FIRST LINES
OF THE
PRACTICE OF PHYSIC.
BY
WILLIAM CULLEN, M.D.
LATE PROFESSOR OF THE PRACTICE OF PHYSIC IN THE
UNIVERSITY OF EDINBURGH, &c. &c.
IN TWO VOLUMES.
With Practical and Explanatory Notes, by
JOHN ROTHERAM, M. D.
VOLUME I.
PHILADELPHIA:
PRINTED AND SOLD BY PARRY HALL, NO. 149, CHESNUT STREET,
BETWEEN FOURTH AND FIFTH STREETS. 
M. DCC. XCII.



CONTENTS.
Page.
PREFACE— ix
INTRODUCTION—33
PART I.
OF PYREXIÆ, OR FEBRILE DISEASES 37
BOOK I.
OF FEVERS—38
CHAPTER I.
Of the Phenomena of FEVERS—38
CHAP. II.
Of the Proximate Cause of FEVER—47
CHAP. III.
Of the Difference of FEVERS, and its Causes 59
CHAP. IV.
Of the Remote Causes of FEVER—68
CHAP. V.
Of the Prognosis of FEVERS—80
CHAP. VI.
Of the Method of Cure in FEVERS—91
Sect. I. Of the Cure of Continued Fevers 91
Sect. II. Of the Cure of Intermittent Fevers 129
BOOK II.
OF INFLAMMATIONS, OR PHLEG—
MASIÆ—133
CHAP. I.
Of INFLAMMATION in general—133
Sect. I. Of the Phenomena of Inflammation 133
Sect. 

vi CONTENTS.
Page.
Sect. II. Of the Proximate Cause of Inflam—
mation—134
Sect. III. Of the Terminations of Inflam—
mation—141
Sect. IV. Of the Remote Causes of Inflam—
mation—147
Sect. V. Of the Cure of Inflammation 148
CHAP. II.
Of INFLAMMATION, more strictly Cutaneous 153
CHAP. III.
Of OPHTHALMIA, or Inflammation of the Eye 155
CHAP. IV.
Of PHRENSY, or Phrenitis—161
CHAP. V.
Of the QUINSY, or Cynanche—164
Sect. I. Of the Cynanche Tonsillaris 164
Sect. II. Of the Cynanche Maligna 167
Sect. III. Of the Cynanche Trachealis 170
Sect. IV. Of the Cynanche Pharyngœa 175
Sect. V. Of the Cynanche Parotidœa 176
CHAP. VI.
Of PNEUMONIC INFLAMMATION—177
CHAP. VII.
Of PERIPNEUMONIA NOTHA, or BASTARD Pe—
ripneumony—196
CHAP. VIII.
Of the GASTRITIS, or Inflammation of the Sto—
mach—201
CHAP. IX.
Of the ENTERITIS, or Inflammation of the In—
testines—208
CHAP. X.
Of the HEPATITIS, or Inflammation of the Liver 210
CHAP. 

vii CONTENTS.
Page.
CHAP. XI.
Of the NEPHRITIS, or Inflammation of the
Kidneys—215
CHAP. XII.
Of the RHEUMATISM—217
CHAP. XIII.
Of the TOOTHACH, or Odentalgia—230
CHAP. XIV.
Of the GOUT—237
BOOK III.
OF EXANTHEMATA, or ERUPTIVE
FEVERS—271
CHAP. I.
Of the SMALL POX—272
CHAP. II.
Of the CHICKEN POX—292
CHAP. III.
Of the MEASLES—293
CHAP. IV.
Of the SCARLET FEVER—299
CHAP. V.
Of the PLAGUE—305
Sect. I. Of the Phenomena of the Plague 305
Sect. II. Of the Prevention of the Plague 308
Sect. III. Of the Cure of the Plague 313
CHAP. VI.
Of ERYSIPELAS, or St. Anthony's Fire 315
CHAP. VII.
Of the MILIARY FEVER—321
CHAP. VIII.
Of the remaining EXANTHEMATA: URTICA—
RIA, PEMPHICUS, and APHTHA 329
BOOK

viii CONTENTS.
Page.
BOOK IV.
OF HEMORRHAGES—331
CHAP. I.
Of HEMORRHAGY in general—331
Sect. I. Of the Phenomena of Hemorrhagy 332
Sect. II. Of the Proximate Cause of Hemorrhagy 334
Sect. III. Of the Remote Causes of Hemorrhagy 349
Sect. IV. Of the Cure of Hemorrhagy 350
CHAP. II.
Of the EPISTAXIS, or Hemorrhagy of the Nose 360
CHAP. III.
Of the HEMOPTYSIS, or Hemorrhagy from the
Lungs—368
Sect. I. Of the Phenomena and Causes of He—
moptysis—368
Sect. II. Of the Cure of Hemoptysis 374
CHAP. IV.
Of the PHTHISIS PULMONAKIS, or Consumpti—
on of the Lungs—377
Sect. I. Of the Phenomena and Causes of the
Phthisis Pulmonalis—377
Sect. II. Of the Cure of Phthisis 398
CHAP. V.
Of the HEMORRHOIS, or of the Hemorrhoidal
Swelling and Flux—408
Sect. I. Of the Phenomena and Causes of the
Hemorrhois—408
Sect. II. Of the Cure of Hemorrhoidal Affec—
tions—416 

[ix]
PREFACE.
TO deliver a System of the Doctrines and Rules pro—
per for directing the Practice of Physic, is an under—
taking that appears to me to be attended with great difficulty;
and, after an experience of more than forty years in that
practice, as well as after much reading and reflection, it was
with great diffidence that I ever entered upon such a work.
It was, however, what seemed to be my duty as a Professor
that induced me to make the attempt; and I was engaged
in it by the same sentiments that the illustrious Dr. Boer—
haave has expressed in the following passage of the Preface
to his Institutions: Simul enim docendo admotus eram sensi,
propriorum cogitatorum explication docentem plus proficere,
quam si opus ab alio conscriptum interpretari suscipit. Sua
quippe optime intellgit, sua cuique quœ cœteris placent, unde
clarior sere doctrina, atque animata plerumque sequitur oratio.
Qui vero sensa alterius exponit, infelicius fœpenumero eadem
affequitur; quumque suo quisque sensu abundat, multa refu—
tanda frequenter invenit, unde gravem frustra laborem aggra—
vat, minusque incitata dictione utitur, It is well known,
that a Text—book is not only extremely useful, but necessary
to Students who are to hear Lectures; and from the same
considerations that moved Dr. Boerhaave, I also wished to
have one for myself; while at the same time, from some
peculiar circumstances in my situation, I had some additi—
onal inducements to undertake such a work.
BEFORE I was established as a Professor of the Practice
of Physic in this University, I had been employed in giving
Clinical Lectures in the Royal Infirmary; and upon that
occasion had delivered, what, in my own opinion, seemed
VOL. I. B most

X PREFACE.
most just with regard to both the nature and the cure of the
diseases of which I had occasion to treat. But I soon found,
that my doctrines were taken notice of, as new, and pecu—
liar to myself; and were accordingly severely criticised by
those who, having long before been trained up in the system
of Boerhaave, had continued to think that that system nei—
ther required any change, nor admitted of any amendment.
I found, at the same time, that my doctrines were frequent—
ly criticised by persons who either had not been informed
of them correctly, or who seemed not to understand them
fully; and therefore, as soon as I was employed to teach a
more complete system of the Practice of Physic, I judged
it necessary to publish a Text—book, not only for the benefit
of my hearers, but that I might also have an opportunity
of obtaining the opinion of the public more at large, and
thereby be enabled either to vindicate my doctrines, or be
taught to correct them. These were the motives for my
attempting the Volumes I formerly published; and now,
from many years experience of their utility to my hearers,
as well as from the favourable reception they have met with
from the public, I am induced to give a new edition of this
Work, not only, as I hope, more correct in many parts,
but also more complete and comprehensive in its general
extent.
AT the first publication of this Work, it was intended
chiefly for the use of those Gentlemen who attended my
Lectures: Although, even then, for the reasons I have
mentioned, it was rendered more full than Text—books com—
monly are; and, in the repeated Editions I have since had
occasion to give, I have been constantly endeavouring to
render it more full and comprehensive. In these respects,
I hope the present edition will appear to be rendered more
fit for general use, and better calculated to afford satisfac—
tion to all those who think they may still receive any in—
struction from reading on this subject.
WHILE I thus deliver my Work in its now more im—
proved state, with the hopes that it may be of use to others
as well as to those who hear my Lectures, I must at the same
time 

xi PREFACE.
time observe, that it presents a system which is in many re—
spects new; and therefore I apprehend it to be not only proper,
but necessary, that I should explain here upon what grounds,
and from what considerations, this has been attempted.
In the first place, I apprehend, that, in every branch of
science with respect to which new facts are daily acquired,
and these consequently giving occasion to new reflections,
which correct the principles formerly adopted, it is neces—
sary, from time to time, to reform and renew the whole
system, with all the additions and amendments which it has
received and is then capable of. That at present this is re—
quisite with regard to the Science of Medicine, will, I be—
lieve, readily occur to every person who at all thinks for
himself, and is acquainted with the Systems which have hi—
therto prevailed. While, therefore, I attempt this, I think
it may be allowable, and upon this occasion even proper,
that I should offer some remarks on the principal Systems of
Medicine which have of late prevailed in Europe, and that
I should take notice of the present state of Physic as it is in—
fluenced by these. Such remarks, I hope, may be of some
use to those who attempt to improve their knowledge by the
reading of books.
Whether the Practice of Physic should admit of rea—
soning, or be entirely rested upon experience, has long been,
and may still be, a matter of dispute. I shall not, however,
at present enter upon the discussion of this; because I can
venture to assert, that, at almost all times, the practice has
been, and still is, with every person, founded, more or less,
upon certain principles established by reasoning: And there—
fore, in attempting to offer some view of the present state of
Physic, I must give an account of those systems of the prin—
ciples of the science which have lately prevailed, or may be
supposed still to prevail, in Europe.
When, after many ages of darkness, which had destroy—
ed almost the whole of ancient literature, learning was again
restored in the fifteenth century; so, from causes which are
well known, it was the system of Galen alone that the Phy—
sicians 

xii PREFACE.
sicians of those days became acquainted with; and during the
course of the sixteenth century, the study of Physicians was
almost solely employed in explaining and confirming that
system. Early, indeed, in the sixteenth century, the noted
Paracelsus had laid the foundation of a Chemical System
which was in direct opposition to that of Galen; and, by the
efficacy of the medicines employed by Paracelsus and his fol—
lowers, their system came to be received by many: But the
systematic Physicians continued to be chiefly Galenists, and
kept possession of the Schools till the middle of the seven—
teenth century. It is not, however, necessary here to enter
into any further detail respecting the fate of those two op—
posite fects; for the only circumstance concerning them,
which I would wish at present to point out, is, that, in the
writings ot both, the explanations they severally attempted
to give of the phænomena of health or sickness turned en—
tirely upon the state of the fluids of the body.
SUCH was the state of the science of Physic till about the
middle of the seventeenth century, when the circulation of
the blood came to be generally known and admitted; and
when this, together with the discovery of the receptacle of
the chyle, and ot the thoracic duct, finally exploded the
Galenic system. About the same period, a considerable
revolution had taken place in the system of Natural Philoso—
phy. In the course of the seventeenth century, Galileo had
introduced mathematical reasoning; and Lord Bacon having
proposed the method of induction, had thereby excited a dis—
position to observe facts, and to make experiments. These
new modes of philosophizing, it might be supposed, would
soon have had some influence on the state of medicine; but
the progress of this was flow. The knowledge of the Circu—
lation did indeed necessarily lead to the consideration as well
as to a clearer view of the Organic System in animal bodies;
which again led to the application of the mechanical philoso—
phy towards explaining the phænomena of the animal eco—
nomy; and it was applied accordingly, and continued, till
very lately, to be the fashionable mode of reasoning on the
subject. Such reasoning, indeed, must still in several respects
continue to be applied: But it would be easy to show, that it
neither 

xiii PREFACE.
neither could, nor ever can be, applied to any great extent
in explaining the animal economy; and we must therefore
look for other circumstances which had a greater share in
modelling the system of Physic.
WITH this view it may be remarked, that, till the period
just now mentioned, every Physician, whether Galenist or
Chemist, had been so much accustomed to consider the state
and condition of the fluids, both as the cause of disease, and
as the foundation for explaining the operation of medicines,
that what we may term an HUMORAL PATHOLOGY still
continued to make a great part of every system. In these
circumstances, it was soon perceived, that chemistry pro—
mised a much better explanation than the Galenic or Aris—
totelian philosophy had done; and, therefore, while the
latter was entirely laid aside, a chemical reasoning was every
where received. Lord Bacon, with his usual sagacity, had
early observed, that chemistry promised a great number of
facts, and he thereby gave it credit; whilst the Corpuscula—
rian philosophy, restored by Gassendi, readily united with the
reasonings of the Chemists; and the philosophy of Des Car—
tes readily united with both. From all these circumstances,
an Humoral, and chiefly a Chemical Pathology, came to
prevail very much till the end of the last century; and has;
indeed, continued to have a great share in our systems down
to the present time.
IT is proper now, however, to observe, that about the be—
ginning of the present century, when every part of science
came to be on a more improved and correct footing, there
appeared in the writings of STAHL, of HOFFMAN, and of
BOERHAAVE, three new, and considerably different, Sys—
tems of Physic; which have ever since had a great share in
directing the practice of it. In order, therefore, to give a
nearer view of the present state of Physic, I shall offer some
remarks upon these different systems; endeavouring to point
out the advantages as well as the disadvantages of each, and
how far they still prevail; or, according to my judgment,
deserve to do so.
I SHALL 

xiv PREFACE.
I SHALL begin with considering that of Dr. Stahl, which
I think appeared first, and for a long time after was the pre—
vailing system in Germany.
The chief and leading principle of this system is, that the
rational soul of man governs the whole economy of his body.
At all times, Physicians have observed, that the animal eco—
nomy has in itself a power or condition, by which, in many
instances, it resists the injuries which threaten it; and by
which it also, on many occasions, corrects or removes the dis—
orders induced, or arising in it. This power, Physicians
very anciently attributed, under a vague idea, to an agent in
the system, which they called nature; and the language of
a vis conservatrix et medicatrix naturœ, has continued in the
schools of medicine from the most ancient times to the
present.
DR. Stahl has explicitly founded his system on the sup—
position, that the power of nature, so much talked of, is en—
tirely in the rational soul. He supposes, that, upon many
occasions, the soul acts independently of the state of the body;
and that, without any physical necessity arising from that
state, the foul, purely in consequence of its intelligence, per—
ceiving the tendency of noxious powers threatening, or of
disorders anywise arising in the system, immediately excites
such motions in the body as are suited to obviate the hurtful
or pernicious consequences which might otherwise take
place. Many of my readers may think it was hardly neces—
sary for me to take notice of a system founded upon so fan—
ciful a hypothesis; but there is often so much seeming ap—
pearance of intelligence and design in the operations of the
animal economy, that many eminent persons, as Perrault in
France, Nichols and Mead in England, Porterfield and Sim—
son in Scotland, and Gaubius in Holland, have verv much
countenanced the same opinion, and it is therefore certainly
entitled to some regard. It is not, however, necessary for
me here to enter into any refutation of it. Dr. Hoffman
has done this fully, in his Commentarius de differentia inter
Hoffmanni doctrinam medico—mechanicam et G. E. Stahlii
medico—organicam; and both Boerhaave and Haller, though
no 

xv PREFACE. 
no favourers of materialism, have maintained a doctrine
very opposite to that of Stahl.
In my Physiology I have offered some arguments against
the same; and I shall only add now, that whoever considers
what has been said by Dr. Nichols in his Oratio de Anima
Medica, and by Dr. Gaubius in some parts of his Pathology,
must perceive, that the admitting of such a capricious go—
vernment of the animal economy, as these authors in some
instances suppose, would at once lead us to reject all the
physical and mechanical reasoning we might employ con—
cerning the human body. Dr. Stahl himself seems to have
been aware of this; and therefore, in his Preface to Junck—
er's Conspectus Therapeia Specialis, has acknowledged, that
his general principle was not at all necessary; which is in
effect saying that it is not compatible with any system of
principles that ought to govern our practice. Upon this
footing, I might have at once rejected the Stahlian princi—
ple: But it is even dangerous to bring any such principle
into view; for, after all Dr. Stahl had said in the passage
just now referred to, I find, that, in the whole of their prac—
tice, both he and his followers have been very much go—
verned by their general principle. Trusting much to the
constant attention and wisdom of nature, they have propos—
ed the Art of curing by expectation; have therefore, for the
most part, proposed only very inert and frivolous remedies;
have zealously opposed the use of some of the most efficaci—
ous, such as opium and the Peruvian bark; and are ex—
tremely reserved in the use of general remedies, such as
bleeding, vomiting, &c.
Although these remarks, upon a system which may
now be considered as exploded or neglected, may seem su—
perfluous; I have been willing to give these strictures on
the Stahlian system, that I might carry my remarks a little
farther, and take this opportunity of observing, that, in
whatever manner we may explain what have been called the
operations of nature, it appears to me, that the general doc—
trine of Nature curing diseases, the so much vaunted Hippo—
cratic method of curing, has often had a very baneful in—
fluence

xvi PREFACE.
fluence on the practice of physic; as either leading physi—
cians into, or continuing them in, a weak and feeble prac—
tice; and at the same time superseding or discouraging all
the attempts of art. Dr. Huxham has properly observed,
that even in the hands of Sydenham it had this effect. Al—
though it may sometimes avoid the mischiefs of bold and rash
practitioners, yet it certainly produces that caution and timi—
dity which have ever opposed the introduction of new and
efficacious remedies. The opposition to chemical medicines
in the sixteenth and seventeenth centuries, and the noted con—
demnation of Antimony by the Medical Faculty of Paris, are
to be attributed chiefly to those prejudices, which the phy—
sicians of France did not entirely get the better of for near a
hundred years after. We may take notice of the reserve it
produced in Boerhaave, with respect to the use of the Peru—
vian bark. We have had lately published, under the title of
Constitutiones Epidemics, notes of the particular practice of
the late Baron Van Swieten; upon which the editor very
properly observes, That the use of the bark, in intermitting
fevers, appears very rarely in that practice; and we know
very well where Van Swieten learned that reserve.
I might go farther, and show how much the attention
to the Autocrateia, allowed of, in one shape or other, by
every sect, has corrupted the practice among all physicians,
from Hippocrates to Stahl. It must, however, be sufficient—
ly obvious, and I shall conclude the subject with observing,
that although the vis medicatrix natures must unavoidably
be received as a fact; yet, wherever it is admitted, it throws
an obscurity upon our system: and it is only where the im—
potence of our art is very manifest and considerable, that
we ought to admit of it in practice.
To finish our remarks upon the Stahlian System I shall
shortly observe, that it did not depend entirely upon the Au—
tocrateia, but also supposed a state of the body and diseases
that admitted of remedies; which, under the power and di—
rection of the soul, acted upon the organization and matter
of the body, so as to cure its diseases. Upon this footing
the Stahlian pathology turned entirely upon Plethora and
Cacochymy. 

xvii PREFACE.
Cacochymy. It was with respect to the former that they
especially applied their doctrine of the Autocrateia in a very
fanatical manner; and, with respect to the latter, they have
been involved in a humoral pathology as much as the syste—
matic physicians who had gone before them, and with a the—
ory so incorrect as not to merit now the smallest attention.
After all, I ought not to dismiss the consideration of the
Stahlian system, without remarking, that as the followers
of this system were very intent upon observing the method
of nature, so they were very attentive in observing the
phenomena of diseases, and have given us in their writings
many facts not to be found elsewhere.
WHILE the doctrines of Stahl were prevailing in the uni—
versity of Halle, Dr. Hoffman, a professor in the same uni—
verfity, proposed a system that was very different. He re—
ceived into his system a great deal of the mechanical, Car—
tesian, and chemical doctrines of the systems which had ap—
peared before: But, with respect; to these, it is of no con—
sequence to observe in what manner he modified the doctrines
of his predecessors, as his improvements in these respects
were no ways considerable, and no part of them now re—
main; and the real value of his works, beyond what I am
just now going to mention, rests entirely on the many facts
they contain. The merit of Dr. Hoffman and of his works
is, that he made, or rather suggested, an addition to the
system, which highly deserves our attention. Of this I can—
not give a clearer account than by giving it in the authors
own words. In his Medicina Rationalis Systematica, Tom.
III. § 1. cap. 4. he has given his Genealogia morborum ex
turbato solidorum et fluidorum mechanisno; and in the 47th
and last paragraph of this chapter, he sums up his doctrine
in the following words: Ex hisce autem omnibus uberius
hactenus excussis, per quam dilucide apparere arbitror, quod
folus SPASMUS et simplex ANONIA, aquabilem, liberum, ac
proportionatum sanguinis omnisque generis fluidorum motum,
quibus excretionum successus et integritas functionum animi et
corporis proxime nititur, turlando ac pervertendo, universam
vitalem œconomiam subruant ac destruant; atque hinc univer—
sa pathologia longe rectius atque facilius EX VITIO MO—
VOL. I. C TUUM 

xviii PREFACE.
TUUM MICROCOSMICORUM IN SOLIDIS, quam EX VA—
RIIS AFFECTIONIBUS VITIOSORUM HUMORUM, de—
duci atque explicari possit, adeoque omnis generis œgritudines
internœ, ad PRÆTERNATURALES GENERIS NERVOSI
AFFECTIONES fint referendœ. Etenim lœsis quocunque modo,
vel nervis per corpus discurrenlibus, vel membranosis quibusvis
nervosis partibus, illico motuum anomaliœ, modo leviores, modo
graviores subsequuntur. Deinde attenta observatio docet, motus
quosvis morbosos principaliter sedem figere et tyrannidem ex—
ercere in nervosis corporis partibus, cujus generis prœter om—
nes canales, qui systaltico et diastaltico motu pollentes, conten—
tos succos tradunt, universum nimirum intestinorum et ventri—
culi ab œsophago ad anum canalem, totum systema vasorum ar—
teriosorum, ductuum biliariorum, salivalium, urinariorum et
subcutaneorum, sunt quoque membranœ nerveo—musculares cere—
bri et medullœ spinalis, prœsertim hœc, quœ dura mater vo—
catur, organis sensoriis obductœ, nec non tunicœ iliœ ac liga—
menta, quœ ossa cingunt artusque firmant. Nam nullus dolor,
nulla inflammatio, nullus spasmus, nulla motus et sensus im—
potentia, nulla febris aut humoris illius excretio, accidit, in
qua non hœ partes patiantur. Porro etiam omnes, quœ mor—
bos gignunt causœ, operationem suam potissimam perficiunt in
partes motu et sensu prœditas, et canales ex his coagmentatos,
eorum motum, et cum hoc fluidorum cursum, pervertendo; ita
tamen, ut ficuti variœ indolis sunt, sic etiam varie in nerveas
partes agant, iisdemque noxam affiricent. Demum omnia quo—
que eximiœ virtutis medicamenta, non tarn in partes fluidas,
earum crasin ac intemperiem corrigendo, quam potius in soil—
das et nervosas, earundem motus alterando ac moderando,
suam edunt operationem: De quibus tamen omnibus, in vul—
gari usque eo recepta morborum doctrina, altum est silentium.
IT is true that Dr. Willis had laid a foundation for this
doctrine, in his Pathologia Cerebri et Nervorum; and Bagli—
vi had proposed a system of this kind in his Specimen de fibra
motrici et morbosa. But, in these writers, it was either not
extensively applied to diseases, or was still so involved in ma—
ny physiological errors, that they had attracted little atten—
tion; and Dr. Hoffman was the first who gave any tolerably
simple 

xix PREFACE.
simple and clear system on the subject, or pointed out any
extensive application of it to the explanation of diseases.
THERE can be no fort of doubt that the phenomena of
the animal economy in health and in sickness, can only be ex—
plained by considering the state and affections of the primary
moving powers in it. It is to me surprising that Physicians
were so long in perceiving this, and I think we are therefore
particularly indebted to Dr. Hoffman for putting us into the
proper train of investigation; and it every day appears that
Physicians perceive the necessity of entering more and more
into this inquiry. It was this, I think, which engaged Dr.
Kaaw Boerhave to publish his work intitled Impetum faci—
ens; as well as Dr. Gaubius to give the Pathology of the So—
lidum vivum. Even the Baron Van Swieten has upon the same
view thought it necessary, in at least one particular, to make
a very considerable change in the doctrine of his master, as
he has done in his Commentary upon the 755th Aphorism.
Dr. Haller has advanced this part of science very much by
his experiments on irritability and sensibility. In these and
in many other instances, particularly in the writings of Mr.
Barthez of Montpelier, of some progress in the study of the
affections of the Nervous System, we must perceive how
much we are indebted to Dr. Hoffman for his so properly
beginning it. The subject, however, is difficult: The laws
of the Nervous System, in the various circumstances of the
animal economy, are by no means ascertained; and, from
want of attention and observation with the view to a sys—
tem on this subject, the business appears to many as an inex—
plicable mystery. There is no wonder, therefore, that, on
such a difficult subject, Dr. Hoffman's system was imperfect
and incorrect; and has had less influence on the writings
and practice of Physicians since his time, than might have
been expected. He himself has not applied his fundament—
al doctrine so extensively as he might have done; and he
has every where intermixed an Humoral Pathology as in—
correct and hypothetical as any other. Though he differed
from his colleague Dr. Stahl in the fundamental doctrines
of his system, it is but too evident that he was very much
infected with the Stahlian doctrines of Plethora and Caco—
chymy, 

xx PREFACE.
chymy, as may be observed throughout the whole course of
his work; and particularly in his chapter De morborum
generatione ex nimia sanguinis quantitate et humorum impu—
ritate.
BUT it is needless for me to dwell any longer upon the
system of Hoffman; and I am next to offer some remarks
on the system of Dr. Boerhaave the cotemporary of both the
other Systematics, and who, over all Europe, and especi—
ally in this part of the world, gained higher reputation than
either of the others.
Dr. BOERHAVVE was a man of general erudition; and,
in applying to medicine, he had carefully studied the auxili—
ary branches of Anatomy, Chemistry, and Botany, so that
he excelled in each. In forming a System of Physic, he
seems to have studied diligently all the several writings of
both ancient and modem Physicians; and, without prejudice
in favour of any former systems, he endeavoured to be a can—
did and genuine ecclectic. Possessed of an excellent syste—
matic genius, he gave a system superior to any that had
ever before appeared. As in the great extent, and seem—
ingly perfect consistency, of system, he appeared to im—
prove and refine upon every thing that had before been of—
fered; and as in his Lectures he explained his doctrines
with great clearness and elegance; he soon acquired a very
high reputation, and his system was more generally receiv—
ed than any former had been since the time of Galen. Whoe—
ver will consider the merits of Dr. Boerhaave, and can com—
pare his system with that of former writers, must acknow—
ledge that he was very justly esteemed, and gave a system
which was at that time deservedly valued.
BUT, in the progress of an inquisitive and industrious age,
it was not to be expected that any system should last so long
as Boerhaave's has done. The elaborate Commentary of
Van Swieten on Boerhaave's system of practice, has been
only finished a few years ago; and though this Commen—
tator has added many facts, and made some corrections, he
has not, except in the particular mentioned above, made any
improvement 

xxi PREFACE.
improvement in the general system. It is even surprising
that Boerhaave himself, though he lived near forty years
after he had first formed his system, had hardly in all that
time made any corrections of it or additions to it; the fol—
lowing is the most remarkable. In Aphorism 755, the words
forte et nervosi, tarn cerebri quam cerebelli cordi destinali iner—
tia, did not appear in any edition before the fourth; and
what a difference of system this points at, every physician
must perceive.
WHEN I first applied to the study of Physic, I learned
only the system of Boerhaave; and even when I came to
take a professor's chair in this university, I found that sys—
tem here in its entire and full force; and as I believe it
still subsists in credit elsewhere, and that no other system of
reputation has been yet offered to the world, I think it
necessary for me to point out particularly the imperfec—
tions and deficiencies of the Boerhaavian system, in order
to show the propriety and necessity of attempting a new
one.
To execute this, however, so fully as I might, would
lead me into a detail that can hardly, be admitted of here;
and I hope it is not necessary, as I think, that every intel—
ligent person, who has acquired any tolerable knowledge of
the present state of our science, must in many instances, per—
ceive its imperfections. I shall therefore touch only upon
the great lines of this system; and from the remarks I am
to offer, trust that both the mistakes and deficiencies which
run through the whole of his works will appear.
Dr. Boerhaave's treatise of the diseases of the simple
solid, has the appearance of being very clear and consistent,
and was certainly considered by him as a fundamental doc—
trine; but, in my apprehension, it is neither correct nor
extensively applicable. Not to mention the useless, and
perhaps erroneous, notion of the composition of earth and
gluten; nor his mistake respecting the structure of compound
membranes; nor his in attention to the state of the cellular
texture; all of their; circumstances which render his doc—
trine 

xxii PREFACE.
trine imperfect; I shall insist only upon the whole bring ve—
ry little applicable to the explaining the phenomena of health
or sickness. The laxity or rigidity of the simple solid, does,
indeed, take place at the different periods of life, and may
perhaps, upon other occasions, occur as the cause of dis—
ease: But I presume, that the state of the simple solid is,
upon few occasions, either changeable or actually changed;
and that, in ninety—nine cases of an hundred, the phenome—
na attributed to such a change, do truly depend on the state
of the solidum vivum; a circumstance which Dr. Boerhaave
has hardly taken notice of in any part of his works. How
much this shows the deficiency and imperfection of his sys—
tem, I need not explain. The learned work of Dr. Gaubi—
us, above referred to, as well as many other treatises of late
authors, point out sufficiently the defects and imperfections
of Boerhaave on this subject.
AFTER Dr. Boerhaave has considered the diseases of the
solids, he in the next place attempts to explain the more
simple diseases of the fluids; and there, indeed, he delivers
a more correct doctrine of acid and alkali than had been
given before: But, after all, he has done it very imperfec—
ly. We have, indeed, since his time, acquired more know—
ledge upon the subject of digestion; and so much as to know,
that a great deal more is yet necessary to enable us to under—
stand in what manner the animal fluids are formed from the
aliments taken in. And although Dr. Boerhaave has fallen
into no considerable error with respect to a morbid acidity
in the stomach, he could not possibly be complete upon that
subject; and his notion of the effects of acidity in the mass
of blood seems to have been entirely mistaken, and is indeed
not consistent with what he himself has delivered elsewhere.
HIS doctrine of alkali is somewhat better founded, but
is probably carried too far; and the state of alkalescency and
putrefaction, as well as all the other changes which can take
place in the condition of animal fluids, are particulars yet
involved in great obscurity, and are therefore still subjects
of dispute. 
THERE

xxiii PREFACE.
THERE is another particular, in which Boerhaave's doc—
trine concerning the fluids appears to me imperfect and un—
satisfactory; and that is, in his doctrine de Glutinoso sponta—
neo. The causes which he has assigned for it are by no
means probable, and the actual existence of it is seldom to
be proved. Some of the proofs adduced for the existence
of the phlegma calidum, are manifestly founded on a mistake
with respect to what has been called the inflammatory crust,
(see Van Swieten's Commentary, page 96;) and the many
examples given by Boerhaave of a glutinosum appearing in
the human body, (Aph. 75.) are all of them nothing more
than instances of collections or concretions found out of the
course of the circulation.
If, then, we consider the imperfection of Dr. Boer—
haave's doctrine with respect to the state and various condi—
tion of the animal fluids; and if at the same time we reflect
how frequently he and his followers have employed the sup—
position of an acrimony or lentor of the fluids, as causes of
disease, and for directing the practice; we must, as I appre—
hend, be satisfied, that his system is not only deficient and
incomplete, but fallacious and apt to mislead. Although it
cannot be denied, that the fluids of the human body suffer va—
rious morbid changes; and that upon these, diseases may
primarily depend; yet I must beg leave to maintain, that
the nature of these changes is seldom understood, and more
seldom still is it known when they have taken place: That
our reasonings concerning them, have been, for the most
part, purely hypothetical; have therefore contributed no—
thing to improve, and have often misled the practice of phy—
sic. In this, particularly, they have been hurtful, that they
have withdrawn our attention from, and prevented our study
of, the motions of the animal system, upon the state of which
the phenomena of diseases do more certainly and generally
depend. Whoever, then, shall consider the almost total ne—
glect of the state of the moving powers of the animal body,
and the prevalence of an hypothetical humoral pathology,
so conspicuous in every part of the Boerhaavian System,
must be convinced of its very great defects, and perceive the
necessity of attempting one more correct.
AFTER 

xxiv PREFACE.
AFTER giving this general view, it is not requisite to
enter into particulars: But, I believe, there are very few
pages of his aphorisms in which there does not occur some
error or defect; although, perhaps not to be imputed to the
fault of Boerhaave, so much as to this, that since his time
a great collection of new facts has been acquired by observa—
tion and experiment. This indeed, affords the best and most
solid reason for attempting a new system: For when many
new facts have been acquired, it becomes requisite that these
should be incorporated into a system, whereby not only
particular subjects may be improved, but the whole may be
rendereal more complete, consistent, and useful. Every sys—
tern, indeed, must be valuable in proportion to the number
of facts that it embraces and comprehends; and Mons.
Ouesney could not pay a higher compliment to the System
of Boerhaave, than by saying that it exhibited La medicine
collective.
But 'here it will, perhaps be suggested to me, that the
only useful work on the subject of Physic, is the making a
collection of all the facts that relate to the art, and therefore
of all that experience has taught us with respect to the cure
of diseases. I agree entirely in the opinion; hut doubt if
it can ever be properly accomplished, without aiming at
some system of principles, by a proper induction and gene—
ralisation of facts: at least I am persuaded that it can be
done not only very safely, but most usefully in this way.
This, however, must be determined by a trial. I know
that the late Mr. Lieutaud has attempted a work on the plan
of collecting facts without any reasoning concerning their
causes: And while I am endeavouring to give some account
of the present state of Physic, I cannot dismiss the subject
with out offering some remarks upon the promising Synopsis
universœ medicinœ, composed by the first physician of a learn—
ed and ingenious nation.
IN this work there are many facts and much observation
from the Author's own experience, which may be useful to
those who have otherwise acquired some knowledge and dis—
cernment; but, throughout the whole work, there is such
total 

xxv PREFACE. 
total want of method, arrangement, system, or decision,
that, in my humble opinion, it can be of little use, and may
prove very perplexing to those who are yet to learn. The
distinction of the genera of diseases, the distinction of the
species of each, and often even that of the varieties, I hold
to be a necessary foundation of every plan of Physic, whe—
ther Dogmatical or Empirical. But very little of this dis—
tinction is to be found in the work of Mr. Lieutaud; and
in his preface he tells us, that he meant to neglect such ar—
guta sedulitas. And indeed his method of managing his sub—
ject must certainly interrupt and retard all methodical noso—
logy. His arrangement of diseases is according to no affi—
nity, but that of the slightest and uninstructive kind, the
place of the body which they happen to affect. His Gene—
ralia et incertœ sedis, have hardly any connexion at all; the
titles Rheumatisms, Hypochondriasis, Hydrops, follow one a—
nother. When he does attempt any general doctrine, it is
not till long after he has treated of the widely scattered par—
ticulars. Under each particular title which he assumes, he
has endeavoured to enumerate the whole of the symptoms
that ever appeared in a disease under that title; and this with—
out aiming at any distinction between the essential and ac—
cidental symptoms, or marking the several combinations un—
der which these symptoms do for the most part steadily ap—
pear. From the concurrence of accidental symptoms,
the variety of the same disease is frequently considerable, a
circumstance necessarily perplexing and distracting to young
practitioners; but it seems strange to me, that an experience
of thirty years, in considerable practice, could do nothing
to relieve them.
MR. LIEUTAUD has at the same time increased the con—
fusion that must arise from this want of distinction, by his
considering as primary diseases, what appear to me to be the
symptoms, effects, and sequels, of other diseases only. Of
this I think the Æstus morbosus, Virum exolutio, Dolores,
Stagnatio sanguinis, Purulentia, Tremor, Pervigilium, Rau—
cedo, Suffocatio, Vomica, Empyema, Singultus, Vomitus Do—
lor Stomachi, Tenesmus, all treated of under separate titles,
are examples. A general symptomatologia may be a very
useful work, with a view to a System of Pathology; but,
VOL. I D with 

xxvi PREFACE.
with a view to practice without any System, it must have
bad effects, as leading only to a palliative practice, and di—
verting from the proper efforts towards obtaining a radical
cure. Mr. Lieutaud, indeed, has endeavoured to exhibit
the symptoms above mentioned as so many primary diseases:
but he has seldom succeeded in this; and in delivering the
practice, he commonly finds it necessary to consider them
as symptoms, and that not without some theory, implied
or expressed, with respect to their proximate causes. His
title of Dolores may be taken as an example of this; and
from which it may be readily perceived how far such trea—
tises can be really useful.
In establishing a proper pathology, there is nothing that
has been of more service than the Dissection of morbid bo—
dies. Mr. Lieutaud has been much and most commendably
employed in this way, and in this Synopsis he has endea—
voured to communicate his knowledge on the subject; but,
in my humble opinion, he has seldom done it in a manner
that can be useful. In the same way that he has delivered
the symptoms of diseases, without any instructive arrange—
ment; so, on the subject of the appearances after death,
he has mentioned every morbid appearance that had ever
been observed after the disease of which he is then treat—
ing; but these appearances are strangely huddled together,
without any notice taken of those which belong to one set
of symptoms, or to another; and with regard to the whole,
without any attempt to distinguish between the causes of
diseases and the causes of death; although the want of such
distinction is the well—known ground of fallacy upon this
subject. I take for an example, the appearances mention—
ed as having been observed after dropsy. Here morbid ap—
pearances, found in every part of the body, in every cavity
of it, and in every viscus contained in these cavities, are e—
numerated;  but which of these morbid states are more fre—
quent or more rare, and which had been more particular—
ly connected with the different causes, or with the different
state of symptoms previously recited, we are not informed,
nor has he enabled us to discover. In short, the dissection
of morbid bodies has been, and may be, highly useful; but
in order to be so, it must be under a different management
from

