treated of here: But as I presume
that the imbecility of the stomach may often
take place without either any organic affection
of this part, or any more primary affection in
any other part of the body; so I suppose and
expect it will appear, from the consideration
of the remote causes, that the dyspepsia may
be often an idiopathic affection, and that it
is therefore properly taken into the system of
methodical Nosology, and becomes the sub-
ject of our consideration here.
MCXCV.
There can be little doubt, that, in most
cases, the weaker action of the muscular fibres
of 

366 PRACTICE
of the stomach, is the most frequent and chief
cause of the symptoms mentioned in MCXC;
but I dare not maintain it to be the only
cause of idiopathic dyspepsia. There is,
pretty certainly, a peculiar fluid in the stom-
ach of animals, or at least a peculiar quality
in the fluids, that we know to be there, upon
which the solution of the aliments taken into
the stomach chiefly depends: And it is at the
same time probable, that the peculiar quality
of the dissolving or digesting fluids may be
variously changed, or that their quantity may
be, upon occasion, diminished. It is there-
fore sufficiently probable, that a change in
the quality or quantity of these fluids may
produce a considerable difference in the phe-
nomena of digestion, and particularly may
give occasion to many of the morbid appear-
ances mentioned in MCXC.
MCXCVI.
This seems to be very well founded, and
points out another proximate cause of dys-
pepsia beside that we have already assigned:
But, notwithstanding this, as the peculiar na-
ture of the digestive fluid, the changes which
it may undergo, or the causes by which it
may be changed, are all matters so little
known, that I cannot found any practical
doctrine upon any supposition with respect
to them; and as, at the same time, the imbe-
cility of the stomach, either as causing the
change 

367 OF PHYSIC.
change in the digestive fluid, or as being in-
duced by that change, seems always to be
present, and to have a great share in occasion-
ing the symptoms of indigestion; so I shall
still consider the imbecility of the stomach as
the proximate and almost sole cause of dys-
pepsia. And I more readily admit of this
manner of proceeding; as, in my opinion,
the doctrine applies very fully and clearly to
the explaining the whole of the practice which
experience has established as the most success-
ful in this disease.
MCXCVII.
Considering this, then, as the proximate
cause of dyspepsia, I proceed to mention the
several remote causes of this disease; as they
are such, as, on different occasions, seem to
produce a loss of tone in the muscular fibres
of the stomach. They may, I think, be con-
sidered under two heads. The first is, of
those which act directly and immediately up-
on the stomach itself: The second is, of those
which act upon the whole body, or particular
parts of it, but in consequence of which the
stomach is chiefly or almost only affected.
MCXCVIII.
Of the first kind are,
1. Certain sedative or narcotic substances
taken into the stomach; such as tea, coffee,
tobacco, 

368 PRACTICE
tobacco, ardent spirits, opium, bitters, aro-
matics, putrids, and acescents.
2. The large and frequent drinking of
warm water, or of warm watery liquids.
3. Frequent surfeit, or immoderate reple-
tion of the stomach.
4. Frequent vomiting, whether spontane-
ously arising, or excited by art.
5. Very frequent spitting, or rejection of
saliva.
MCXCIX.
Those causes which act upon the whole
body, or upon particular parts and functions
of it, are,
1. An indolent and sedentary life.
2. Vexation of mind, and disorderly pas-
sions of any kind.
3. Intense study, or close application to
business too long continued.
4. Excess in venery.
5. Frequent intoxication; which partly
belongs to this head, partly to the former.
6. The being much exposed to moist and
cold air when without exercise.
Though the disease, as proceeding from the
last set of causes, may be considered as a
symptomatic affection only; yet as the affec-
tion of the stomach is generally the first, al-
ways the chief, and often the only effect
which these causes produce or discover, I
think the affection of the stomach may be
considered 

369 OF PHYSIC.
considered as the disease to be attended to in
practice; and the more properly so, as in
many cases the general debility is only to be
cured by restoring the tone of the stomach,
and by remedies first applied to this organ.
MCCI.
For the cure of this disease, we form three
several indications; a preservative, a palliative,
and a curative.
The first is, to avoid or remove the remote
causes just now enumerated.
The second is, to remove those symptoms
which especially contribute to aggravate and
continue the disease. And,
The third is, to restore the tone of the
stomach; that is, to correct or remove the
proximate cause of the disease.
MCCII.
The propriety and necessity of the first in-
dication is sufficiently evident, as the contin-
ued application, or frequent repetition of
those causes, must continue the disease; may
defeat the use of remedies; or, in spite of
these, may occasion the recurrence of the dis-
ease. It is commonly the neglect of this in-
dication which renders this disease so fre-
quently obstinate. How the indication is to
be executed, will be sufficiently obvious from
the consideration of the several causes: But 
it