xxvii PREFACE.
from what we find, either in this Synopsis, or even in the
Historia Anatomico—medica.
I cannot dismiss this subject without remarking, that
the dissection of morbid bodies is chiefly valuable upon ac—
count of its leading us to discover the proximate causes of
diseases; and the great and valuable work of the illustrious
Morgagni is properly entitled De sedibus et CAUSIS. It
may well seem surprising, then, that Lieutaud should find
the whole of proximate causes atra caligine mersas; and
that he should never have thought of applying his dissecti—
on towards the ascertaining at least some of these.
But let me now proceed to consider the important part
of every practical work, and of this Synopsis universœ me—
dicinœ; that is, the method of curing diseases.
HERE, again, upon the same plan as in giving the his—
tories of disease, the method of cure is delivered by enume—
rating the whole of the remedies that have ever been em—
ployed in a disease under the title prefixed; without assign—
ing the species, or the circumstances to which the remedies,
though of a very different, and sometimes opposite nature,
are peculiarly adapted. On the subject of Asthma, he very
justly observes, that physicians have been to blame in con—
founding, under this title, almost all the species of Dys—
pnœa; and he himself very properly considers Asthma as a
disease distina from all the other cases of Dyspnœa. Still,
however, he considers Asthma as of many different species
arising from many different causes, which, till we under—
stand better, we cannot attempt to remove. Notwithstand—
ing all this, he proceeds to deliver a very general cure.
Parum abest, says he, quin speafici litulo gaudeant pectora—
lia, vulneraria, et incidentia! But from such language  I re—
ceive no clear idea; nor can I obtain any clear direction
from the enumeration of his medicines. Baccœ juniperi,
gummi tragacanthum vel ammoniacum, sapo, aqua picea, te—
rebinthina, &c. quœ tamen haud indiscriminatim sunt usurp—
anda, sed pro re nata, delectu opus est. Very justly indeed,
deletu opus est; but here, as in many other instances, he
gives us no fort of assistance.
FROM 

xxviii PREFACE.
FROM his endeavours, though not always successful, to
neglect all system, his practice is generally delivered in a 
very indecisive manner; or, what has the same effect, in a
way so conditional as will render it always difficult, and
often impossible, for a young practitioner to follow him.
Let us take, for example, his cure of Dropsy. “ The cure
“ may be begun by bloodletting in certain conditions; but,
“ in others, it cannot be employed without danger. It gives
“  relief in difficult breathing; but, after it is practised, the
“  symptoms are aggravated, and rendered more obstinate. It
“  is not to be concealed that some persons have been cured
“  by repeated bloodlettings, or spontaneous hæmorrhagies;
“  but it is at the same time known, that such a remedy in—
“  opportunely employed, has in many instances hastened on the
“ fatal event.”
IN the same manner he treats of vomiting, purging,
sweating, and the use of mineral waters; but I must con—
fess, that he has no where removed any of my doubts or
difficulties, and indeed he has sometimes increased them.
He says, that hepatics, or aperients, such as the lingua cer—
vina, herbœ capillares, &c. deserve commendation; but
that, when the disease has arisen to a certain degree, they
have been, for the most part, found to be useless. He ob—
serves, that the powder of toads given in wine, to the quan—
tity of a scruple or more, has succeeded with severals.
SUCH are, commonly, the methods of cure delivered by
Mr. Lieutaud, longiori et forte selicissima praxi edoctus.
IT would be tedious to enter further into that detail,
which a criticism of this unmethodical and uninstructive
work might lead me into; but, if the bounds proper for
this preface did not prevent me, I would particularly show
that the work is far from being free from those reasonings
which the author pretends to avoid, and would affect even
to despise. He still holds the doctrines of the CONCOC— 
TION and CRITICAL EVACUATION of MORBIFIC MAT—
TER; doctrines depending upon subtile theories, and which,
in my opinion, can in nowise be ascertained as matters of
fact. Mr. Lieutaud likewise is still very much upon the
old 

xxix PREFACE. 
old plan of following NATURE, and therefore gives often 
what I consider as a feeble and inert practice. The hu—
mectantia, diluentia, demulcentia, et temperantia, are with
him vety universal remedies, and often those which alone
are to be employed.
THE mention of these medicines might lead me to take
notice of Mr. Lieutaud's second volume, in which, ab in—
sula remediorum sarragine alienus, he promises a great re—
formation upon the subject; but this falls so far short of the
idea of British physicians, that I need not make any remarks
upon it. With respect to his list of simples, or Emporetica,
as he is pleased to term them, an English apothecary would
smile at it; and with respect to his Officinalia, I believd
they are to be found no where but in the Codex Medica—
mentarius of Paris; and in his Magistralia his doses are ge—
nerally such as the most timid practitioner of this country
would hardly descend to, and such as none of our practiti—
oners of experience would depend upon. In short, the
whole of the work, both with respect to the theories with
which it abounds, and to the facts which it gives, will
not, in my apprehension, bear any serious criticism. But
I must conclude; and shall only say further, that such as
I have represented it, is this work, executed by a man of
the first rank in the profession. It is indeed for that reason
I have chosen it as the example of a work, upon the plan
of giving facts only, and of avoiding the study or even the
notice of the proximate causes of diseases; and with what
advantage such a plan is pursued, I shall leave my readers
to consider.
IN the following treatise I have followed a different
course. I have endeavoured to collect the facts relative to
the diseases of the human body, as fully as the nature of the
work and the bounds necessarily prescribed to it would ad—
mit: But I have not been satisfied with giving the facts,
without endeavouring to apply them to the investigation of
proximate causes, and upon these to establish a more scien—
tific and decided method of cure. In aiming at,this, I flat—
ter myself that I have avoided hypothesis, and what have
been called theories. I have, indeed, endeavoured to esta—
blish 

xxx PREFACE.
blish many general doctrines, both physiological and pa—
thological; but I trust that these are only a generalisation of
facts, or conclusions from a cautious and full induction;
and if any one shall refuse to admit, or directly shall op—
pose, my general doctrines, he must do it by showing that
I have been deficient or mistaken in assuming and applying
facts. I have, myself, been jealous of my being sometimes
imperfect in these respects; but I have generally endeavour—
ed to obviate the consequences of this, by proving, that the
proximate causes which I have assigned, are true in fact, as
well as deductions from any reasoning that I may seem to
have employed. Further, to obviate any dangerous fallacy
in proposing a method of cure, I have always been anxious
to suggest that which, to the best of my judgment, appear—
ed to be the method approved of by experience, as much
as it was the consequence of system.
UPON this general plan I have endeavoured to form a sys—
tem of physic that should comprehend the whole of the facts
relating to the science, and that will, I hope, collect and
arrange them in better order than has been done before, as
well as point out in particular those which are still wanting
to establish general principles. This which I have attempt—
ed, may, like other systems, hereafter suffer a change;
but I am confident that we are at present in a better train
of investigation than physicians were in before the time of
Dr. Hoffman. The affections of the motions and moving
powers of the animal economy, must certainly be the lead—
ing inquiry in considering the diseases of the human body.
The inquiry may be difficult; but it must be attempted, or
the subject must be deserted altogether. I have, therefore,
assumed the general principles of Hoffman, as laid down in
the passage which I have quoted above; and if I have ren—
dered them more correct, and more extensive in their ap—
plication; and, more particularly, if I have avoided intro—
ducing the many hypothetical doctrines of the Humoral Pa—
thology which disfigured both his and all the other systems
which have hitherto prevailed; I hope I shall be excused
for attempting a system, which upon the whole may appear
new.
EDINBURGH, Nov. 1783. 

PART I.
OF PYREXIÆ,
OR
FEBRILE DISEASES.
 



[33]
FIRST LINES
OF THE
PRACTICE OF PHYSIC.
INTRODUCTION.
I.
IN teaching the Practice of Physic, we en—
deavour to give instruction for discerning, dis—
tinguishing, preventing, and curing diseases, as they
occur in particular persons.
2.
The art of DISCERNING and DISTINGUISHING 
diseases, may be best attained by an accurate and
complete observation of their phenomena, as these
occur in concourse and in succession, and by con—
stantly endeavouring to distinguish the peculiar and
inseparable concurrence of symptoms, to establish.
a METHODICAL NOSOLOGY, or an arrangement
of diseases according to their genera and species,
founded upon observation alone, abstracted from
all reasoning. Such an arrangement I have at—
tempted in another work, to which in the course of
the present I shall frequently refer.
VOL. I. E 3. The 

34 PRACTICE
3.
The PREVENTION of diseases depends upon the
knowledge of their remote causes; which is party
delivered in the general Pathology, and partly to
be delivered in this treatise.
4.
The CURE of diseases is chiefly, and almost un—
avoidably, founded in the knowledge of their prox—
imate causes. This requires an acquaintance with
the Institutions of Medicine; that is, the know—
ledge of the structure, action, and functions of the
human body; of the several changes which it may
undergo; and of the several powers by which it can
be changed. Our knowledge of these particulars,
however, is still incomplete, is in many respects
doubtful, and has been often involved in mistake
and error. The doctrine, therefore, of proximate
causes, founded upon that knowledge, must be fre—
quently precarious and uncertain. It is, however,
possible for a judicious physician to avoid what is
vulgarly called theory, that is, all reasoning found—
ed upon hypothesis, and thereby many of the er—
rors which have formerly taken place in the Insti—
tutions of Medicine. It is possible also for a person
who has an extensive knowledge of the facts rela—
tive to the animal economy in health and sickness,
by a cautious and complete induction, to establish
many general principles which may guide his rea—
soning with safety; and while, at the same time, a
physician admits as a foundation of practice those
reasonings only which are simple, obvious and cer—
tain, and for the most part admits as proximate
causes those alone that are established as matters of
fact rather than as deductions of reasoning, he may
with great advantage establish a system of practice
chiefly founded on the doctrine of proximate causes.
But 

35 OF PHYSIC. 
But when this cannot be done with sufficient cer—
tainty, the judicious and prudent physician will have
recourse to EXPERIENCE alone; always, however,
aware of the hitherto incomplete and fallacious
state of Empiricism.
5.
With a strict attention to these considerations in
the whole of the following Treatise, I proceed to
treat of particular diseases in the order of my Me—
thodical Nosology.
PART 



PART I.
Of Pyrexiœ, or Febrile Diseases.
6.
PYREXIÆ, or febrile diseases, are distinguish—
ed by the following appearances. After be—
ginning with some degree of cold shivering, they
show some increase of heat, and an increased fre—
quency of pulse, with the interruption and disorder
of several functions, particularly some diminution
of strength in the animal functions.
7.
Of these Pyrexiæ I have formed a class, and
have subdivided it into the five orders of FEVERS,
INFLAMMATIONS, ERUPTIONS, HEMORRHAGIES,
and FLUXES. See Synopsis Nosologiæ Methodi—
cæ, Edit. 3. 1780.
BOOK 

[38]
BOOK I.
OF FEVERS.
CHAP. I.
OF THE PHENOMENA OF FEVERS.
8.
THOSE diseases are more strictly called FE—
VERS, which have the general symptoms of
Pyrexia, without having along with them any to—
pical affection that is essential and primary, such as
the other orders of the Pyrexiæ always have.
9.
Fevers, as differing in the number and variety
of their symptoms, have been very properly consi—
dered as of distinct genera and species. But we
suppose, that there are certain circumstances in
common to all diseases comprehended under this or—
der, which are therefore those essentially necessary
to, and properly constituting the nature of fever
It is our business especially, and in the first place,
to investigate these; and I expect to find them as
they occur in the paroxysm, or fit, of an intermit—
tent fever, as this is most commonly formed.
1O.
The phenomena to be observed in such a parox—
ysm are the following. The person is affected, first,
with 

39 PRACTICE, &c. 
with a languor or sense of debility, a sluggishness
in motion, and some uneasiness in exerting it, with
frequent yawning and stretching. At the same time,
the face and extremities become pale; the features
shrink; the bulk of every external part is diminish—
ed; and the skin, over the whole body, appears
constricted, as if cold had been applied to it. At
the coming on of these symptoms, some coldness of
the extremities, though little taken notice of by the
patient, may be perceived by another person. At
length, the patient himself feels a sensation of cold,
commonly first in his back, but, from thence, pass—
ing over the whole body; and now his skin feels
warm to another person. The patient's sense of
cold increasing, produces a tremor in all his limbs,
with frequent successions or rigors of the trunk of
the body. When this sense of cold, and its effects,
have continued for some time, they become less
violent, and are alternated with warm flushings.
By degrees, the cold goes off entirely; and a heat,
greater than natural, prevails, and continues over
the whole body. With this heat, the colour of the
skin returns, and a preternatural redness appears,
especially in the face. Whilst the heat and red—
ness come on, the skin is relaxed and smoothed,
but, for some time, continues dry. The features
of the face, and other parts of the body, recover
their usual size, and become even more turgid.
When the heat, redness, and turgescence have in—
creased and continued for some time, a moisture
appears upon the forehead, and by degrees becomes
a sweat, which gradually extends downwards over
the whole body. As this sweat continues to flow,
the heat of the body abates; the sweat, after con—
tinuing some time; gradually ceases; the body re—
turns to its usual temperature; and most of the
functions are restored to their ordinary state.
11. This 

40 PRACTICE
11.
This series of appearances gives occasion to di—
vide the paroxysm into three different stages; which
are called the COLD, the HOT, and the SWEAT—
ING STAGES or Fits.
In the course of these, considerable changes hap—
pen in the state of several other functions, which
are now to be mentioned.
12.
Upon the first approach of languor, the pulse be—
comes sometimes flower, and always weaker than
before. As the sense of cold comes on, the pulse
becomes smaller, very frequent, and often irregu—
lar. As the cold abates, and the heat comes on,
the pulse becomes more regular, hard, and full;
and in these respects, increases till the sweat breaks
out. As the sweat flows, the pulse becomes softer,
and less frequent, till the sweat ceasing altogether,
it returns to its usual state.
13.
The respiration also suffers some changes. Dur—
ing the cold stage, the respiration is small, frequent,
and anxious, and is sometimes attended with a
cough; as the hot stage comes on, the respiration
becomes fuller and more free; but continues still
frequent and anxious, till the flowing of the sweat
relieves the anxiety, and renders the breathing less
frequent and more free. With the ceasing of the
sweat, the breathing returns to its ordinary state.
14.
The natural functions also suffer a change. Up—
on the approach of the cold stage, the appetite for
food 

41 OF PHYSIC.
food ceases, and does not return till the paroxysm
be over, or the sweat has flowed for some time.
Generally, during the whole of the paroxysm, there
is not only a want of appetite, but an aversion from
all solid, and especially animal food. As the cold
stage advances, there frequently comes on a sick—
ness and nausea, which often increase to a vomit—
ing of a matter that is for the most part bilious.
This vomiting commonly puts an end to the cold
stage, and brings on the hot. As the hot stage ad—
vances, the nausea and vomiting abate; and when
the sweat breaks out, they generally cease alto—
gether.
15.
A considerable degree of thirst is commonly felt
during the whole course of the paroxysm. During
the cold stage, the thirst seems to arise from the
dryness and clamminess of the mouth and fauces;
but, during the hot stage, from the heat which then
prevails over the whole body; and, as the sweat
flows, the mouth becomes moister, and the thirst,
together with the heat, gradually abates.
16.
In the course of a paroxysm, there is often a con—
siderable change in the state of the secretions. The
circumstances just now mentioned show it in the se—
cretion of the saliva and mucus of the mouth; and
it is it still more remarkable with respect to the urine.
During the cold stage, the urine is almost colour—
less, and without cloud or sediment. In the hot
stage, it becomes high coloured, but is still with—
out sediment. After the sweat has flowed freely,
the urine deposites a sediment, commonly lateriti—
ous, and continues to do so for some time after the
paroxysm is over.
VOL. I. F 17. Excepting 

42 PRACTICE
17.
Excepting in certain uncommon cases which are
attended throughout with a diarrhœa, stools seldom
occur till towards the end of a paroxysm, when
commonly a stool happens, and which is generally
of a loose kind. 
18.
Analogous to these changes in the state of the se—
cretions, it frequently happens, that tumours sub—
sisting on the surface of the body, suffer, during
the cold stage of fevers, a sudden and considerable
detumescence; but generally, though not always,
the tumours return to their former size during the
sweating stage. In like manner, ulcers are some—
times dried up during the cold stage; and return
again to discharge matter during the sweating stage,
or after the paroxysm is over.
19.
Certain changes appear also in sensation and
thought. During the cold stage, the sensibility is
often greatly impaired; but when the hot stage is
formed, the sensibility is recovered, and often con—
siderably increased.
20.
With respect to the intellectual functions, when
he cold stage comes on, attention and recollection
become difficult, and continue more or less so dur—
ing the whole paroxysm. Hence some confusion
of thought takes place, and often arises to a deli—
rium, which sometimes comes on at the beginning
of the cold stage, but more frequently not till the
hot stage be formed.
21. It 

43 OF PHYSIC. 
21.
It belongs also to this place to remark, that the
cold stage sometimes comes on with a drowsiness
and stupor, which often increase to a degree that
may be called comatose, or apoplectic.
22.
We have still to add, that sometimes, early in
the cold stage, a headach comes on; but which,
more commonly, is not felt till the hot stage be
formed, and then is usually attended with a throb—
bing of the temples. The headach continues till
the sweat breaks out; but as this flows more free—
ly, that gradually goes off. At the same time with
the headach, there are commonly pains of the back,
and of some of the great joints; and these pains
have the same course with the headach.
23.
These are nearly the whole, and are at least the
chief of the phenomena which more constantly ap—
pear in the paroxysm of an intermittent fever; and
we have pointed out their ordinary concourse and
succession. With respect to the whole of them,
however, it is to be observed, that, in different
cases, the several phenomena are in different de—
grees; that the series of them is more or less com—
plete; and that the several parts or stages in the
time they occupy, are in a different proportion to
one another.
24.
It is very seldom that a fever consists of a single
paroxysm, such as we have now described; and it
more generally happens, after a certain length of
time 

44 PRACTICE
time has elapsed from the ceasing of the paroxysm,
that the same series of phenomena again arises and
observes the same course as before; and these states
of FEVER and APYREXIA often continue to alter—
nate with one another for many times. In such
cases, the length of time from the end of one pa—
roxysm to the beginning of another, is called an
Intermission; and the length of time from the
beginning of one paroxysm to the beginning of ano—
ther next succeeding, is called an INTERVAL.
25.
When the disease consists of a number of parox—
ysms, it is generally to be observed, that the inter—
vals between them are nearly equal; but these in—
tervals are of different lengths in different cases.
The most usual interval is that of forty eight hours,
which is named the TERTIAN period. The next
most common is that of seventy two hours, and is
named the QUARTAN period. Some other inter—
vals also are observed, particularly one of twenty
four hours, named therefore the QUOTIDIAN; and
the appearance of this is pretty frequent. But all
other intervals longer than that of the quartan are
extremely rare, and probably are only irregulari—
ties of the tertian or quartan periods.
26.
The paroxysms of pure intermittent fevers are
always finished in less than twenty four hours; and
though it happens that there are fevers which con—
sist of repeated paroxysms, without any entire in—
termission between them ; yet in fuch cafes it is ob—
served, that, though the hot and sweating stages of
the paroxysm do not entirely cease before the twen—
ty four hours from their beginning have expired,
they suffer, however, before that time, a consider—
able abatement or REMISSION of their violence;
and, 

45 OF PHYSIC.
and, at the return of the quotidian period, a pa—
roxysm is in some shape renewed, which runs the
same course as before. This constitutes what is
called a REMITTENT FEVER.
27.
When in these remittents the remission is consi—
derable, and the return of a new paroxysm is dis—
tinctly marked by the symptoms of a cold stage at
the beginning of it; such fevers retain strictly the
appellation of REMITTENTS. But when it happens,
as it does in certain cases, that the remission is not
considerable, is perhaps without sweat, and that
the returning paroxysm is not marked by the most
usual symptoms of a cold stage, but chiefly by the
aggravation or EXACERBATION of a hot stage, the
disease is called a CONTINUED FEVER. 
28.
In some cases of continued fever, the remissions
and exacerbations are so inconsiderable as not to
be easily observed or distinguished; and this has
led physicians to imagine, that there is a species of
fever subsisting for several days together, and seem—
ingly consisting of one paroxysm only. This they
have called a CONTINENT FEVER; but, in a long
course of practice, I have not had an opportunity
of observing such a fever.
29.
It is, however, to be observed here, that the fe—
vers of a continued form are to be distinguished
from one another; and that, while some of a ve—
ry continued form do still belong to the section of
intermittents, there are others which, though still
consisting of separate and repeated paroxysms, yet,
as different by their causes and circumstances from
intermittents, 

46 PRACTICE
intermittents, are to be distinguished from the whole
of these, and are more strictly to be called and con—
sidered as CONTINUED. Such are most of those
which have been commonly supposed to be CON—
TINENT; and those which by most writers have
been simply named CONTINUED; and which term
I have employed as the title of a Section, to be dis—
tinguished from that of INTERMITTENT.
I shall here add the marks by which, in practice,
these different continued fevers may be distinguish—
ed from one another.
Those fevers of a continued form, which, how—
ever, still belong to the section of Intermittents,
may be distinguished by their having passed from
an intermittent or remittent form, to that of a con—
tinued; by their showing some tendency to become
intermittent, or at least remittent; by their being
known to have been occasioned by marsh miasmata;
and, for the most part, by their having but one
paroxysm, or one exacerbation and remission, in
the course of twenty four hours.
On the other hand, Continued Fevers, to be
more strictly so called, may be distinguished by their
showing little tendency to become intermittent or
remittent in any part of their course, and especial—
ly after the first week of their continuance; by their
being occasioned by human contagion, at least by
other causes than the marsh miasmata; and by their
having pretty constantly an exacerbation and re—
mission twice in the course of every twenty four
hours. In both cases, the knowledge of the nature
of the epidemic for the time prevailing, may have
a great share in determining the nature of the par—
ticular fever.
30.
With respect to the form, or TYPE, of fevers,
this further may be observed, That the quartan,
while it has the longest interval, has, at the same
time,

47 OF PHYSIC.
time, the longest and most violent cold stage; but,
upon the whole, the shortest paroxysm: That the
tertian, having a shorter interval than the quartan,
has, at the same time, a shorter and less violent
cold stage; but a longer paroxysm: And, lastly,
that the quotidian, with the shortest interval, has
the least of a cold stage, but the longest paroxysm.
31.
The type of fevers is sometimes changed in their
course. When this happens, it is generally in the
following manner: Both tertians and quartans
change into quotidians, quotidians into remittents,
and these last become often of the most continued
kind. In all these cases, the fever has its parox—
ysms protraaed longer than usual, before it chan—
ges into a type of more frequent repetition.
32.
From all this a presumption arises, that every fe—
ver consists of repeated paroxysms; differing from
others chiefly in the circumstances and repetition
of the paroxysms; and, therefore, that it was al—
lowable for us to take the paroxysm of a pure in—
termittent as an example and model of the whole.
CHAP. II.
OF THE PROXIMATE CAUSE OF FEVER. 
33.
THE proximate cause of fever seems hitherto to
have eluded the research of physicians; and I
shall not pretend to ascertain it in a manner that
may remove every difficulty; but I shall endeavour
to make an approach towards it, and such as, I
hope, 

48 PRACTICE
hope, may be of use in conducting the practice in
this disease; while at the same time I hope to avoid
several errors which have formerly prevailed on this
subject.
34.
As the hot stage of fever is so constantly preced—
ed by a cold stage, we presume that the latter is the
cause of the former; and, therefore, that the cause
of the cold stage is the cause of all that follows in the
course of the paroxysm. See Boerh. Aph. 756.
35.
To discover the cause of the cold stage of fevers,
we may observe, that it is always preceded by strong
marks of a general debility prevailing in the system.
The smallness and weakness of the pulse, the pale—
ness and coldness of the extreme parts, with the
shrinking of the whole body, sufficiently show that
the action of the heart and larger arteries is, for the
time, extremely weakened. Together with this,
the languor, inactivity, and debility of the animal
motions, the imperfect sensations, the feeling of
cold, while the body is truly warm, and some other
symptoms, all show that the energy of the brain is,
on this occasion, greatly weakened; and I presume,
that, as the weakness of the action of the heart can
hardly be imputed to any other cause, this weak—
ness also is a proof of the diminished energy of the
brain.
36.
I shall hereafter endeavour to show, that the
most noted of the remote causes of fever, as conta—
gion, miasmata, old, and fear, are of a sedative
nature; and therefore render it probable that a de—
bility is induced. Likewise, when the paroxysms
of a fever have ceased to be repeated, they may
again 

49 OF PHYSIC.
again be renewed, and are most commonly renew—
ed by the application of debilitating powers. And,
further, the debility which subsists in the animal
motions and other functions through the whole of
fever, renders it pretty certain that sedative or de—
bilitating powers have been applied to the body.
37.
It is therefore evident, that there are three states
which always take place in fever; a state of debili—
ty, a state of cold, and a state of heat; and as these
three states regularly and constantly succeed each
other in the order we have mentioned them, it is
presumed that they are in the series of cause and
effect with respect to one another. This we hold
as a matter of fact, even although we should not be
able to explain in what manner or by what me—
chanical means these states severally produce each
other.
38.
How the state of debility produces some of the
symptoms of the cold stage, may perhaps be readi—
ly explained; but how it produces all of them, I
cannot explain otherwise than by referring the mat—
ter to a general law of the animal economy, where—
by it happens, that powers which have a tendency
to hurt and destroy the system, often excite such
motions as are suited to obviate the effects of the
noxious power. This is the VIS MEDICATRIX NA—
TURÆ, so famous in the schools of physic; and it
seems probable, that many of the motions excited
in fever are the effects of this power.
39.
That the increased action of the heart and arte—
ries, which takes place in the hot stage of fevers, is
VOL. I. G to 

50 PRACTICE
to be considered as an effort of the vis medicatrix
naturœ, has been long a common opinion among
physicians; and I am disposed to assert, that some
part of the cold stage may be imputed to the same
power. I judge so, because the cold stage appears
to be universally a means of producing the hot;
because cold, externally applied, has very often si—
milar effects; and more certainly still, because it
seems to be in proportion to the degree of tremor
in the cold stage, that the hot stage proceeds more
or less quickly to a termination of the paroxysm,
and to a more complete solution and longer inter—
mission. See 30.
40.
It is to be particularly observed, that during the
cold stage of fever, there seems to be a spasm indu—
ced every where on the extremities of the arteries,
and more especially of those upon the surface of the
body. This appears from the suppression of all ex—
cretions, and from the shrinking of the external
parts; and although this may perhaps be imputed,
in, part, to the weaker action of the heart in pro—
pelling the blood into the extreme vessels; yet, as
these symptoms often continue after the action of
the heart is restored, there is reason to believe,
that a spasmodic constriction has taken place; that
it subsists for some time, and supports the hot stage;
for this stage ceases with the flowing of the sweat,
and the return of other excretions, which are marks
of the relaxation of vessels formerly constricted.
Hoffman. Med. rat. System. Tom. 4. P. 1. Sect.
1. Cap. 1. art. 4.
41.
The idea of fever, then, may be, that a spasm
of the extreme vessels, however induced, proves
an irritation to the heart and arteries; and that
this 

51 OF PHYSIC.
this continues till the spasm is relaxed or overcome.
There are many appearances which support this
opinion; and there is little doubt that a spasm does
take place, which proves an irritation to the heart,
and therefore may be considered as a principal
part in the proximate cause of fever. It will still,
however, remain a question, what is the cause of
this spasm; whether it be directly produced by the
remote cause of fever, or if it be only a part of the
operation of the vis medicatrix naturœ.
42.
I am disposed to be of the latter opinion, because
in the first place, while it remains still certain that
a debility lays the foundation of fever, it is not ob—
vious in what manner the debility produces the
spasm, and, what seems to be its effect, the increas—
ed action of the heart and arteries; and, secondly,
because, in almost all the cases, in which an effort
is made by the vis medicatrix naturœ, a cold fit and
a spasm of the extreme vessels are almost always the
beginnings of such an effort. See Gaub. Pathol.
Medicin. art. 750.
43.
It is therefore presumed, that such a cold fit and
spasm, at the beginning of fever, is a part of the
operation of the vis medicatrix; but, at the same
time, it seems to me probable, that during the
whole course of the fever, there is an atony subsist—
ing in the extreme vessels, and that the relaxation
of the spasm requires the restoring of the tone and
action of these.
44.
This it may be difficult to explain; but I think
it may be ascertained as a fact, by the consideration
of 

52 PRACTICE
of the symptoms which take place, with respect to
the functions of the stomach in fevers, such as the
anorexia, nausea, and vomiting. (14.)
From many circumstances it is sufficiently certain,
that there is a consent between the stomach and
surface of the body; and in all cases of the consent
of distant parts, it is presumed to be by the connex—
ion of the nervous system, and that the consent
which appears, is between the sentient and mov—
ing fibres of the one part with those of the other,
is such, that a certain condition prevailing in the
one part, occasions a similar condition in the other.
In the case of the stomach and surface of the bo—
dy, the consent particularly appears by the con—
nexion which is observed between the state of the
perforation, and the state of the appetite in heal—
thy persons; and if it may be presumed that the
appetite depends upon the state of tone in the mus—
cular fibres of the stomach, it will follow, that the
connexion of appetite and perspiration depends up—
on a consent between the muscular fibres of the
stomach, and the muscular fibres of the extreme
vessels, or of the organ of perspiration, on the sur—
face of the body.
It is further in proof of the connexion between
the appetite and perspiration, and at the same time
of the circumstances on which it depends, that
cold applied to the surface of the body, when it
does not stop perspiration, but proves a stimulus to
it, is always a powerful means of exciting appetite.
Having thus established the connexion or con—
sent mentioned, we argue, that as the symptoms of
anorexia, nausea, and vomiting, in many cases ma—
nisestly depend upon a state of debility or loss of
tone in the muscular fibres of the stomach; so it
may be presumed, that these symptoms, in the be—
ginning of fever, depend upon an atony commu—
nicated to the muscular fibres of the stomach, from
the muscular fibres of the extreme vessels on the
surface of the body.
That 

53 OF PHYSIC. 
That the debility of the stomach which produces
vomiting in the beginning of fevers, actually de—
pends upon an atony of the extreme vessels on the
surface of the body, appears particularly from a
fact observed by Dr. Sydenham. In the attack of
the plague, a vomiting happens, which prevents
any medicine from remaining on the stomach; and
Dr. Sydenham tells us, that in such cases he could
not overcome this vomiting but by external means
applied to produce a sweat; that is, to excite the
action of the vessels on the surface of the body.
The same connexion between the state of the sto—
mach and that of the extreme vessels on the surface
of the body, appears from this also, that the vomit—
ing, which so frequently happens in the cold stage
of fevers, commonly ceases upon the coming on
of the hot, and very certainly upon any sweat's
coming out (14.) It is indeed probable, that the
vomiting in the cold stage of fevers, is one of the
means employed by nature for restoring the deter—
mination to the surface of the body; and it is a
circumstance affording proof, both of this, and of
the general connexion between the stomach and
surface of the body, that emetics thrown into the
stomach, and operating there, in the time of the
cold stage, commonly put an end to it, and bring
on the hot stage.
It also affords a proof of the same connexion,
that cold water, taken into the stomach produces
an increase of he at on the surface of the body, and
is very often a convenient and effectual means of
producing sweat.
From the whole we have now said on this sub—
ject, I think it is sufficiently probable, that the
symptoms of anorexia, nausea, and vomiting, de—
pend upon, and are a proof of, an atony subsisting
in the extreme vessels on the surface of the body;
and that this atony therefore, now ascertained as a
matter of fact, may be considered as a principal cir—
cumstance in the proximate cause of fever.
45. This 

54 PRACTICE
45.
This atony we suppose to depend upon a diminu—
tion of the energy of the brain; and that this di—
minution takes place in fevers, we conclude, not
not only from the debility prevailing in so many
of the functions of the body, mentioned above
(35.) but particularly from symptoms which are pe—
culiar to the brain itself. Delirium is a frequent
symptom of fever; and as from the physiology and
pathology we learn that this symptom commonly
depends upon some inequality in the excitement of
the brain or intellectual organ; we hence conclude,
that, in fever, it denotes some diminution in the
energy of the brain. Delirium, indeed, seems of—
ten to depend upon an increased impetus of the
blood in the vessels of the brain, and therefore at—
tends phrenitis. It frequently appears also in the
hot stage of fevers, accompanied with a headach
and throbbing of the temples. But as the impetus
of the blood in the vessels of the head is often con—
siderably increased by exercise, external heat, pas—
sions, and other causes, without occasioning any
delirium; so, supposing that the same impetus, in
the case of fever, produces delirium, the reason
must be, that at the same time, there is some cause
which diminishes the energy of the brain, and pre—
vents a free communication between the parts con—
cerned in the intellectual functions. Upon the
same principles also, I suppose there is another
species of delirium, depending more entirely on
the diminished energy of the brain, and which may
therefore arise, when there is no unusual increase
of the impetus of the blood in the vessels of the
brain. Such seems to be the delirium occurring at
the beginning of the cold stage of fevers, or in the
hot stage of such fevers as show strong marks of
debility in the whole system.
46. Upon 

55 OF PHYSIC.
46.
Upon the whole, our doctrine of fever is expli—
citly this. The remote causes (36.) are certain se—
dative powers applied to the nervous system, which
diminishing the energy of the brain, thereby pro—
duce a debility in the whole of the functions (35.)
and particularly in the action of the extreme ves—
sels (43. 44.) Such, however, is, at the same
time, the nature of the animal economy, (38.) that
this debility proves an indirect stimulus to the fan—
guiserous system; whence, by the intervention of
the cold stage, and spasm connected with it (39. 40.)
the action of the heart and larger arteries is increas—
ed (40.) and continues so (41.) till it has had the ef—
fect of restoring the energy of the brain, of extend—
ing this energy to the extreme vessels, of restoring
therefore their action, and thereby especially over—
coming the spasm affecting them; upon the remov—
ing of which, the exertion of sweat, and other
marks of the relaxation of excretories, take place.
47.
This doctrine will, as I suppose, serve to ex—
plain not only the nature of fever in general, but
also the various cases of it which occur. Before
proceeding, however, to this, it may be proper to
point out the opinions, and, as I apprehend, the
mistakes, which have formerly prevailed on this
subject.
48.
It has been supposed that a lentor or viscidity,
prevailing in the mass of blood, and stagnating
in the extreme vessels, is the cause of the cold
stage of fevers and its consequences. But there is
no evidence of any such viscidity previously sub—
sisting in the fluids; and as it is very improbable 
that

56 PRACTICE
that such a state of them can be very quickly pro—
duced, so the suddenness with which paroxysms
come on, renders it more likely that the pheno—
mena depend upon some cause acting upon the ner—
vous system, or the primary moving powers of the
animal economy. See Van Swieten apud Boerh.
Aph. 755.
49.
Another opinion, which has been almost univer—
sally received, is, that a noxious matter introdu—
ced into, or generated in, the body, is the prox—
imate cause of fever; and that the increased action
of the heart and arteries, which forms so great a
part of the disease, is an effort of the vis medica—
trix naturæ to expel this morbific matter; and par—
ticularly to change or concoct it, so as to render
it either altogether innocent, or, at least, fit for be—
ing more easily thrown out of the body. This
doctrine, however, although of as great antiquity
as any of the records of physic now remaining
and although it has been received by almost every
school of medicine, yet appears to me to rest upon
a very uncertain foundation. There are fevers
produced by cold, fear, and other causes, accom—
panied with all the essential circumstances of fever,
and terminating by sweat; but, at the same time,
without any evidence or suspicion of morbific mat—
ter.
There have been fevers suddenly cured by a he—
morrhagy so moderate as could not carry out any
considerable portion of a matter diffused over the
whole mass of blood; nor can we conceive how
the morbific matter could be collected or determi—
ned to pass off by such an outlet as in that case is
opened.
Even supposing a morbific matter were present
there is no explanation given, in what manner the
concoction of it is performed; nor is it shown
that 

57 OF PHYSIC.
that any such change does in fact take place. In
certain cases, it is indeed evident, that a noxious
matter is introduced into the body, and proves the
cause of fever; but, even in these cases, it appears
that the noxious matter is thrown out again, with—
out having suffered any change; that the fever oft—
en terminates before the matter is expelled; and
that, upon many occasions, without waiting the
supposed time of concoction, the fever can be cu—
red, and that by remedies which do not seem to
operate upon the fluids, or to produce any evacu—
ation.
50.
While we thus reason against the notion of fever
being an effort of nature, for concocting and ex—
pelling a morbific matter; I by no means intend to
deny that the cause of fever frequently operates
upon the fluids, and particularly produces a pu—
trescent state of them. I acknowledge that this is
frequently the case; but, at the same time, I main—
tain, that such a change of the fluids is not com—
monly the cause of fever; that very often it is an
effect only; and that there is no reason to believe
the termination of the fever to depend upon the ex—
pulsion of the putrid matter.
51.
Another opinion which has prevailed, remains
still to be mentioned. In intermittent fevers, a
great quantity of bile is commonly thrown out by
vomiting; and this is so frequently the case, that
many have supposed an unusual quantity of bile,
and perhaps a peculiar quality of it, to be the cause
of intermittent fevers. This, however, does not
appear to be well founded. Vomiting, by what—
ever means excited, if often repeated with violent
draining, seems to be powerful in emulging the bi—
VOL. I. H liary

58 PRACTICE
liary ducts, and commonly throws out a great deal
of bile. This will happen especially in the case or
intermittent fevers. For as, in the state of debili—
ty and cold stage of these fevers, the blood is not
propelled in the usual quantity into the extreme
vessels, and particularly into those on the surface
of the body, but is accumulated in the vessels of
the internal parts, and particularly in the vena por—
tarum; so this may occasion a more copious se—
cretion of bile.
These considerations will, in some measure, ac—
count for the appearance of an unusual quantity
of bile in intermittent fevers; but the circum—
stance which chiefly occasions the appearance of
bile in these cases, is the influence of warm cli—
mates and seasons. These seldom fail to produce
a state of the human body, in which the bile is dis—
posed to pass off, by its secretories, in greater
quantity than usual; and perhaps also changed in
its quality, as appears from the disease of cholera,
which so frequently occurs in warm seasons. At
the same time, this disease occurs often without
fever; and we shall hereafter render it sufficiently
probable, that intermittent fevers, for the most
part, arise from another cause, that is, from marsh
effluvia: while, on the other hand, there is no evi—
dence of their arifing from the ftate of the bile on—
ly. The marsh effluvia, however, commonly ope—
rate most powerfully in the same season that produ—
ces the change and redundance of the bile; and
therefore, considering the vomiting, and other cir—
cumstances of the intermittent fevers which here
concur, it is not surprising that autumnal intermit—
tents are fo often attended with effusions of bile.
This view of the subject does not lead us to con—
sider the state of the bile as the cause of intermit—
tents, but merely as a circumstance accidentally
concurring with them, from the state of the season
in which they arise. What attention this requires
in 

59 OF PHYSIC. 
in the conduct of the disease, I shall consider here—
after.
52.
From this view of the principal hypotheses
which have hitherto been maintained with respect
to the proximate cause of fever, it will appear,
that fevers do not arise from changes in the state
of the fluids; but that, on the contrary, almost
the whole of the phenomena of fevers lead us to
believe that they chiefly depend upon changes in
the state of the moving powers of the animal sys—
tem. Though we should not be able to explain all
the circumstances of the disease, it is at least of
some advantage to be led into the proper train of
investigation. I have attempted to pursue it; and
shall now endeavour to apply the doctrine already
delivered, towards explaining the diversity of fevers.
CHAP. III.
OF THE DIFFERENCE OF FEVERS, AND
ITS CAUSES.
53.
TO ascertain the difference of fevers, I think it
necessary to observe, in the first place, that
every fever of more than one day's duration consists
of repeated, and in some measure separate, parox—
ysms; and that the difference of fevers taken no—
tice of above (from 25. to 30.) appears to consist
in the different state of paroxysms, and in the dif—
ferent circumstances of their repetition.
54.
That fevers generally consist of distinct, and in
some measure separately repeated paroxysms, I
have 

60 PRACTICE
have alledged above to be a matter of fact; but I
shall here endeavour to confirm it, by assigning the
cause.
55.
In every fever, in which we can distinctly ob—
serve any number of separate paroxysms, we con—
stantly find that each paroxysm is finished in less
than twenty four hours; but as I cannot perceive
any thing in the cause of fevers determining to
this, I must presume it to depend on some general
law of the animal economy. Such a law seems to
be that which subjects the economy, in many re—
spects, to a diurnal revolution. Whether this de—
pends upon the original conformation of the body,
or upon certain powers constantly applied to it,
and inducing a habit, I cannot positively deter—
mine; but the returns of sleep and watching, of
appetites and excretions, and the changes which
regularly occur in the state of the pulse, show suf—
ficiently, that in the human body a diurnal revolu—
tion takes place.
56.
It is this diurnal revolution which, I suppose
determines the duration of the paroxysms of fe—
vers; and the constant and universal limitation of
these paroxysms, (as observed in 55.) while no
other cause of it can be assigned, renders it suffici—
ently probable, that their duration depends upon,
and is determined by, the revolution mentioned.
And that these paroxysms are connected with that
diurnal revolution, appears further from this, that
though the intervals of paroxysms are different in
different cases, yet the times of the accession of pa—
roxysms are generally fixed to one time of the day;
so that Quotidians come on in the morning Ter—
tians at noon, and Quartans in the afternoon.
57. It 

61 OF PHYSIC.
57.
It remains to be remarked, that as Quartans and
Tertians are apt to become Quotidians, these to
pass into the state of Remittents, and these last to
become Continued; and that, even in the Conti—
nued form, daily exacerbations and remissions are
generally to be observed; so all this shows so much
the power of diurnal revolution, that when, in cer—
tain cases, the daily exacerbations and remissions
are with difficulty distinguished, we may still pre—
sume, that the general tendency of the economy
prevails, that the disease still consists of repeated
paroxysms, and, upon the whole, that there is no
such disease as that which the schools have called
a Continent Fever. I expect that this doctrine
will be confirmed by what I shall say hereafter,
concerning the periodical movements observed in
continued fevers.
58. 
It being thus proved, that every fever, of more
than one clay's duration, consists of repeated parox—
ysms; we, in the next place, remark, that the re—
petition of paroxysms depends upon the circum—
stances of the paroxysms which have already taken
place. From what was observed (in 30. and 31.) it
appears, that the longer paroxysms are protracted,
they are the sooner repeated; and, therefore,
that the cause of the frequent repetition is to be
fought for in the cause of the protraction of parox—
ysms.
59.
Agreeably to what is laid down in 46. and to the
opinion of most part of physicians, I suppose, that,
in every fever, there is a power applied to the bo—
dy, 

62 PRACTICE
dy, which has a tendency to hurt and destroy it,
and produces in it certain motions which deviate
from the natural state; and, at the same time, in
every fever which has its full course, I suppose,
that, in consequence of the constitution of the ani—
mal economy, there are certain motions excited,
which have a tendency to obviate the effects of the
noxious power, or to correct and remove them.
Both these kinds of motion are considered as con—
stituting the disease.
But the former is perhaps strictly the morbid
state, while the latter is to be considered as the ope—
ration of the vis medicatrix nature of salutary ten—
dency, and which I shall hereafter call the REACTI—
ON of the system.
60.
Upon the supposition that these two states take
place in every paroxysm of fever, it will appear to
be chiefly in the time of the hot stage that the re—
action operates in removing the morbid state; and
therefore, as this operation succeeds more or less
quickly, the hot stage of paroxysms will be shorter
or longer. But as the length of paroxysm depends
chiefly upon the duration of the hot stage, so the
longer duration of this and of paroxysms, must be
owing either to the obstinacy of resistance in the
morbid state, or to the weakness of the salutary re—
action; and it is probable that sometimes the one
and sometimes the other of these circumstances
takes place.
6l.
It seems to be only by the state of the spasm,
that we can judge of the resistance of the morbid
state of fever; And with respect to this spasm I ob—
serve, that either the cause exciting it may be dif—
ferent in different cases; or, though the cause should
be 

63 OF PHYSIC. 
be the same in different persons, the different de—
gree of irritability in each may give occasion to a
greater or lesser degree of spasm; and therefore,
the reaction in fever being given, the continuance
of the hot stage, and of the whole paroxysm, may
be longer or shorter, according to the degree of
spasm that has been formed.
62.
One cause of the obstinacy of spasm in fevers
may be clearly perceived. In inflammatory dis—
eases, there is a diathesis phlogistica prevailing in
the body, and this diathesis we suppose to consist
in an increased tone of the whole arterial system.
When, therefore, this diathesis accompanies fever,
as it sometimes does, it may be supposed to give
occasion to the febrile spasm's being formed more
strongly, and thereby to produce more protracted
paroxysms. Accordingly we find, that all inflam—
matory fevers are of the continued kind; and that
all the causes of the diathesis phlogistica have a ten—
dency to change intermittent into continued fevers.
Continued fevers, then, being often attended with
the diathesis phlogistica, we conclude, that in mam—
cases, this is the cause of their continued form.
63.
In many fevers, however, there is no evidence
of any diathesis phlogistica being present, nor of
any other cause of more considerable spasm; and,
in such cases, therefore, we must impute the pro—
traction of paroxysms, and the continued form of
the fever, to the weakness of reaction. That this
cause takes place, we conclude from hence, that,
in many cases of fever, wherein the separate pa—
roxysms are the longest protracted, and the most
difficultly observed, we find the most considerable
symptoms of a general debility: And therefore we
infer,

64 PRACTICE
infer, that, in such cases, the protracted paroxysms,
and continued form, depend upon a weaker reac—
tion; owing either to the causes of debility applied
having been of a more powerful kind, or from cir—
cumstances of the patient's constitution favouring
their operation.
64.
Upon these principles we make a step towards ex—
plaining in general, with some probability, the dif—
ference of fevers; but must own, that there is much
doubt and difficulty in applying the doctrine to par—
ticular cases. It applies tolerably well to explain
the different states of intermittents, as they are
more purely such, or as they approach more and
more to the continued form: But several difficul—
ties still remain with respect to many circumstances
of intermittents; and more still with respect to the
difference of those continued fevers, which we have
distinguished in our Nosology as different from in—
termittents, and as more especially intitled to the
appellation of Continued, (see Syn. Nos. Meth. P.
V. Ch. 1. Sect. 2.) and explained more fully above.
65.
From the view given (63. and 64.) of the causes
of the protraction of paroxysms, and therefore of
the form of Continued fevers, strictly so called, it
seems probable, that the remote causes of these ope—
rate by occasioning either a phlogistic diathesis, or a
weaker reaction; for we can observe, that the most
obvious difference of continued fevers depends up—
on the prevalence of one or other of these states.
66.
Continued fevers have been accounted of great
diversity; but physicians have not been succesful in
marking 

65 OF PHYSIC.
marking these differences, or in reducing them to
any general heads. The distinctions made by the
ancients are not well understood; and, so far as
either they or the modern nosologists have distin—
guished continued fevers by a difference of dura—
tion, their distinctions are not well founded, and
do not apply in such a manner as to be of any use.
We think it agreeable to observation, and to the
principles above laid down (63. 64.) to distinguish
continued fevers according as they show either an
inflammatory irritation, or a weaker reaction.
67.
This distinction is the same with that of fevers in—
to the INFLAMMATORY and NERVOUS; the distinc—
tion at present most generally received in Britain.
To the first, as a genus, I have given the name of
Synocha; to the second, that of Typhus; and, lit—
tle studious whether these names be authorised by
the ancient use of the same terms, I depend upon
their being understood by the characters annexed
to them in our Nosology, which I apprehend to be
founded on observation.
68.
By these characters I think continued fevers may
in practice be distinguished; and if that be the case,
the principles above laid down will be confirmed.
69.
Besides these differences of continued fever, now
mentioned, I am not certain of having observed
any other that can be considered as fundamental.
But the most common form of continued fevers,
in this climate, seems to be a combination of these
two genera; and I have therefore given such a ge—
nus a place in our Nosology, under the title of Sy—
nochus. At the same time, I think that the limits
VOL. I. I between 

66 PRACTICE
between the Synochus and Typhus will be with dif—
ficulty assigned; and I am disposed to believe, that
the Synochus arises from the same causes as the Ty—
phus, and is therefore only a variety of it.
70.
The Typhus seems to be a genus comprehending
several species. These, however, are not yet well
ascertained by observation; and in the mean time
we can perceive that many of the different cases ob—
served, do not imply any specific difference, but
seem to be merely varieties, arising from a differ—
ent degree of power in the cause, from different
circumstances of the climate or season in which
they happen, or from different circumstances in the
constitution of the persons affected.
71.
Some of the effects arising from these circumstan—
ces require to be particularly explained.
One is, an unusual quantity of bile appearing in
the course of the disease. This abundance of bile
may possibly attend some continued fevers, strictly
so called; but, for the reasons above explained, it
more commonly attends intermittents, and, we be—
lieve, it might have been enumerated (29.) among
the marks distinguishing the latter kind of fevers
from the former. But, though an unusual quanti—
ty of bile should appear with continued fevers, it
is considered in this case, as in that of intermit—
tents, to be a coincidence only, owing to the state
of the season, and producing no different species
or fundamental distinction, but merely a variety of
the disease. I think it proper to observe here,
that it is probable that the most part of the conti—
nued fevers, named Bilious, have been truly such
as belong to the section of Intermittents.
72. Another 

67 OF PHYSIC. 
72.
Another effect of the circumstances occasionally
varying the appearance of typhus, is a putrescent
state of the fluids. The ancients, and likewise the
moderns, who are in general much disposed to fol—
low the former, have distinguished fevers, as pu—
trid and nonputrid: But the notions of the ancients,
on this subject, were not sufficiently correct to de—
serve much notice; and it is only of late, that the
matter has been more accurately observed, and bet—
ter explained.
From the dissolved state of the blood, as it pre—
sents itself when drawn out of the veins, or as it
appears from the red blood's being disposed to be
effused and run off by various outlets, and from se—
veral other symptoms to be hereafter mentioned,
I have now no doubt, how much soever it has been
disputed by some ingenious men, that a putrescen—
cy of the fluids, to a certain degree, does really
take place in many cases of fever. This putref—
cency, however, often attends intermittent, as well
as continued fevers, and, of the continued kind,
both the synochus and typhus, and all of them in
very different degrees; so that, whatever attention
it may deserve in practice, there is no fixing such
limits to it as to admit of establishing a species un—
der the title of Putrid.
73.
Beside differing by the circumstances already
mentioned, fevers differ also by their being accom—
panied with symptoms which belong to diseases of
the other orders of pyrexiæ. This sometimes hap—
pens in such a manner, as to render it difficult to
determine which of the two is the primary disease.
Commonly, however, it may be ascertained by the
knowledge of the remote cause, and of the prevail—
ing 

68 PRACTICE
ing epidemic, or by observing the series and suc—
cession of symptoms.
74.
Most of our systems of physic have marked, as a
primary one, a species of fever under the title of
HECTIC; but, as it is described, I have never seen
it as a primary disease. I have constantly found it
as a symptom of some topical affection, most com—
monly of an internal suppuration; and as such it
shall be considered in another place.
75.
The distinction of the several cases of intermit—
tent fever I have not prosecuted here; both because
we cannot assign the causes of the differences which
appear; and because I apprehend that the differ—
ences which in fact occur may be readily under—
stood from what is said above (25. 26. and 27.)
and more fully from our Methodical Nosology, Cl.
I. Sect. I. 
CHAP. IV.
OF THE REMOTE CAUSES OF FEVER.
76.
AS fever has been held to consist chiefly in an
increased action of the heart and arteries,
physicians have supposed its remote causes to be
certain direct stimulants fitted to produce this in—
created action. In many cases, however, there is
no evidence of such stimulants being applied; and,
in those in which they are applied, they either pro—
duce only a temporary frequency of the pulse,
which cannot be considered as a disease; or, if
they 

69 OF PHYSIC.
they do produce a permanent febrile state, it is by
the intervention of a topical inflammation, which
produces a disease different from what is strictly
called fever. (8.)
77.
That direct stimulants are the remote causes of
fever, seems farther improbable; because the sup—
position does not account for the phenomena attend—
ing the accession of fevers, and because other re—
mote causes can with greater certainty be assigned.
78.
As fevers are so generally epidemic, it is proba—
ble, that some matter floating in the atmosphere,
and applied to the bodies of men, ought to be con—
sidered as the remote cause of fevers: And these
matters present in the atmosphere, and thus acting
upon men, may be considered, either as CONTA—
GIONS, that is, effluvia arising directly or original—
ly from the body of a man under a particular dis—
ease, and exciting the same kind of disease in the
body of the person to whom they are applied; or
MIASMATA, that is, effluvia arising from other sub—
stances than the bodies of men, producing a dis—
ease in the person to whom they are applied.
79.
Contagions have been supposed to be of great va—
riety; and it is possible this may be the case; but
that they truly are so, does not appear clearly from
any thing we know at present. The genera and
species of contagions diseases, of the class of Py-
rexiæ, at present known, are in number not very
great. They chiefly belong to the order of Fevers,
to that of Exanthemata, or that of Profluvia. Whe—
ther there be any belonging to the order of Phleg—
masiæ, 

70 PRACTICE
masiæ, is doubtful; and though there should, it
will not much increase the number of contagious
pyrexiæ. Of the contagious exanthemata and pro—
fluvia, the number of species is nearly ascertained;
and each of them is so far of a determined nature,
that though they have now been observed and dis—
tinguished for many ages, and in many different
parts of the world, they have been always found to
retain the same general character, and to differ on—
ly in circumstances, that may be imputed to season,
climate, and other external causes, or to the pecu—
liar constitutions of the several persons affected. It
seems, therefore, probable, that, in each of these
species, the contagion is of one specific nature; and
that the number of contagious exanthemata or pro—
fluvia is hardly greater than the number of species
enumerated in the systems of nosology.
80.
If, while the contagious exanthemata and proflu—
via are thus limited, we should suppose the conta—
gious pyrexiæ to be still of great and unlimited va—
riety, it must be with respect to the genera and spe—
cies of continued fevers. But if I be right in li—
miting, as I have done, the genera of these fevers
(67.—70.) it will appear likely that the contagions
which produce them are not of great variety; and
this will be much confirmed, if we can render it
probable that there is one principal, perhaps one
common, source of such contagion.
81.
To this purpose, it is now well known, that the
effluvia constantly arising from the living human
body, if long retained in the same place, without
being diffused in the atmosphere, acquire a singular
virulence; and, in that state, being applied to the
bodies of men, become the cause of a fever which
is highly contagious.
The 

71 OF PHYSIC.
The existence of such a cause is fully proved by
the late observations on jail and hospital fevers;
and that the same virulent matter may be produced
in many other places, must be sufficiently obvious:
And it is probable that the contagion arising in this
manner is not, like many other contagions, perma—
nent and constantly existing; but that, in the cir—
cumstances mentioned, it is occasionally generated.
At the same time, the nature of the fevers from
thence, upon different occasions, arising, renders
it probable that the virulent state of human effluvia
is the common cause of them, as they differ only
in a state of their symptoms; which may be imput—
ed to the circumstances of season, climate, &c. con—
curring with the contagion, and modifying its force.
82.
With respect to these contagions, though we have
spoken of them as of a matter floating in the atmo—
sphere, it is proper to observe, that they are never
found to act but when they are near to the sources
from whence they arise; that is, either near to the
bodies of men, from which they immediately issue;
or near to some substances which, as having been
near to the bodies of men, are imbued with their
effluvia, and in which substances these effluvia are
sometimes retained in an active state for a very
long time.
The substances thus imbued with an active and
infectious matter, may be called Fomites; and it
appears to me probable, that contagions, as they
arise from fomites, are more powerful than as they
arise immediately from the human body.
83.
Miasmata are next to be considered. These may
arise from various sources, and be of different kinds;
but we know little of their variety, or of their se—
veral 

72 PRACTICE.
veral effects. We know with certainty only one
species of miasma, which can be considered as the
cause of fever; and, from the universality of this,
it may be doubted if there be any other.
84.
The miasma, so universally the cause of fever,
is that which arises from marines or moist ground,
acted upon by heat. So many observations have
now been made, with respect to this, in so many
different regions of the earth, that there is neither
any doubt of its being in general a cause of fevers,
nor of its being very universally the cause of inter—
mittent fevers, in all their different forms. The
similarity of the climate, season and foil, in the
different countries in which intermittents arise,
and the similarity of the diseases, though arising in
different regions, concur in proving that there is
one common cause of these diseases; and that this
is the marsh miasma.
What is the particular nature of this miasma, we
know not; nor do we certainly know whether or
not it differs in kind: but it is probable that it
does not; and that it varies only in the degree of
its power, or perhaps as to its quantity, in a given
space.
85.
It has beer, now rendered probable, that the re—
mote causes of fevers (8) are chiefly Contagions of
Miasmata, and neither of them of great variety.
We have supposed that miasmata are the cause of
intermittents, and contagions the cause of con—
tinued fevers, strictly so named; but we cannot
with propriety employ these general terms. For,
as the cause of continued fevers may arife from
fomites, and may, in such cases, be called a Mias—
ma; and as other miasmata also may produce con—
tagious 

73 OF PHYSIC.
tagious diseases; it will be proper to distinguish the
causes of fevers, by using the terms Human or Marsh
Effluvia, rather than the general ones of Contagi—
on or Miasma.
86.
To render our doctrine of fever consistent and
complete, it is necessary to add here, that those re—
mote causes of fever, human and marsh effluvia,
seem to be of a debilitating or sedative quality.
They arise from a putrescent matter. Their pro—
duction is favoured, and their power increased, by
circumstances which favour putrefaction; and they
often prove putrefactive ferments with respect to
the animal fluids. As putrid matter, therefore, is
always, with respect to animal bodies, a powerful
sedative, so it can hardly be doubted that human
and marsh effluvia are of the same quality; and it
is confirmed by this, that the debility which is al—
ways induced, seems to be in proportion to the o—
ther marks that appear of the power of those causes.
87.
Though we have endeavoured to show that fe—
vers generally arise from marsh or human effluvia,
we cannot, with any certainty, exclude some other
remote causes, which are commonly supposed to
have at least a share in producing those diseases.
And I proceed, therefore, to inquire concerning
these causes; the first of which, that merits attenti—
on, is, the power of cold applied to the human body.
88.
The operation of cold on a living body is so dif—
ferent in different circumstances, as to be of diffi—
cult explanation; it is here, therefore, attempted
with some diffidence.
VOL. I. K The 

74 PRACTICE
The power of cold may be considered as absolute
or relative. 
The absolute power is that by which it can dimi—
nish the temperature of the body to which it is ap—
plied. And thus, if the natural temperature of
the human—body is, as we suppose it to be, that of
98 degrees of Farenheit's thermometer*; every de—
gree of temperature less than that, may be consi—
dered as cold with respect to the human body; and,
in proportion to its degree, will have a tendency
to diminish the temperature of the body. But as
the living human body has in itself a power of ge—
nerating heat, so it can sustain its own proper heat
to the degree above mentioned, though surround—
ed by air or other bodies of a lower temperature
than itself; and it appears from observation, that,
in this climate, air or other bodies, applied to the
living man, do not diminish the temperature of his
body, unless the temperature of the bodies applied
be below 62 degrees. From hence it appears, that
the absolute power of cold in this climate, does not
an upon the living human body, unless the cold
applied be below the degree just now mentioned.
It appears also, that the human body's being sur—
rounded by air of a lower temperature than itself,
is necessary to its being retained in its proper tem—
perature of 98 degrees; for, in this climate, every
temperature of the air above 62 degrees, applied to
the human body, though still of a lower tempera—
ture than itself, is found to increase the heat of it.
And from all this it appears, that the absolute pow—
er of cold with respect to the human body, is very
different from what it is with respect to inanimate
bodies.
89.
The relative power of cold with respect to the
living human body, is that power by which it pro—
duces.
* In every instance of our mentioning degrees of heat or cold, we shall mention 
them by the degree in Farenheit's scale; and the expression of higher or lower shall 
always be according to that scale.

75 OF PHYSIC.
duces a sensation of cold in it; and with respect to
this, it is agreeable to the general principle of sen—
sation, that the sensation produced, is not in pro—
portion to the absolute force of impression, but ac—
cording as the new impression is stronger or weaker
than that which had been applied immediately be—
fore. Accordingly, with respect to temperature,
the sensation produced by any degree of this, de—
pends upon the temperature to which the body had,
been immediately before exposed; so that whatever
is higher than this feels warm, and whatever is low—
er than it feels cold; and it will therefore happen
that the opposite sensations of heat and cold may on
different occasions arise from the same temperature,
as marked by the thermometer.
With respect to this, however, it is to be observ—
ed, that though every change of temperature gives
a sensation of cold or heat, as it is lower or high—
er than the temperature applied immediately before,
the sensation produced is, in different cases, of dif—
ferent duration. If the temperature at any time
applied is under 62 degrees, every increase of tem—
perature applied will give a sensation of heat; but
if the increase of temperature does not arise to 62
degrees, the sensation produced will not continue
long, but be soon changed to a sensation of cold.
In like manner, any temperature, applied to the
human body, lower than that of the body itself,
gives a sensation of cold; but if the temperature
applied does not go below 62 degrees, the sensati—
on of cold will not continue long, but be soon
changed to a sensation of heat.
It will appear hereafter, that the effects of the,
sensation of cold will be very different, according
as it is more permanent or transitory. 
90.
Having thus explained the operation of cold, as
absolute or relative, with respect to the human bo—
dy, 

76 PRACTICE
dy, I proceed to mention the general effects of cold
upon it.
1. Cold, in certain circumstances, has manifest—
ly a sedative power. It can extinguish the vital
principle entirely, either in particular parts, or in
the whole body; and considering how much the vi—
tal principle of animals depends upon heat, it can—
not be doubted that the power of cold is always
more or less directly sedative.
This effect may be said to take place from every
degree of absolute cold; and when the heat of the
body has upon any occasion been preternaturally
increased, every lower temperature may be useful
in diminishing the activity of the system; but it can—
not diminish the natural vigour of the vital princi—
ple, till the cold applied is under 62 degrees; nor
even then will it have this effect, unless the cold
applied be of an intense degree, or be applied for
some length of time to a large portion of the body.
2. It is equally manifest, that in certain circum—
stances, cold proves stimulus to the living body,
and particularly to the sanguiferous system.
It is probable, that this effect takes place in
every case, in which the temperature applied pro—
duces a sensation of cold; and this, therefore, as
depending entirely on the relative power of cold,
will be in proportion to the change of temperature
that takes place.
It appears to me probable, that every change of
temperature, from a higher to a lower degree, will
prove more or less stimulant; excepting when the
cold applied is so intense, as immediately to ex—
tinguish the vital principle in the part.
3. Beside the sedative and stimulant powers of
cold, it is manifestly also a powerful astringent,
causing a contraction of the vessels on the surface
of the body, and thereby producing a paleness of
the skin, and a suppression of perspiration; and it
seems to have similar effects when applied to inter—
nal parts. It is likewise probable, that this con—
striction, 

77 OF PHYSIC.
striction, as it takes place especially in consequence
of the sensibility of the parts to which the cold is
applied, will in some measure be communicated to
other parts of the body; and that thereby the ap—
plication of cold proves a tonic power with respect
to the whole system.
These effects of tonic and astringent power seem
to take place both from the absolute and relative
power of cold; and therefore every application of
it, which gives a sensation of cold, is, in its first
effect, both astringent and stimulant, though the
former may be often prevented from being either
considerable or permanent, when the latter imme—
diately takes place.
91.
It will be obvious, that these several effects of
cold cannot all take place at the same time, but
may in succession be variously combined. The sti—
mulant power taking place obviates the effects, at
least the permanency of the effects, that might
otherwise have arisen from the sedative power.
That the same stimulant power prevents these front
the astringent, I have said above; but the stimu—
lant and tonic powers of cold are commonly, per—
haps always, conjoined.
92.
These general effects of cold, now pointed out,
are sometimes salutary, frequently morbid; but it
is the latter only I am to consider here, and they
seem to be chiefly the following.
1. A general inflammatory disposition of the
system, which is commonly accompanied with
Rheumatism, or other Phlegmasiæ.
2. The same inflammatory disposition accompa—
nied with Catarrh.
3. A Gangrene of particular parts.
4. A Palsy 

78 PRACTICE
4. A Palsy of a single member. 
5. A Fever, or Fever strictly so called (8) which
it often produces by its own power alone, but more
commonly it is only an exciting cause of fever, by
concurring with the operation of human or marsh
effluvia.
93.
Cold is often applied to the human body, with—
out producing any of these morbid effects, and it is
difficult to determine, in what circumstances it es—
pecially operates in producing them. It appears
to me, that the morbid effects of cold depend part—
ly upon certain circumstances of the cold itself,
and partly on certain circumstances of the person
to whom it is applied.
94.
The circumstances of the cold applied, which
seem to give it effect, are, 1. The intensity or de—
gree of the cold; 2. The length of time during
 which it is applied; 3. The degree of moisture at
the same time accompanying it; 4. Its being ap—
plied by a wind or current of air; 5. Its being a
a vicissitude or sudden and considerable change of
temperature, from heat to cold.
95.
The circumstances of persons rendering them
more liable to be affected by cold, seem to be,
1. The weakness of the system, and particularly the
lessened vigour of the circulation, occasioned by
fasting, by evacuations, by fatigue, by a last night's
debauch, by excess in venery, by long watching,
by much study, by rest immediately after great ex—
ercise, by sleep, and by preceding disease. 2. The
body, or its parts, being deprived of their accus—
tomed 

79 OF PHYSIC. 
tomed coverings. 3. One part of the body being
exposed to cold, while the rest is kept in its usual
or a greater warmth.
96.
The power of these circumstances (95.) is demon—
strated by the circumstances enabling persons to re—
fill cold. These are a certain vigour of constitu—
tion, exercise of the body, the presence of active
passions, and the use of cordials.
Besides these, there are other circumstances
which, by a different operation, enable persons to
refill cold acting as a sensation; such as, passions
engaging a close attention to one object, the use
of narcotics, and that state of the body in which
sensibility is greatly diminished, as in maniacs.
To all which is to be added, the power of habit
with respect to those parts of the body to which cold
is more constantly applied, which both diminishes
sensibility and increases the power of the activity
generating heat.
97.
Beside cold, there are other powers that seem to
be remote causes of fever; such as, fear, intem—
perance in drinking, excess in venery, and other
circumstances, which evidently weaken the system.
But whether any of these sedative powers be alone
the remote cause of fever, or if they only operate
either as concurring with the operation of marsh or
human effluvia, or as giving an opportunity to the
operation of cold, are questions not to be positive—
ly answered; they may possibly of themselves pro—
duce fever; but most frequently they operate as
concurring in one or other of the ways above men—
tioned.
98. Having 

80 PRACTICE
98.
Having now mentioned the chief of the remote
causes of fevers, it may be further observed, that
these will arise more or less readily, according as
miasmata and contagions are more or less prevail—
ing and powerful, or as these are more or less fa—
voured by the concurrence of cold and other seda—
tive powers.
CHAP. V.
OF THE PROGNOSIS OF FEVERS.
99.
AS fevers (by 60.) consist of both morbid and
salutary motions and symptoms, the tenden—
cy of the disease to a happy or fatal issue, or the
prognostic in fevers, has been established by mark—
ing the prevalence of the morbid or of the salutary
symptoms; and it might be properly so established,
if we could certainly distinguish between the one
and the other of these kinds of symptoms; but the
operation of the reaction, or salutary efforts of na—
ture in curing fevers, is still involved in so much
obscurity, that I cannot explain the several symp—
toms of it so clearly as to apply them to the establish—
ing prognostics; and this, I think, may be done
better, by marking the morbid symptoms which
show the tendency to death in fevers.
100.
This plan of the prognostics in fevers must pro—
ceed upon our knowledge of the causes of death in
general, and in fevers more particularly.
The 

81 OF PHYSIC.
The causes of death, in general, are either direct
or indirect.
The first are those which directly attack and de—
stroy the vital principle, as lodged in the nervous
system; or destroy the organization of the brain im—
mediately necessary to the action of that principle.
The second, or the indirect causes of death, are
those which interrupt such functions as are necessa—
ry to the circulation of the blood, and thereby ne—
cessary to the due continuance and support of the
vital principle.
101.
Of these general causes, those which operate
more particularly in fevers seem to be, first, The
violence of reaction; which either, by repeated vio—
lent excitements, destroys the vital power itself; or,
by its violence, destroys the organization of the
brain necessary to the action of that power; or, by
the same violence, destroys the organization of the
parts more immediately necessary to the circulation
of the blood.
Secondly, The cause of death in fevers may be a
poison, that is, a power capable of destroying the
vital principle; and this poison may be either the
miasma or contagion which was the remote cause
of the fever, or it may be a putrid matter generated
in the course of the fever. In both cases, the ope—
ration of such a power appears either as acting
chiefly on the nervous system, inducing the symp—
toms of debility; or as acting upon the fluids of
the body, inducing a putrescent state in them.
102.
From all this it appears, that the symptoms show—
ing the tendency to death in fevers, may be disco—
vered by their being either the symptoms
Of violent reaction;
VOL. I. L. Of 

82 PRACTICE
Of great debility;
Or, of a strong tendency to putrefaction in the
fluids.
And upon this supposition, I proceed now to
mark those symptoms more particularly.
1O3.
The symptoms which denote the violence of reac—
tion, are, 1. The increased force, hardness, and
frequency of the pulse. 2. The increased heat of
the body. 3. The symptoms which are the marks
of a general inflammatory diathesis, and more espe—
cially of a particular determination to the brain,
lungs, or other important viscera. 4. The symp—
toms which are the marks of the cause of violent
reaction; that is, of a strong stimulus applied, of
of a strong spasm formed, the latter appearing in a
considerable suppression of the excretions.
1O4.
The symptoms which denote a great degree of de-
bility, are,
In the ANIMAL FUNCTIONS: I. The weakness
of the voluntary motions; II. The irregularity of
the voluntary motions, depending on their debili—
ty; III. The weakness of sensation; IV. The weak—
ness and irregularity of the intellectual operations.
In the VITAL FUNCTIONS: I. The weakness of
the pulse; II. The coldness or shrinking of the ex—
tremities; III. The tendency to a deliquium animi
in an erect posture; IV. The weakness of respira—
tion.
In the NATURAL FUNCTIONS: I. The weakness
of the stomach, as appearing in anorexia, nausea,
and vomiting; II. Involuntary excretions depend—
ing upon a palsy of the sphincters; III. Difficult
deglutition, depending upon a palsy of the muscles
of the fauces,
105. Lastly, 

83 OF PHYSIC. 
105.
Lastly, The symptoms denoting the putrescent
state of the fluids, are,
I. With respect to the stomach; the loathing of
animal food, nausea and vomiting, great thirst, and
a desire of acids.
II. With respect to the fluids; 1. The blood
drawn out of the veins not coagulating as usual;
2. Hemorrhagy from different parts, without marks
of increased impetus; 3. Effusions under the skin
or cuticle, forming petechiæ, maculæ, and vibices;
4. Effusions of a yellow serum under the cuticle.
III. With respect to the state of the excretions;
fetid breath, frequent loose and fetid stools, high
coloured turbid urine, fetid sweats, and the fetor
and lived colour of blistered places.
IV. The cadaverous smell of the whole body.
106.
These several symptoms have very often, each
of them singly, a share in determining the progno—
stic; but more especially by their concurrence and
combination with one another; particularly those
of debility with those of putrescency.
1O7.
On the subject of the prognostic, it is proper to
observe, that many physicians have been of opini—
on there is something in the nature of fevers which
generally determines them to be of a certain dura—
tion; and therefore that their terminations, whe—
ther salutary or fatal, happen at certain periods of
the disease, rather than at others. These periods
are called the CRITICAL DAYS; carefully marked
by Hippocrates and other ancient physicians, as well
as by many moderns of the greatest eminence in prac—
tice; 

84 PRACTICE
tice; whilst at the same time many other moderns,
of no inconsiderable authority, deny their taking
place in the fevers of these northern regions which
we inhabit.
108.
I am of opinion that the doctrine of the ancients,
and particularly that of Hippocrates, on this sub—
ject, was well founded; and that it is applicable to
the fevers of our climate.
109.
I am of this opinion, first, Because I observe
that the animal economy, both from its own con—
stitution, and from habits which are easily produce
ed in it, is readily subjected to periodical move—
ments. Secondly, Because, in the diseases of the
human body, I observe periodical movements to
take place with great constancy and exactness; as
in the case of intermittent fevers, and many other
diseases.
110.
These considerations render it probable, that
exact periodical movements may take place in con—
tinued fevers; and I think there is evidence of
such movements actually taking place.
III.
The critical days, or those on which we suppose
the termination of continued fevers especially to
happen, are, the third, fifth, seventh, ninth, ele—
venth, fourteenth, seventeenth, and twentieth. We
mark none beyond this last; because, though fe—
vers are sometimes protracted beyond this period,
it is, however, more rarely; so that there are not
a suffi— 

85 OF PHYSIC. 
a sufficient number of observations to ascertain the
course of them; and further, because it is proba—
ble that, in fevers long protracted, the movements
become less exact and regular, and therefore less
easily observed.
112.
That the days now mentioned are the critical
days, seems to be proved by the particular facts
which are found in the writings of Hippocrates.
From these facts, as collected from the several wri—
tings of that author by M. de Haen, it appears,
that of one hundred and sixty three instances of
the termination of fevers, which happened on one
or other of the first twenty days of the disease,
there are one hundred and seven, or more than
two thirds of the whole number, which happened
on one or other of the eight days above mentioned;
that none happened on the second or thirteenth
day; and upon the eighth, tenth, twelfth, fifteenth,
sixteenth, eighteenth, and nineteenth, there are
but eighteen instances of termination, or one ninth
of the whole.
113.
As the terminations which happen on the seven
days last mentioned, are, upon the whole, few;
and, upon any one of them, fewer than those which
happen on any of our supposed critical days; so
there are therefore nine days which may be called
NONCRITICAL; while, on the other hand, the ma—
ny terminations which happened on the seventh,
fourteenth, and twentieth days, afford a proof both
of critical days in general, and that these are the
chief of them. Hereafter I shall mention an ana—
logy that renders the power of the other critical
days sufficiently probable.
114. It 

86 PRACTICE
114.
It appears further, that as, of the terminations
which were final and salutary, not a tenth part hap—
pened on the noncritical days; and of the termina—
tions which were final and fatal, though the great—
er number happened on the critical days, yet above
a third of them happened on the noncritical; so it
would appear that the tendency of the animal eco—
nomy is to observe the critical days, and that it is
by the operation of some violent and irregular cause
that the course of things is sometimes turned to the
noncritical.
115.
What has been said gives sufficient ground for
presuming, that it is the general tendency of the
animal economy to determine the periodical move
ments in fevers to be chiefly on the critical days.
At the same time, we must acknowledge it to be a
general tendency only; and that, in particular cases,
many circumstances may occur to disturb the regu—
lar course of it. Thus, though the chief and more
remarkable exacerbations in continued fevers hap—
pen on the critical days, there are truly exacerba—
tions happening every day; and these, from cer—
tain causes, may become considerable and critical.
Further, though intermittent fevers are certainly
very strongly determined to observe a tertian or
quartan period, we know there are circumstances
which prevent them from observing these periods
exactly, and which render them either anticipating
or postponing so much, that the days of paroxysms
come to be quite changed; and it is allowable to
suppose, that the like may happen with respect to
the exacerbations of continued fevers, so as there—
by to disturb the regular appearance of critical days.
A par— 

87 OF PHYSIC.
A particular instance of this occurs with respect
to the sixth day of fevers. In the writings of Hip-
pocrates, there are many instances of terminations
happening on the sixth day; but it is not therefore
reckoned among the critical days; for, of the termi—
nations happening on that day, there is not one
which proves finally of a salutary kind; the great—
er number are fatal; and all the rest are imperfect,
and followed with a relapse. All this shows, that
some violent cause had, in these cases, produced a
deviation from the ordinary course of nature; that
the terminations on the sixth day are nothing more
than anticipations of the seventh, and therefore a
proof of the power of this last.
116.
The doctrine of critical days has been much em—
barrassed by some dissonant accounts of it, which
appear in the writings imputed to Hippocrates. But
this may be justly accounted for from these writ—
ings being truly the works of different persons, and
from the most genuine of them having suffered ma—
ny corruptions; so that, in short, every thing
which is inconsistent with the facts above laid down,
may be ascribed to one or other of these causes.
117.
This, further, has especially disturbed the doc—
trine of critical days, that Hippocrates himself at—
tempted, perhaps too hastily, to establish general
rules, and to bring the doctrine to a general theo—
ry, drawn from Pythagorean opinions concerning
the power of numbers. It is this which seems to
have produced the idea of odd days, and of a qua—
ternary and septenary period, doctrines which ap—
pear so often in the writings of Hippocrates. These,
however, are inconsistent with the facts above laid
down; 

88 PRACTICE
down; and indeed, as Asclepiades and Celsus have
observed, are inconsistent with one another.
118.
Upon the whole, therefore, it is apprehended,
that the critical days above assigned are truly the
critical days of Hippocrates, and may be consist-
ently explained in the following manner.
119.
From the universality of tertian or quartan pe—
riods in intermittent fevers, we cannot doubt of
there being, in the animal economy, a tendency to
observe such periods; and the critical days above
mentioned are consistent with this tendency of the
economy, as all of them mark either tertian or
quartan periods. These periods, however, are not
promiscuously mixed, but occupy constantly their
several portions in the progress of the disease; so
that, from the beginning to the eleventh day, a
tertian period takes place; and, from the eleventh
to the twentieth, and perhaps longer, a quartan
period is as steadily observed.
120.
What determines the periods to be changed about
the eleventh day, we have not clearly perceived;
but the fact is certain; for there is no instance of
any termination on the thirteenth, that is, the ter—
tian period next following the eleventh; whereas,
upon the fourteenth, seventeenth, and twentieth,
which mark quartan periods, there are forty three
instances of terminations, and six only on all the
intermediate days between these.
This prevalence of a quartan period leaves no
room for doubting that the twentieth, and not the
twenty first, is the critical day marked by Hippo—
crates, 