370 PRACTICE
it is proper for the practitioner to attend to
this, that the execution is often exceedingly
difficult, because it is not easy to engage men
to break in upon established habits, or to re-
nounce the pursuit of pleasure; and partic-
ularly, to persuade men that these practices
are truly hurtful which they have often prac-
tised with seeming impunity.
MCCIII.
The symptoms of this disease which espec-
ially contribute to aggravate and continue it,
and therefore require to be more immediate-
ly corrected or removed, are, first, the crudi-
ties of the stomach already produced by the
disease, and discovered by a loss of appetite,
by a sense of weight and uneasiness in the
stomach, and particularly by the eructation
of imperfectly digested matters.
Another symptom to be immediately cor-
rected, is an unusual quantity, or a higher
degree than usual, of acidity present in the
stomach, discovered by various disorders in
digestion, and by other effects to be men-
tioned afterwards.
The third symptom aggravating the dis-
ease, and otherwise in itself urgent, is costive-
ness, and therefore constantly requiring to be
relieved.
MCCIV.
The first of these symptoms is to be reliev-
ed by exciting vomiting; and the use of this
remedy, 

371 OF PHYSIC.
remedy, therefore, usually and properly be-
gins the cure of this disease. The vomiting
may be excited by various means, more gen-
tle or more violent. The former may an-
swer the purpose of evacuating the contents
of the stomach: But emetics, and vomiting,
may also excite the ordinary action of the
stomach; and both, by variously agitating
the system, and particularly by determining
to the surface of the body, may contribute to
remove the causes of the disease. But these
latter effects can only be obtained by the
use of emetics of the more powerful kind,
such as the antimonial emetics especially are.
MCCV.
The second symptom to be palliated, is an
excess of acidity, either in quantity or quali-
ty, in the contents of the stomach. In man
there is a quantity of acescent aliment almost
constantly taken in, and, as I think, always
undergoes an acetous fermentation in the
stomach; and it is therefore that, in the hu-
man stomach, and in the stomachs of all ani-
mals using vegetable food, there is always
found an acid present. This acid, however,
is generally innocent, and occasions no disor-
der, unless either the quantity of it is very
large, or the acidity proceeds to a higher de-
gree than usual. But, in either of these cases,
the acid occasions various disorders, as flat-
ulency, eructation, heartburn, gnawing pains
of 

372 PRACTICE
of the stomach, irregular appetites and crav-
ings, looseness, griping, emaciation, and debil-
ity. To obviate or remove these effects ag-
gravating and continuing the disease, it is not
only necessary to correct the acid present in
the stomach; but, especially as this acid
proves a ferment determining and increasing
the acescency of the aliments afterwards taken
in, it is proper also, as soon as possible, to cor-
rect the disposition to excessive acidity.
MCCVI.
The acidity present in the stomach may be
corrected by the use of alkaline salts, or ab-
sorbent earths; or by such substances, con-
taining these, as can be decomposed by the
acid of the stomach. Of the alkalines, the
caustic is more effectual than the mild; and
this accounts for the effects of lime water.
By employing absorbents, we avoid the excess
of alkali, which might sometimes take place.
The absorbents are different, as they form a
neutral more or less laxative; and hence the
difference between magnesia alba and other
absorbents. It is to be observed, that alka-
lines and absorbents may be employed to ex-
cess; as, when employed in large quantity,
they may deprive the animal fluids of the acid
necessary to their proper composition.
MCCVII.
The disposition to acidity may be obviat-
ed by avoiding acescent aliments, and using
animal 