89 OF PHYSIC. 
crates; though the last is mentioned as such in the
common edition of the Aphorisms, taken from an
erroneous manuscript, which Celsus also seems to
have copied.
121.
A consistency with the general tendency of the
system, renders the series of critical days we have
mentioned, probably the true one; and the only
remaining difficulty in finding what we have de—
livered to be the same with the genuine doctrine of
Hippocrates, is the frequent mention of the fourth
as a critical day.
It is true there are more instances of termina—
tions happening on this day, than on some of those
days we have asserted to be truly critical; but its;
inconsistency with the more general tendency, and
some other considerations, lead us to deny its be—
ing naturally a critical day; and to think, that the
instances of terminations, which have really oc—
curred on the fourth day, are to be reckoned
among the other irregularities that happen in this
matter.
122.
I have thus endeavoured to support the doctrine
of critical days, chiefly upon the particular facts
to be found in the writings of Hippocrates: And
although I might also produce many other testimo—
nies of both ancient and modern times, yet it must
be owned, that some of these testimonies may be
suspected to have arisen rather from a veneration
of Hippocrates, than from accurate observation.
123.
With respect to the opinions of many moderns,
who deny the prevalence of critical days, they are
VOL. I. M to 

90 PRACTICE
to be little regarded; for the observation of the
course of continued fevers is known to be difficult
and fallacious; and therefore the regularity of that
course may have often escaped inattentive and pre—
judiced observers.
124.
Our own observations amount to this, that fe—
vers with moderate symptoms, generally cases of
the synocha, frequently terminate in nine days, or
sooner, and very constantly upon one or other of
the critical days which fall within that period; but
it is very rare, in this climate, that cases of either
the typhus or synochus terminate before the ele—
venth day; and when they do terminate on this day,
it is for the most part fatally. When they are pro—
tracted beyond this time, I have very constantly
found, that their terminations were upon the four—
teenth, seventeenth, or twentieth day.
In such cases, the salutary terminations are sel—
dom attended with any considerable evacuation.
A sweating frequently appears, but is seldom con—
siderable; and I have hardly ever observed critical
and deceive terminations attended with vomiting,
evacuations by stool, or remarkable changes in the
urine. The solution of the disease is chiefly to be
discerned from some return of sleep and appetite,
the ceasing of delirium, and an abatement of the
frequency of the pulse. By these symptoms we can
often mark a crisis of the disease; but it seldom
happens suddenly and entirely; and it is most com—
monly from some favourable symptoms occurring
upon one critical day, that we can announce a
more entire solution upon the next following.
Upon the whole, I am persuaded, that, if obser—
vations shall be made with attention, and without
prejudice, I shall be allowed to conclude with the
words of the learned and sagacious Gaubius, “ Fal—
“ lor, 

91 OF PHYSIC. 
“ lor, ni sua constiterit HIPPOCRATI auctoritas,
“ GALENO sides, NATURÆ virtus et ordo.”
CHAP. VI.
OF THE METHOD OF CURE IN FEVERS.
SECT. I.
Of the CURE of CONTINUED FEVERS.
125.
AS it is allowed, that, in every fever which has
its full course, there is an effort of nature of
a salutary tendency, it might be supposed that the
cure of fevers should be left to the operations of
nature, or that our art should be only directed to
support and regulate these operations, and that we
should form our indications accordingly. This
plan, however, I cannot adopt, because the ope—
rations of nature are very precarious, and not so
well understood as to enable us to regulate them
properly. It appears to me, that trusting to these
operations has often given occasion to a negligent
and inert practice; and there is reason to believe,
that an attention to the operations of nature may
be often superseded by art.
126.
The plan which to me appears to be most suitable,
is that which forms the indications of cure upon
the view of obviating the tendency to death; while,
at the same time, the means of executing these in—
dications are directed by a proper attention to the
proximate cause of fevers.
Upon this plan, in consequence of what has been
laid down above on the subject of the prognostic,
we 

93 PRACTICE
we form three general indications in the cure of
continued fevers; and the one or other of these is
to be employed according as the circumstances of
the fever (102.) shall direct.
The first therefore is, To moderate the violence of
reaction. 
The second is, To remove the causes or obviate
the effects of debility. And,
The third is, To obviate or correct the tendency of
the fluids to putrefaction.
127.
The first indication may be answered, that is, the
violence of reaction may be moderated,
1. By all those means which diminish the action
of the heart and arteries.
2. By those means which take off the spasm of
the extreme vessels, which we suppose to be the
chief cause of violent reaction.
128.
The action of the heart and arteries may be di—
minished,
1. By avoiding or moderating those irritations,
which, in one degree or other, are almost constant—
ly applied to the body.
2. By the use of certain sedative powers.
3. By diminishing the tension and tone of the
arterial system.
129.
The irritations (128. 1.) almost constantly appli—
ed, are the impressions made upon our senses; the
exercise of the body and mind; and the taking in
of aliments. The avoiding these as much as pos—
sible, or the moderating their force, constitute
what is rightly called the ANTIPHLOGISTIC REGI— 
MEN,

93 OF PHYSIC. 
MEN, proper to be employed in almost every con—
tinued fever.
13O.
The conduct of this regimen is to be directed by
the following rules and considerations.
1. Impressions on the external senses, as being
stimulant to the system, and a chief support of its
activity, should be avoided as much as possible;
those especially of more constant application, those
of a stronger kind, and those which give pain and
uneasiness.
No impression is to be more carefully guarded
against, than that of external heat; while at the
same time, every other means of increasing the
heat of the body is to be shunned. Both these pre—
cautions are to be observed, as soon as a hot stage
is fully formed, and to be attended to during its
continuance; excepting in certain cases, where a
determination to sweating is necessary, or where
the stimulant effects of heat may be compensated
by circumstances which determine it to produce a
relaxation and revulsion.
2. All motion of the body is to be avoided,
especially that which requires the exercise of its own
muscles; and that posture of the body is to be cho—
sen, which employs the fewest muscles, and which
keeps none of them long in a state of contraction.
Speaking, as it accelerates respiration, is parti—
cularly to be refrained from.
It is to be observed, that every motion of the
body is the more stimulant, in proportion as the
body is weaker.
3. The exercise of the mind also is a stimulus to
the body; so that all impressions, which lead to
thought, and those especially which may excite
emotion or passion, are to be carefully shunned.
With respect to avoiding impressions of all kinds,
an exception is to be made in the case of a deliri—
um 

94 PRACTICE
um coming on, when the presenting of accustom—
ed objects may have the effect of interrupting and
diverting the irregular train of ideas then arising in
the mind.
4. The presence of recent aliment in the stomach
proves always a stimulus to the system, and ought
therefore to be as moderate as possible. A total
abstinence for some time may be of service; but as
this cannot be long continued with safety, we must
avoid the stimulus of aliment, by choosing that
kind which gives the least. We suppose that ali—
mentary matters are more stimulant, according as
they are more alkalescent; and this leads to avoid
all animal, and to use vegetable food only.
As our drinks also may prove stimulant, so all
aromatic and spirituous liquors are to be avoided;
and in answering the present indication, all fer—
mented liquors, excepting those of the lowest qua—
lity, are to be abstained from.
131.
Besides these stimulant powers more constantly
applied, there are others, which, although occa—
sional only, yet, as commonly accompanying fe—
vers, must be attended to and removed.
One is, the sense of thirst, which as a powerful
stimulus, ought, always, in one way or other, to be
removed.
Another stimulus frequently arises from crudi—
ties, or corrupted humours, in the stomach; and
it is to be removed by vomiting, by dilution, or
by the use of acids.
A third stimulus often arises from the preterna—
tural retention of fæces in the intestines; and ought
to be removed by frequent laxative glysters.
A fourth stimulus to be constantly suspected in
fevers, is a general acrimony of the fluids, as pro—
duced by the increase of motion and heat, joined
with an interruption of the excretions. This acri—
mony 

95 OF PHYSIC. 
mony is to be obviated or removed by the taking
in of large quantities of mild antiseptic liquors.
132.
The avoiding of irritation in all these particulars,
(130. and 131.) constitutes the antiphlogistic regi—
men absolutely necessary for moderating the vio—
lence of reaction; and, if I mistake not, is proper
in almost every circumstance of continued fevers;
because the propriety and safety of employing sti—
mulants is often uncertain; and because several of
those above mentioned, beside their stimulant pow—
ers, have other qualities by which they may be
hurtful.
It appears to me, that the supposed utility of
stimulants, in certain cases of fever, has often
arisen from a mistake in having ascribed to their
stimulant, what really depended upon their anti—
spasmodic power.
l33.
A second head of the means (128. 2.) for mo—
derating the violence of reaction, comprehends
certain sedative powers, which may be employed
to diminish the activity of the whole body, and
particularly that of the sanguiferous system.
The first of these to be mentioned is the appli—
cation of cold.
Heat is the chief support of the activity of the
animal system; which is therefore provided in it—
self with a power of generating heat. But, at the
same time, we observe, that this would go to ex—
cess, were it not constantly moderated by a cooler
temperature in the surrounding atmosphere. When,
therefore, that power of the system generating heat
is increased, as is commonly the case in fevers, it
is necessary not only to avoid all means of increas—
ing it further, but it seems proper also to apply air 
of

96 PRACTICE
of a cooler temperature; or at least to apply it
more entirely and freely, than in a state of health.
Some late experiments in the small pox and in
continued fevers, show that the free admission of
cool air to the body, is a powerful remedy in mo—
derating the violence of reaction; but what is the
mode of its operation, to what circumstances of fe—
ver it is peculiarly adapted, or what limitations it
requires, I shall not venture to determine, till more
particularly instructed by further experience.
134.
A second sedative power which may be employ—
ed in fevers, is that of certain medicines, known,
in the writings on the Materia Medica, under the
title of REFRIGERANTS.
The chief of these are acids of all kinds, when suf—
ficiently diluted; and they are, in several respects,
remedies adapted to continued fevers. Those espe—
cially in use are, the Vitriolic and Vegetable; and,
on many accounts, we prefer the latter.
135.
Another set of refrigerants are, the Neutral Salts,
formed of the vitriolic, nitrous or vegetable acids;
with alkalines, either fixed or volatile. All these
neutrals, while they are dissolving in water, gene—
rate cold; but as that cold ceases soon after the
solution is finished, and as the salts are generally
exhibited in a dissolved state, their refrigerant
power in the animal body does not at all depend
upon their power of generating cold with water.
The neutral chiefly employed as a refrigerant, is
Nitre; but all the others, compounded as above
mentioned, partake more or less of the same quality.
136. Besides

97 OF PHYSIC.
136.
Besides these neutrals, some metallic salts also
have been employed as refrigerants in fevers; and
particularly the Sugar of Lead. But the refriger—
ant powers of this are not well ascertained; and its
deleterious qualities are too well known to admit
of its being freely used.
137.
Under the third general head (128. 3.) of the
means to be employed for moderating the violence
of reaction, are comprehended the several means
of diminishing the tension, tone, and activity, of
the sanguiferous system. As the activity of this
system depends, in a great measure, upon the tone,
and this again upon the tension of the vessels, giv—
en to them by the quantity of fluids they contain,
it is evident, that the diminution of the quantity
of these must diminish the activity of the sanguife—
rous system.
138.
The quantity of fluids contained in the sangui—
ferous system, may be diminished most convenient—
ly by the evacuations of bloodletting and purging.
l39.
Nothing is more evident, than that bloodletting
is one of the most powerful means of diminishing
the activity of the whole body, especially of the
sanguiferous system; and it must therefore be the
most effectual means of moderating the violence of
reaction in fevers. Taking this as a fact, I omit
inquiring into its mode of operation, and shall on—
ly consider in what circumstances of fevers it may
be most properly employed.
VOL. I. N 140. When 

98 PRACTICE
140.
When the violence of reaction, and its constant
attendant, a phlogistic diathesis are sufficiently
manifest; when these constitute the principal part
of the disease, and may be expected to continue
throughout the whole of it, as in the cases of syno—
cha; then bloodletting is the principal remedy, and
may be employed as far as the symptoms of the dis—
ease may seem to require, and the constitution of
the patient will bear. It is, however, to be attend—
ed to, that a greater evacuation than is necessary,
may occasion a slower recovery, may render the
person more liable to a relapse, or may bring on
other diseases.
141.
In the case of synocha, therefore, there is little
doubt about the propriety of bloodletting; but
there are other species of fever, as the synochus, in
which a violent reaction and phlogistic diathesis
appear, and prevail during some part of the course
of the disease; while, at the same time, these cir—
cumstances do not constitute the principal part of
the disease, nor are to be expected to continue
during the whole course of it; and it is well known,
that, in many cases, the state of violent reaction is
to be succeeded, sooner or later, by a state of de—
bility, from the excess of which the danger of the
disease is chiefly to arise. It is, therefore, neces—
sary, that, in many cases, bloodletting should be
avoided; and even although during the inflamma—
tory state of the disease, it may be proper, it will
be necessary, to take care that the evacuation be
not so large as to increase the state of debility
which is to follow.
142. From 

99 OF PHYSIC.
142. 
From all this it must appear, that the employing
bloodletting, in certain fevers, requires much dis—
cernment and skill, and is to be governed by the
consideration of the following circumstances:
1. The nature of the prevailing epidemic:
2. The nature of the remote cause.
3. The season and climate in which the disease
occurs.
4. The degree of phlogistic diathesis present.
5. The period of the disease.
6. The age, vigour, and plethoric state of the
patient.
7. The patient's former diseases and habits of
bloodletting.
8. The appearance of the blood drawn out.
9. The effects of the bloodletting that may have
been already practised.
143.
When, after the consideration of these circum—
stances, bloodletting is determined to be necessa—
ry, it should be observed, that it is more effectual,
according as the blood is more suddenly drawn off,
and as the body is at the same time more free from
all irritation, and consequently when in a posture
in which the fewest muscles are in action.
144.
Another evacuation, whereby the quantity of
fluids contained in the body can be considerably
diminished, is that of purging.
145.
If we consider the quantity of fluids constantly
present in the cavity of the intestines, and the quan—
tity 

100 PRACTICE
tity which may be drawn from the innumerable ex—
cretories that open into this cavity, it will be ob—
vious, that a very great evacuation can be made
by purging; and if this be done by a stimulus ap—
plied to the intestines, without being at the same
time communicated to the rest of the body, it may,
by emptying both the cavity of the intestines, and
the arteries which furnish the excretions poured in—
to it, induce a considerable relaxation in the whole
system; and therefore purging seems to be a reme—
dy suited to moderate the violence of reaction in
fevers.
146.
But it is to be observed, that as the fluid drawn
from the excretories opening into the intestines, is
not all drawn immediately from the arteries, as a
part of it is drawn from the mucous follicles only;
and as what is even more immediately drawn from
the arteries, is drawn off slowly, so the evacuation
will not, in proportion to its quantity, occasion
such a sudden depletion of the red vessels, as blood—
letting does; and therefore cannot operate so
powerfully in taking off the phlogistic diathesis of
the system.
147.
At the same time, as this evacuation may induce
a considerable degree of debility; so, in those ca—
ses, in which a dangerous state of debility is like—
ly to occur, purging is to be employed with a
great deal of caution; and more especially as the
due measure of the evacuation is more difficult to
be applied than in the case of bloodletting.
148.
As we shall presently have occasion to observe,
that it is of great importance, in the cure of fevers,
to 

l01 OF PHYSIC.
to restore the determination of the blood to the ves—
sels on the surface of the body; so purging as in
some measure taking off that determination, seems
to be an evacuation not well adapted to the cure
of fevers.
149.
If, notwithstanding these doubts, (146. 147. and
148.) it shall be asserted, that purging, even from
the exhibition of purgatives, has often been useful
in fevers; I would beg leave to maintain, that this
has not happened from a large evacuation; and
therefore, not by moderating the violence of reac—
tion, excepting in the case of a more purely inflam—
matory fever, or of exanthemata of an inflamma—
tory nature. In other cases of fever, I have seen
a large evacuation by purging, of mischievous con—
sequence; and if upon occasion, a more moderate
evacuation has appeared to be useful, it is appre—
hended to have been only by taking off the irrita—
tion of retained fæces, or by evacuating corrupted
humours, which happened to be present in the in—
testines; for both of which purposes, frequent lax—
atives may be properly employed.
15O.
Another set of means (127, 2.) for moderating
the violence of reaction in fevers, are those suited
to take off the spasm of the extreme vessels, which
we believe to be the irritation that chiefly supports
the reaction.
Though I have put here this indication of taking
off the spasm of the extreme vessels, as subordinate
to the general indication of moderating the vio—
lence of reaction; it is, however, to be observed
here, that as fever universally consists in an increas—
ed action of the heart, either in frequency or in
force, which in either case is supported by a spasm
of 

102 PRACTICE
of the extreme vessels, so the indication for remov—
ing this is a very general one, and applicable in al—
most every circumstance of fever, or at least, with
a few exceptions, to be taken notice of hereafter.
151.
For taking off the spasm of the extreme vessels,
the means to be employed are either internal or
external.
152.
The internal means (151.) are,
1. Those which determine the force of the cir—
culation to the extreme vessels on the surface of the
body, and, by restoring the tone and activity of
these vessels, may overcome the spasm on their ex—
tremities.
2. Those medicines which have the power of tak—
ing off spasm in any part of the system, and which
are known under the title of ANTISPASMODICS.
153.
Those remedies which are fit to determine to the
surface of the body, are,
1. DILUENTS.
2. NEUTRAL SALTS. 
3. SUDORIFICS. 
4. EMETICS. 
154.
Water enters, in a large proportion, into the
composition of all the animal fluids, and a large
quantity of it is always diffused through the whole
of the common mass. Indeed, in a found state,
the fluidity of the whole mass depends upon the
quantity of water present in it. Water, therefore,
is 

103 OF PHYSIC.
is the proper diluent of our mass of blood; and
other fluids are diluent only in proportion to the
quantity of water they contain.
155.
Water may be said to be the vehicle of the seve-
ral matters which ought to be excerned; and in a
healthy state the fulness of the extreme vessels, and
the quantity of excretions, are nearly in proportion
to the quantity of water present in the body. In
fever, however, although the excretions are in some
measure interrupted, they continue in such quan—
tity as to exhale the more fluid parts of the blood;
and while a portion of them is at the same time ne—
cessarily retained in the larger vessels, the smaller
and the extreme vessels, both from the deficiency
of fluid, and their own contracted state, are less
filled, and therefore allowed to remain in that con—
dition.
156.
To remedy this contracted state, nothing is more
necessary than a large supply of water or watery
fluids, taken in by drinking or otherwise; for as
any superfluous quantity of water is forced off by
the several excretories, such a force applied, may
be a means of dilating the extreme vessels, and of
overcoming the spasm affecting their extremities.
157.
Accordingly the throwing in of a large quantity
of watery fluids has been, at all times, a remedy
much employed in fevers; and in no instance more
remarkably, than by the Spanish and Italian phy—
sicians, in the use of what they call the Diœta
aquea.
158. This 

104 PRACTICE
158.
This practice consists in taking away every other
kind of aliment and drink, and in giving in divid—
ed portions every day, for several days together,
six or eight pounds of plain water, generally cold,
but sometimes warm. All this, however, is to be
done only after the disease has continued for some
time, and, at least, for a week.
159.
A second means (153. 2.) of determining to the
surface of the body, is by the use of neutral salts.
These, in a certain dose taken into the stomach,
produce, soon after, a sense of heat upon the sur—
face of the body; and, if the body be covered close
and kept warm, a sweat is readily brought out.
The same medicines, taken during the cold stage
of a fever, very often put an end to the cold stage,
and bring on the hot; and they are also remarka—
ble for stopping the vomiting which so frequently
attends the cold stage of fevers. All this shows,
that neutral salts have a power of determining the
blood to the surface of the body, and may there—
fore be of use in taking off the spasm which in fe—
vers subsists there.
160.
The neutral most commonly employed in fevers
is that formed of an alkali with the native acid of
vegetables; but all the other neutrals have more or
less of the same virtue; and perhaps some of them,
particularly the ammoniacal salts, possess it in a
stronger degree.
161. As 

105 OF PHYSIC.
161.
As cold water taken into the stomach, often shows
the same diaphoretic effects with the neutral salts,
it is probable that the effect of the latter depends
upon their refrigerant powers mentioned above,
(134.) What is the effect of the neutral salts, giv—
en when they are forming and in a state of effer—
vescence? It is probable that this circumstance
may increase the refrigerant power of these salts,
and may introduce into the body a quantity of fix—
ed air; but for these purposes it would seem pro—
per to contrive that the whole of the effervescence
should take place in the stomach. 
162.
A third means (153. 3.) of determining to the
surface of the body, and taking off the spasm sub—
sisting there, is by the use of sudorific medicines,
and of sweating.
163.
The propriety of this remedy has been much
disputed; and specious arguments may be adduced
both for and against the practice.
In favour of the practice, it may be said;
1. That, in healthy persons, in every case of in—
creased action of the heart and arteries, a sweating
takes place, and is seemingly the means of prevent—
ing the bad effects of such increased action.
2. That, in fevers, their most usual solution and
termination is by spontaneous sweating
3. That, even when excited by art, it has been
found manifestly useful, at certain periods, and in
certain species of fever.
VOL. I. O 164. Upon 

106 PRACTICE
164.
Upon the other hand, it may be urged against
the practice of sweating;
1. That as in fevers a spontaneous sweating does
not immediately come on, so there must be in these
some circumstances different from those in the state
of health, and which may therefore render it doubt—
ful, whether the sweating can be safely excited by
art. 
2. That, in many cases, the practice has been at—
tended with bad, consequences. The means com—
monly employed have a tendency to produce an
inflammatory diathesis; which, if not taken off by
the sweat following their use, must be increased
with much danger. Thus sweating, employed to
prevent the accessions of intermitting fevers, has
often changed them into a continued form, which
is always dangerous.
3. The utility of the practice is further doubt—
ful, because sweating, when it happens, does not
always give a final determination; as must be ma—
nifest in the case of intermittents, as well as in ma—
ny continued fevers, which are sometimes in the
beginning attended with sweatings that do not prove
final; and, on the contrary, whether spontaneous
or excited by art, seem often to aggravate the
disease.
165.
From these considerations, it is extremely doubt—
ful if the practice of sweating can be admitted very
generally; but at the same time, it is also doubt—
ful, if the failure of the practice, or the mischiefs
said to have arise from it, have not been owing
to the improper conduct of the practitioner.
With respect to this last, it is almost agreed a—
mong physicians. 
1. That 

107 OF PHYSIC. 
I. That sweating has been generally hurtful,
when excited by stimulant, heating, and inflamma—
tory medicines.
2. That it has been hurtful, when excited by
much external heat, and continued with a great
increase of the heat of the body.
3. That it is always hurtful, when it does not
soon relieve, but rather increases, the frequency
and hardness of the pulse, the anxiety and difficul—
ty of breathing, the head ach, and delirium—
4. That it is always hurtful, if it be urged when
the sweat is not fluid, and when it is partial, and
on the superior parts of the body only.
166. 
In these cases, it is probable, that either an in—
flammatory diathesis is produced, which increases
the spasm on the extreme vessels; or that, from
other causes, the spasm is too much fixed to yield
easily to the increased action of the heart and arte—
ries; and, upon either supposition, it must be ob—
vious, that urging the sweat, as ready to produce
a hurtful determination to some of the internal
parts, may be attended with very great danger.
167. 
Though the doubts started (164.) are to be at—
tended to; and although the practices (165.) hav—
ing been found hurtful, are therefore to be reject—
ed; it still remains true,
1. That sweating has certainly been often useful
in preventing the accession of fevers, when the
times of this have been certainly foreseen, and a
proper conduct employed.
2. That, even after fevers have in some measure
come on, sweating, when properly employed, either
at the very beginning of the disease, or during its
approach 

108 PRACTICE
approach and gradual formation, has often pre—
vented their further progress.
3. That, even after pyrexiæ have continued for
some time, sweating has been successfully employæ
ed in curing them, as particularly in the case of
rheumatism.
4. That certain fevers, produced by a very pow—
erful sedative contagion, have been generally treat—
ed, so far as we yet know, most successfully by
sweating.
168.
These instances (167.) are in favour of sweating,
but give no general rule; and it must be left to
further experience to determine how far any gene—
ral rule can be established in this matter. In the
mean time, if the practice of sweating is to be at—
tempted, we can venture to lay down the follow—
ing rules for the conduct of it.
1. That it should be excited without the use of
stimulant inflammatory medicines.
2. That it should be excited with as little exter—
nal heat, and with as little increase of the heat of
the body, as possible.
3. That, when excited, it should be continued
for a due length of time, not less than twelve hours,
and sometimes for twenty four or forty eight hours;
always, however, providing that it proceeds with—
out the circumstances mentioned (165. 3. 4.) 
4. That for some part of the time, and as long
as the person can easily bear, it should be carri—
ed on without admitting of sleep.
5. That it should be rendered universal over the
whole body; and, therefore, particularly, that care
be taken to bring the sweating to the lower extre—
mities.
6. That the practice should be rendered safer
by moderate purging, excited at the fame time.
7. That 

109 OF PHYSIC.
7. That it should not be suddenly checked by
cold any how applied to the body.
169.
When attention is to be given to these rules,
the sweating may be excited, 1. By warm bathing,
or a fomentation of the lower extremities. 2. By
frequent draughts of tepid liquors, chiefly water,
rendered more grateful by the addition of a light
aromatic, or more powerful by that of a small
quantity of wine. 3. By giving some doses of neu—
tral salts. 4. Most effectually, and perhaps most
safely, by a large dose of an opiate, joined with a
portion of neutral salts, and of an emetic.
In what cases may cold water, thrown into the
stomach in large quantities, be employed to excite
sweating? See CELSUS, Lib. III. Cap. vii.—ix.
170.
The fourth means (153. 1.) of determining to
the surface of the body, and thereby taking off the
spasm affecting the extreme vessels, is by the use
of emetics.
171.
Emetics, and particularly antimonial emetics,
have been employed in the cure of fevers ever since
the introduction of chemical medicines; but, for
a long time, they were employed by chemists and
chemical practitioners only; and although of late
the use of them has become very general, their
efficacy is still disputed, and their manner of ope—
rating is not commonly explained.
172.
Vomiting is, in many respects, useful in fevers;
as it evacuates the contents of the stomach; as it
emulges 

110 PRACTICE
emulges the biliary and pancreatic ducts; as it eva—
cuates the contents of the duodenum, and perhaps
also of a larger portion of the intestines; as it agi—
tates the whole of the abdominal viscera, expedes
the circulation in them, and promotes their several
secretions; and, lastly, as agitating also the viscera
of the thorax, it has like effects there. All these
several effects are, in many cases and circumstances
of fever, procured with advantage; but do not pro—
perly fall under our view here, where we are to
consider only the effect of vomiting in determining
to the surface of the body.
173.
This effect we do not impute to the exercise of
vomiting, in agitating the whole frame; but to the
particular operation of emetics upon the muscular
fibres of the stomach, whereby they excite the ac—
tion of the extreme arteries on the surface of the
body, so as thereby effectually to determine the
blood into these vessels, remove the atony, and
take off the spasm affecting them.
174.
That such is the power of emetics, will appear
from the several considerations mentioned above
(44.); and therefore, that they are remedies well
suited to the cure of fevers.
175.
Emetics, for that purpose, are administered in
two different ways; that is, either in such doses
as may excite full and repeated vomitings; or in
such doses as may excite sickness and nausea only,
with little or no vomiting at all.
176. Full 

111 OF PHYSIC.
176.
Full vomiting is best suited to the several pur—
poses mentioned (172.); and is also well suited to
determine to the surface of the body, so as there—
by to obviate the atony and spasm which lay the
foundation of fever. Thus vomiting, excited a
little before the expected accession of the paroxysm
of an intermittent, has been found to prevent the
paroxysm altogether. And it has been observed
also, that when contagion has been applied to a
person, and first discovers its operation, a vomit
given will prevent the fever, which was otherwise
to have been expected. See LIND on Fevers and
Infection.
177.
These are advantages to be obtained by exci—
ting vomiting at the first approach of fevers, or of
the paroxysms of fevers; and after fevers are form—
ed, vomiting may also be employed, to take off,
perhaps entirely, the atony and spasm, or at least
to moderate these, so that the fever may proceed
more gently and safely.
178.
It is seldom, however, that vomiting is found to
produce a final solution of fevers; and after they
are once formed, it is commonly necessary to re—
peat the vomiting several times; but this is attend—
ed; with inconvenience, and sometimes with disad—
vantage. The operation of full vomiting common—
ly, soon ceases, and the exercise of vomiting is oft—
en a debilitating power; and therefore, when the
vomiting does not remove the atony and spasm
entirely, it may give occasion to their recurring
with greater force.
179. For 

112 PRACTICE
179.
For these reasons, after fevers are fully formed,
physicians have thought proper to employ emetics
in nauseating doses only. These are capable of
exciting the action of the extreme vessels, and their
operation is more permanent. At the same time,
they often show their power by exciting some de—
gree of sweat; and their operation is rendered more
safe, by their commonly producing some evacuati—
on by stool.
180.
Such are the advantages to be procured by nau—
seating doses of emetics; and it only remains to
mention, what are the medicines most fit to be em—
ployed in that manner, what are the most proper
times for exhibiting, and what is the best manner
of administering them.
181.
The emetics at present chiefly in use, are, Ipe—
cacuanha and Antimony.
The former may be employed for every purpose
of emetics, particularly those mentioned (172). It
may likewise be employed, either in larger or
smaller doses, for determining to the surface of the
body; but, even in very small doses, it so readily
excites vomiting, as to be with difficulty employed
for the purpose of nauseating only; and, however
employed, there is reason to believe, that its effects
are less permanent, and less powerfully communi—
cated from the stomach to the rest of the system,
than those of Antimony.
182. This, 

113 OF PHYSIC. 
l82.
This, therefore, is generally preferred; and its
preparations, seemingly various, may all be refer—
red to two heads; the one comprehending those in
which the reguline part is in a condition to be act—
ed upon by acids; and therefore, on meeting with
acids in the stomach, becomes active; and the other
comprehending those preparations in which the re—
guline part is already joined with an acid, render—
ing it active.
183.
Of each kind there are great numbers, but not
differing essentially from one another. It will be
enough for us to compare the Calx Antimonii Ni—
trata of the Edinburgh Dispensatory with the Eme—
tic Tartar of the same. The former, as I judge,
is nearly the same with what is called James's Pow—
der. Which of these is best suited to the cure of
fevers, as above explained, seems doubtful; but it
appears to me, that, although the former may have
some advantages from its flower operation, and may
thereby seem to be more certainly sudorific and
purgative, yet the uncertainty of its dose renders
it inconvenient, has often given occasion to the
timid to be disappointed, and to the bold to do
mischief. On the other hand, the dose of the
Emetic Tartar can be exactly ascertained; and I
think it may be exhibited in such a manner as to
produce all the advantages of the other. 
184.
Whichsoever of these preparations be employed,
I judge the most proper time for exhibiting them,
to be the time of accessions; or a little before, when
that can be certainly known. In continued fevers,
VOL. I. P the 

114 PRACTICE
the exacerbations are not always very observable;
but there is reason to think, that one commonly
happens about noon, or soon after it, and another
in the evening; and that these, therefore, are the
most proper times for exhibiting emetics.
185.
With respect to the manner of administration,
that of the Calx Nitrata is simple, as the whole of
what is judged a proper dose is given at once, and
no more can properly be given till the time of the
next accession.
The administration of the Emetic Tartar is differ—
ent. It is to be given in small doses, not sufficient
to excite vomiting; and these doses, after short in—
tervals, are to be repeated for several times, till,
sickness, nausea, and some, but not much, vomit—
ing, come on. The difference of this administra—
tion must depend upon the dose, and the length
of the intervals at which it is given. If it be in—
tended that the medicine should certainly operate
by stool, the doses are made small, and the inter—
vals long. On the contrary, when vomiting is pro—
per, or when much purging ought to be avoided,
and therefore some vomiting must be admitted, the
doses are made larger and the intervals shorter.
186.
With respect to both kinds of preparations, the
repetition is to be made at the times of accession,
but not very often; for if the first exhibitions, du—
ly managed, have little effect, it is seldom that the
after exhibitions have much; and it sometimes hap—
pens that the repeated vomitings, and especially
repeated purgings, do harm by weakening the pa—
tient.
187. The 

ll5 OF PHYSIC.
187.
The other set of internal medicines, (152. 2.)
which I suppose may be useful in taking off the
spasm of the extreme vessels, are those named An—
tispasmodic. How many of these may be proper—
ly employed, I am uncertain; and their mode of
operation is involved in great obscurity. It is cer—
tain, however, that opium, camphor, musk, and
perhaps some others, have been employed in fevers
with advantage; but the circumstances in which
they are especially proper and safe, I find difficult
to ascertain; and therefore cannot venture here to
lay down any general doctrine concerning them.
188.
The external means (151.) suited to take off the
spasm of the extreme vessels, are BLISTERING and
WARM BATHING.
189.
What are the effects of Blistering, so frequently
employed in fevers, is not yet agreed upon among
physicians; and many different opinions have been
maintained on this subject, drawn not only from
reasoning, but also from presumed experience. I
must not, however, enter into controversy; but
shall deliver my own opinion in a few words.
190.
I am persuaded, that the small quantity of can—
tharides absorbed from a blistering plaster, is not
sufficient to change the consistence of the mass of
blood; and therefore that such a quantity can nei—
ther do good, by resolving phlogistic lentor, if it
exists; nor do harm, by increasing the dissolution 
of

116 PRACTICE
of the blood arising from a putrid tendency in it.
I therefore neglect entirely the effects of canthari—
des upon the fluids.
191.
The inflammation produced by the application of
cantharides to the skin, affords a certain proof of
their stimulant power; but in many persons, the
effect of that stimulus is not considerable; in many
it is not communicated to the whole system; and
even when the effect does take place in the whole
system, it seems to be taken off entirely, by the ef—
fusion and evacuation of serum from the blistered
part. I conclude, therefore, that neither much
good is to be expected, nor much harm to be ap—
prehended, from the stimulant power of blistering;
and the certainty of this conclusion is established,
by the great benefit arising from the proper prac—
tice of blistering in inflammatory diseases.
192.
Much has been imputed to the evacuation occa—
sioned by blistering; but it is never so considerable
as to affect the whole system; and therefore can
neither, by sudden depletion, relax the sanguife—
rous vessels, nor, by any revulsion, affect the ge—
neral distribution of the fluids.
193.
The evacuation, however, is so considerable as
to affect the neighbouring vessels; and the mani—
fest utility of blistering near the part affected, in
inflammatory diseases, leads me to believe, that
blistering, by deriving to the skin, and producing
an effusion there, relaxes the spasm of the deeper
seated vessels. I apprehend it to be in this man—
ner, that the tumour of a joint, from an effusion
into 

117 OF PHYSIC. 
into the cellular texture under the skin, takes off
the rheumatic pain affecting that joint.
194.
Analogous to this, it may be held, that the good
effects of blistering in continued fevers, arise from
its relaxing the spasm of the extreme vessels, by a
communication of the blistered part with the rest
of the skin; and this is illustrated by the effect of
blistering in colic and dysentery.
195.
It appears to me, that blistering may be employ—
ed at any period of continued fevers; but that it
will be of most advantage in the advanced state of
such fevers, when the reaction being weaker, all
ambiguity from the stimulant power of blistering is
removed, and when it may best concur with other
circumstances tending to a final solution of the
spasm.
196.
From the view of this matter given in (193. and
194.) it will appear, that the part of the body to
which blisters ought to be applied, is indifferent,
excepting upon the suspicion of topical affection,
when the blistering ought to be made as near as
possible to the part affected.
197.
Whether SINAPISMS, and other RUBEFACIENT— 
TIA, act in a manner analogous to what we have
supposed of blistering, may be doubtful; but their
effects in rheumatism, and other inflammatory dis—
eases render it probable.
198. The 

118 PRACTICE
198.
The other external means of taking off the spasm
of the extreme vessels, is Warm Bathing. This
was frequently, and in various circumstances, em—
ployed by the ancients; but till very lately has been
neglected by modern physicians. As the heat of
the bath stimulates the extreme vessels, and, with
the concurrence of moisture, also relaxes them, it
seems to be a safe stimulus, and well suited to take
off the spasm affecting them.
199.
It may be applied to the whole body by immer—
sion; but this is, in many respects, inconvenient;
and whether some of the inconveniences of immer—
sion might not be avoided by a vapour—bath, I have
not learned from experience. I know, however,
from much experience, that most of the purposes
of warm bathing can be obtained by a fomentation
of the legs and feet, if properly administered, and
continued for a due length of time, which ought
not to be less than an hour.
200.
The marks of the good effects of such a fomen—
tation, are, the patient's bearing it easily, its re—
lieving delirium, and inducing sleep.
201.
Having now considered the several means of
satisfying the first general indication in the cure of
fevers, I proceed to the second, (126.) which is,
To remove the cause, or obviate the effects, of debility.
202. Most 

119 OF PHYSIC.
202.
Most of the sedative powers inducing debility,
cease to act soon after they have been first applied;
and, therefore, the removing them is not an ob—
ject of our present indication. There is only one
which may be supposed to continue to act for a long
time; and that is, the contagion applied; but we
know nothing of the nature of contagion that can
lead us to any measures for removing or correct—
ing it. We know only its effects as a sedative pow—
er inducing debility, or as a ferment inducing a
tendency to putrefaction in the fluids. The obvi—
ating the latter will be considered under our third
general indication, and the former alone is to be
considered here.
203.
The debility induced in fevers by contagion, or
other causes, appears especially in the weaker ener—
gy of the brain; but in what this consists, or how
it may be directly restored, we do not well know.
As nature, however, does, seemingly for this pur—
pose, excite the action of the heart and arteries,
we ascribe the continuance of debility to the weak—
er reaction of the sanguiferous system; so that the
means to be employed for obviating debility, are
immediately directed to support and increase the
action of the heart and arteries; and the remedies
used are TONICS or STIMULANTS. 
204.
In contagious diseases, both from the effects
which appear, and from dissections, it is known that
the tone of the heart and arteries is considerably
diminished; and that tonic remedies, therefore, are
properly indicated.
These 

120 PRACTICE
These are to be considered as of two kinds; the
first being the power of cold, the second that of
tonic medicines.
205.
The power of cold, as a tonic, I have mentioned
above (90.); and it is employed, in fevers, in two
ways; either as the cold matter is thrown into the
stomach, or as it is applied to the surface of the
body.
206.
As it has been shown above, that the tonic pow—
er of cold can be communicated from any one part
to every other part of the system; so it will readi—
ly be allowed, that the stomach is a part as fit for
this communication as any other; and that cold
drink, taken into the stomach, may, therefore,
prove an useful tonic in fevers.
207.
This the experience of all ages has confirmed;
but, at the same time, it has been frequently ob—
served, that, in certain circumstances, cold drink,
taken into the stomach, has proved very hurtful;
and, therefore, that the use of cold drink in fevers
requires some limitations. What these limitations
should be, and what are all the circumstances which
may forbid the use of cold drink, is difficult to de—
termine; but it seems clearly forbidden, in all ca—
ses where a phlogistic diathesis prevails in the sys—
tem, and more especially when there are topical af—
fections of an inflammatory nature.
208.
The other method of employing cold as a tonic,
is, by applying it to the surface of the body. The
application 

121 OF PHYSIC.
application of cold air to the surface of the body,
as a refrigerant power fit to moderate the violence
of reaction, I have spoken of above (133.); but
probably it may also be considered here as a tonic,
and useful in cases of debility.
209.
Not only cool air, but cold water also, may be
applied to the surface of the body, as a refrigerant,
and perhaps as a tonic. The ancients frequently
applied it with advantage, to particular parts, as a
tonic; but it is a discovery of modern times, that
in the case of putrid fevers, attended with much de—
bility, the body may be washed all over with cold
water.
21O.
This was first practised at Breslaw in Silesia, as ap—
pears from a dissertation, under the title of Epi—
demia verna quœ Wratislaviam, anno 1737, afflixit,
to be found in the appendix to the Acta Nat. Curios—
Vol. X. And from other writers we find, that
the practice has passed into some of the neighbour—
ing countries; although in this island, so far as I
know, we have hitherto had no experience of it.
211
The medicines which have been employed in fe—
vers, as tonics, are various. If the Saccharum Sa—
turni has been found useful, it is, probably, as a
tonic, rather than as a refrigerant; and the Ens Ve—
neris, or other preparations of iron which have
been employed, can act as tonics only. The pre—
parations of copper, from their effects in epilepsy,
are presumed to possess a tonic power; but, whe—
ther their use in fevers be founded upon their tonic
or their emetic powers, may be uncertain. The
VOL. I. Q use 

122 PRACTICE
use of arsenic and of alum, in intermittent fevers,
seems manifestly to depend upon their tonic power
And, upon the whole, there may occur cases of
continued fevers, which may be cured by tonics
taken from the fossil kingdom; but the use of these
has been rare, as well as the effects uncertain; and
physicians have employed, more commonly, the
vegetable tonics.
212.
A great variety of these has been employed in the
cure of intermittent fevers; but how many of them
may be employed in continued fevers, or in what
circumstances of these fevers, is not well ascertain—
ed; and I shall now only consider the question
with respect to the most celebrated of these tonics,
the Peruvian Bark.
213.
This bark has been commonly considered as a
specific, or as a remedy of which the operation was
not understood. But it is certainly allowable to in—
quire into this matter; and I apprehend it may
be explained.
214.
To this purpose it is to be remarked, that as, in
many cases, the effects of the bark are perceived
soon after its being taken into the stomach, and be—
fore it can possibly be conveyed to the mass of blood,
we may conclude, that its effects do not arise from
its operating on the fluids; and must, therefore,
depend upon its operating on the nerves of the
stomach, and being thereby communicated to the
rest of the nervous system. This operation seems
to be a tonic power, the bark being a remedy in
many cases of debility, particularly in gangrene;
and, 

123 OF PHYSIC. 
and, as the recurrence of the paroxysms of inter—
mittent fevers depends upon a recurrence of atony,
(35. and 36.); so probably the bark, by it stonic pow—
er, prevents the recurrence of these paroxysms; and
this is greatly confirmed by observing, that many
other tonic medicines answer the same purpose.
215:
If the operation of the bark may be thus explain—
ed, from its poffessing a tonic power, it is easy to
perceive why it is improper when a phlogistic dia—
thesis prevails; and, from the same view, we can
ascertain in what cases of continued fever it may be
admitted. These are either after considerable re—
missions have appeared, when it may be employed
to prevent the return of exacerbations, on the same
footing that it is used in intermittent fevers, or in
the advanced state of fevers, when all suspicion of an
inflammatory state is removed, and a general debi—
lity prevails in the system; and its being then em—
ployed is sufficiently agreeable to the present prac—
tice.
2l6.
With respect to the use of the bark, it is proper
to add, that good effects are to be expected from
it, almost only when given in substance and in large
quantity.
217.
Another set of medicines to be employed for ob—
viating debility and its effects, are the direct stimu—
lants (203.) These, in some measure, increase the
tone of the moving fibres; but they are different
from the tonics, as more directly exciting and in—
creasing the action of the heart and arteries. This
mode of their operation renders the use of them
ambiguous; and when an inflammatory diathesis is
present, 

l24 PRACTICE
present, as so often happens in the beginning of fe—
vers, the effects of these stimulants may be very
hurtful; but it still remains probable, that, in the
advanced state of fevers, when debility prevails,
they may be useful.
218.
What are the stimulants that may be most pro—
perly employed, I am uncertain, as the use of them
in this age has been rare; but I am disposed to be—
lieve that, of all kinds, wine is the best.
219.
Wine has the advantage of being grateful to the
palate and stomach, and of having its stimulant
parts so much diluted, that it can be conveniently
given in small doses; so that it may be employed
with sufficient caution; but it is of little service,
unless taken pretty largely.
220.
It may be supposed, and on good grounds, that
wine has an operation analogous to that of opi—
um, and some other narcotic medicines. It may
indeed be said, that we can distinctly mark its
stimulant power only, which renders its effects in
the phrenitic delirium manifestly hurtful, and, in
the mild delirium, depending on debility, as re—
markably useful. But in all this the analogy with
opium is still obvious; and it is probable, that both
wine and opium are more useful by their sedative
and antispasmodic, than by their stimulant powers.
221.
These are the means of answering our second
general indication (126. 2.); and I now proceed 
to

125 OF PHYSIC. 
to the third, which is, To obviate or to correct the
tendency of the fluids to putrefaction.
222.
This may be done,
1. By avoiding any new application of putrid
or putrescent matter.
2. By evacuating the putrid or putrescent mat—
ter already present in the body.
3. By correcting the putrid or putrescent mat—
ter remaining in the body.
4. By supporting the tone of the vessels, and
thereby refilling further putrefaction, or obviating
its effects.
223.
The further application of putrid or putrescent
matter may be avoided,
1. By removing the patient from places filled
with corrupted air.
2. By correcting the air from which he cannot
be removed.
3. By preventing the accumulation of the pa—
tient's own effluvia, by a constant ventilation, and
by a frequent change of bed—clothes and body—
linen.
4. By the careful and speedy removal of all ex—
cremental matters from the patient's chamber.
5. By avoiding animal food, or correcting it.
224.
The putrid or putrescent matter, already present
in the body, may be evacuated, partly by evacua—
ting frequently the contents of the intestines; and
more effectually still, by supporting the excretions
of perspiration and urine, by the plentiful use of
diluents.
225. The 

126 PRACTICE
225.
The putrid or putrescent matter, remaining in
the body, may be rendered more mild and innocent
by the use of diluents; or may be corrected by
the use of antiseptics. These last are of many and
various kinds; but which of them are convenient—
ly applicable, or more particularly suited to the
case of fevers, is not well ascertained. Those most
certainly applicable and useful, are acescent ali—
ments, acids of all kinds, neutral salts, and fixed
air.
226.
The progress of putrefaction may be considera-
bly retarded, and its effects obviated, by support—
ing the tone of the vessels; and this may be done
by tonic remedies; the chief of which are, Cold,
and Peruvian Bark, both sufficiently treated of
above, (205. et seq.)
227.
I have now finished the consideration of the
three general indications to be formed in the cure
of continued fevers; and have mentioned most of
the remedies which have been, upon any occasion,
employed in this business. It was necessary, in the
first place, to consider these indications and reme—
dies separately, and to explain the operation of the
latter more generally; but from what has been
now delivered, compared with what was said above,
concerning the difference of fevers, and the signi—
fication of their several symptoms in forming the
prognostic, I expect it will not be difficult to assign
the indication, and to select and combine the seve—
ral remedies mentioned, so as to adapt them to the
several

127 OF PHYSIC. 
several species and circumstances of continued
fevers.
I think it may be useful for my Readers to have
the whole of the cure of Continued Fevers
brought under one View, as in the following
Table.
IN THE CURE OF CONTINUED FEVERS,
The INDICATIONS are,
I. To moderate the violence of reaction.
Which may be done, by
1. Diminishing the action of the heart and arteries, by
A. Avoiding or moderating those irritations which are almost
constantly applied to the body; as,
a. The impressions made upon our senses, particularly,
a. Increased heat, whether arising from
aa. External heat, or,
BB. The accumulation of the heat of the body.
b. The exercise of the body,
c. The exercise of the mind,
d. The taking in of aliment.
e. Particular irritations arising from
a. The sense of thirst,
B. Crudities, or corrupted humours, in the stomach,
y. The preternatural retention of fæces,
d. A general acrimony of the fluids.
B. Employing certain sedative powers; as,
a. Cold,
b. Refrigerants; the chief of which are,
a. Acids of all kinds,
B. Neutral salts,
y. Metallic salts.
C. Diminishing the tension and tone of the arterial system, by
a. Bloodletting,
b. Purging.
2. Taking off the spasm of the extreme vessels, by
A. Internal means; which are,
a. Those remedies which determine to the surface, as,
a. Diluents,
B. Neutral salts,
y. Sudorifics,
d. Emetics.
b. Those remedies named antispasmodics.
B. External 

128 PRACTICE
B. External means; as,
a. Blistering,
b. Warm bathing.
II. To remove the causes, or obviate the effects, of 
debility, by
I. Supporting and increasing the action of the heart and arteries,
by
A. Tonics, as,
a. Cold,
b. Tonic medicines, which are either,
a. Fossil, as,
aa. Saccharum saturni, &c. or,
B. Vegetable, as,
aa. Peruvian bark.
B. Stimulants, as,
a. Aromatics, &c.
b. Wine.
III. To obviate or correct the tendency of the fluids to
putrefaction, by
I. Avoiding the application of putrid or putrescent matter, by
A. Removing the patient from places filled with corrupted air.
B. Correcting the air, from which he cannot be removed.
C. Avoiding the accumulation of the patient's own effluvia, by
a. A constant ventilation,
b. Frequently changing the bed—clothes and body—linen.
D. Removing carefully and speedily all excremental matters.
E. Avoiding animal food, or correcting it.
2. Evacuating the putrid or putrescent matter already present in
the body, by
A. Evacuating frequently the intestines.
B. Supporting the excretions of perspiration and urine, by
a. Diluents,
b. Neutral salts.
3. Correcting the putrid or putrescent matter remaining in the
body, by
A. Diluents,
B. Antiseptics,
C. Fixed air.
4. Resisting farther putrefaction, or obviating its effects, by
Supporting the tone of the vessels, by
Tonic remedies.
SECT. II. 

129 OF PHYSIC.
SECT. II.
Of the CURE of INTERMITTIENT FEVERS.
228.
It still remains to consider the cure of intermit—
tent fevers; and, with respect to these, we form
also three general indications.
1. In the time of intermission, to prevent the recur—
rence of paroxysms.
2. In the time of paroxysms, to conduct these so as
to obtain a final solution of the disease.
3. To take off certain circumstances which might
prevent the fulfilling of the two first indications.
229.
The first indication may be answered in two
ways:
1. By increasing the action of the heart and ar—
teries some time before the period of accession,
and supporting that increased action till the period
of the accession be over, so as thereby to prevent
the recurrence of the atony and spasm of the ex—
treme vessels, which give occasion to the recur—
rence of paroxysms.
2. Without increasing the action of the heart
and arteries, the recurrence of paroxysms may be
prevented, by supporting the tone of the vessels,
and thereby preventing atony, and the consequent
spasm.
23O.
For the purpose mentioned in (229. 1.), the ac—
tion of the heart and arteries may be increased;
1. By various stimulant remedies, internally
given, or externally applied, and that without ex—
citing sweat.
VOL. I. R 2. By 

130. PRACTICE
2. By the same remedies, or others so managed
as to excite sweating, and to support that sweating
till the period of accession be for some time past.
3. By nauseating doses of emetics, given about
an hour before the time of accession, thereby sup—
porting and increasing the tone and action of the
extreme vessels.
231.
The tone of the extreme vessels may be support—
ed without increasing the action of the heart and
arteries, (229. 2.) by various tonic medicines; as,
1. Astringents alone.
2. Bitters alone.
3. Astringents and bitters conjoined.
4. Astringents and aromatics conjoined.
5. Certain metallic tonics.
6. Opiates.
Lastly, An impression of horror.
A good deal of exercise, and as full a diet as the
condition of the patient's appetite and digestion
may allow of, will be proper during the time of in—
termission, and may be considered as belonging to
this head.
232.
Of all the tonic remedies mentioned (231.) the
most celebrated, and perhaps the most certainly
effectual, is the Peruvian bark, the tonic power
of which we have endeavoured to demonstrate
above, (214.) and have at the same time explained
its use in continued fevers.
The same observation, as made in (216.), is es—
pecially proper in the case of intermittents; and
further with respect to these, the following observa—
tions, or rules are offered here.
1. That the bark may be employed with safety
at any period of intermittent fevers, providing
that, 

131 OF PHYSIC.
that, at the same time, there be neither a phlogis—
tic diathesis prevailing in the system, nor any con—
siderable or fixed congestion present in the abdo—
minal viscera.
2. The proper time for exhibiting the bark in
intermittent fevers, is during the time of intermis—
sion; and where intermissions are to be expect—
ed, it is to be abstained from in the time of parox—
ysms.
3. In remittents, though no entire apyrexia oc—
curs, the bark may be given during the remissions;
and it should be given, even though the remissions
be inconsiderable, if from the known nature of the
epidemic, intermissions or considerable remissions
are not to be soon expected, and that great danger
is apprehended from repeated exacerbations.
4. In the case of genuine intermittents, while a
due quantity of bark is to be employed, the exhi—
bition of it ought to be brought as near to the time
of accession, as the condition of the patient's sto—
mach will allow.
5. In general, in all cases of intermittents, it is
not sufficient that the recurrence of paroxysms be
stopped for once,, by the use of the bark; a relapse
is commonly to be expected, and should be pre—
vented by the exhibition of the bark, repeated at
proper intervals.
233.
Our second general indication for conducting
the paroxysms of intermittent fevers, so as to ob—
tain a final solution of the disease, may be answered.
1. By exhibiting emetics during the time of the
cold stage, or at the beginning of the hot.
2. By opiates given during the time of the hot
stage.
234. The 

132 PRACTICE, &c.
234.
The circumstances which may especially prevent
the fulfilling of those two indications, and therefore
give occasion to our third, are a phlogistic diathe—
sis prevailing in the system, and congestions fixed
in the abdominal viscera. The first must be remov—
ed by bloodletting and the antiphlogistic regimen;
the second, by vomiting and purging.
Where these measures are not immediately effec—
tual, i hold it safer to attempt the cure of the dis—
ease by the means pointed out in general in (229.),
rather than by those in article second of the same
paragraph.
BOOK 

[133]
BOOK II.
OF INFLAMMATIONS, OR
PHLEGMASIÆ
CHAP. I.
OF INFLAMMATION IN GENERAL.
SECT. I.
Of the PHENOMENA of INFLAMMATION. 
235.
WHEN any part upon the surface of the body
is affected with unusual redness, heat, pain,
and tumour, we name the disease an Inflammation
or Phlegmasia. These symptoms of inflammation
are never considerable, without the whole system
being, at the same time, affected with pyrexia.
236.
As the external, so likewise the internal parts
may be affected with inflammation; and we judge
them to be so, when, together with pyrexia, there
is a fixed pain in any internal part, attended with
some interruption in the exercise of its functions.
237. We 

134 PRACTICE
237.
We judge of the presence of inflammation also
from the state of the blood drawn out of the veins,
When the blood, after cooling and concreting,
shows a portion of the gluten separated from the rest
of the mass, and lying on the surface of the crassa—
mentum; as such separation happens in all cases of
more evident phlegmasia; so, in ambiguous cases,
we, from this appearance, joined with other symp—
toms, infer the presence of inflammation. At the
lame time, it must be observed, that as several cir—
cumstances in bloodletting, may prevent this sepa—
ration of gluten from taking place in blood otherwise
disposed to it; so, from the absence of such appear—
ance, we cannot always conclude against the pre—
sence of inflammation.
238.
I cannot easily give any other general history of
the phenomena of inflammation than what is con—
tained in the three preceding paragraphs; and the
variations which may take place in its circumstan—
ces, will occur to be more properly taken notice of
under the several heads of the particular genera
and species to be hereafter mentioned. I proceed,
therefore, to inquire into the proximate cause of
inflammation in general.
SECT. II.
Of the PROXIMATE CAUSE of INFLAMMATION.
239.
The phenomena of inflammation (235.) all con—
cur in showing, that there is an increased impetus of 
the

135 OF PHYSIC.
the blood in the vessels of the part affected; and
as, at the same time, the action of the heart is not
always evidently increased, there is reason to pre—
sume, that the increased impetus of the blood in
the particular part is owing especially to the increas—
ed action of the vessels of that part itself.
24O.
The cause of this increased action in the vessels
of a particular part is, therefore, what we are to
consider as the proximate cause of inflammation.
In many cases, we can manifestly perceive, that
inflammation arises from the application of stimu—
lant substances to the part. When the application
of such stimulants, therefore, is evident, we seek
for no other cause of inflammation; but as, in ma—
ny cases, such application is neither evident, nor,
with any probability, to be supposed, we must, in
such cases, seek for some other cause of the increas—
ed impetus of the blood in the vessels of the part.
241.
Many physicians have supposed, that an obstruc—
tion of the extreme vessels, any how produced, may
prove a cause of inflammation; and particularly,
that this may arise from an obstruction formed by
a matter stopping up these vessels. But many dif—
ficulties attend this doctrine.
1. The opinion seems chiefly to have arisen from
the appearance of the blood described in (237.) when
the separated gluten was considered as a preterna—
ural and morbid matter; but we now know very
certainly, that this gluten is constantly a constitu—
ent part of the human blood; and that it is only a
peculiar separation of the parts of the blood that
happens in consequence of inflammation and some
other circumstances, which gives occasion to the 
appear—

136 PRACTICE
appearance that was falsely considerd as a mark of 
a morbid lentor in the blood. 
2. There are no experiments directly in proof
of a preternatural lentor prevailing in the mass of
blood; nor is there any evidence of certain parts
of the blood occasionally acquiring a greater den—
sity and force of cohesion than ordinary; neither
is there any proof of the denser or more coherent
parts being present in the mass of blood, in such
greater proportion than usual, as to occasion a dan—
gerous spissitude. The experiments of Dr. Browne 
Langrish on this subject afford no conclusion, hav— 
ing been made on certain parts of the blood sepa—
rated from the rest, without attending to the cir—
cumstances of bloodletting, which very much al—
ter the state of the separation and concretion of the
blood drawn out of the veins.
3. The supposition of a preternatural lentor or
viscidity of the blood, is not well founded; for it
is probable, that nature has specially provide
against a state of the fluids, so incompatible with
the exercise of the most important functions of the
animal economy. While motion continues to pre—
vent any separation of parts, and heat continues to
preserve the fluidity of the more viscid, there seems
to be always so large a proportion of water present
as to give a sufficient fluidity to the whole. I must
own that this is not absolutely conclusive; but I
still repeat it, as giving a probability to the gene—
ral argument.
4. In the particular case of inflammation, there
are several circumstances which render it probable
that the blood is then more fluid than usual.
5. I presume that no such general lentor, as Bo—
erhaave and his disciples have supposed, does ever
take place; because if it did, it must show more
considerable effects than commonly appear.
6. Besides the supposition of an obstructing len—
tor, physicians have supposed, that an obstruction
may be formed by an impermeable matter of ano—
ther 

137 OF PHYSIC. 
ther kind, and that such an obstruction may also be
the cause of inflammation. This supposition is
what is well known in the schools under the title of
an error loci; but it is an opinion, that I cannot
find to be at all probable; for the motion of the
blood in the extreme vessels is so weak and slow,
as readily to admit a retrograde course of it; and
therefore, if a particle of blood should happen to
enter a vessel whose branches will not allow of its
passage, it will be moved backwards, till it meet
with a vessel fit for transmitting it; and the fre—
quent ramifications and anastomoses of the extreme
arteries are very favourable to this. I must own
indeed, that this argument is not absolutely conclu—
sive; because I allow it to be pretty certain, that
an error loci does actually upon occasion happen;
but for the reasons I have given, it is probable that
it seldom happens, and is therefore rarely the cause
of inflammation; or if it be, that it is not merely
by the obstruction that it produces; as, among
other reasons, I conclude particularly from the
following argument.
7. Though an obstruction should be supposed to
take place, it will not be sufficient for producing
the effects, and exhibiting the phenomena, that
appear in inflammation. The theory that has been
commonly employed on this occasion is by no means
satisfying; and in fact, it appears, from many ob—
servations and experiments, that considerable ob—
structions may be formed, and may subsist, with—
out producing the symptoms of inflammation.
242.
Obstruction, therefore, from a matter stopping
up the vessels, Gaub. Pathol. 249. i. is not to be
considered as the primary cause of inflammation;
but, at the same time, it is sufficiently probable,
that some degree of obstruction does take place in
every case of inflammation. The distention, pain,
VOL. I. S redness, 

138 PRACTICE
redness, and tumour attending inflammation, are
to be explained only by supposing, that the extre—
mities of the arteries do not readily transmit the
unusual quantity of blood impelled into them by
the increased action in the course of these vessels.
Such an obstruction may be supposed to happen in
every case of an increased impetus of the blood;
but it is probable, that, in the case of inflammation,
there is also a preternatural resistance to the free
passage of the fluids.
243.
From the doctrine of fever, we are led to be—
lieve, that an increased action of the heart and ar—
teries is not supported for any length of time by any
other means than a spasm affecting the extreme ves—
sels; and that the same spasm takes place in inflam—
mation seems likely, because that every considera—
ble inflammation is introduced by a cold stage, and
is accompanied with that and other circumstances
of pyrexia. It seems also probable, that something
analogous to this occurs even in the case of those
inflammations which appear less considerable, and to
be purely topical.
244.
From all this, the nature of inflammation may in
many cases be explained in the following manner.
Some causes of inequality in the distribution of the
blood may throw an unusual quantity of it upon par—
ticular vessels, to which it must necessarily prove a
stimulus. But, further, it is probable, that, to re—
lieve the congestion, the vis medicatrix natures in—
creases still more the action of these vessels; and
which, as in all other febrile diseases, it effects by
the formation of a spasm on their extremities.
245. A 

139 OF PHYSIC.
245.
A spasm of the extreme arteries, supporting an
increased action in the course of them, may there—
fore be considered as the proximate cause of inflam—
mation; at least, in all cases not arising from direct
stimuli applied; and even in this case the stimuli
may be supposed to produce a spasm of the extreme
vessels.
246.
That, in inflammation, there is the concurrence
of a constriction of the extreme vessels, with an in—
creased action in the other parts of them, seems pro—
bable, from the consideration of Rheumatism. This
is a species of inflammation which is often manifestly
produced, either by cold applied to over distended
vessels, or by causes of an increased impetus, and
over distention in vessels previously constricted.
Hence the disease especially appears at seasons lia—
ble to frequent and considerable vicissitudes of heat
and cold.
To this we may add, that the parts of the body
most frequently affected with inflammation, are
those exposed, both to over distention, from a
change in the distribution of the fluids, and, at the
same time, to the immediate action of cold. Hence,
quinsies, and pneumonic inflammations, are more
frequent than any others.
247.
That a spasm of the extreme vessels takes place
in inflammation, is to be further presumed from
what is at the same time the state of the whole arte—
rial system. In every considerable inflammation,
though arising in one part only, an affection is
communicated to the whole system, in consequence 
of

l40 PRACTICE
of which an inflammation is readily produced in
other parts beside that first affected. This ge—
neral affection is well known among physicians, un—
der the name of the DIATHESIS PHLOGISTICA.
It appears most commonly in persons of the most
rigid fibres: is often manifestly induced by the to—
nic or astringent powers of cold; is increased by
all tonic and stimulant powers applied to the body;
is always attended with a hardness of the pulse; and
is moft effectually taken off by the relaxing power
of bloodletting. From these circumstances, it seems
probable, that the diathesis phlogistica consists in
an increased tone, or contractility, and perhaps
in an increased contraction of the muscular fibres
of the whole arterial system. Such a state of the
system seems often to arise, and subsist for some
time, without the apparent inflammation of any par—
ticular part; but such a state of the system renders
it likely, that a spasm may, at the same time, rea—
dily arise in any of the extreme vessels, and a par—
ticular inflammation be there produced. It does,
however, appear also, that the general diathesis
frequently arises from inflammation begun in a par—
ticular part.
248.
I have thus endeavoured, in the case of inflam—
mation, to explain the state of the whole system,
as well as that of the part more particularly affect—
ed. The latter I have considered as when in its
first formation; but after it has subsisted for some
time, various changes take place in the part affect—
ed; and of these I must now take notice.
SECT. III. 

141 OF PHYSIC.
SECT. III.
Of the TERMINATIONS of INFLAMMATION.
249.
If an inflammation be cured while the state and
texture of the part remain entire, the disease is said
to be terminated by RESOLUTION.
This happens when the previous congestion and
spasm have, been in a moderate degree, and the in—
creased impetus of the blood has been sufficient to
overcome the spasm, to dilate the vessels, and to
remove the congestion, so that the part is restored
to its ordinary and healthy state.
A resolution takes place also when the increased
impetus of the fluids has produced an increased ex—
halation into the adjoining cellular texture, or an
increased excretion in some neighbouring part, and
has thereby relaxed the spasm, and relieved the
congestion, in the vessels of the part more particu—
larly affected.
Lastly, A resolution may take place, when the
increased impetus of the blood in the whole system
Occasions an evacuation, which, though in a dis—
tant part, may prove sufficient to take off the phlo—
gistic diathesis of the whole system, and thereby re—
the congestion and spasm of the particular
Impart affected by inflammation.
250
The tumour which appears in inflammation may
be imputed in part to the congestion of fluids in
their proper vessels; but is owing chiefly to an ef—
fusion of matter into the adjoining cellular texture;
and, accordingly, tumours seldom appear but in
parts adjoining to a lax cellular texture. If, in this
case, the matter effused be only a larger quantity
of 

l42 PRACTICE
of the ordinary exhaling fluid this, when the free
circulation in the vessels is restored, will be: readi—
ly absorbed, and the state of the part will become
the same as before. But, if the increased impetus
of the blood in an inflamed part, dilate the exha—
bnt vessels to such a degree that they pour out an
entire serum, this will not be so readily reabsorb—
ed; from the experiments of Sir John Prin—
gle, and especially from those of Mr. Gaber, Mis—
cell. Taurin. Vol. II. we learn, that the serum, un—
der stagnation, may suffer a particular change by
having the gluten present in it changed into a white,
opaque, moderately viscid, mild liquor, which we
name PUS. When this change takes place in the
inflamed part, as it is at the same time attended
with an abatement of the redness, heat, and pain,
which before distinguished the inflammation, so
the disease is said to be terminated by SUPPURA—
TION; and an inflamed part, containing a collec—
tion of pus, is called an ABSCESS.
251.
In inflammation, the tendency of it to suppura—
tion may be discovered, by the long continuance
of the inflammation, without the symptoms of re—
folution ; by fome remiffion of the pain of disten—
tion; by the pain becoming of a throbbing kind
more distinctly connected with the pulsation of the
arteries being fuller and softer; and often by the
patient's being frequently affected with cold shiver—
ings. The period at which this takes place is not
determined, but may be sometimes sooner, some—
times later. When the tendency is determined, the
time necessary to a complete suppuration is differ—
ent in different cases.
When pus is completely formed, the pain in the
part entirely ceases, and a weight is felt in it, If
the collection be formed immediately under the
skin, the tumour becomes pointed, the part be—
comes 

143 OF PHYSIC. 
comes soft, and the fluctuation of the fluid within
can commonly be perceived; while, at the same
time, for the most part, the redness of the skin
formerly prevailing is very much gone.
252.
In abscesses, while the pus is formed of one part
of the matter which had been effused, the other
and thinner parts are reabsorbed, To that, in the
abscess, when opened, a pus alone appears. This
pus, however, is not the converted gluten alone;
for the conversion of this being the effect of a par—
ticular fermentation, which may affect the solid sub—
stance of the part, and perhaps every solid of ani—
mal bodies; so it most readily, and particularly,
affects the cellular texture, eroding much of it,
which thereby becomes a part of the pus. It gene—
ccally happens also, that some of the smaller red ves—
sels are eroded, and thereby some red blood often
appears mixed with the pus in abscesses. Upon
the whole, the internal surface of an abscess is to
be considered as an ulcerated part.
253.
This account of suppuration explains, why an
abscess, when formed, may either spread into the
cellular texture of the neighbouring parts; or, by
eroding the incumbent teguments, be poured out
upon the surface of the body, and produce an open
ulcer. 
254.
We have here given the idea of an abscess as a
collection of matter following inflammation; but
he term has been applied to every collection of
matter effused, and changed by stagnation in an
inclosed cavity.
The 

144 PRACTICE
The matter of abscesses, and of the ulcers fol—
lowing them, is various, according to the nature
of what is effused, and which may be,
1. A matter thinner than serum.
2. An entire and pure serum.
3. A quantity of red globules.
4. A matter furnished by particular glands seated
in the part.
5. A mixture of matters from different sources,
changed by peculiar fermentation.
It is the second only which affords a proper pus;
the effusion whereof, whether in suppurating parts
or ulcers, seems to be the peculiar effect of an in—
flammatory state of the vessels; and for this reason
it is, that, when ulcers do not produce a proper
pus, a circumstance always absolutely necessary to
their healing, we, in many cases, bring the ulcers
to a state of proper suppuration, by the application
of stimulants exciting inflammation, such as bal—
sams, mercury, copper, &c.
255.
When the matter effused into the cellular tex—
ture of an inflamed part, is tainted with aput rid
ferment, this produces, in the effused matter, a
state approaching more or less to that of putrefac—
tion. When this is in a moderate degree, and af—
fects only the fluids effused, with the substance of
the cellular texture, the part is said to be affected
with GANGRENE; but if the putrefaction affect
also the vessels and muscles of the part, the disease
is said to be a SPHACELUS.
256.
A gangrene, and its consequences, may arise
from a putrid ferment diffused in the mass of blood,
and poured out with the serum effused, which it
operates upon more powerfully, while the serum is
stagnant,

145 OF PHYSIC. 
stagnant, and retained in the heat of the body; but
it may also arise from the peculiar nature of the
matter effused being disposed to putrefaction; as
particularly seems to be the case of the red globules
of the blood effused in a large quantity. In a third
manner also, a gangrene seems frequently to arise
from the violent excitement of the inflammation
destroying the tone of the vessels; whereby the
whole fluids stagnate, and run into putrefaction,
which taking place in any degree, destroys still fur—
ther the tone of the vessels, and spreads the
gangrene.
257.
In inflammation, the tendency to gangrene may
be apprehended from an extreme violence of pain
and heat in the inflamed part, and from a great de—
gree of pyrexia attending the inflammation.
The actual coming on of gangrene may be per—
ceived, by the colour of the inflamed part chang—
ing from a clear to a dark red; by blisters arising
upon the part; by the part becoming soft, flaccid,
and insensible; and by the ceasing of all pain while
these appearances take place.
As the gangrene proceeds, the colour of the part
becomes livid, and by degrees, quite black; the
he at of the part entirely ceases; the softness and
flaccidity of the part increase; it loses its consist—
ence, exhales a cadaverous smell, and may then
be considered as affected with sphacelus.
258
Gangrene is thus a third manner in which inflam—
mation terminates; and the schools have common—
ly marked a fourth termination of inflammation;
which is, by a scirrhus, or an indolent hardness of
the part formerly affected with inflammation. This,
however, is a rare occurrence, and does not seem
VOL. I. T to 

146 PRACTICE
to depend so much upon the nature of inflamma—
tion, as upon the circumstances of the part affect—
ed. It is in glandular parts chiefly that scirrhosity
is observed; and it is probably owing to the parts
readily admitting a stagnation of the fluids. I have
observed, that inflammation seldom induces scirr—
hus; but that this more commonly arises from
other causes; and when inflammation supervenes,
which it is sooner or later apt to do, it does not so
commonly increase, as change the scirrhosity into
some kind of abscess. From these considerations
it does not seem necessary to take any further no—
tice of scirrhus as a termination of inflammation.
259.
There are, however, some other terminations of
inflammation, not commonly taken notice of, but
now to be mentioned.
One is, by the effusion of a portion of the entire
mass of blood, either by means of rupture or of
anastomosis, into the adjoining cellular texture.
This happens especially in inflammations of the
lungs, where the effused matter, by compressing
the vessels, and stopping the circulation, occasions
a fatal suffocation; and this is perhaps the manner
in which pneumonic inflammation most commonly
proves fatal.
260.
Another kind of termination is, that of certain
inflammations on the surface of the body, when
there is poured out under the cuticle a fluid, which
being too gross to pass through its pores, therefore
separates it from the skin, and raises it up into the
form of a vesicle containing the effused fluid; and
by which effusion the previous inflammation is tak—
en off.
261. Beside 

147 OF PHYSIC.
26l.
Beside these already mentioned, I believe there
is still another manner in which inflammation ter—
minates. When the internal parts are affected with
inflammation, there seems to have been almost al—
ways upon their surface, an exudation, which ap—
pears partly as a viscid concretion upon their sur—
face, and partly as a thin serous fluid effused into
the cavities in which the inflamed viscera are placed.
Though we have become acquainted with these ap—
pearances only, as very constantly accompanying
those inflammations which have proved fatal, it is
however probable, that like circumstances may have
attended those which were terminated by resolu—
tion, and may have contributed to that event. It
is in favour of this supposition that there are in—
stances of pneumonic inflammation terminating in
a hydrothorax.
SECT. IV.
Of the REMTOE CAUSES of INFLAMMATION. 
262.
The remote causes of inflammation may be re—
duced to five heads.
1. The application of stimulant substances; a—
mong which are to be reckoned the action of fire,
or burning.
2. External violence operating mechanically in
wounding, bruising, compressing, or overstretching
the parts.
3. Extraneous substances, lodged in any part of
the body, irritating by their chemical acrimony or
mechanical form, or compressing by their bulk or  
gravity. 
4. Cold,

148 PRACTICE
4. Cold, in a certain degree, not sufficient im—
mediately to produce gangrene.
5. An increased impetus of the blood determin—
ed to a particular part. 
It will not be difficult to understand how these re—
mote causes, singly, or in concurrence, produce
the proximate cause of inflammation.
263.
It does not appear, that in different cases of in—
flammation, there is any difference in the state of the
proximate cause, except in the degree of it; and
though some difference of inflammation may arise
from the difference of the remote causes, yet this
is not necessary to be taken notice of here; because
the different appearances which attend different in—
flammations may be referred, for the most part, to
the difference of the part affected; as will appear
when we shall consider the several genera and spe—
cies marked in the Nosology. When I come to
treat of these, I shall find a more proper occasion
for taking notice of the different states of the prox—
imate, or of the differences of the remote cause,
than by treating of them in general here.
SECT. V.
Of the CURE of INFLAMMATION.
264.
The indications of cure in inflammation are dif—
ferent, according as it may still be capable of reso—
lution, or may have taken a tendency to the several
other terminations above mentioned. As the ten—
dency to these terminations is not always immedi—
ately evident, it is always proper, upon the first ap—
pearance of inflammation, to attempt the cure of it
by

149 OF PHYSIC. 
by resolution. For this purpose, the indications of
cure are,
1. To remove the remote causes, when they are
evident, and continue to operate.
2. To take off the phlogistic diathesis affecting
either the whole system, or the particular part.
3. To take off the spasm of the particular part,
by remedies applied either to the whole system, or
to the part itself.
265.
The means of removing the remote causes will
readily occur, from considering the particular na—
ture and circumstances of the different kinds.
Acrid matters must be removed, or their action
must be prevented, by the application of correct—
ors or demulcents. Compressing and overstretch—
ing powers must be taken away; and, from their
several circumstances, the means of doing so will
be obvious.
266.
The means of taking off the phlogistic diathesis
of the system are the same with those for moderat—
ing the violence of reaction in fever, which are
mentioned and treated of from (127. to 159.), and
therefore need not be repeated here. I only ob—
serve, that, in the use of those remedies, there is
less occasion for any reserve than in many cases of
fever; and more particularly, that topical bleed—
ings are here particularly indicated and proper.
267.
The means of taking off the spasm of the parti—
cular part are nearly the same as those mentioned
above, for taking off the spasm of the extreme ves—
sels in the case of fever, and which are treated of
from 

150 PRACTICE
from (150. to 200.) Only it is observed here that 
some of these are here especially indicated, and that 
some of them are to be directed more particularly 
to the part especially affected; the management of 
which will be more properly considered when we 
shall treat of particular inflammations. 
268.
When a tendency to suppuration (251.) is dis—
tinctly perceived, as we suppose it to depend upon
the effusion of a fluid which cannot be easily reab—
forbed, so it becomes necessary that this fluid be
converted into pus, as the only natural means of
obtaining its evacuation; and as the effusion is,
perhaps, seldom made without some rupture of the
vessels, to the healing of which a pus is absolutely
necessary; so, in the case of a tendency to suppu—
ration, the indication of cure always is, to promote
the production of a perfect pus as quickly as possible.
269.
For this purpose, various remedies, supposed to
possess a specific power, have been proposed; but I
can perceive no such power in any of them; and,
in my opinion, all that can be done is, to favour
the suppuration by such applications as may sup—
port a proper heat in the part, as by some tenacity
may confine the perspiration of the part, and as,
by an emollient quality, may weaken the cohesion
of the teguments, and favour their erosion.
27O.
As, in the case of certain effusions, a suppura—
tion is not only unavoidable, but desirable, it may 
be supposed, that most of the means of resolution 
formerly mentioned should be avoided; and accord—
ingly our practice is commonly so directed. But 
as we observe, on the one hand, that a certain de—
gree 