373 OF PHYSIC.
animal food little capable of acescency. This,
however, cannot be long continued without
corrupting the state of our blood; and as veg-
etable food cannot be entirely avoided, the
excess of their acescency may in some meas-
ure be avoided, by choosing vegetable food
the least disposed to a villous fermentation,
such as leavened bread and well fermented
liquors, and, instead of fresh native acids, em-
ploying vinegar.
MCCVIII.
The acid arising from acescent matters in a
found state of the stomach, does not proceed
to any high degree, or is again soon involved
and made to disappear: But this does not al-
ways happen; and a more copious acidity, or
a higher degree of it, may be produced, either
from a change in the digestive fluids, become
less fit to moderate fermentation and to cover
acidity, or from their not being supplied in
due quantity. How the former may be oc-
casioned, we do not well understand; but we
can readily perceive that the latter, perhaps
the former also, may proceed from a weaker
action of the muscular fibres of the stomach.
In certain cases, sedative passions, immediately
after they arise, occasion the appearance of
acidity in the stomach which did not appear
before; and the use of stimulants often cor-
rects or obviates an acidity that would other-
wise have appeared. From these considera-
tions, we conclude, that the production and
subsistence of acidity in the stomach, is to be
VOL. II. R especially 

374 PRACTICE
especially prevented by restoring and exciting
the proper action of it, by the several means
to be mentioned hereafter.
MCCIX.
But it is also to be further observed, that
though there are certain powers in the stom-
ach for preventing a too copious acidity, or a
high degree of it, they are not however always
sufficient for preventing acescency, or for cov-
ering the acidity produced; and therefore, as
long as vegetable substances remain in the
stomach, their acescency may go on and in-
crease. From hence we perceive, that a spec-
ial cause of the excess of acidity may be, the
too long retention of acescent matters in the
stomach; whether this may be from these
matters being of more difficult solution, or
from the weakness of the stomach more slow-
ly discharging its contents into the duodenum,
or from some impediment to the free evacu-
ation of the stomach by the pylorus. The
latter of these causes we are well acquainted
with, in the case of a scirrhous pylorus, pro-
ducing commonly the highest degree of acid-
ity. In all the instances of this scirrhosity I
have met with, I have found it incurable:
But the first of these causes is to be obviated
by avoiding such aliments as are of difficult
solution; and the second is to be mended by
the several remedies for exciting the action of
the stomach, to be mentioned afterwards.
MCCX. 

375 OF PHYSIC.
MCCX.
The third symptom commonly accompa-
nying dyspepsia, which requires to be imme-
diately removed, is costiveness. There is so
much connexion between the several portions
of the alimentary canal with respect to the pe-
ristaltic motion, that, if accelerated or retard-
ed in any one part, the other parts of it are
commonly affected in the same manner. Thus,
as the brisker action of the stomach must ac-
celerate the action of the intestines, so the
slower action of the intestines must in some
measure retard that of the stomach. It is
therefore of consequence to the proper action
of the stomach, that the peristaltic motion of the
intestines determining their contents down-
wards, be regularly continued; and that all
costiveness, or interruption of that determina-
tion, be avoided. This may be done by the
various means of exciting the action of the in-
testines: But it is to be observed here, that as
every considerable evacuation of the intestines
weakens their action, and is ready therefore
to induce costiveness when the evacuation is
over; so those purgatives which produce a
large evacuation, are unfit for correcting the
habit of costiveness. This, therefore, should
be attempted by medicines which do no more
than solicit the intestines to a more ready dis-
charge of their present contents, without either
hurrying their action, or increasing the excre-
tions made into their cavity; either of which
effects might produce a purging. There are,
R2 I think, 

376 PRACTICE
I think, certain medicines peculiarly proper
on this occasion, as they seem to stimulate es-
pecially the great guts, and to act little on the
higher parts of the intestinal canal.
MCCXI.
We have thus mentioned the several means
of executing our second indication; and I
proceed to the third, which is, as we have
said, the proper curative; and it is to restore
the tone of the stomach, the loss of which we
consider as the proximate cause of the disease,
or at least as the chief part of it. The means
of satisfying this indication we refer to two
heads. One is, of those means which operate
directly and chiefly on the stomach itself; and
the other is, of those means which, operating
upon the whole system, have their tonic ef-
fects thereby communicated to the stomach.
MCCXII.
The medicines which operate directly on
the stomach, are either stimulants or tonics.
The stimulants are saline or aromatic.
The saline are acids or neutrals.
Acids of all kinds seem to have the power
of stimulating the stomach, and therefore oft-
en increase appetite: But the native acids, as
liable to fermentation, may otherwise do harm,
and are therefore of ambiguous use. The acids,
therefore, chiefly and successfully employed,
are the vitriolic, muriatic, and the distilled acid
of vegetables, as it is found in tar water, which
are all of them antizymics.
The 