151 OF PHYSIC. 
gree of increased impetus, or of the original cir—
cumstances of inflammation, is requisite to produce
a proper suppuration; so it is then especially ne—
cessary to avoid those means of resolution that may
diminish too much the force of the circulation.
And as, on the other hand, the impetus of the
blood, when violent, is found to prevent the pro—
per suppuration; so, in such cases, although a ten—
dency to suppuration may have begun, it may be
proper to continue those means of resolution which
moderate the force of the circulation.
With respect to the opening of abscesses, when
completely formed, I refer to the writings on sur—
gery.
271.
When an inflammation has taken a tendency to
gangrene, that event is to be prevented by every
possible means; and these must be different, ac—
cording to the nature of the several causes occasion—
ing that tendency, as may be understood from what
has been already said of them. After a gangrene
has, in some degree, taken place, it can be cured
only by the separation of the dead from the living
parts. This, in certain circumstances, can be per—
formed by the knife, and always most properly,
when it can be so done.
In other cases, it can be done by exciting a sup—
puratory inflammation on the verge of the living
part, whereby its cohesion with the dead may be
every where broken off, so that the latter may fall
off by itself. While this is doing, it is proper to
prevent the further putrefaction of the part, and
its spreading wider. For this purpose, various anti—
septic applications have been proposed: But it ap—
pears to me, that, while the teguments are entire,
these applications can hardly have any effect; and,
therefore, that the fundamental procedure must be
to scarify the part so as to reach the living substance,
and, 

152 PRACTICE
and, by the wounds made there, to excite the sup—
puration required. By the same incisions also, we
give access to antiseptics, which may both prevent
the progress of the putrefaction in the dead, and
excite the inflammation necessary on the verge of
the living part.
272.
When the gangrene proceeds from a loss of tone;
and when this, communicated to the neighbouring
parts, prevents that inflammation, which, as I have
said, is necessary to the separation of the dead part
from the living; it will be proper to obviate this
loss of tone, by tonic medicines given internally;
and, for this purpose, the Peruvian bark has been
found to be especially effectual. That this medi—
cine operates by a tonic power, I have endeavour—
ed to prove above (214.); and from what is said in
(215.), the limitations to be observed in employing
it may also belearned. When the gangrene arises
from the violence of inflammation, the bark may
not only fail of proving a remedy, but may do
harm; and its power as a tonic is especially suited
to those cases of gangrene which proceed from an
original loss of tone, as in the case of palsy and
œdema; or to those cases of inflammation where
a loss of tone takes place, while the original inflam—
matory symptoms are removed.
273.
The other terminations of inflammation either do
not admit of any treatment, except that of prevent—
ing them by the means of resolution; or they be—
long to a treatise of surgery, rather than to this
place.
Having thus, therefore, delivered the general
doctrine, I proceed now to consider the particular
genera and species of inflammation. 
It

153 OF PHYSIC.
It has been hinted above (263.), that the differ—
ence of inflammation arises chiefly from the differ—
ence of the part affected: I have therefore arrang—
ed them, as they are CUTANEOUS, VISCERAL, or
ARTICULAR; and in this order they are now to be
considered.
CHAP. II.
OF INFLAMMATION, MORE STRICTLY
CUTANEOUS.
274.
CUTANEOUS inflammations are of two kinds,
commonly distinguished by the names of
PHLEGMON and ERYSIPELAS.
Of the latter there are two cases, which ought
to be distinguished by different appellations. When
the disease is an affection of the skin alone, and ve—
ry little of the whole system, or when the affection
of the system is only symptomatical of the external
inflammation, I shall give the disease the name of
ERYTHEMA; but when the external inflammation
is an exanthema, and symptomatical of an affection
of the whole system, I shall then name the disease
ERYSIEPELAS. 
275.
It is the Erythema only that I am to consider
here.
For the distinction between Erythema and Phleg—
mon, I have formerly referred to the characters
given of them in our Nosology. See Synops. No—
solog. Meth. Vol. II. p. 5. gen. vii. spec. 1. and 2.
But I think it proper now to deliver the characters
of them more fully and exactly here, as follows.
A Phlegmon is an inflammatory affection of the
skin, with a swelling, rising generally to a more con—
VOL. I. U siderable 

154 PRACTICE
siderable eminence in the middle of it; of a bright
red colour; both the swelling and colour being
pretty exactly circumscribed; the whole being at—
tended with a pain of distention, often of abound—
ing or throbbing kind, and frequently ending in
An Erythema, Rose, or St. Anthony's Fire is
an inflammatory affection of the skin, with hardly
any evident swelling; of a mixed and not very
bright red colour, readily disappearing upon pres— 
sure, but quickly returning again; the redness of
no regular circumscription, but spreading unequal—
ly, and continuing almost constantly to spread up—
on the neighbouring part; with a pain like to that
from burning; producing blisters, sometimes of a
small, sometimes of a larger size; and always end—
ing in a desquamation of the scarf skin, sometimes
in gangrene.
This subject I am not to prosecute here, as pro—
perly belonging to surgery, the business of which I
am seldom to enter upon in this work; and shall
therefore observe only as necessary here, that the
difference of these appearances seems to depend on
the different seat of the inflammation. In the
phlegmon, the inflammation seems to affect especi—
ally the vessels on the internal surface of the skin
communicating with the lax subjacent cellular tex—
ture; whence a more copious effusion, and that of
serum, convertible into pus, takes place. In the
erythema, the inflammation seems to have its seat
in the vessels on the external surface of the skin,
communicating with the rete mucosum, which does
not admit of any effusion, but what separates the
cuticle, and gives occasion to the formation of a
blister, while the smaller size of the vessels admits
only of the effusion of a thin fluid, very seldom
convertible into pus.
Besides these differences in the circumstances of
these two kinds of inflammation, it is probable that
they also differ with respect to their causes. Ery—
thema 

155 OF PHYSIC. 
thema is the effect of all kinds of acrids externally
applied to the skin; and, when arising from an in—
ternal cause, it is from an acrimony poured out
on the surface of the skin under the cuticle. In the
phlegmon, an acrimony is not commonly evident.
276.
These differences in the seat and causes of the
phlegmon and erythema being admitted, it will be
evident, that when an erythema affects any inter—
nal part, it can take place in those only whose sur—
faces are covered with an epithelion, or membrane
analogous to the cuticle.
277.
The same distinction between the seat and causes
of the two diseases will, as I judge, readily explain
what has been delivered by practical writers, with
respect to the cure of these different cutaneous in—
flammations. But I shall not, however, prosecute
this here, for the reason given above (275.); and,
for the same reason, shall not say any thing of the
variety of external inflammation, that might other—
wise be considered here.
CHAP. III.
OF OPHTHALMIA, OR INFLAMMATION
OF THE EYE.
278.
THE inflammation of the eye maybe considered
as of two kinds; according as it has its seat in
the membranes of the ball of the eye, when I would
name it OPHTHALMIA MEMBRANARUM; or as it
has its seat in the sebaceous glands placed in the
tarsus, 

156 PRACTICE
tarsus, or edges of the eyelids, in which case it may
be termed OPHTHALMIA TARSI.
These two kinds are very frequently combined
together, as the one may readily excite the other;
but they are still to be distinguished according as
the one or the other may happen to be the primary
affection, and properly as they often arise from
different causes.
279.
The inflammation of the membranes of the eye
affects especially, and most frequently, the adnata,
appearing in a turgescence of its vessels; so that the
red vessels, which are naturally there, become not
only increased in size, but there appear many more
than did in a natural state. This turgescence of
the vessels is attended with pain, especially upon
the motion of the ball of the eye; and this, like
every other irritation applied to the surface of the
eye, produces an effusion of tears from the lachry—
mal gland.
This inflammation commonly, and chiefly, af—
fects the adnata spread on the anterior part of the
bulb of the eye; but usually spreads also along the
continuation of that membrane on the inside of the
palpebræ, and, as that is extended on the tarsus
palpebrarum, the excretories of the sebaceous
glands opening there are also frequently affected.
When the affection of the adnata is considerable,
it is frequently communicated to the subjacent
membranes of the eye, and even to the retina itself,
which thereby acquires so great a sensibility, that
the slightest impression of light becomes painful.
280.
The inflammation of the membranes of the eye
is in different degrees, according as the adnata is
more or less affected, or according as the inflam—
mation 

157 OF PHYSIC. 
mation is either of the adnata alone, or of the sub—
jacent membranes also; and upon these differen—
ces, different species have been established, and
different appellations given to them. But shall
not, however, prosecute the consideration of these,
being of opinion, that all the cases of the Oph—
thalmia membranarum differ only in degree, and
are to be cured by remedies of the same kind,
more or less employed.
The remote causes of Ophthalmia are many and
various; as,
1. External violence, by blows, contusions, and
wounds, applied to the eyes; and even very slight
impulses applied, whilst the eyelids are open, to
the ball of the eye itself, are sometimes sufficient
for the purpose.
2. Extraneous bodies introduced under the eye—
lids, either of an acrid quality, as smoke and other
acrid vapours, or of a bulk sufficient to impede
the free motion of the eyelids upon the surface of
the eyeball.
3. The application of strong light, or even of a
moderate light long continued.
4. The application of much heat, and particular—
ly of that with moisture.
5. Much exercise of the eyes in viewing minute
objects.
6. Frequent intoxication.
7. Irritation from other and various diseases of
the eyes.
8. An acrimony prevailing in the mass of blood,
and deposited in the sebaceous glands on the edges
of the eyelids.
9. A change in the distribution of the blood,
whereby either a more than usual quantity of blood,
and with more than usual force, is impelled into
the vessels of the head, or whereby the free return
of the venous blood from the vessels of the head is
interrupted.
10. A certain consent of the eyes with the other
parts of the system, whereby, from a certain state
of 

158 PRACTICE
of these parts, either a simultaneous, or an altering
affection of the eyes, is produced.
28l.
The proximate cause of Ophthalmia is not dif—
ferent from that of inflammation in general; and
the different circumstances of Ophthalmia may be
explained by the difference of its remote causes,
and by the different parts of the eye which it hap—
pens to affect. This may be understood from what
has been already said; and I shall now therefore
proceed to consider the Cure.
282.
In the cure of Ophthalmia, the first attention
will be always due to the removing of the remote
causes, and the various means necessary for this
purpose will be directed by the consideration of
these causes enumerated above.
The Ophthalmia membranarum requires the re—
medies proper for inflammation in general; and
when the deeper seated membranes are affected,
and especially when a pyrexia is present, large ge—
neral bleedings may be necessary. But this is sel—
dom the case; as the Ophthalmia, for the most
part, is an affection purely local, accompanied
with little or no pyrexia. General bleedings,
therefore, from the arm or foot, have little effect
upon it; and the cure is chiefly to be obtained by
topical bleedings, that is, blood drawn from vessels
near the inflamed part; and opening the jugular
vein on the temporal artery, may be considered as
in some measure of this kind. It is commonly suf—
ficient to apply a number of leeches round the eye;
and it is perhaps better still to draw blood from
the temples, by cupping and scarifying. In many
cases, a very effectual remedy is, that of scarifying
the internal surface of the inferior eyelid; and 
more

159 OF PHYSIC. 
more so still, is cutting the turgid vessels upon the
adnata itself.
283.
Besides bloodletting, purging, as a remedy suit—
ed to inflammation in general, has been consider—
ed as peculiarly adapted to inflammations in any of
the parts of the head, and therefore to Ophthalmia;
and it is sometimes useful; but, for the reasons
given before with respect to general bleeding,
purging in the case of Ophthalmia does not prove
useful in any degree in proportion to the evacua—
tion excited.
284.
For the relaxing the spasm in the part, and tak—
ing off the determination of the fluids to it, blister—
ing near the part has commonly been found useful.
285.
Electrical sparks taken from the eye will often
suddenly discuss the inflammation of the adnata:
but the effect is seldom permanent, and even a fre—
quent repetition seldom gives an entire cure.
286.
Ophthalmia, as an external inflammation, ad—
mits of topical applications. All those, however,
that increase the heat and relax the vessels of the
part, prove commonly hurtful; and the admission
of cool air to the eye, the proper application of
cold water immediately to the ball of the eye, and
the application of various cooling and astringent
medicines, which at the same time do not produce
much irritation, prove generally useful; even spi—
rituous liquors, employed in moderate quantity,
have often been of service,
287. In 

160 PRACTICE
287.
In the cure of Ophthalmia, much care is requi—
site to avoid all irritation, particularly that of light;
and the only safe and certain means of doing this,
is by confining the patient to a very dark chamber.
288.
These are the remedies of the Ophthalmia mem—
branarum; and in the Ophthalmia tarsi, for as it
is produced by Ophthalmia membranarum, the same
remedies may be necessary. As, however, the Oph—
thalmia tarsi may often depend upon an acrimony
deposited in the sebaceous glands of the part, so it
may require various internal remedies according to
the nature of the acrimony in fault; for which I
must refer to the consideration of scrophula, syphi—
lis, or other diseases with which this Ophthalmia
may be connected; and when the nature of the ac—
rimony is not ascertained, certain remedies, more
generally adapted to the evacuation of acrimony,
such, for instance, as mercury, may be employed.
289.
In the Ophthalmia tarsi, it almost constantly hap—
pens, that some ulcerations are formed on the tar—
sus. These require the application of mercury or
copper, either of which may by itself sometimes 
entirely cure the affection; and these may even be
useful when the disease depends upon a fault of
the whole system.
29O.
Both in the Ophthalmia membranarum, and in
the Ophthalmia tarsi, it is necessary to obviate that
gluing or sticking together of the eyelids which
commonly happens in sleep; and this may be done
by 

161 OF PHYSIC. 
by insinuating a little of any mild unctuous medi—
cine of some tenacity between the eyelids before
the patient shall go to sleep.
CHAP. IV.
OF PHRENSY, OR PHRENITIS.
291.
THIS disease is an inflammation of the parts
contained in the cavity of the cranium; and
may affect either the membranes of the brain, or
the substance of the brain itself. Nosologists have
apprehended, that these two cases might be distin—
guished by different symptoms, and therefore by
different appellations; but this does not seem to be
confirmed by observation and dissection; and there—
fore I shall treat of both cases under the title of
Phrensy, or Phrenitis.
292.
An idiopathic phrensy is a rare occurrence, a
sympathic more frequent; and the ascertaining ei—
ther the one or the other is, upon many occasions,
difficult. Many of the symptoms by which the dis—
ease is most commonly judged to be present, have
appeared, when, from certain considerations, it
was presumed, and even from dissection it appeared,
that there had been no internal inflammation; and,
on the other hand, dissections have shown, that
the brain had been inflamed, when few of the pe—
culiar symptoms of phrensy had before appeared.
293.
The symptoms by which this disease may be most
certainly known are, a vehement pyrexia, a vio—
VOL. I. X lent 

162 PRACTICE
lent deep seated headach, a redness and turgescence
of the face and eyes, an impatience of light or noise,
a constant watching, and a delirium impetuous and
furious. Some nosologists have thought these symp—
toms peculiar to an inflammation of the membranes,
and that the inflammation of the substance of the
brain was to be distinguished by some degree of
coma attending it. It was for this reason that in
the Nosology I added the Typhomania to the cha—
racter of Phrenitis; but, upon farther reflection,
I find no proper foundation for this; and, if we
pass from the characters above delivered, there will
be no means of fixing the variety that occurs.
I am here, as in other analogous cases, of opi—
nion, that the symptoms above mentioned of an
acute inflammation, always mark inflammations of
membranous parts; and that an inflammation of
the paronchyma or substance of viscera, exhibits,
at least commonly, a more chronic affection.
294.
The remote causes of phrensy, are all those which
directly stimulate the membranes, or substance of
the brain; and particularly all those which increase
the impetus of the blood in the vessels of the brain.
Among these the exposure of the naked head to
the direct rays of a very warm fun, is a frequent
cause. The passions of the mind, and certain poi—
sons, are amongst the remote causes of phrensy;
but in what manner they operate, is not well un—
derstood.
295.
The cure of phrensy is the same with that of in—
flammation in general; but in phrensy the most
powerful remedies are to be immediately employ—
ed. Large and repeated bloodletting is especially
necessary; and the blood should be drawn from
vessels as near as possible to the part affected. The
opening 

163 OF PHYSIC. 
opening of the temporal artery has been recom—
mended, and with some reason; but the practice
is attended with inconvenience; and I apprehend,
that opening the jugular veins may prove more ef—
fectual; but, at the same time, it will be generally
proper to draw blood from the temples by cupping
and scarifying.
296.
It is probable, that purging, as it may operate
by revulsion, may be of more use in this than in
some other inflammatory affections.
For the same purpose of revulsion, warm pedilu—
via are a remedy; but, at the same time, some—
what ambiguous. The taking off the force of the
blood in the vessels of the head by an erect posture,
is generally useful.
297.
Shaving of the head is always proper and neces—
say for the admission of other remedies. Blister—
ing is commonly useful in this disease, but chiefly
when applied near to the part affected.
298.
Every part of the antiphlogistic regimen is here
necessary, and particularly the admission of cold
air. Even cold substances, applied close to the
head, have been found safe and highly useful; and
the application of such refrigerants as vinegar, is
certainly proper.
299
It appears to me certain, that opiates are hurt—
ful in every inflammatory state of the brain; and
it is to be observed, that, from the ambiguity men—
tioned 

164 PRACTICE
tioned in (292.), the accounts of practitioners, with
regard to the juvantia and lædentia in this disease,
are of very uncertain application.
CHAP. V.
OF THE QUINSY, OR CYNANCHE.
300.
THIS name is applied to every inflammation of
the internal fauces; but these inflammations
are different, according to the part of the fauces
which may be affected, and according to the na—
ture of the inflammation. In the Nosology, there—
fore, after giving the character of the Cynanche as
a genus, I have distinguished five different species,
which must here likewise be separately considered.
SECT. I.
Of the CYNANCHE TONSILLARIS. 
301.
THIS is an inflammation of the mucous mem—
brane of the fauces, affecting especially that con—
geries of mucous follicles which forms the tonsils,
and speading from thence along the velum and
uvula, so as frequently to affect every part of the
mucous membrane.
302.
The disease appears by some tumour, sometimes
considerable, and by a redness of the parts; is at—
tended with a painful and difficult deglutition; with
a pain sometime shooting into the ear; with a trou—
blesome 

165 OF PHYSIC. 
blesome clamminess of the mouth and throat; with
a frequent, but difficult, excretion of mucous; and
the whole is accompanied with a pyrexia.
303.
This species of quinsy is never contagious. It
terminates frequently by resolution, sometimes by
suppuration, but hardly ever by gangrene; although
in this disease some sloughy spots commonly sup—
posed to be forerunners of gangrene, sometimes
appear upon the fauces.
304.
This disease is commonly occasioned by cold ex—
ternally applied, particularly about the neck. It
affects especially the young and sanguine, and a
disposition to it is often acquired by habit; so that
from every considerable application of cold to any
part of the body, this disease is readily induced.
It occurs especially in spring and autumn, when
vicissitudes of heat and cold frequently take place.
The inflammation and tumour are commonly at
first most considerable in one tonsil; and after—
wards, abating in that, increase in the other.
305.
In the cure of this inflammation, some bleeding
may be proper; but large general bleedings will
seldom be necessary. The opening of the ranular
veins seems to be an insignificant remedy; and
leeches let upon the external fauces are of more
efficacy.
306.
At the beginning of the disease, full vomiting has
been frequently found to be of great service.
307. This 

166 PRACTICE
307.
This inflammation maybe often relieved by mo—
derate astringents, and particularly by acids appli—
ed to the inflamed parts. In many cases, however,
nothing has been found to give more relief than
the vapour of warm water received into the fauces
by a proper apparatus.
308.
The other remedies of this disease are rubefa-
cient or blistering medicines, applied externally to
the neck; and, with these, the employment of an—
tiphlogistic purgatives, as well as every part of the
antiphlogistic regimen, excepting the application
of cold.
309.
This disease, as we have said, often terminates
by resolution, frequently accompanied with sweat—
ing; which is therefore to be prudently favoured
and encouraged.
31O.
When this disease shall have taken a tendency
to suppuration, nothing will be more useful, than
the frequent taking into the fauces the steams of
warm water. When the abscess is attended with
much swelling, if it break not spontaneously, it
should be opened by a lancet; and this does not
require much caution, as even the inflammatory 
state may be relieved by some scarification of the
tonsils. I have never had occasion to see any case
requiring bronchotomy.
SECT. 

167 OF PHYSIC
SECT. II.
Of the CYNANCHE MALIGNA. 
311.
THIS is a contagious disease, seldom sporadic,
and commonly epidemic. It attacks persons of
all ages, but more commonly those in a young
and infant state. It attacks persons of every con—
stitution when exposed to the contagion, but most
readily the weak and infirm.
312.
This disease is usually attended with a consider—
able pyrexia; and the symptoms of the accession
of this, such as frequent cold shiverings, sickness,
anxiety, and vomiting, are often the first appear—
ances of the disease. About the same time, a stiff—
ness is felt in the neck, with some uneasiness in the
internal fauces, and some hoarseness of the voice.
The internal fauces, when viewed, appear of a
deep red colour, with some tumour; but this last
is seldom considerable, and deglutition is seldom
difficult or painful. Very soon, a number of white
or ash coloured spots appear upon the inflamed
parts. These spots spread and unite, covering al—
most the whole fauces with thick sloughs; which
falling off, discover ulcerations. While these symp—
toms proceed in the fauces, they are generally at—
tended with a coryza, which pours out a thin acrid
and fetid matter, excoriating the nostrils and lips.
There is often also, especially in infants, a fre—
quent purging; and a thin acrid matter flows from
the anus, excoriating this and the neighbouring
parts.
313. With 

168 PRACTICE
3l3.
With these symptoms, the pyrexia proceeds with
a small, frequent, and irregular pulse; and then
occurs a manifest exacerbation every evening, and
some remission in the mornings. A great debility
appears in the animal functions; and the sensorium
is affected with delirium, frequently with coma.
314.
On the second day, or sometimes later, efflores—
cences appear upon the skin, which are sometimes
in small points hardly eminent; but, for the most
part, in patches of a red colour, spreading and unit—
ing so as to cover the whole skin. They appear first
about the face and neck, and in the course of some
days spread by degrees to the lower extremities.
The scarlet redness is often considerable on the
hands and extremities of the fingers, which feel stiff
and swelled. This eruption is often irregular, as
to the time of its appearance, as to its steadiness,
and as to the time of its duration. It usually
continues four days, and goes off by some def—
quamation of the cuticle; but neither on its first
appearance, nor on its desquamation, does it al—
ways produce a remission of the pyrexia, or of the
other symptoms.
315.
The progress of the disease depends on the state
of the fauces and of the pyrexia. When the ulcers
on the fauces, by their livid and black colour, by
the fetor of the breath, and by many marks of acri—
mony in the fluids, show a tendency to gangrene,
this takes place to a considerable degree; and, the
symptoms of a putrid fever constantly increasing, the
patient dies, often on the third day, sometimes later,
but 

169 OF PHYSIC.
but for the most part before the seventh. The acri—
mony poured out from the diseased fauces must ne—
cessarily, in part, pass into the pharynx, and there
spread the infection into the œsophagus, and some—
times through the whole of the alimentary canal,
propagating the putrefaction, and often exhausting
the patient by a frequent diarrhœa.
The acrid matter poured out in the fauces be—
ing again absorbed, frequently occasions large
swellings of the lymphatic glands about the neck,
and sometimes to such a degree as to occasion suf—
focation.
It is seldom that the organs of respiration escape
entirely unhurt, and very often the inflammatory
affection is communicated to them. From dissec—
tions it appears, that, in the Cynanche maligna,
the larynx and trachea are often affected in the
same manner as in the Cynanche trachealis; and
it is probable, that, in consequence of that affec—
tion, the Cynanche maligna often proves fatal by
such a sudden suffocation as happens in the proper
Cynanche trachealis; but there is reason to sus—
pect that upon this subject dissectors have not al—
ways distinguished properly between the two dis—
eases.
316.
These are the several fatal terminations of the
Cynanche maligna; but they do not always take
place. Sometimes the ulcers of the fauces are of a
milder nature; and the fever is more moderate, as
well as of a less putrid kind. And when, upon
the appearance of the efflorescence on the skin, the
fever suffers a remission; when the efflorescence
continues for three or four days, till it has spread
over the whole body, and then ends by a desqua—
mation, giving a further remission of the fever;
this often entirely terminates, by gentle sweats, on
or before the seventh day; and the rest of the dis—
VOL. I. Y ease 

170 PRACTICE
ease terminates in a few days more by an excre—
tion of sloughs from the fauces, while sleep, appe—
tite, and the other marks of health, return.
From what is said in this and the preceding pa—
ragraph, the prognostics in this disease may be
readily learned.
317.
In the cure of this disease, its septic tendency is
chiefly to be kept in view. The debility, with
which it is attended, renders all evacuations by
bleeding and purging improper, except in a few
instances where the debility is less, and the inflam—
matory symptoms more considerable. The fauces
are to be preserved from the effects of the acrid
matter poured out upon them, and are therefore to
be frequently washed out by antiseptic gargles of
injections; and the septic tendency of the whole
system should be guarded against and corrected by
internal antiseptics, especially by the Peruvian
bark given in substance, from the beginning, and
continued through the course of the disease. E—
metics, both by vomiting and nauseating, prove
useful, especially when employed early in the dis—
ease. When any considerable tumour occurs, blis—
ters applied externally will be of service, and in
any case may be fit to moderate the internal
inflammation.
SECT. III.
Of the CYNANCHE TRACHEALIS.
318.
This name has been given to an inflammation
of the glottis, larynx, or upper part of the
trachea, whether it affect the membranes of these
parts, 

171 OF PHYSIC. 
parts, or the muscles adjoining. It may arise first
in these parts, and continue to subsist in them a—
lone; or it may come to affect these parts from
the Cynanche tonsillaris or maligna spreading into
them.
319.
In either way it has been a rare occurrence, and
few instances of it have been marked and record—
ed by physicians. It is to be known by a peculiar
ringing found of the voice, by difficult respiration,
with a sense of straitening about the larynx, and by
a pyrexia attending it.
320.
From the nature of these symptoms, and from
the dissection of the bodies of persons who had di—
ed of this disease, there is no doubt of its being of
an inflammatory nature. It does not however al—
ways run the course of inflammatory affections;
but frequently produces such an obstruction of the
passage of the air, as suffocates, and thereby proves
suddenly fatal.
321.
If we judge rightly of the nature of this disease,
it will be obvious, that the cure of it requires the
most powerful remedies of inflammation, to be em—
ployed upon the very first appearance of the symp—
toms. When a suffocation is threatened, whether
any remedies can be employed to prevent it, we
have not had experience to determine.
322.
The accounts which books have hitherto given
us of inflammations of the larynx, and the parts
connected 

172 PRACTICE
connected with it, amount to what we have now
said; and the instances recorded have almost all of
them happened in adult persons; but there is a pe—
culiar affection of this kind happening especially to
infants, which till lately has been little taken notice
of Dr. Home is the first who has given any dis—
tinct account of it; but since he wrote several
other authors have taken notice of it, (see MI—
CHAELIS De angina polyposa five membranica. Ar—
geniorati 1778); and have given different opinions
with regard to it. Concerning this diversity of
opinions I shall not at present inquire; but shall
deliver the history and cure of this disease, in so
far as these have arisen from my own observation,
from that of Dr. Home, and of other skilful per—
sons in this neighbourhood,
323.
This disease seldom attacks infants till after they
have been weaned. After this period, the young—
er they are, the more they are liable to it. The
frequency of it becomes less, as children become
more advanced; and there are no instances of
children above twelve years of age being affected
with it. It attacks children of the midland coun—
tries, as well as those who live near the sea. It
does not appear to be contagious, and its attacks
are frequently repeated in the same child. It is
often manifestly the effect of cold applied to the bo—
dy; and therefore appears most frequently in the
winter and spring seasons. It very commonly
comes on with the ordinary symptoms of a catarrh;
put sometimes the peculiar symptoms of the disease
show themselves at the very first.
324.
These peculiar symptoms are the following: A
hoarseness, with some shrillness and ringing found,
both 

173 OF PHYSIC 
both in speaking and coughing, as if the noise
came from a brazen tube. At the same time there
is a sense of pain about the larynx, some difficulty
of respiration, with a whizzing found in inspira—
tion, as if the passage of the air were straitened.
The cough which attends it, is commonly dry; and
if any thing be spit up, it is a matter of a purulent
appearance, and sometimes films resembling por—
tions of a membrane. Together with these symp—
toms, there is a frequency of pulse, a restlessness,
and an uneasy sense of heat. When the internal
fauces are viewed, they are sometimes without any
appearance of inflammation; but frequently a red—
ness, and even swelling, appear; and sometimes
in the fauces, there is an appearance of matter like
to that rejected by coughing. With the symptoms
now described, and particularly with great difficul—
ty of breathing, and a sense of strangling in the
fauces, the patient is sometimes suddenly taken off.
325.
There have been many dissections made of in—
fants who had died of this disease; and almost con—
stantly there has appeared a preternatural mem—
brane lining the whole internal surface of the up—
per part of the trachea, and extending in the same
manner downwards into some of its ramifications.
This preternatural membrane may be easily sepa—
rated, and sometimes has been found separated in
part, from the subjacent proper membrane of the
trachea. This last is commonly found entire, that
is, without any appearance of erosion or ulceration;
but it frequently shows the vestiges of inflamma—
tion, and is covered by a matter resembling pus,
like to that rejected by coughing; and very often
a matter of the same kind is found in the bronchiæ,
sometimes in considerable quantity.
326. From 

174 PRACTICE
326.
From the remote causes of this disease; from
the catarrhal symptoms commonly attending it;
from the pyrexia constantly present with it; from
the same kind of preternatural membrane being
found in the trachea when the cynanche maligna
is communicated to it; and from the vestiges of in—
flammation on the trachea discovered upon dissec—
tion; we must conclude, that the disease consists in
an inflammatory affection of the mucous membrane
of the larynx and trachea, producing an exudation
analogous to that found on the surface of inflamed
viscera, and appearing partly in a membranous
crust, and partly in a fluid resembling pus.
327.
Though this disease manifestly consists in an in—
flammatory affection, it does not commonly end
either in suppuration or gangrene. The peculiar
and troublesome circumstance of the disease seems
to consist in a spasm of the muscles of the glottis,
which, by inducing a suffocation, prevents the com—
mon consequences of inflammation.
328.
When this disease terminates in health, it is by a
resolution of the inflammation, by a ceasing of the
spasm of the glottis, by an expectoration of the
matter exuding from the trachea, and of the crusts
formed there; and frequently it ends without any
expectoration, or at least with such only as attends
an ordinary catarrh.
329.
When the disease ends fatally, it is by a suffo—
cation; seemingly, as we have said, depending up—
on 

175 OF PHYSIC.
on a spasm affecting the glottis; but sometimes pro—
bably depending upon a quantity of matter filling
the bronchiæ.
330.
As we suppose the disease to be an inflammatory
affection, so we attempt the cure of it by the usual
remedies of inflammation, and which for the most
part I have found effectual. Bleeding, both ge—
neral and topical, has often given immediate relief;
and, by being repeated, has entirely cured the dis—
ease. Blistering also, near to the part affected, has
been found useful. Upon the first attack of the
disease, vomiting, immediately after bleeding, seems
to be of considerable use, and sometimes suddenly
removes the disease. In every stage of the disease,
the antiphlogistic regimen is necessary, and parti—
cularly the frequent use of laxative glysters. Though
We suppose that a spasm affecting the glottis is oft—
en fatal in this disease, I have not found antispas—
modic medicines to be of any use.
SECT. IV.
Of the CYNANCHE PHARYNGÆA.
331.
IN the Cynanche tonsillaris, the inflammation
of the mucous membrane often spreads upon the
pharynx, and into the beginning of the œsophagus,
and thereby renders deglutition more difficult and
uneasy; but such a case does not require to be dis—
tinguished as a different species, from the common
Cynanche tonsillaris; and only requires that blood—
letting, and other remedies, should be employed
with greater diligence than in ordinary cases. We
have never seen any case, in which the inflamma—
tion 

176 PRACTICE
tion began in the pharynx, or in which this part alone
was inflamed; but practical writers have taken no—
tice of such a case; and to them, therefore I must
refer, both for the appearances which distinguish
it, and for the method of cure.
SECT. V.
Of the CYNANCHE PAROTIDÆA.
332.
This is a disease known to the vulgar, and among
them has got a peculiar appellation in every coun—
try of Europe; but has been little taken notice of
by medical writers. It is often epidemic, and ma—
nifestly contagious. It comes on with the usual
symptoms of pyrexia, which is soon after attended
with a considerable tumour of the external fauces
and neck. This tumour appears first as a glandu—
lar moveable tumour at the corner of the lower
jaw; but the swelling soon becomes uniformly dif—
fused over a great part of the neck, sometimes on
one side only, but more commonly on both. The
swelling continues to increase till the fourth day;
but from that period it declines, and in a few days
more passes off entirely. As the swelling of the
fauces recedes, some tumour affects the testicles in
the male sex, or the breasts in the female. These
tumours are sometimes large, hard, and somewhat
painful; but in this climate, are seldom either ve—
ry painful or of long continuance. The pyrexia,
attending this disease is commonly slight, and re—
cedes with the swelling of the fauces; but some—
times, when the swelling of the testicles does not
succeed to that of the fauces, or when the one or the
other has been suddenly repressed, the pyrexia be—
comes more considerable, is often attended with de—
lirium, and has sometimes proved fatal.
333. As

177 OF PHYSIC. 
333.
As this disease commonly runs its course with—
out either dangerous or troublesome symptoms, so
it hardly requires any remedies. An antiphlogis—
tic regimen, and avoiding cold, are all that will be
commonly necessary. But when upon the reced—
ing of the swellings of the testicles in males, or of
the breasts in females, the pyrexia comes to be con—
siderable, and threatens an affection of the brain,
it will be proper, by warm fomentations, to bring
back the swelling; and, by vomiting, bleeding,
or blistering, to obviate the consequences of its
absence.
CHAP. VI.
OF PNEUMONIA, OR PNEUMONIC
INFLAMMATION.
334.
UNDER this title I mean to comprehend the
whole of the inflammations affecting either the
viscera of the thorax or the membrane lining the
interior surface of that cavity; for neither do our
diagnostics serve to ascertain exactly the seat of the
disease; nor does the difference in the seat of the
disease exhibit any considerable variation in the
state of the symptoms, nor lead to any difference
in the method of cure.
335.
Pneumonic inflammation, however various in its
seat, seems to me to be always known and distin—
guished by the following symptoms; pyrexia, diffi—
cult breathing, cough, and pain in some part of the
VOL. I. Z thorax. 

178 PRACTICE
thorax. But these symptoms are, on different oc—
casions, variously modified.
336.
The disease almost always comes on with a cold
stage, and is accompanied with the other symptoms
of pyrexia; though in a few instances the pulse may
not be more frequent, nor the heat of the body in—
creased beyond what is natural. Sometimes the py—
rexia is from the beginning accompanied with the
other symptoms; but frequently it is formed for
some hours before the other symptoms become con—
siderable, and particularly before the pain be felt.
For the most part, the pulse is frequent, full, strong,
hard, and quick; but in a few instances, especially
in the advanced state of the disease, the pulse is
weak and soft, and at the same time irregular.
337.
The difficulty of breathing is always present, and
most considerable in inspiration; both because the
lungs do not easily admit of a full dilatation, and
because the dilatation aggravates the pain attend—
ing the disease. The difficulty of breathing is also
greater, when the patient is in one posture of his
body rather than another. It is generally greater
when he lies upon the side affected; but sometimes
the contrary happens. Very often the patient can—
not lie easy upon either side, finding ease only
when lying on his back; and sometimes he cannot
breathe easily, except when in somewhat of an
erect posture.
338.
A cough always attends this disease; but in dif—
ferent cases, is more or less urgent and painful.
It is sometimes dry, that is, without any expecto—
ration, 

179 OF PHYSIC.
ration, especially in the beginning of the disease;
but more commonly it is, even from the first, moist,
and the matter spit up various both in consistence
and colour; and frequently it is streaked with blood.
339.
The pain attending this disease is, in different
cases, felt in different parts of the thorax, but most
frequently in one side. It has been said to affect
the right side more frequently than the left; but
this is not certain; while on the other hand it is
certain that the left side has been very often affect—
ed. The pain is felt sometimes as if it were under
the sternum; sometimes in the back between the
shoulders; and when in the sides, its place has been
higher or lower, more forward or backward; but
the place of all others most frequently affected, is
about the sixth or seventh rib, near the middle of
its length, or a little more forward. The pain is
often severe and pungent; but sometimes more
dull and obtuse, with a sense of weight rather than
of pain. It is most especially severe and pungent
when occupying the place last mentioned. For
the most part it continues fixed in one place; but
sometimes shoots from the side to the scapula, on
one hand, or to the sternum and clavicle, on the
other.
340.
The varying state of symptoms now mentioned,
does not always ascertain precisely the seat of the
disease. To me it seems probable, that the disease
is always seated, or at least begins, in some part
of the pleura; taking that membrane in its great—
est extent, as now commonly understood; that is,
as covering not only the internal surface of the ca—
vity of the thorax, but also as forming the medias—
tinum,

180 PRACTICE
tinum, and as extended over the pericardium and
over the whole surface of the lungs.
341.
There is therefore little foundation for distin—
guishing this disease by different appellations taken
from the part which may be supposed to be chiefly
affected. The term Pleurisy might with propriety
be applied to every case of the disease; and has
been very improperly limited to that inflammation
which begins in, and chiefly affects, the pleura cos—
talis. I have no doubt that such a case does truly
occur; but, at the same time, I apprehend it to be
a rare occurrence; and that the disease much more
frequently begins in, and chiefly affects, the pleu—
ra investing the lungs, producing all the symptoms
supposed to belong to what has been called the
Pleuritis vera.
342.
Some physicians have imagined, that there is a
case of pneumonic inflammation particularly enti—
tled to the appellation of Peripneumony; and that
is, the case of an inflammation beginning in the pa—
renchyma or cellular texture of the lungs, and ha—
ving its seat chiefly there. But it seems to me ve—
ry doubtful, if any acute inflammation of the lungs,
or any disease which has been called Peripneumo—
ny, be of that kind. It seems probable, that every
acute inflammation begins in membranous parts;
and in every dissection of persons dead of peripneu—
mony, the external membrane of the lungs, or
some part of the pleura, has appeared to have been
considerably affected.
343.
An inflammation of the pleura covering the up—
per surface of the diaphragm, has been distinguish—
ed 

181 OF PHYSIC.
ed by the appellation of Paraphrenitis, as supposed
to be attended with the peculiar symptoms of deli—
rium, risus sardonicus, and other convulsive mo—
tions; but it is certain, that an inflammation of
that portion of the pleura, and affecting also even
the muscular substance of the diaphragm, has often
taken place without any of these symptoms; and I
have not met with either dissections, or any ac—
counts of dissections, which support the opinion,
that an inflammation of the pleura covering the dia—
phragm, is attended with delirium, more common—
ly than any other pneumonic inflammation.
344.
With respect to the seat of pneumonic inflamma—
tion, I must observe further, that although it may
arise and subsist chiefly in one part of the pleura
only, it is however frequently communicated to
other parts of the same, and commonly communi—
cates a morbid affection through its whole extent.
345.
The remote cause of pneumonic inflammation,
is, commonly, cold applied to the body, obstrua—
ing perspiration, and determining to the lungs;
while at the same time the lungs themselves are
exposed to the action of cold. These circumstan—
ces operate especially, when an inflammatory dia—
thesis prevails in the system; and consequently, up—
on persons of the greatest vigour; in cold climates;
in the winter season; and particularly in the spring,
when vicissitudes of heat and cold are frequent.
The disease, however, may arise in any season
when such vicissitudes occur.
Other remote causes also may have a share in
this matter; such as every means of obstructing,
straining, or otherwise injuring, the pneumonic
organs.
Pneumonic 

l82 PRACTICE
Pneumonic inflammation may happen to persons
of any age, but rarely to those under the age of
puberty; and most commonly it affects persons
somewhat advanced in life, as those between forty
five and sixty years; those, too, especially of a ro—
bust and full habit.
The pneumonic inflammation has been sometimes
so much an epidemic, as to occasion a suspicion of
its depending upon a specific contagion; but I have
not met with any evidence in proof of this. See
MORGAGNI de causis et sedibus morborum, epist.
xxi. art. 26.
346.
The pneumonic, like other inflammations, may
terminate by resolution, suppuration, or gangrene;
but it has also a termination peculiar to itself, as
has been hinted above, (259); and that is, when
it is attended with an effusion of blood into the
cellular texture of the lungs, which soon interrupt—
ing the circulation of the blood through this viscus,
produces a fatal suffocation. This, indeed, seems
to be the most common termination of pneumonic
inflammation, when it ends fatally; for, upon the
dissection of almost every person dead of the dis—
ease, it has appeared that such an effusion had
happened.
347.
From these dissections also we learn, that, pneu—
monic inflammation commonly produces an exuda—
tion from the internal surface of the pleura; which
appears partly as a soft viscid crust, often of a com—
pact, membranous form, covering every where
the surface of the pleura, and particularly those
parts where the lungs adhere to the pleura costalis,
or mediastinum; and this crust seems always to be
the cement of such adhesions.
The 

183 OF PHYSIC. 
The same exudation shows itself, also, by a quan—
tity of a serous whitish fluid, commonly found in
the cavity of the thorax; and some exudation or
effusion is usually found to have been made like—
wise into the cavity of the pericardium.
348.
It seems probable, too, that a like effusion is
sometimes made into the cavity of the bronchiæ;
for, in some persons who have died after labouring
under a pneumonic inflammation for a few days
only, the bronchiæ have been found filled with a
considerable quantity of a serous and thickish flu—
id; which, I think, must be considered rather as
the effusion mentioned, having had its thinner parts
taken off by respiration, than as a pus so suddenly
formed in the inflamed part.
349.
It is, however, not improbable, that this effusi—
on, as well as that made into the cavities of the
thorax and pericardium, may be a matter of the
same kind with that which, in other inflammations,
is poured into the cellular texture of the parts in—
flamed, and there converted into pus; but, in the
thorax and pericardium, it does not always assume
that appearance, because the crust covering the
surface prevents the absorption of the thinner part.
This absorption, however, may be compensated in
the bronchiæ by the drying power of the air; and
therefore the effusion into them may put on a more
purulent appearance.
In many cases of pneumonic inflammation, when
the SPUTA are very copious, it is difficult to sup—
pose that the whole of them proceed from the mu—
cous follicles of the bronchiæ. It seems more pro—
bable that a great part of them may proceed from
the effused serous fluid we have been mentioning;
and 

184 PRACTICE
and this too will account for the sputa being so oft—
en of a purulent appearance. Perhaps the same
thing may account for that purulent expectoration,
as well as that purulent matter found in the bron—
chiæ, which the learned Mr. de Haen says he had
often observed, when there was no ulceration of
the lungs; and this explanation, is at least more
probable, than Mr. de Haen's supposition of a pus
formed in the circulating blood.
350.
To conclude this subject, it would appear, that
the effusion into the bronchiæ, which we have men—
tioned, often concurs with the effusion of red blood
in occasioning the suffocation, which fatally termi—
nates pneumonic inflammation; that the effusion
of serum alone may have this effect; and, that the
serum poured out in a certain quantity, rather than
any debility in the powers of expectoration, is
the cause of that ceasing of expectoration which ve—
ry constantly precedes the fatal event. For, in ma—
ny cases, the expectoration has ceased, when no
other symptoms of debility have appeared, and
when, upon dissection, the bronchiæ have been
found full of liquid matter. Nay, it is even pro—
bable, that, in some cases, such an effusion may
take place, without any symptoms of violent in—
flammation; and, in other cases, the effusion tak—
ing place, may seem to remove the symptoms of
inflammation which had appeared before, and thus
account for those unexpected fatal terminations
which have sometimes happened. Possibly this ef—
fusion may account also for many of the phenome—
na of the Peripneumonia Notha.
351.
Pneumonic inflammation seldom terminates of
resolution, without being attended with some evi—
dent

185 OF PHYSIC.
dent evacuation. An hemorrhagy from the nose
happening upon some of the first days of the disease,
has sometimes put an end to it; and it is said, that
an evacuation from the hemorrhoidal veins, a bili—
ous evacuation by stool, and an evacuation of urine
with a copious sediment, have severally had the
same effect; but such occurrences have been rare
and unusual.
The evacuation most frequently attending, and
seeming to have the greatest effect in promoting
resolution, is an expectoration of a thick white or
yellowish matter, a little streaked with blood, co—
pious, and brought up without either much or vio—
lent coughing.
Very frequently the resolution of this disease is
attended with, and perhaps produced by, a sweat,
which is warm, fluid, copious over the whole body,
and attended with an abatement of the frequency
of the pulse, of the heat of the body, and of other
febrile symptoms.
352.
The prognostics in this disease are formed from
observing the state of the principal symptoms.
A violent pyrexia is always dangerous.
The danger, however, is chiefly denoted by the
difficulty of breathing. When the patient can lie
on one side only; when he can lie on neither side,
but upon his back only; when he cannot breathe
with tolerable ease, except the trunk of his body
be erect; when, even in this posture, the breath—
ing is very difficult, and attended with a turgescence
and flushing of the face, together with partial
sweats about the head and neck, and an irregular
pulse; these circumstances mark the difficulty of
breathing in progressive degrees, and, consequent—
ly, in proportion, the danger of the disease.
A frequent violent cough aggravating the pain,
is always the symptom of art obstinate disease.
VOL. I. A a As 

186 PRACTICE
As I apprehend that the disease is hardly ever
resolved, without some expectoration; so a dry
cough must be always an unfavourable symptom.
As the expectoration formerly described, marks
that the disease is proceeding to a resolution; so
an expectoration which has not the conditions there
mentioned, must denote at least a doubtful state of
the disease; but the marks taken from the colour
of the matter, are for the most part fallacious.
An acute pain, very much interrupting inspira—
tion, is always the mark of a violent disease;
Though not of one more dangerous, than an obtuse
pain, attended with very difficult respiration.
When the pains, which at first had affected one
side only, have afterwards spread into the other;
or when leaving the side first affected, they entire—
ly pass into the other; these are always marks of an
increasing, and therefore of a dangerous, disease.
A delirium coming on during a pneumonic in—
flammation, is constantly a symptom denoting much
danger.
353.
When the termination of this disease proves fa—
tal, it is on one or other of the days of the first
week, from the third to the seventh. This is the
most common case; but in a few instances, death
has happened at a later period of the disease.
When the disease is violent, but admitting of re—
solution, this also happens frequently in the course
of the first week; but in a more moderate state of
the disease the resolution is often delayed to the
second week. 
The disease, on some of the days from the third
to the seventh, generally suffers a remission; which,
however, may be often fallacious, as the disease
does sometimes return again with as much violence
as before, and then with great danger.
Sometimes 

187 OF PHYSIC. 
Sometimes the disease disappears on the second
or third day, while an erysipelas makes its appear—
ance on some external part; and, if this conti—
nue fixed, the pneumonic inflammation does not
recur.
354.
Pneumonia, like other inflammations, often ends
in suppuration or gangrene.
355.
When a pneumonia, with symptoms neither very
violent nor very flight, has continued for many
days, it is to be feared it will end in a suppuration.
This however is not to be determined precisely by
the number of days; for not only after the fourth,
but even after the tenth day, there have been ex—
amples of a pneumonia ending by a resolution;
and if the disease has suffered some intermission,
and again recurred, there may be instances of a
resolution happening at a much later period from
the beginning of the disease, than that just now
mentioned.
356.
But if a moderate disease, in spite of proper re—
medies employed, be protracted to the fourteenth
day, without any considerable remission, a suppu—
ration is pretty certainly to be expected; and it
will be still more certain, if no signs of resolution
have appeared, or if an expectoration which had
appeared shall have again ceased, and the difficulty
of breathing has continued or increased, while the
other symptoms have rather abated.
357. That 

188 PRACTICE
357.
That in a pneumonia the effusion is made, which
may lay the foundation of a suppuration, we con—
clude from the difficulty of breathing becoming
greater when the patient is in a horizontal posture,
or when he can lie more easily upon the affected
side.
358.
That in such cases a suppuration has actually be—
gun, may be concluded from the patient's being
frequently affected with slight cold shiverings, and
with a sense of cold felt sometimes in one and some—
times in another part of the body. We form the
same conclusion also from the state of the pulse,
which is commonly less frequent and softer, but
sometimes quicker and fuller, than before.
359.
That a suppuration is already formed, may be 
inferred from there being a considerable remission
of the pain which had before subsisted, while, along
with this, the cough, and especially the dyspnœa,
continue, and are rather augmented. At the same
time, the frequency of the pulse is rather increas—
ed; the feverish state suffers considerable exacer—
bations every evening, and by degrees a hectic in
all its circumstances comes to be formed.
360.
The termination of pneumonia by gangrene, is
much more rare than has been imagined; and,
when it does occur, it is usually joined with the
termination by effusion (346), and the symptoms of
the 

189 OF PHYSIC. 
the one are hardly to be distinguished from those
of the other.
361.
The cure of pneumonic inflammation must pro—
ceed upon the general plan (264); but the import—
ance of the part affected, and the danger to which
it is exposed, require that the remedies be fully, as
well as early, employed.
362.
The remedy chiefly to be depended upon, is that
of bleeding at the arm; which will be performed
with most advantage in the arm of the side affect—
ed; but may be done in either arm, as may be most
convenient for the patient or the surgeon. The
quantity drawn must be suited to the violence of
the disease, and to the vigour of the patient; and
generally ought to be as large as this last circum—
stance will allow. The remission of pain, and the
relief of respiration during the flowing of the blood,
may limit the quantity to be then drawn; but if
these symptoms of relief do not appear, the bleed—
ing should be continued till the symptoms of a be—
ginning syncope come on. It is seldom that one
bleeding, however large, will prove a cure of this
disease; and although the pain and difficulty of
breathing may be much relieved by the first bleed—
ing, these symptoms commonly, and after no long
interval, recur; often with as much violence as
before. In the event of such recurrence, the
bleeding is to be repeated, even in the course of
the same day, and perhaps to the same quantity as
before.
Sometimes the second bleeding may be larger
than the first. There are persons who, by their
constitution, are ready to faint even upon a small
bleeding; and, in such persons, this may prevent
the 

190 PRACTICE
the drawing so much blood at first as a pneumonic
inflammation might require; but, as the same per—
sons are frequently found to bear after bleedings
better than the first, this allows the second and sub—
sequent bleedings to be larger, and to such a quan—
tity as the symptoms of the disease may seem to
demand.
363.
It is according to the state of the symptoms that
bleedings are to be repeated; and they will be more
effectual when practised in the course of the first
three days, than afterwards; but they are not to
be omitted, although four days of the disease may
have already elapsed. If the physician shall not
have been called in sooner; or if the bleedings
practised during the first days shall not have been
large enough, or even although these bleedings
shall have procured some remission; yet, upon the
recurrence of the urgent symptoms, the bleeding
should be repeated at any period of the disease,
especially within the first fortnight; and even af—
terwards, if a tendency to suppuration be not evi—
dent, or if, after a seeming solution, the disease
shall have again returned.
364.
With respect to the quantity of blood which
ought, or which with safety may be taken away,
no general rules can be delivered, as it must be ve—
ry different, according to the state of the disease,
and the constitution of the patient. In an adult
male of tolerable strength, a pound of blood, avoir—
dupois, is a full bleeding. Any quantity above
twenty ounces is a large, and any quantity below
twelve a small, bleeding. A quantity of from four
to five pounds, in the course of two or three days,
is generally as much as such patients will safely 
bear; 

191 OF PHYSIC.
bear; but, if the intervals between the bleedings
and the whole of the time during which the bleed—
ings have been employed have been long, the quan—
tity taken upon the whole may be greater.
365.
When a large quantity of blood has been alrea—
dy taken from the arm, and when it is doubtful
if more can with safety be drawn in that manner,
some blood may still be taken by cupping and scar—
ifying. Such a measure will be more particularly
proper, when the continuance or recurrence of pain,
rather than the difficulty of breathing, becomes the
urgent symptom; and then the cupping and scari—
fying should be made as near to the pained part
as can conveniently be done.
366.
An expectoration takes place sometimes very ear—
ly in this disease; but if, notwithstanding that, the
urgent symptoms should still continue, the expec—
toration must not supersede the bleedings mention—
ed; and during the first days of the disease, its so—
lution is not to be trusted to the expectoration
alone. It is in a more advanced stage only, when
the proper remedies have been before employed,
and when the symptoms have suffered a considera—
ble remission, that the entire cure may be trusted
to a copious and free expectoration.
367.
During the first days of the disease, I have not
found that bleeding stops expectoration. On the
contrary, I have often observed bleeding promote
it; and it is in a more advanced stage of the disease
only, when the patient, by large evacuations, and
the continuance of the disease, has been already
exhausted, 

192 PRACTICE
exhausted, that bleeding seems to stop expectora—
tion. It appears to me, that even then bleeding
dows not stop expectoration, so much by weaken—
ing the powers of expectoration, as by favouring
the serous effusion into the bronchiæ (348), and
thereby preventing it.
368.
While the bleedings we have mentioned shall be
employed, it will be necessary to employ also every
part of the antiphlogistic regimen (130. 132.), and
particularly to prevent the irritation which might
arise from any increase of heat. For this purpose,
it will be proper to keep the patient out of bed,
while he can bear it easily; and when he cannot,
to cover him very lightly while he lies in bed.
The temperature of his chamber ought not to ex—
ceed sixty degrees of Farenheit's thermometer; and
whether it may be at any time colder, I am un—
certain.
369.
Mild and diluent drinks, moderately tepid, at
least never cold, given by small portions at a time,
ought to be administered plentifully. These drinks
may be impregnated with vegetable acids. They may
be properly accompanied also with nitre, or some
other neutrals; but these salts should be given se—
parately from the drink.
It has been alledged, that both acids and nitre
arc ready to excite coughing, and in some persons
they certainly have this effect; but, except in per—
sons of a peculiar habit, I have not found their ef—
fects in exciting cough so considerable or trouble—
some as to prevent our seeking the advantages
otherwise to be obtained from these medicines. 
370. Some 

193 OF PHYSIC.
370.
Some practitioners have doubted, if purgatives
can be safely employed in this disease; and indeed
a spontaneous diarrhœa occurring in the beginning
of the disease has seldom proved useful; but I
have found the moderate use of cooling laxatives
generally safe; and have always found it useful to
keep the belly open by frequent emollient glysters.
371.
To excite full vomiting by emetics, I judge to
be a dangerous practice in this disease; but I have
found it useful to exhibit nauseating doses; and
in a some what advanced state of the disease, I have
found such doses prove the best means of promo—
ting expectoration.
372.
Fomentations and poultices applied to the pain—
ed part have been recommended, and may be use—
ful; but the application of them is often inconve—
nient, and may be entirely omitted for the fake of
the more effectual remedy, blistering.
Very early in the disease, a blister should be ap—
plied as near to the pained part as possible. But
as, when the irritation of a blister is present, it ren—
ders bleeding less effectual; so the application of
the blister should be delayed till a bleeding shall
have been employed. If the disease be moderate,
the blister may be applied immediately after the first
bleeding; but if the disease be violent, and it is
presumed that a second bleeding may be necessary
soon after the first, it will then be proper to delay
the blister till after the second bleeding, when it
may be supposed that any farther bleeding may be
postponed till the irritation arising from the blister
VOL. I. Bb shall 

194 PRACTICE
shall have ceased. It may be frequently necessary
in this disease to repeat the blistering; and, in that
case, the plasters should always be applied some—
where on the thorax; for, when applied to more
distant parts, they have little effect. The keeping
the blistered parts open, and making what is called
a perpetual blister, has much less effect than a fresh
blistering.
373.
As this disease often terminates by an expectora—
tion, so various means of promoting this have been
proposed; but none of them appear to be very ef—
fectual; and some of them, being acrid stimulant
substances, cannot be very safe.
The gums usually employed seem too heating;
squills seem to be less so; but they are not very
powerful, and sometimes inconvenient by the con—
stant nausea they induce.
The volatile alkali may be of service as an ex—
pectorant; but it should be reserved for an advan—
ced state of the disease.
Mucilaginous and oily demulcents appear to be
useful, by allaying that acrimony of the mucus
which occasions too frequent coughing; and which
coughing prevents the stagnation and thickening of
the mucus, and thereby its becoming mild.
The receiving into the lungs the steams of warm
water impregnated with vinegar, has often proved
useful in promoting expectoration.
But, of all other remedies, the most powerful for
this purpose, are antimonial medicines, given in
nauseating doses, as in (179). Of these, however,
I have not found the kermes mineral more effica—
cious than emetic tartar, or antimonial wine; and
the dose of the kermes is much more uncertain
than that of the others.
374. Though 

195 OF PHYSIC.
374.
Though a spontaneous sweating often proves the
crisis of this disease, it ought not to be excited by
art, unless with much caution. At least, I have
not yet found it either so effectual or safe, as some
writers have alledged. When, after some remissi—
on of the symptoms, spontaneous sweats of a pro—
per kind arise, they may be encouraged; but it
ought to be without much heat, and without stimu—
lant medicines. If, however, the sweats be partial
and clammy only, and a great difficulty of breath—
ing still remain, it will be very dangerous to en—
courage them.
375.
Physicians have differed much in opinion with
regard to the use of opiates in pneumonic inflam—
mation. To me it appears, that, in the beginning
of the disease, and before bleeding and blistering
have produced some remission of the pain, and of
the difficulty of breathing, opiates have a very bad
effect, by their increasing the difficulty of breath—
ing, and other inflammatory symptoms. But in a
more advanced state of the disease, when the dif—
ficulty of breathing has abated, and when the urg—
ent symptom is a cough, proving the chief cause of
the continuance of the pain and of the want of sleep,
opiates may be employed with great advantage and
safety. The interruption of the expectoration,
which they seem to occasion, is for a short time
only; and they seem often to promote it, as they
occasion a stagnation of what was by frequent cough—
ing dissipated insensibly, and therefore give the ap—
pearance of what physicians have called Concocted
Matter.
CHAP.

196 PRACTICE
CHAP. VII.
OF THE PERIPNEUMONIA NOTHA, OR
BASTARD PER1PNEUMONY.
376.
A DISEASE under this name is mentioned in
some medical writings of the sixteenth cen—
tury; but it is very doubtful if the name was then
applied to the same disease to which we now apply
it. It appears to me, that unless some of the cases
described under the title of Catarrhus Suffocativus
be supposed to have been of the kind I am now to
treat of, there was no description of this disease
given before that by Sydenham, under the title I
have employed here.
377.
After Sydenham, Boerhaave was the first who in
a system took notice, of it as a distinct disease; and
he has described it in his aphorisms, although with
some circumstances different from those in the de—
scription of Sydenham. Of late, Mr. Lieutaud
has with great confidence asserted, that Sydenham
and Boerhaave had, under the same title, described
different diseases; and that, perhaps, neither of
them bed on this subject delivered any thing but
hypothesis. 
378.
Notwithstanding this bold assertion, I am hum—
bly of opinion, and the Baron Van Swieten seems
to have been of the same, that Sydenham and Boer—
haave did describe under the same title, one and
the same disease. Nay, I am further of opinion,
that the  disease described by Mr. Lieutaud himself, 
is

197 OF PHYSIC. 
is not essentially different from that described by
both the other authors. Nor will the doubts of the
very learned, but modest Morgagni, on this subject,
disturb us, if we consider, that while very few de—
scribers of diseases either have it in their power, or
have been sufficiently attentive in distinguishing
between the essential end accidental symptoms of
disease; so, in a disease which may have not only
different, but a greater number of symptoms, in
one person than it has in another, we need not
wonder that the descriptions of the same disease by
different persons should come out in some respects
different. I shall, however, enter no further into
this controversy; but endeavour to describe the
disease as it has appeared to myself; and, as I
judge, in the essential symptoms, much the same as
it has appeared to all the other authors mentioned.
379.
This disease appears at the same seasons that
other pneumonic and catarrhal affections common—
ly do; that is, in autumn and in spring. Like these
diseases, also, it is seemingly occasioned by sudden
changes of the weather from heat to cold. It ap—
pears, also, during the prevalence of contagious
catarrhs; and it is frequently under the form of
the Peripneumonia Notha, that these catarrhs prove
fatal to elderly persons.
This disease attacks most commonly persons
somewhat advanced in life, especially those of a
full phlegmatic habit; those who have before been
frequently liable to catarrhal affections, and those
who have been much addicted to the large use of
fermented and spirituous liquors.
The disease commonly comes on with the same
symptoms as other febrile diseases; that is, with al—
ternate chills and heats; and the symptoms of py—
rexia are sometimes sufficiently evident; but in
most cases these are very moderate, and in some
hardly 

198 PRACTICE
hardly at all appear. With the first attack of the
disease, a cough comes on; usually accompanied
with some expectoration; and in many cases there
is a frequent throwing up of a considerable quanti—
ty of a viscid opaque mucus. The cough often be—
comes frequent and violent; is sometimes accom—
panied with a rending headach; and, as in other
cases of cough, a vomiting is sometimes excited by
it. The face is sometimes flushed, and some gid—
diness or drowsiness often attends the disease. A
difficulty of breathing, with a sense of oppression,
or straitening in the chest, with some obscure pains
there, and a sense of lassitude over the whole body,
very constantly attend this disease. The blood
drawn in this disease, shows a buffy surface, as in
other inflammatory affections.
The disease has often the appearance only of a
more violent catarrh, and after the employment of
some remedies is entirely relieved by a free and
copious expectoration. In other cases, however,
the feverish and catarrhal symptoms are at first ve—
ry moderate, and even slight; but, after a few
days, these symptoms suddenly become considera—
ble, and put an end to the patient's life when the
indications of danger were before very little evi—
dent.
380.
From the different circumstances in which the
disease appears, the pathology of it is difficult. It
is certainly often no other at first than a catarrhal
affection, which in elderly persons, is frequently
attended with a large afflux of mucus to the lungs;
and was on this footing that Sydenham consider—
ed it as only differing in degree from his Febris Hy—
emalis. A catarrh, however, is strictly an affection
of the mucous membrane and follicles of the bron—
chiæ alone; but it may readily have, and frequent.
ly has, a degree of pneumonic inflammation join.
ed 

199 OF PHYSIC. 
ed to it; and in that case may prove more proper—
ly the peculiar disease we treat of here. But, fur—
ther, as pneumonic inflammation very often pro—
duces an effusion of serum into the bronchiæ (348.),
so this, in elder persons, may occur in consequence
of a slight degree of inflammation; and when it
does happen, will give exquisite and fatal cases of
the peripneumonia notha.
381.
After this attempt to establish the pathology, the
method of cure in the different circumstances of
the disease will not be difficult.
In case the fever, catarrah and pneumonic symp—
toms, are immediately considerable, a bloodletting
will certainly be proper and necessary; but, where
these symptoms are moderate, a bloodletting will
hardly be requisite; and, when an effusion is to be
feared, the repetition of bloodletting may prove
extremely hurtful.
In all cases, the remedies chiefly to be depend—
ed upon, are vomiting and blistering.
Full vomiting may be frequently repeated, and
nauseating doses ought to pe constantly employed.
Purging may perhaps be useful; but as it is sel—
dom so in pneumonic affections, nothing but gen—
tle laxatives are here necessary.
In all the circumstances of this disease, the anti—
phlogistic regimen is proper; cold is to be guarded
against; but much external heat is to be as careful—
ly avoided.
382.
If a person sweats easily, and it can be brought
out by the use of mild tepid liquors only, the prac—
tice may in such persons be tried. See MORGAG— 
NI de Sed. et Caus. Epist. xiii. Art. 4.
383. I might 

200 PRACTICE
383.
I might here, perhaps, give a separate section on
the Carditis and Pericarditis, or the inflammations
of the Heart and Pericardium; but they hardly re—
quire a particular consideration. An acute inflam—
mation of the pericardium is almost always a part
of the same pneumonic affection I have been treat—
ing of; and is not always distinguished by any dif—
ferent symptoms; or, if it be, does not require any
different treatment. The same may be said of an
acute inflammation of the heart itself; and when it
happens that the one or other is discovered by the
symptoms of palpitation or syncope, no more will
be implied than that the remedies of pneumonic in—
flammation should be employed with greater
diligence.
From dissections, which show the heart and pe—
ricardium affected with erosions, ulcerations, and
abscesses, we discover that these parts had been be—
fore affected with inflammation; and that in cases
where no symptoms of pneumonic inflammation
had appeared; it may therefore be alledged, that
those inflammations of the heart and pericardium
should be considered as diseases independent of the
pneumonic. This indeed is just; but the history
of such cases proves that those inflammations had
been of a chronic kind, and hardly discovering
themselves by any peculiar symptoms; or if attend—
ed with symptoms marking an affection of the
heart, these were however such as have been known
frequently to arise from other causes than inflam—
mation. There is, therefore, upon the whole, no
room for our treating more particularly of the in—
flammation of the heart or pericardium.
CHAP. 

201 OF PHYSIC. 
CHAP. VIII.
OF THE GASTRITIS, OR INFLAMMA—
TION OF THE STOMACH.
334.
AMONG the inflammations of the abdominal
region, I have given a place in our Nosolo—
gy to the Peritonitis; comprehending under that
title, not only the inflammations affecting the peri—
tonæum lining the cavity of the abdomen, but also
those affecting the extensions of this membrane in
the omentum and mesentery. It is not, however,
proposed to treat of them here, because it is very
difficult to say by what symptoms they are always
to be known; and farther, because when known,
they do not require any remedies beside those of
inflammation in general. I proceed therefore to
treat of those inflammations, which, affecting vis—
cera of peculiar functions, both give occasion to
peculiar symptoms, and require some peculiarities
in the method of cure; and I shall begin with the
inflammation of the stomach.
385.
The inflammation of the stomach is of two kinds;
Phlegmonic, or Erythematic*. The first may be
seated in what is called the Nervous Coat of the
stomach, or in the peritonæum investing it. The
second is always seated in the villous coat and cel—
lular texture immediately subjacent.
386.
The Phlegmonic inflammation of the stomach,
or what has been commonly treated of under the
Vol. I. C c title
 * This is a new term; but whoever considers what is said in 274, will, I
expect, perceive the propriety, and even the necessity, of it. 

202 PRACTICE
title of Gastritis, is known by an acute pain in some
part of the region of the stomach, attended with
pyrexia, with frequent vomiting, especially upon
occasion of any thing being taken down into the
stomach, and frequently with hickup. The pulse is
commonly small and hard; and there is a greater
loss of strength in all the functions of the body, than
in the case of almost any other inflammation.
387.
This inflammation may be produced by various
causes; as, by external contusion; by acrids of
various kinds taken into the stomach; frequently
by very cold drink, taken into it, while the body
is very warm; and sometimes by over distention,
from the having taken in a large quantity of food
of difficult digestion. All these may be considered
as external causes; but the disease sometimes arises
also from internal causes not so well understood.
It may arise from inflammations of the neighbour—
ing parts communicated to the stomach, and is then
to be considered as a symptomatic affection only.
It may arise also from various acrimonies generat—
ed within the body, either in the stomach itself, or
in other parts, and poured into the cavity of the
stomach. These are causes more directly applied
to the stomach; but there are perhaps others origi—
nating elsewhere, and affecting the stomach only
sympathetically. Such may be supposed to have
acted in the case of putrid fevers and exanthematic
pyrexiæ; in which, upon dissection, it has been
discovered that the stomach had been affected with
inflammation.
388.
From the sensibility of the stomach, and its com—
munication with the rest of the system, it will be
obvious, that the inflammation of this organ, by
whatever 

203 OF PHYSIC.
whatever causes produced, may be attended with
fatal consequences. In particular, by the great de—
bility which such an inflammation suddenly produ—
ces, it may quickly prove fatal, without running
the common course of inflammations.
When it lasts long enough to follow the ordina—
ry course of other inflammations, it may terminate
by resolution, gangrene, or suppuration. The scir—
rhosities which are often discovered affecting the
stomach, are seldom known to be the consequences
of inflammation.
389.
The tendency of this disease to admit of resolu—
tion, may be known by its having arisen from no
violent cause; by the moderate state of the symp—
toms; and by a gradual remission of these, especi—
ally in consequence of remedies employed in the
course of the first, or at farthest the second, week
of the disease.
390.
The tendency to suppuration may be known by
the symptoms continuing, in a moderate degree,
for more than one or two weeks; and likewise by
a considerable remission of the pain, while a sense
of weight and anxiety still remain.
When an abscess has been formed, the frequen—
cy of the pulse is at first abated; but soon after, it
is again increased, with frequent cold shiverings,
and with marked exacerbations in the afternoon
and evening, followed by night sweatings and o—
ther symptoms of hectic fever. These at length
prove fatal, unless the abscess open into the cavity
of the stomach, the pus be evacuated by vomiting,
and the ulcer soon heal.
391. The 

204 PRACTICE
391.
The tendency to gangrene may be suspected from
the violence of the symptoms not yielding to the
remedies employed during the first days of the dis—
ease; and that a gangrene has already begun, may
be known from the sudden remission of the pain,
while the frequency of the pulse continues, and at
the same time becomes weaker, accompanied with
other marks of an increasing debility in the whole
system.
392.
From the dissection of dead bodies it appears,
that the stomach very often has been affected with
inflammation, when the characteristic symptoms of
it (386.) had not appeared; and therefore it is very
difficult to lay down any general rules for the cure
of this disease.
393.
It is only in the case of phlegmonic inflammati—
on, as characterised in (386.), tha twe can advise the
cure or resolution to be attempted by large and re—
peated bleedings employed early in the disease; and
we are not to be deterred from these by the small—
ness of the pulse; for, after bleeding, it common—
ly becomes fuller and softer. After bleeding, a
blister ought to be applied to the region of the sto—
mach; and the cure will be assisted by fomentations
of the whole abdomen, as well as by frequent emol—
lient and laxative glysters.
394.
In this disease, the irritability of the stomach
will not admit of any medicines being thrown into
it;

205 OF PHYSIC. 
it; and, if any internal medicines can be supposed
necessary, they must be exhibited in glysters. The
giving of drink may be tried; but it ought to be of
the very mildest kind, and in very small quantities
at a time.
395.
Opiates, in whatever manner exhibited, are ve—
ry hurtful during the first days of the disease; but
when its violence shall have abated, and when the
violence of the pain and vomiting recur at inter—
vals only, opiates given in glysters may be cauti—
ously tried, and sometimes have been employed
with advantage.
396.
A tendency to suppuration, in this disease, is to
be obviated by the means just now proposed. Af—
ter a certain duration of the disease, it cannot be
prevented by any means whatever; and when actu—
ally begun, must be left to nature; the business of
the physician being only to avoid all irritation.
397.
A tendency to gangrene can be obviated in no
other way than by the means suggested (393.), em—
ployed early in the disease; and, when it does ac—
tually supervene, admits of no remedy.
398.
Erythematic inflammations of the stomach, are
more frequent than those of the phlegmonic kind.
It appears, at least, from dissections, that the sto—
mach has often been affected with inflammation,
when neither pain nor pyrexia had before given any
notice of it; and such inflammation I apprehend to
have 

206 PRACTICE
have been chiefly of the erythematic kind. This
species of inflammation also, is especially to be ex—
pected from acrimony of any kind thrown into the
stomach; and would certainly occur more frequent—
ly from such a cause, were not the interior surface
of this organ commonly defended by mucus exud—
ing in large quantities from the numerous follicles
placed immediately under the villous coat. Upon
many occasions, however, the exudation of mucus
is prevented, or the liquid poured out is of a less
viscid kind, so as to be less fitted to defend the sub—
jacent nerves; and it is in such cases that matters
even of moderate acrimony, may produce any ery—
thematic affection of the stomach.
399.
From what has been said it must appear, that an
erythematic inflammation of the stomach may fre—
quently occur; but will not always discover itself,
as it sometimes takes place without pyrexia, pain,
or vomiting.
400.
There are cases, however, in which it may be
discovered. The affection of the stomach some—
times spreads into the œcsophagus, and appears in
the pharynx, as well as on the whole internal sur—
face of the mouth. When, therefore, an erythe—
matic inflammation affects the mouth and fauces,
and when at the same time there shall be in the sto—
mach an unusual sensibility to all acrids, with a
frequent vomiting, there can be little doubt of the
stomach being affected with the same inflammation
that has appeared in the fauces. Even when no
inflammation appears in the fauces, yet if some de—
gree of pain be felt in the stomach, if there be a
want of appetite, an anxiety, frequent vomiting, an
unusual sensibility with respect to acrids, some thirst,
and 

207 OF PHYSIC. 
and frequency of pulse, there will then be room to
suspect an erythematic inflammation of the stomach;
and we have known such symptoms, after some
time, discover their cause more clearly by the ap—
pearance of the inflammation in the fauces or mouth.
Erythematic inflammation is often disposed to
spread from one place to another on the same sur—
face; and, in doing so, to leave the place it had at
first occupied. Thus, such an inflammation has
been known to spread successively along the whole
course of the alimentary canal, occasioning in the
intestines diarrhœa, and in the stomach vomitings;
the diarrhœa ceasing when the vomitings came on,
or the vomitings upon the coming on of the diar—
rhœa.
When an erythematic inflammation of the sto—
mach shall be discovered, it is to be treated differ—
ently, according to the difference of its causes and
symptoms.
When it is owing to acrid matters taken in by
the mouth, and when these may be supposed still
present in the stomach, they are to be washed out
by throwing in a large quantity of warm and mild
liquids, and by exciting vomiting. At the same
time, if the nature of the acrimony and its proper
corrector be known, this should be thrown in; or
if a specific corrector be not known, some general
demulcents should be employed.
402.
These measures, however, are more suited to
prevent the inflammation, than to cure it after it
has taken place. When this last may be supposed
to be the case, if it be attended with a sense of heat,
with pain and pyrexia, according to the degree of
these symptoms, the measures proposed in (393) are
to be more or less employed.
403. When 

208 PRACTICE
403.
When an erythematic inflammation of the sto—
mach has arisen from internal causes, if pain and
pyrexia accompany the disease, some bleeding in
persons not otherwise weakened, may be employed; 
but, as the affection often arises in putrid diseases,
and in convalescents from fever; so in these cases,
bleeding is inadmissible; all that can be done being
to avoid irritation, and to throw into the stomach
what quantity of acids, and of acescent aliments,
it shall be found to bear.
In some conditions of the body, in which this
disease arises, the Peruvian bark and bitters may
seem to be indicated; but an erythematic state of
the stomach does not commonly allow of them.
CHAP. IX.
OF THE ENTERITIS, OR INFLAMMA—
TION OF THE INTESTINES.
404.
THE inflammation of the intestines, like that of
the stomach, may be either phlegmonic or
erythematic; but, on the subject of the latter, I
have nothing to add to what has been said in the
last chapter; and shall here therefore treat of the
phlegmonic inflammation only.
405.
This inflammation may be known to be present,
by a fixed pain of the abdomen, attended with py—
rexia, costiveness, and vomiting. Practical wri—
ters mention the pain in this case as felt in different
parts of the abdomen, according to the different 
seat

209 OF PHYSIC. 
seat of the inflammation; and so, indeed, it some—
times happens; but very often the pain spreads
over the whole belly, and is felt more especially
about the navel.
406.
The Enteritis and Gastritis arise from like causes;
but the former, more readily than the latter, pro—
ceeds from cold applied to the lower extremities,
or to the belly itself. The enteritis has likewise its
own peculiar causes, as supervening upon the
spasmodic colic, incarcerated hernia, and volvulus.
407.
Inflammations of the intestines have the same
terminations as those of the stomach; and, in both
cases, the several tendencies are to be discovered
by the same symptoms (389. 391.)
408.
The cure of the enteritis is, in general, the same
with that of the gastritis (393. & seq.), but in the
enteritis, there is commonly more access to the
introduction of liquids, of acid, acescent, and other
cooling remedies, and even of laxatives. As how—
ever a vomiting so frequently attends this disease,
care must be taken not to excite that vomiting by
either the quantity or the quality of any thing
thrown into the stomach.
The same observation, with respect to the use of
opiates, is to be made here as in the case of gastritis.
409.
Under the title of Enteritis, it has been usual
with practical writers to treat of the remedies pro—
per for the colic, and its higher degree named Ileus;
VOL. I. D d but, 

210 PRACTICE
but, although it be true that the enteritis and colic
do frequently accompany each other, I still hold
them to be distinct diseases, to be often occurring
separately, and accordingly to require and admit
of different remedies. I shall therefore delay
speaking of the remedies proper for the colic, till
I shall come to treat of this disease in its proper
place.
410.
What might be mentioned with respect to the
suppuration or gangrene occurring in the enteritis,
may be sufficiently understood from what has been
said on the same subject with respect to the gastritis.
CHAP. X.
OF THE HEPATITIS, OR INFLAMMA—
TION OF THE LIVER.
411.
THE inflammation of the liver seems to be of
two kinds; the one acute, the other chronic.
412.
The acute is attended with pungent pain; con—
siderable pyrexia; a frequent, strong, and hard
pulse; and high coloured urine.
413.
The chronic hepatitis very often does not exhi—
bit any of these symptoms; and it is only discover—
ed to have happened, by our finding in the liver,
upon dissection, large abscesses, which are presum—
ed to be the effect of some degree of previous in—
flammation.