377 OF PHYSIC.
The neutral salts answering this intention,
are especially those which have the muriatic
acid in their composition, though it is pre-
sumed that neutrals of all kinds have more or
less of the same virtue.
MCCXIII.
The aromatics, and perhaps some other
acrids, certainly stimulate the stomach, as
they obviate the acescency and flatulency of
vegetable food: But their stimulus is transi-
tory; and if frequently repeated, and taken
in large quantities, they may hurt the tone of
the stomach.
MCCXIV.
The tonics employed to strengthen the
stomach are bitters, bitters and astringents
combined, and chalybeates.
Bitters are undoubtedly tonic medicines,
both with respect to the stomach and the whole
system: But their long continued use has
been found to destroy the tone of the stom-
ach, and of the whole system; and, whether
this is from the mere repetition of their tonic
operation, or from some narcotic power join-
ed with the tonic in them, I am uncertain.
MCCXV.
Bitters and astringents combined, are, prob-
ably more effectual tonics than either of them
taken singly; and we suppose such a com-
bination to take place in the Peruvian bark;
which therefore proves a powerful tonic, both
R3 with 

378 PRACTICE
with respect to the stomach and to the whole
system. But I have some ground to suspect,
that the long continued use of this bark may,
like bitters, destroy both the tone of the stom-
ach and of the whole system.
MCCXVI.
Chalybeates may be employed as tonics in
various forms, and in considerable quantities,
with safety. They have been often employ-
ed in the form of mineral waters, and seem-
ingly with success: But whether this is owing
to the chalybeate in the composition of these
waters, or to some other circumstances attend-
ing their use, I dare not positively determine;
but the latter opinion seems to me the more
probable.
MCCXVII.
The remedies which strengthen the stom-
ach, by being applied to the whole body, are,
exercise and the application of cold.
As exercise strengthens the whole body, it
must also strengthen the stomach; but it does
this also in a particular manner, by promot-
ing perspiration, and exciting the action of
the vessels on the surface of the body, which
have a particular content with the muscular
fibres of the stomach. This particularly ex-
plains why the exercises of gestation, though
not the most powerful in strengthening the
whole system, are, however, very powerful in
strengthening the stomach; of which we have
a remarkable proof in the effects of sailing.
In 

379 OF PHYSIC.
In strengthening the general system, as fatigue
must be avoided, so bodily exercise is of am-
biguous use; and perhaps it is thereby, that
riding on horseback has been so often found
to be one of the most powerful means of
strengthening the stomach, and thereby of
curing dyspepsia.
MCCXVIII.
The other general remedy of dyspepsia, is
the application of cold: Which may be in
two ways; that is, either by the application
of cold air, or of cold water. It is probable,
that, in the atmosphere constantly surround-
ing our bodies, a certain degree of cold, con-
siderably less than the temperature of our
bodies themselves, is necessary to the health
of the human body. Such a degree of cold
seems to strengthen the vessels on the surface
of the body, and therefore the muscular fibres
of the stomach. But, further, it is well known,
that if the body is in exercise sufficient to sup-
port such a determination to the surface, as to
prevent the cold from producing an entire
constriction of the pores; a certain degree of
cold in the atmosphere, with such exercise,
will render the perspiration more consider-
able. From the sharp appetite that in such
circumstances is commonly produced, we can
have no doubt, that by the application of
such cold, the tone of the stomach is consider- 
ably strengthened. Cold air, therefore, ap-
plied with exercise, is a most powerful tonic
with respect to the stomach; and this explains
R4 why,

380 PRACTICE
why, for that purpose, no exercises within
doors, or in close carriages, are so useful as
those in the open air.
MCCXIX.
From the same reasoning, we can perceive,
that the application of cold water, or cold
bathing, while it is a tonic with respect to the
system in general, and especially as exciting
the action of the extreme vessels, must in both
respects be a powerful means of strengthening
the tone of the stomach.
MCCXX.
These are the remedies to be employed to-
wards a radical cure of idiopathic dyspepsia;
and it might be, perhaps, expected here, that
I should treat also of the various cases of the
sympathic disease. But it will be obvious that
this cannot be properly done without treating
of all the diseases of which the dyspepsia is a
symptom, which cannot be proper in this
place. It has been partly done already, and
will be further treated of in the course of this
work. In the mean time, it may be proper
to observe, that there is not so much occasion
for distinguishing between the idiopathic and
sympathic dyspepsia, as there is in many oth-
er cases of idiopathic and sympathic diseases.
For, as the sympathic cases of dyspepsia are
owing to a loss of tone in some other part of
the system, which is from thence communi-
cated to the stomach; so the tone of the stom-
ach restored, may be communicated to the
part 

381 OF PHYSIC. 
part primarily affected; and therefore the
remedies of the idiopathic may be often use-
fully employed, and are often the remedies
chiefly employed, in sympathic dyspepsia.
MCCXXI.
Another part of our business here might be
to say, how some other of the urgent symp-
toms, besides those above mentioned, are to be
palliated. On this subject, I think it is enough
to say, that the symptoms chiefly requiring
to be immediately relieved, are flatulency,
heartburn, other kinds of pain in the region
of the stomach, and vomiting.
The dyspeptic is ready to suppose that
the whole of their disease consists in a flatu-
lency. In this it will be obvious that they are
mistaken; but, although the flatulency is not
to be entirely cured, but by mending the im-
becility of the stomach by the means above
mentioned; yet the flatulent distention of the
stomach may be relieved by carminatives, as
they are called, or medicines that produce a
discharge of wind from the stomach; such are
the various antispasmodics, of which the most
effectual is the vitriolic æther.
The heartburn may be relieved by absorb-
ents, antispasmodics, or demulcents.
The other pains of the stomach may be
sometimes relieved by carminatives, but most
certainly by opiates.
Vomiting is to be cured most effectually by
opiates thrown by injection into the anus.
VOL.2. R5 CHAP.

382 PRACTICE
CHAP. III.
OF HYPOCHONDRIASIS, OR THE HY-
POCHONDRIAC AFFECTION, COM-
MONLY CALLED VAPOURS OR LOW
SPIRITS.
MCCXXII.
IN certain persons there is a
State of mind distinguished by a concurrence
of the following circumstances: A languor,
listlessness, or want of resolution and activity
with respect to all undertakings; a disposition
to seriousness, sadness, and timidity; as to all
future events, an apprehension of the worst
or most unhappy state of them; and there-
fore, often upon slight grounds, an apprehen-
sion of great evil. Such persons are particu-
larly attentive to the state of their own health,
to every the smallest change of feeling in their
bodies; and from any unusual feeling, per-
haps of the slightest kind, they apprehend
great danger, and even death itself. In res-
pect to all these feelings and apprehensions,
there is commonly the most obstinate belief
and persuasion.
MCCXXIII.
This state of mind is the Hypochondriasis
of medical writers. See Linnæi Genera Mor-
borum, Gen. 76. et Sagari Systema Symp-
tomaticum, 

383 OF PHYSIC.
tomaticum, Class XIII. Gen. 5. The same
state of mind is what has been commonly call-
ed Vapours and Low Spirits. Though the
term Vapours may be founded on a false the-
ory, and therefore improper, I beg leave, for
a purpose that will immediately appear, to
employ it for a little here.
MCCXXIV.
Vapours, then, or the state of mind des-
cribed above, is, like every other state of mind,
connected with a certain state of the body,
which must be inquired into in order to its
being treated as a disease by the art of physic.
MCCXXV.
This state of the body, however, is not very
easily ascertained: For we can perceive, that
on different occasions it is very different; va-
pours being combined sometimes with dys-
pepsia, sometimes with hysteria, and some-
times with melancholia, which are diseases
seemingly depending on very different states
of the body.
MCCXXVI.
The combination of vapours with dyspep-
sia is very frequent, and in seemingly very
different circumstances. It is, especially,
these different circumstances that I would
wish to ascertain; and I remark, that they are
manifestly of two different kinds. First, as
the disease occurs in young persons of both
R6 sexes, 

384 PRACTICE
sexes, in persons of a sanguine temperament,
and of a lax and flaccid habit. Secondly, as
it occurs in elderly persons of both sexes, of
a melancholic temperament, and of a firm
and rigid habit.
MCCXXVII.
These two different cases of the combina-
tion of vapours and dyspepsia, I consider as
two distinct diseases, to be distinguished chief-
ly by the temperament prevailing in the per-
sons affected.
As the dyspepsia of sanguine temperaments
is often without vapours; and as the vapours,
when joined with dyspepsia in such tempera-
ments, may be considered as, perhaps, always
a symptom of the affection of the stomach;
so to this combination of dyspepsia and va-
pours, I would still apply the appellation of
Dyspepsia, and consider it as strictly the dis-
ease treated of in the preceding chapter.
But the combination of dyspepsia and va-
pours in melancholic temperaments, as the
vapours or the turn of mind peculiar to the
temperament, nearly that described above in
MCCXXII, are essential circumstances of the
disease; and as this turn of mind is often with
few, or only slight symptoms of dyspepsia;
and, even though the latter be attending, as
they seem to be rather the effects of the gen-
eral temperament, than of any primary or
topical affection of the stomach; I consider
this combination as a very different disease
from 

385 OF PHYSIC.
from the former, and would apply to it strict-
ly the appellation of Hypochondriasis.
MCCXXVIII.
Having thus pointed out a distinction be-
tween Dyspepsia and Hypochondriasis, I shall
now, using these terms in the strict sense above
mentioned, make some observations which
may, I think, illustrate the subject, and more
clearly and fully establish the distinction pro-
posed.
MCCXXIX.
The dyspepsia often appears early in life,
and is frequently much mended as life ad-
vances: But the hypochondriasis seldom ap-
pears early in life, and more usually in more
advanced years only; and more certainly still,
when it has once taken place, it goes on in-
creasing as life advances to old age.
This seems to be particularly well illustrat-
ed, by our observing the changes in the state
of the mind which usually take place in the
course of life. In youth, the mind is cheer-
ful, active, rash, and moveable: But as life
advances, the mind by degrees becomes more
serious, slow, cautious, and steady; till at
length, in old age, the gloomy, timid, distrust-
ful, and obstinate state of melancholic temper-
aments, is more exquisitely formed. In pro-
ducing these changes, it is true, that moral
causes have a share; but it is at the same time
obvious, that the temperament of the body
determines the operation of these moral caus-
es, 

386 PRACTICE
es, sooner or later, and in a greater or lesser
degree, to have their effects. The sanguine
temperament retains longer the character of
youth, while the melancholic temperament
brings on more early the manners of old age.
MCCXXX.
Upon the whole, it appears, that the state of
the mind which attends, and especially distin-
guishes hypochondriasis, is the effect of that
same rigidity of the solids, torpor of the ner-
vous power, and peculiar balance between the
arterial and venous systems which occur in
advanced life, and which at all times take
place more or less in melancholic tempera-
ments. If therefore there be also somewhat
of a like state of mind attending the dyspep-
sia which occurs early in life in sanguine tem-
peraments and lax habits, it must depend up-
on a different state of the body, and probably
upon a weak and moveable state of the ner-
vous power.
MCCXXXI.
Agreeable to all this, in dyspepsia, there is
more of spasmodic affection, and the affection
of the mind (MCCXXII) is often absent, and,
when present, is perhaps always of a slighter
kind: While, in hypochondriasis, the affec-
tion of the mind is more constant, and the
symptoms of dyspepsia, or the affections of
the stomach, are often absent, or, when pres-
ent, are in a slighter degree.
I believe 

387 OF PHYSIC.
I believe the affection of the mind is com-
monly different in the two diseases. In dys-
pepsia, it is often languor and timidity only,
easily dispelled; while in hypochondriasis, it
is generally the gloomy and rivetted appre-
hension of evil.
The two diseases are also distinguished by
some other circumstances. Dyspepsia, as I
have said, is often a symptomatic affection;
while hypochondriasis is, perhaps, always a
primary and idiopathic disease.
As debility may be induced by many dif-
ferent causes, dyspepsia is a frequent disease;
while hypochondriasis, depending upon a pe-
culiar temperament, is more rare.
MCCXXXII.
Having thus endeavoured to distinguish the
two diseases, I suppose the peculiar nature and
proximate cause of hypochondriasis will be
understood; and I proceed therefore to treat
of its cure.
So far as the affections of the body, and par-
ticularly of the stomach, are the same here as
in the case of dyspepsia, the method of cure
might be supposed to be also the same; and
accordingly the practice has been carried on
with little distinction: But I am persuaded
that a distinction is often necessary.
MCCXXXIII.
There may be a foundation here for the
same preservative indication as first laid down
in 

388 PRACTICE
in the cure of dyspepsia (MCCII); but I can-
not treat this subject so clearly or fully as I
could wish, because I have not yet had so
much opportunity of observation as I think
necessary to ascertain the remote causes; and
I can hardly make use of the observations of
others, who have seldom or never distinguish-
ed between the two diseases. What, indeed,
has been said with respect to the remote caus-
es of melancholia, will often apply to the hy-
pochondriasis, which I now treat of; but the
subject of the former has been so much in-
volved in a doubtful theory, that I find it dif-
ficult to select the facts that might properly
and strictly apply to the latter. I delay this
subject, therefore, till another occasion; but
in the mean time trust, that what I have said
regarding the nature of the disease, and some
remarks I shall have occasion to offer in con-
sidering the method of cure, may in some
measure supply my deficiency on this subject
of the remote causes.
MCCXXXIV.
The second indication laid down in the cure
of dyspepsia (MCCI) has properly a place
here; but it is still to be executed with some
distinction.
MCCXXXV.
An anorexia, and accumulation of crudities
in the stomach, does not so commonly occur
in hypochondriasis as in dyspepsia; and there-
fore vomiting (MCCIV) is not so often nec-
essary in the former as in the latter.
MCCXXXVI. 

389 OF PHYSIC.
MCCXXXVI.
The symptom of excess of acidity, from the
flow evacuation of the stomach in melanchol-
ic temperaments, often arises to a very high
degree in hypochondriasis; and therefore, for
the same reason as in MCCV, it is to be ob-
viated and corrected with the utmost care.
It is upon this account that the several an-
tacids, and the other means of obviating acid-
ity, are to be employed in hypochondriasis,
and with the same attentions and considera-
tions as in MCCVI, and following; with this
reflection, however, that the exciting the ac-
tion of the stomach there mentioned, is to be
a little differently understood, as shall be here-
after explained.
MCCXXXVII.
As costiveness, and that commonly to a
considerable degree, is a very constant attend-
ant of hypochondriasis, so it is equally hurt-
ful as in dyspepsia. It may be remedied by
the same means in the former as in the latter,
and they are to be employed with the same
restrictions as in MCCX.
MCCXXXVIII.
It is especially with respect to the third in-
dication laid down in the cure of dyspepsia
(MCCI), that there is a difference of practice
to be observed in the cure of hypochondriasis;
and that often one directly opposite to that in
the case of dyspepsia, is to be followed.
MCCXXXIX. 

390 PRACTICE
MCCXXXIX.
In dyspepsia, the chief remedies are the to-
nic medicines, which to me seem neither nec-
essary nor safe in hypochondriasis; for in this
there is not a loss of tone, but a want of activ-
ity that is to be remedied.
Chalybeate mineral waters have commonly
been employed in hypochondriasis, and seem-
ingly with success. But this is probably to
be imputed to the amusement and exercise
usually accompanying the use of these waters,
rather than to the tonic power of the small
quantity of iron which they contain. Per-
haps the elementary water, by favouring the
excretions, may have a share in relieving the
disease.
MCCXL.
Cold bathing is often highly useful to the
dyspeptic, and, as a general stimulant, may
sometimes seem useful to the hypochondriac;
but it is not commonly so to the latter; while,
on the other hand, warm bathing, hurtful to
the dyspeptic, is often extremely useful to the
hypochondriac.
MCCXLI.
Another instance of a contrary practice
necessary in the two diseases, and illustrating
their respective natures, is, that the drinking
tea and coffee are always hurtful to the dys-
peptic, 

391 OF PHYSIC.
peptic, but is commonly extremely useful to
the hypochondriac.
MCCXLII.
Exercise, as it strengthens the system, and
thereby the stomach, and more especially, as,
by increasing the perspiration, it excites the
action of the stomach, it proves one of the
most useful remedies in dyspepsia; and fur-
ther, as, by increasing the perspiration, it ex-
cites the activity of the stomach, it likewise
proves an useful remedy in the hypochondri-
asis. However, in the latter case, as I shall
explain presently, it is still a more useful rem-
edy by its operation upon the mind than by
that upon the body. 
MCCXLIII.
It is now proper that we proceed to con-
sider the most important article of our prac- 
tice in this disease, and which is, to consider
the treatment of the mind; an affection of
which sometimes attends dyspepsia, but is al- 
ways the chief circumstance in hypochondria-
sis. What I am to suggest here, will apply
to both diseases; but it is the hypochondriasis
that I am to keep most constantly in view.
MCCXLIV.
The management of the mind, in hypo-
chondriacs, is often nice and difficult. The
firm 

392 PRACTICE
firm persuasion that generally prevails in such
patients, does not allow their feelings to be
treated as imaginary, nor their apprehension
of danger to be considered as groundless,
though the physician may be persuaded that
it is the case in both respects. Such patients,
therefore, are not to be treated either by rail-
lery or by reasoning.
It is said to be the manner of hypochon-
driacs to change often their physician; and
indeed they often do it consistently: For a
physician who does not admit the reality of
the disease, cannot be supposed to take much
pains to cure it, or to avert the danger of
which he entertains no apprehension.
If in any case the pious fraud of a placebo
be allowable, it seems to be in treating hypo-
chondriacs; who, anxious for relief, are fond
of medicines, and, though often disappointed,
will still take every new drug that can be pro-
posed to them.
MCCXLV.
As it is the nature of man to indulge every
present emotion, so the hypochondriac cher-
ishes his fears, and, attentive to every feeling,
finds in trifles light as air a strong confirma-
tion of his apprehensions. His cure there-
fore depends especially upon the interrup-
tion of his attention, or upon its being di-
verted to other objects than his own feel-
ings.
MCCXLVI.

393 OF PHYSIC.
MCCXLVI. 
Whatever aversion to application of any
kind may appear in hypochondriacs, there is
nothing more pernicious to them than abso-
lute idleness, or a vacancy from all earnest
pursuit. It is owing to wealth admitting of
indolence, and leading to the pursuit of tran-
sitory and unsatisfying amusements, or to
that of exhausting pleasures only, that the
present times exhibit to us so many instances
of hypochondriacism.
The occupations of business suitable to
their circumstances and situation in life, if
neither attended with emotion, anxiety, nor
fatigue, are always to be admitted, and per-
sisted in by hypochondriacs. But occupa-
tions upon which a man's fortune depends,
and which are always therefore, objects of
anxiety to melancholic men; and more par-
ticularly where such occupations are exposed
to accidental interruptions, disappointments,
and failures, it is from these that the hypo-
chondriac is certainly to be withdrawn.
MCCXLVII.
The hypochondriac who is not necessarily,
by circumstances or habits, engaged in busi-
ness, is to be drawn from his attention to his
own feelings by some amusement.
The various kinds of sport and hunting, as
pursued with some ardor, and attended with
exercise,

394 PRACTICE
exercise, if not too violent, are amongst the
most useful.
All those amusements which are in the
open air, joined with moderate exercise, and
requiring some dexterity, are generally of use.
Within doors, company which engages at-
tention, which is willingly yielded to, and is
at the same time of a cheerful kind, will be
always found of great service.
Play, in which some skill is required, and
where the stake is not an object of much
anxiety, if not too long protracted, may often
be admitted.
In dyspeptics, however, gaming, liable to
sudden and considerable emotions, is danger-
ous; and the long continuance of it, with
night watching, is violently debilitating. But
in melancholics, who commonly excel in skill,
and are less susceptible of violent emotions,
it is more admissible, and is often the only
amusement that can engage them.
Music, to a nice ear, is a hazardous amuse-
ment, as long attention to it is very fatiguing.
MCCXLVIII.
It frequently happens, that amusements of
every kind are rejected by hypochondriacs;
and in that case, mechanical means of inter-
rupting thought are the remedies to be sought
for.
Such is to be found in brisk exercise, which
requires some attention in the conduct of it.
Walking 

395 OF PHYSIC.
Walking is seldom of this kind; though, as
gratifying to the restlessness of hypochondri-
acs, it has sometimes been found useful.
The required interruption of thought is
best obtained by riding on horseback, or in
driving a carriage of any kind.
The exercise of sailing, except it be in an
open boat, engaging some attention, does very
little service.
Exercise in an easy carriage, in the direction
of which the traveller takes no part, unless it
be upon rough roads, or driven pretty quick-
ly, and with long continuance, is of little ad-
vantage.
MCCXLIX.
Whatever exercise may be employed, it
will be most effectual when employed in the
pursuit of a journey; first, because it with-
draws a person from many objects of uneasi-
ness and care which might present themselves
at home; secondly, as it engages in more con-
stant exercise, and in a greater degree of it
than is commonly taken in airings about
home; and, lastly, as it is constantly present-
ing new objects which call forth a person's
attention.
MCCL.
In our system of Nosology we have next
to Hypochondriasis, placed the Chlorosis, be- 
cause

396 PRACTICE
cause I once thought it might be considered
as a genus, comprehending, besides the Chlo-
rosis of Amenorrhœa, some species of Ca-
chexy: But, as I cannot find this to be well
founded, and cannot distinctly point out any
such disease, I now omit considering Chloro-
sis as a genus here; and, as a symptom of
Amenorrhœa, I have endeavoured before to
explain it under that title.
END
OF VOL. II.
PRINTED AT WORCESTER, BY ISAIAH THOMAS,
MDCCXC.