211 OF PHYSIC. 
flammation. As this chronic inflammation is sel—
dom to be certainly known, and therefore does not
lead to any determined practice, we omit treating
of it here, and shall only treat of what relates to
the acute species of the hepatitis.
414.
The acute hepatitis may be known by a pain
more or less acute in the right hypochondrium, in—
creased by pressing upon the part. The pain is ve—
ry often in such a part of the side as to make it ap—
pear like that of a pleurisy; and frequently, like
that too, is increased on respiration. The disease
is, in some instances, also attended with a cough,
which is commonly dry, but sometimes humid;
and when the pain thus resembles that of a pleuri—
sy, the patient cannot lie easily except upon the
side affected.
In every kind of acute hepatitis, the pain is oft—
en extended to the clavicle, and to the top of the
shoulder. The disease is attended sometimes with
hickup, and sometimes with vomiting. Many prac—
tical writers have mentioned the jaundice, or a yel—
low colour of the skin and eyes, as a very constant
symptom of the hepatitis; but experience has shown,
that it may often occur without any such symptom.
415.
The remote causes of hepatitis are not always to
he discerned, and many have been assigned on a
very uncertain foundation. The following seem to
be frequently evident. 1. External violence from
contusions or falls, and especially those which have
occasioned a figure of the cranium. 2. Certain
passions of the mind. 3. Violent summer heats.
4. Violent exercise. 5. Intermittent and remit—
tent fevers. 6. Cold applied externally, or inter—
nally; and therefore in many case; the same causes
which 

212 PRACTICE
which produce pneumonic inflammation, produce
hepatitis; and whence also the two diseases are
sometimes joined together. 7. Various solid con—
cretions or collections of liquid matter, in the sub—
stance of the liver, produced by unknown causes,
Lastly, The acute is often induced by a chronic
inflammation of this viscus.
416.
It has been supposed, that the hepatitis may be
an affection either of the extremities of the hepa—
tic artery, or of those of, the vena potarum; but of
the last supposition there is neither evidence nor
probability.
417.
It seems probable, that the acute hepatitis is al—
ways an affection of the external membrane of the
liver; and that the parenchymatic is of the chronic
kind. The acute disease may be seated either on
the convex or on the concave surface of the liver,
In the former case, a more pungent pain and hick—
up may be produced, and the respiration is more
considerabiy affected. In the latter, there occurs
less pain; and a vomiting is produced, commonly
by some inflammation communicated to the stomach,
The inflammation of the concave surface of the li—
ver, may be readily communicated to the gall blad—
der and biliary duas; and this perhaps is the only
case of idiopathic hepatitis attended with jaundice.
418.
The hepatitis, like other inflammations, may end
by resolution, suppuration, or gangrene; and the
tendency to the one or the other of these events,
may be known from what has been delivered above.
419. The 

213 OF PHYSIC.
419.
The resolution of hepatitis is often the conse—
quence of, or is attended with, evacuations of dif—
ferent kinds. A hemorrhagy, sometimes from the
right nostril, and sometimes from the hemorrhoid—
al vessels, gives a solution of the disease. Some—
times a bilious diarrhœa contributes to the same
event; and the resolution of the hepatitis, as of
other inflammations, is attended with sweating, and
with an evacuation of urine, depositing a copious
sediment. Can this disease be resolved by expec—
toration? It would seem to be sometimes cured by
an erysipelas appearing in some external part.
420.
When this disease has ended in suppuration, the
pus collected may be discharged by the biliary
duas; or, if the suppurated part does not any where
adhere closely to the neighbouring parts, the pus
may be discharged into the cavity of the abdomen;
but if, during the first state of inflammation, the
affected part of the liver shall have formed a close
adhesion to some of the neighbouring parts, the
discharge of the pus after suppuration may be vari—
ous, according to the different seat of the abscess.
When seated on the convex part of the liver, if
the adhesion be to the peritonæum lining the com—
mon teguments, the pus may make its way through
these, and be discharged outwardly; or, if the ad—
hesion should have been to the diaphragm, the
pus may penetrate through this, and into the cavi—
ty of the thorax, or of the lungs; and through the
latter may he discharged by coughing. When the
abscess of the liver is seated on its concave part,
then, in consequence of adhesions, the pus may be
discharged into the stomach or the intestines; and
into these last, either directly, or by the interven—
tion of the biliary ducts, 421. The 

214 PRACTICE
421.
The prognostics in this disease are established
upon the general principles relating to inflammati—
on, upon the particular circumstances of the liver,
and upon the particular state of its inflammation.
The cure of this disease must proceed upon the
general plan; by bleeding, more or less, according
to the urgency of pain or pyrexia; by the applica—
tion of blisters; by fomentations, of the external
parts in the usual manner, and of the internal parts
by frequent emollient glysters; by frequently open—
ing the belly by means of gentle laxatives, and by
diluent and refrigerant remedies.
422.
Although, in many cases, the chronic hepatitis
does not clearly discover itself; yet, upon many
occasions, it may perhaps be discovered, or at least
suspected, from those causes which might affect the
liver (316; having been applied; from some fulness
and some tenseness of weight in the right hypo—
chondrium; from some shooting pains at times felt
in that region; from some uneasiness or pain felt
upon pressure in that part; from some uneasiness
from lying upon the left side; and lastly, from some
degree of pyrexia, combined with more or fewer of
these symptoms.
When from some of these circumstances a chro—
nic inflammation is to be suspected, it is to be
treated by the same remedies as in the last para—
graph, employed more or less as the degree of the
several symptoms shall more distinctly indicate.
423.
When from either kind of inflammation a suppu—
ration of the liver has been formed, and the abscess
points

215 OF PHYSIC.
points outwardly, the part must be opened, the pus
evacuated, and the ulcer healed according to the
ordinary rules for cleansing and healing such ab—
scesses and ulcers.
424.
I might here consider the Splenitis, or inflamma—
tion of the spleen; but it does not seem necessary,
because the disease very seldom occurs. When it
does, it may be readily known by the character giv—
en in our Nosology; and its various termination,
as well as the practice which it requires, may be un—
derstood from what has been already said with re—
spect to the inflammations of the other abdominal
viscera.
CHAP. XI.
OF THE NEPHRITIS, OR THE INFLAM—
MATION OF THE KIDNEYS.
425.
THIS disease, like other internal inflammati—
ons, is always attended with pyrexia; and is
especially known from the region of the kidney be—
ing affected by pain, commonly obtuse, sometimes
pungent. This pain is not increased by the moti—
on of the trunk of the body, so much as a pain of
the rheumatic kind affecting the same region. The
pain of the nephritis may be often distinguished by
its shooting along the course of the ureter; and is
frequently attended with a drawing up of the testicle,
and with a numbness of the limb on the side affect—
ed; although, indeed, these symptoms most com—
monly accompany the inflammation arising from a
calculus in the kidney or in the ureter. The ne—
phritis is almost constantly attended with frequent
vomiting, 

216 PRACTICE
vomiting, and often with costiveness and colic pains.
Usually the state of the urine is changed; it is most
commonly of a deep red colour, is voided frequent—
ly, and in small quantity at a time. In more vio—
lent cases, the urine is sometimes colourless.
426.
The remote causes of this disease may be various;
as, external contusion; violent or long continued
riding; strains of the muscles of the back incum—
bent on the kidneys; various acrids in the course
of the circulation conveyed to the kidney; and
perhaps some other internal causes not yet well
known. The most frequent is that of calculous 
matter obstructing the tubuli uriniferi, or calculi
formed in the pelvis of the kidneys, and either
sticking there, or fallen into the ureter.
427.
The various event of this disease may be under—
stood from what has been delivered on the subject
of other inflammations.
428.
Writers, in treating of the cure of nephritis,
have commonly at the same time treated of the
cure of the Calculus renalis; but, though this may
often produce nephritis, it is to be considered as a
distinct and separate disease; and what I have to
offer as to the mode of treating it, must be reserv—
ed to its proper place. Here I shall treat only of
the cure of the Nephritis Vera or Idiopathica.
429.
The cure of this proceeds upon the general plan,
by bleeding, external fomentation, frequent emol— 
lient

217 OF PHYSIC.
lient glysters, antiphlogistic purgatives, and the free
use of mild and demulcent liquids. The applicati—
on of blisters is hardly admissible; or, at least, will
require great care, to avoid any considerable ab—
sorption of the cantharides.
430.
The Cystitis, or inflammation of the bladder, is
seldom a primary disease; and therefore is not to
be treated of here. The treatment of it, so far as
necessary to be explained, may be readily under—
stood from what has been already delivered.
431.
Of the visceral inflammations, there remains to
be considered the inflammation of the Uterus; but
I omit it here, because the consideration of it can—
not be separated from that of the diseases of child
bearing women.
CHAP. XII.
OF THE RHEUMATISM. 
432.
OF this disease there are two species; the one
named the Acute, the other the Chronic
rheumatism.
433.
It is the Acute Rheumatism which especially be—
longs to this place, as from its causes, symptoms,
and methods of cure, it will appear to be a species
of phlegmasia or inflammation.
VOL. I. E e 434. This 

2l8 PRACTICE
434.
This disease is frequent in cold, and more un—
common in warm, climates. It appears most fre—
quently in autumn and spring, less frequently in
winter when the cold is considerable and constant,
and very seldom during the heat of summer. It
may occur, however, at any season, if vicissitudes
of heat and cold be for the time frequent.
435.
The acute rheumatism generally arises from the
application of cold to the body when any way unu—
sually warm; or when one part of the body is ex—
posed to cold whilst the other parts are kept warm;
or lastly, when the application of the cold is long
continued, as it is when wet or moist clothes are
applied to any part of the body.
436.
These causes may affect persons of all ages; but
the rheumatism seldom appears in either very young
or in elderly persons, and most commonly occurs
from the age of puberty to that of thirty five years.
437.
These causes (435.) may also affect persons of
any constitution; but they most commonly affect
those of a sanguine temperament.
438.
This disease is particularly distinguished by pains
affecting the joints, for the most part the joints alone,
but sometimes affecting also the muscular parts.
Very often the pains shoot along the course of the
muscles, 

219 OF PHYSIC. 
muscles, from one joint to another, and are always
much increased by the action of the muscles belong—
ing to the joint or joints affected.
439.
The larger joints are most frequently affected;
such as the hip joint, and knees of the lower, and
the shoulders and elbows of the upper extremities.
The ankles and wrists are also frequently affected;
but the smaller joints, such as those of the toes or
fingers, seldom suffer.
440.
This disease, although sometimes confined to one
part of the body only, yet very often affects many
parts of it; and then it comes on with a cold stage,
which is immediately succeeded by the other symp—
toms of pyrexia, and particularly by a frequent, full,
and hard pulse. Sometimes the pyrexia is formed
before my pains are perceived; but more common—
ly pains are felt in particular parts, before any symp—
toms of pyrexia appear.
441.
When no pyrexia is present, the pain is some—
times confined to one joint only; but, when any
considerable pyrexia is present, although the pain
may be chiefly in one joint, yet it seldom happens
but that the pains affect several joints often at the
very same time, but for the most part shifting their
place, and, having abated in one joint, become
more violent in another. They do not commonly
remain long in the same joint, but frequently shift
from one to another, and sometimes return to joints
formerly affected; and in this manner the disease
often continues for a long time.
442. The 

220 PRACTICE
442.
The pyrexia attending this disease has an exacer—
bation every evening, and is most considerable dur—
ing the night, when the pains also become more vi—
olent; and it is at the same time that the pains shift
their place from one joint to another. The pains
seem to be also increased during the night, by the
body being covered more closely, and kept warmer.
443.
A joint, after having been for some time affect—
ed with pain, commonly becomes affected also with
some redness and swelling, which is painful to the
touch. It seldom happens, that a swelling coming
on does not alleviate the pain of the joint; but the
swelling does not always take off the pain entirely,
nor secure the joint against a return of it.
444.
This disease is commonly attended with some
sweating, which occurs early in the course of the
disease; but it is seldom free or copious, and sel—
dom either relieves the pains or proves critical.
445.
In the course of this disease the urine is high co—
loured, and in the beginning without sediment;
but as the disease advances, and the pyrexia has
more considerable remissions, the urine deposits a
lateritious sediment. This, however, does not prove
entirely critical; for the disease often continues
long after such a sediment has appeared in the urine.
446. When 

221 OF PHYSIC. 
446.
When blood is drawn in this disease, it always
exhibits the appearance mentioned (237.)
447.
The acute rheumatism, though it has so much
of the nature of the other phlegmasiæ, differs from
all those hitherto mentioned, in this, that it is not
apt to terminate in suppuration. This almost ne—
ver happens in rheumatism; but the disease some—
times produces effusions of a transparent gelati—
nous fluid into the sheaths of the tendons. If we
may be allowed to suppose that such effusions are
frequent, it must also happen, that the effused flu—
id is commonly reabsorbed; for it has seldom hap—
pened, and never indeed to my observation, that
considerable or permanent tumours have been pro—
duced, or such as required to be opened, and to
have the contained fluid evacuated. Such tu—
mours, however, have occurred to others, and the
opening made in them has produced ulcers difficult
to heal. Vide Storck. Ann. Med. II.
448.
With the circumstances mentioned from (438. to
447.), the disease often continues for several weeks.
It seldom, however, proves fatal; and it rarely
happens that the pyrexia continues to be consider—
able for more than two or three weeks. While the
pyrexia abates in its violence, if the pains of the
joints continue, they are less violent, more limited
in their place, being confined commonly to one or
a few joints only, and are less ready to change
their place.
449. When 

222 PRACTICE
449.
When the pyrexia attending rheumatism has en—
tirely ceased; when the swelling, and particularly
the redness of the joints, are entirely gone; but
when pains still continue to affect certain joints,
which remain stiff, which feel uneasy upon motion,
or upon changes of weather; the disease is named
the Chronic Rheumatism, as it very often conti—
nues for a long time. As the chronic is common—
ly the sequel of the acute rheumatism, I think it
proper to treat of the former also in this place.
450.
The limits between the acute and chronic rheu—
matism are not always exactly marked.
When the pains are still ready to shift their place;
when they are especially severe in the night—time;
when, at the same time, they are attended with
some degree of pyrexia, and with some swelling,
and especially with some redness of the joints; the
disease is to be considered as still partaking the
nature of the acute rheumatism.
But when there is no degree of pyrexia remain—
ing; when the pained joints are without redness;
when they are cold and stiff; when they cannot
easily be made to sweat; or when, while a free
and warm sweat is brought out on the rest of the
body, it is only clammy and cold on the pained
joints; and when, especially, the pains of these
joints are increased by cold, and relieved by heat
applied to them; the case is to be considered as
that of a purely chronic rheumatism.
451.
The chronic rheumatism may affect different
joints; but is especially ready to affect those joints
which 

223 OF PHYSIC.
which are surrounded with many muscles, and those
of which the muscles are employed in the most con—
stant and vigorous exertions. Such is the case of
the vertebræ of the loins, the affection of which is
named Lumbago; or that of the hip joint, when the
disease is named Ischias, or Sciatica.
452.
Violent strains and spasms occurring on sudden
and somewhat violent exertions, bring on rheuma—
tic affections, which at first partake of the acute, but
very soon change into the nature of the chronic
rheumatism.
453.
I have thus delivered the history of rheumatism;
and suppose, that, from what has been said, there—
mote causes, the diagnosis, and prognosis, of the
disease, may be understood. The distinction of
the rheumatic pains from those resembling them,
which occur in the syphilis and scurvy, will be
obvious, either from the seat of those pains, or
from the concomitant symptoms peculiar to these
diseases. The distinctions of rheumatism from gout
will be more fully understood from what is to be
delivered in the following chapter.
454.
With respect to the proximate cause of rheuma—
tism, there have been various opinions. It has
been imputed to a peculiar acrimony; of which,
however, in ordinary cases, I can find no evidence;
and, from the consideration of the remote causes,
the symptoms, and cure of the disease, I think the
supposition very improbable.
The cause of an Ischias Nervosa assigned by CO—
TUNNIUS, appears to me hypothetical, and is not
supported 

224 PRACTICE
supported by either the phenomena or method of
cure. That, however, a disease of a rheumatic
nature may be occasioned by an acrid matter appli—
ed to the nerves, is evident from the toothach, a
rheumatic affection generally arising from a cari—
ous tooth.
That pains resembling those of rheumatism, may
arise from deep seated suppurations, we know from
some cases depending on such a cause, and which,
in their symptoms, resemble the lumbago or ischi—
as. I believe, however, that, by a proper atten—
tion, these cases depending on suppuration, may
be commonly distinguished from the genuine cases
of lumbago and ischias; and, from what is said in
(447.) I judge it to be at least improbable, that a
genuine lumbago or ischias does ever end in sup—
puration.
455.
The proximate cause of rheumatism has been by
many supposed to be a lentor of the fluids obstrua—
ing the vessels of the part; but the same considera—
tion as in (241. 1, 2, 3, 4, and 5.) will apply equal—
ly here for rejecting the supposition of a lentor.
456.
While I cannot, therefore, find either evidence
or reason for supposing that the rheumatism de—
pends upon any change in the state of the fluids, I
must conclude that the proximate cause of acute
rheumatism, is commonly the same with that of
other inflammations not depending upon a direct
stimulus.
457.
In the case of rheumatism I suppose, that the
most common remote cause of it, that is, cold ap—
plied, 

225 OF PHYSIC. 
plied, operates especially on the vessels of the
joints, from these being less covered by a cellular
texture than those of the intermediate parts of the
limbs. I suppose further, that the application of
cold produces a constriction of the extreme vessels
on the surface, and at the same time an increase of
tone or phlogistic diathesis in the course of them,
from which arises an increased impetus of the
blood, and, at the same time, a resistance to the
free passage of it, and consequently inflammation
and pain. Further, I suppose, that the resistance
formed excites the vis medicatrix to a further in—
crease of the impetus of the blood; and to support
this, a cold stage arises, a spasm is formed, and a
pyrexia and phlogistic diathesis are produced in the
whole system.
458.
According to this explanation, the cause of acute
rheumatism appears to be exactly analogous to that
of the inflammations depending on an increased
afflux of blood to a part while it is exposed to the
action of cold.
But there seems to be also, in the case of rheu—
matism, a peculiar affection of the fibres of the mus—
cles. These fibres seem to be under some degree
of rigidity, and therefore less easily admit of mo—
tion; and are pained upon the exertions of it.
It is also an affection of these fibres which gives
an opportunity to the propagation of pains from
one joint to another, along the course of the mus—
cles; and which pains are more severely felt in the
extremities of the muscles terminating in the joints,
because beyond these the oscillations are not pro—
pagated.
This affection of the muscular fibres attending
rheumatism, seems to explain why strains and
Ipasms produce rheumatic affections; and, upon
the whole, shows, that, with an inflammatory af—
VOL. I. F f fection 

226 PRACTICE
fection of the sanguiferous system, there is also in
rheumatism a peculiar affection of the muscular fi—
bres, which has a considerable share in producing
the phenomena of the disease.
459.
Having thus given my opinion of the proximate
cause of rheumatism, I proceed to treat of the cure.
460.
Whatever difficulty may occur with respect to the
explanation given (457. and 458.), this remains cer—
tain, that in acute rheumatism, at least in all those
cases which do not arise from direct stimuli, there
is an inflammatory affection of the parts, and a
phlogistic diathesis in the whole system; and upon
these is founded the method of cure, which fre—
quent experience has approved of.
461.
The cure therefore requires, in the first place,
an antiphlogistic regimen, and particularly a total
abstinence from animal food, and from all ferment—
ed or spirituous liquors; substituting a vegetable
or milk diet, and the plentiful use of bland diluent
drinks.
462.
Upon the same principle (449.), at least with per—
haps the same exception as above, bloodletting is
the chief remedy of acute rheumatism. The blood
ought to be drawn in large quantity, and the bleed—
ing is to be repeated in proportion to the frequen—
cy, fullness, and hardness of the pulse, and to the
violence of the pain. For the most part, large and
repeated bleedings, during the first days of the dis—
ease,

227 OF PHYSIC.
ease, seem to be necessary, and accordingly have
been very much employed; but to this some bounds
are to be set; for very profuse bleedings occasion a
slow recovery, and, if not absolutely effectual, are
ready to produce a chronic rheumatism.
463.
To avoid that debility of the system, which ge—
neral bleedings are ready to occasion, the urgent
symptom of pain may be often relieved by topical
bleedings; and, especially when any swelling and
redness have come upon a joint, the pain of it may
be very certainly relieved by such bleedings; but,
as the continuance of the disease seems to depend
more upon the phlogistic diathesis of the whole
system, than upon the affection of particular parts,
so topical bleedings will not always supply the place
of the general bleedings proposed above.
464.
To take off the phlogistic diathesis prevailing in
this disease, purging may be useful, if procured
by medicines which do not stimulate the whole sys—
tem, such as the neutral salts, and which have in
some measure a refrigerant power. Purging, how—
ever, is not so powerful as bleeding, in removing
phlogistic diathesis; and, when the disease has be—
come general and violent, frequent stools are in—
convenient, and even hurtful, by the motion and
pain which they occasion.
465.
In acute rheumatism, applications to the pained
parts are of little service. Fomentations, in the
beginning of the disease, rather aggravate than re—
lieve the pains. The rubifacients and camphire
are more effectual in relieving the pains; but ge—
nerally 

228 PRACTICE
nerally they only shift the pain from one part into
another, and do little towards the cure of the ge—
neral affection. Blistering, applied to the pained
part, may also be very effectual in removing the
pain from it; but will be of little use, except where
the pains are much confined to one part.
466.
The several remedies mentioned from (450. to
454.), moderate the violence of the disease, and
sometimes remove it entirely; but they sometimes
fail in this, and leave the cure imperfect. The at—
tempting a cure by large and repeated bleedings,
is attended with many inconveniences, (see 140);
and the most effectual and safe method of curing
this disease, is, after some general bleedings for
taking off, or at least diminishing the phlogistic
diathesis, to employ sweating, conducted by the
rules laid down (168. and 169.)
467.
Opiates, except where they are directed to pro—
cure sweat, always prove hurtful in every stage of
this disease.
468.
The Peruvian bark has been supposed a remedy
in some cases of this disease; but we have seldom
found it useful, and, in some cases, hurtful. It
appears to me to be fit in those cases only, in which
the phlogistic diathesis is already much abated;
and where at the same time the exacerbations of
the disease are manifestly periodical, with consi—
derable remissions interposed.
469. Calomel, 

229 OF PHYSIC.
469.
Calomel, and some other preparations of mer—
cury, have been recommended in the acute rheuma—
tism; but I believe they are useful only in cases
of the chronic kind, or at least in cases approach—
ing to the nature of these.
470.
Having now treated fully of the cure of the
acute rheumatism, I proceed to treat of the cure
of the chronic, which is so frequently a sequel of
the former.
471.
The phenomena of the purely chronic rheuma—
tism, mentioned in (438. and 439.), lead me to con—
clude, that its proximate cause is an atony; both
of the blood vessels and of the muscular fibres of
the part affected, together with a degree of rigi—
dity and contraction in the latter, such as frequent—
ly attends them in a state of atony.
472.
Upon this view of the proximate cause, the ge—
neral indication of cure must be to restore the ac—
tivity and vigour of the vital principle in the part;
and the remedies for this disease, which experience
has approved of, are chiefly such as are manifestly
suited to the indication proposed.
473.
These remedies are either external or internal.
The external are, The supporting the heat of
the part, by keeping it constantly covered with
flannel; 

230 PRACTICE
flannel; the increasing the heat of the part by ex—
ternal heat, applied either in a dry or in a humid
form; the diligent use of the flesh brush, or other
means of friction; the application of electricity in
sparks or shocks; the application of cold water by
affusion or immersion; the application of essential
oils of the most warm and penetrating kind; the
application of salt brine; and, lastly, the employ—
ment of exercise, either of the part itself, so far as
it can easily bear it; or of the whole body, by ri—
ding, or other mode of gestation.
474.
The internal remedies are, 1. Large doses of es—
sential oil drawn from resinous substances, such as
turpentine; 2. Substances containing such oils,
as guaiac; 3. Volatile alkaline salts; 4. These, or
other medicines directed to procure sweat, (169);
and lastly, Calomel, or other preparation of mer—
cury, in small doses, continued for some time.
475.
These (462. 463.) are the remedies successfully
employed in the purely chronic rheumatism; and
there are still others recommended; as bleeding,
general and topical; burning; blistering; and is—
sues: But these appear to me to be chiefly, per—
haps only, useful when the disease still partakes of
the nature of acute rheumatism.
CHAP. XIII.
OF THE TOOTHACH OR ODONTALGIA.
476. 
I HAVE formerly considered this disease as a
species of Rheumatism, to be treated upon the 
same

231 OF PHYSIC. 
same principles as those delivered in the preceding
chapter; but now, from more attentive considera—
tion, I am led to consider the toothach as a distinct
disease. Whilst the most of what has been deliver—
ed in the last chapter proceeds upon the suppositi—
on that the rheumatism depends upon a certain state
of the blood vessels and of the motion of the blood
in them, without this being produced by the irrita—
tion of any acrid matter applied; I judge, that in
the toothach, though there are often the same cir—
cumstances in the state of the blood vessels as in the
cases of rheumatism, these circumstances in tooth—
ach always arise from the application of an acrid
matter to the nerves of the teeth.
477.
This disease is often no other than a pain felt in
a particular tooth, without any inflammatory affec—
tion being at the same time communicated to the
neighbouring parts. This, however, is rarely the
case; and for the most part, together with the pain
of the tooth, there is some degree of pain and of
inflammatory affection communicated to the neigh—
bouring parts, sometimes to the whole of those on
the same side of the head with the affected tooth.
478.
This inflammatory affection seems to me to be al—
ways an affection of the muscles and of the membra—
nous parts connected with these, without any ten—
dency to suppuration; and such an affection, as is
excited by cold in similiar parts elsewhere. It is
from these circumstances that I conclude the affec—
tion to be of the rheumatic kind.
479.
It is possible that the muscles and membranes of
the jaw may be affected by the same causes which
produce 

232 PRACTICE
produce the rheumatism in other parts; and it is
also possible, that a rheumatic diathesis at first pro—
duced by irritation, may subsist in the muscles and
membranes of the jaw, so that the inflammatory
affection may be renewed by certain causes with—
out any new application of acrid matter: But I am
persuaded that either of these occurrences are very
rare, and I have never been able to ascertain any
cases of toothach to be of these kinds. I consider
it, therefore, as highly probable that this rheuma—
tic affection of the jaws which we name toothach,
is always dependent upon some immediate applica—
tion of acrid matter to the nerves of the teeth.
480.
It is however to be observed, that this applica—
tion of acrid matter does not always excite a pain
in the tooth itself, or an inflammatory affection of
the neighbouring parts; but that it very often ope—
rates by producing a diathesis only; so that cold
applied to the neighbouring parts does excite both
a pain in the tooth, and an inflammatory affection
of the neighbouring parts which did not appear
before.
There seems to be also certain states of the bo—
dy, which operate upon the same diathesis so as to
produce toothach. Such seems to be the case of
pregnant women, who are more liable to toothach
than other women. There are probably also some
cases of increased irritability which render persons
more subject to toothach. Thus women are more
liable to the disease than men, and particularly mo—
men liable to hysteric affections.
481.
The acrid matter producing this disease seems to
be generated first in the hard substances of the
teeth; and as it often appears first upon the exter—
nal 

233 OF PHYSIC. 
nal surface of these, it might be suspected to arise
from the application of external matters to the teeth:
But as the production of this acrimony is often be—
gun in the internal cavity of the teeth, where the
operation of external matters cannot be suspected,
and as even when it begins upon the external parts
of the teeth, the operation of the cause is at first in
a small portion of the teeth only, that it is diffi—
cult to suppose that any matter externally applied
could as in such a partial manner; so it is presum—
ed that the acrid matter occasioning the toothach
is produced by some vice originating in the sub—
stance of the tooth itself. When it begins upon
the external surface, it is on the enamel; but upon
the internal surface, it must be in the bony part.
From what causes it arises in either of these sub—
stances, I do not at all know; but I suspect that it
often arises from some more general fault in the
fluids of the body. The frequent use of mercury,
especially when thrown much upon the mouth, and
the state of the fluids in scurvy, seem both of them
to give a disposition to a caries in the teeth; and it
is possible that some other acrimonious states of the
fluids may have the same effect.
482.
A caries in some part of the teeth, whether aris—
ing upon their internal surface or upon their exter—
nal, proceeding so far as to reach the nerves in the
cavity of the teeth, is pretty manifestly the cause
of toothach, and of the first attacks of it; but when
the cavity of the teeth has been opened, so that the
external air or other matters can reach that cavity,
these are often the exciting causes of toothach, and
serve to prove in general, that acrid matters appli—
ed to the nerves occasion the disease.
VOL. I. G g 483. What 

234 PRACTICE 
483.
What is the nature of the matter produced in the
caries of the teeth, I do not understand, nor have
I found any proper corrector of it; but I presume
it to be of the putrid kind, as it often taints the
breath with a fetid odour.
484.
In the cure of this disease, a long experience has
shown, that the extraction of the carious tooth
proves the most effectual, and very often the only
effectual, remedy of the disease. But as in some
cases this extraction is not proper, and as in many
cases it is obstinately avoided, other means of cur—
ing the disease, or at least of relieving the pain,
have been sought for and much practised.
485.
Among these remedies, those are likely to be
the most effectual which entirely destroy the affect—
ed nerve, or at least so much of it as is exposed to
the action of the acrid matter in the tooth. When
an opening is made into the cavity of the tooth, the
nerve of it may be destroyed most certainly by the
actual cautery, and it may also possibly be done by
the application of potential caustics, either of the
alkaline or acid kind.
486.
When these remedies cannot be rendered effectu—
al, relief may often be obtained by diminishing the
sensibility of the nerve affected, by the application
of opium, or of the more acrid aromatic oils, di—
rectly to the nerve in the tooth. It appears also,
that the sensibility of the affected nerve may often 
be

235 OF PHYSIC. 
be for some time diminished by the external appli—
cation of opium to the extremities of those nerves
in the skin, which are branches of the same fifth
pair of nerves with those of the teeth.
487.
When the disease consists entirely in a pain of
the nerve of the tooth, without any considerable
affection communicated to the neighbouring parts,
the remedies already mentioned are those especial—
ly to be employed; but when the disease consists
very much in an inflammatory affection of the mus—
cles and membranes of the jaw, and when at the
same time there is little or no access for the above
mentioned remedies to the affected nerve, other
measures are to be employed for relieving the dis—
ease.
488.
If the disease be attended with any general phlo—
gistic diathesis of the system, or with any consider—
able degree of pyrexia, a general bleeding may be
useful in relieving the disease; but these circum—
stances occur very rarely, and the disease is for the
most part a purely topical affection; in which, as I
observed before, a general bleeding is of very lit—
tle service. As this disease, however, is a topical
inflammation, it might be supposed that topical
bleedings would be very useful, and sometimes
they are so; but it is seldom that their effects are
either considerable or permanent. The reasons of
this I take to be, that the disease does not consist
in an affection of the blood vessels alone, as in the
ordinary cases of rheumatism; but in a peculiar
affection of the fibres both of the muscles and of the
vessels of the part induced by irritation. The in—
efficacy of topical bleedings is with me a proof of
the disease being of the latter kind.
489. The 

236 PRACTICE
489.
The remedies therefore necessary to give relief
in this disease, are those which take off the spasm
of the vessels, and especially of the muscles and
membranes affected. Such are blistering, brought
as near to the part affected as can be conveniently
done; and such are also increased excretions ex—
cited in the neighbouring parts, as of the saliva
and mucus of the mouth by the use of acrid masti—
catories. It is often sufficient to excite a strong
sensation in the neighbouring parts; as by eau de
luce, spirit of lavender, or Hungary water snuffed
up the nostrils; or by the vitriolic æther properly
applied to the cheek. It is upon the same footing
that I suppose brandy or other ardent spirit held in
the mouth is often of service.
49O.
There are cases of toothach in which it does not
appear that the disease arises from an acrid matter
immediately applied to the nerve of a tooth; but
from the external application of cold, or some
other causes immediately applied to the muscles
and membranes of the jaw; and which therefore
seem to require some remedies different from those
above mentioned. But in all such cases, it is to be
suspected, that the effects of cold or of other such
causes are owing to a diathesis produced by an
acrid matter applied to the nerve of a tooth, and
continuing in some measure to act there; and we
have accordingly often found, that the action of
those external causes were to be obviated only by
the extraction of the tooth from which the diathe—
sis had arisen.
CHAP. 

237 OF PHYSIC.
CHAP. XIV.
OF THE GOUT.
491. 
THE Gout, not only as it occurs in different
persons, but even as it occurs in the same
person at different times, is a disease of such vari—
ous appearance, that it is difficult to render the
history of it complete and exact, or to give a cha—
racter of it that wull universally apply. However,
I shall endeavour to describe the disease as it most
commonly appears, and to mark the varieties of it
as well as I can. From such a history I expect
that a general character may be given; and such
I think is the following, as given in the last editi—
on of our Nosology:
GEN. XXIII. PODAGRA. Morbus hæredi—
tarius, oriens sine causa externa evidente, sed præ—
eunte plerumque ventriculi affectione insolita; py—
rexia; dolor ad articulum et plerumque pedis pol—
lici, certe pedum et manuum juncturis, potissimum
infestus; per intervalla revertens, et sæpe cum
ventriculi et internarum partium affectionibus al—
ternans.
492.
The gout is generally a hereditary disease: But
some persons, without hereditary disposition, seem
to acquire it; and, in some, a hereditary dispositi—
on may be countered by various causes. These
circumstances may seem to give exceptions to our
general position; but the facts directly supporting
it are very numerous
493. This 

238 PRACTICE
493.
This disease attacks especially the male sex; but
it sometimes, though more rarely, attacks also the
female. The females liable to it are those of the
more robust and full habits; and it very often hap—
pens to such long before the menstrual evacuation
has ceased. I have found it occuring in several
females, whose menstrual evacuations were, more
abundant than usual.
494.
This disease seldom attacks eunuchs; and, when
it does, they seem to be those who happen to be
of a robust habit, to lead an indolent life, and to
live very full.
495.
The gout attacks especially men of robust and
large bodies, men of large heads, of full and cor—
pulent habits, and men whose skins are covert
with a thicker rete mucosum, which gives a coarser
surface.
496.
If, with the ancients, we might ascertain, by
certain terms, the temperaments of men, I would
say that the gout attacks especially men of a chole—
rico sanguine temperament, and that it very seldom
attacks the purely sanguine or melancholic. It is,
however, very difficult to treat this matter with due
precision.
497.
The gout seldom attacks persons employed in
constant bodily labour, or persons who live much
upon 

239 OF PHYSIC.
upon vegetable aliment. It is also said to be less
frequent among those people who make no use of
wine or other fermented liquors.
498.
The gout does not commonly attack men, till
after the age of five and thirty; and generally not
till a still later period. There are indeed instan—
ces of the gout occurring more early; but these
are few in comparison of the numbers which agree
with what we have given as the general rule.
When the disease does appear early in life, it seems
to be in those in whom the hereditary disposition is
very strong, and to whom the remote causes to be
hereafter mentioned have been applied in a consi—
derable degree.
499.
As the gout is a hereditary disease, and affects
especially men of a particular habit, its remote
causes may be considered as predisponent and oc—
casional.
500.
The predisponent cause, so far as expressed by
external appearances, or by the general tempera—
ment, we have already marked; and physicians
have been very confident in assigning the occasion—
al causes: But, in a disease depending so much up—
on a predisposition, the assigning occasional causes
must be uncertain; as, in the predisposed, the oc—
casional causes may not always appear, and in per—
sons not predisposed, they may appear without ef—
fect. This uncertainty must particularly affect the
case of the gout; but I shall offer what appears to
me most probable on the subject.
501. The 

240 PRACTICE
501.
The occasional caues of the gout seem to be of
two kinds. First, those which induce a plethoric
state of the body. Secondly, those which, in ple—
thoric habits, induce a state of debility.
502.
Of the first kind are a sedentary indolent man—
ner of life, a full diet of animal food, and the large
use of wine or of other fermented liquors. These
circumstances commonly precede the disease; and
if there should be any doubt of their power of pro—
ducing it, the fact, however, will be rendered suffi—
ciently probable by what has been observed in (497.)
503.
Of the second kind of occasional causes which
induce debility are, excess in venery; intemper—
ance in the use of intoxicating liquors; indigestion,
produced either by the quantity or quality of ali—
ments; much application to study or business;
night watching; excessive evacuations; the ceasing
of usual labour; the sudden change from a very
full to a very spare diet; the large use of acids and
acescents; and, lastly, cold applied to the lower
extremities.
504.
The first (502.) seem to act by increasing the pre—
disposition. The last (503.) are commonly the ex—
citing causes, both of the first attacks, and of the
repetitions of the disease.
505. It

241 OF PHYSIC. 
505.
It is ah inflammatory affection of some of the
joints which especially constitutes what we call a pa—
roxysm of the gout. This sometimes comes on sud—
denly without any warning, but is generally prece—
ded by several symptoms; such as the ceasing of
a sweating which the feet had been commonly af—
fected with before; an unusual coldness of the feet
and legs; a frequent numbness, alternating with a
sense of prickling along the whole of the lower ex—
tremities; frequent cramps of the muscles of the
legs; and an unusual turgescence of the veins.
506.
While these symptoms take place in the lower
extremities, the whole body is affected with some
degree of torpor and languor, and the functions of
the stomach in particular are more or less disturbed
The appetite is diminished; and flatulency, or o—
ther symptoms of indigestion, are felt. These symp—
toms, and those of (505.) take place for several
days, sometimes for a week or two, before a parox—
ysm comes on; but commonly, upon the day im—
mediately preceding it, the appetite becomes great—
er than usual.
507.
The circumstances of paroxysms are the follow—
ing: They come on most commonly in the spring,
and sooner or later according as the vernal heat
succeeds sooner or later to the winter's cold; and
perhaps sooner or later also according as the body
may happen to be more or less exposed to vicissi—
tudes of heat and cold.
VOL. I. H h 508. The 

242 PRACTICE
508.
The attacks are sometimes felt first in the even—
ing, but more commonly about two or three o'clock
of the morning. The paroxysm begins with a pain
affecting one foot, most commonly in the ball or
first joint of the great toe, but sometimes in other
parts of the foot. With the coming on of this pain,
there is commonly more or less of a cold shivering,
which, as the pain increases, gradually ceases, and
is succeeded by a hot stage of pyrexia, which con—
tinues for the same time with the pain itself. From
the first attack, the pain becomes by degrees more
violent, and continues in this state with great rest—
lessness of the whole body till next midnight, after
which it gradually remits; and, after it has conti—
nued for twenty four hours from the commence—
ment of the first attack, it commonly ceases very
entirely, and, with the coming on of a gentle sweat,
allows the patient to fall asleep. The patient, up—
on coming out of this sleep in the morning, finds
the pained part affected with some redness and swel—
ling, which, after having continued for some days,
gradually abate.
509.
When a paroxysm has thus come on, although
the violent pain after twenty four hours be consi—
derably abated, the patient is not entirely relieved
from it. For some days he has every evening a re—
turn of more considerable pain and pyrexia, and
which continue with more or less violence till morn—
ing. After continuing in this manner for several
days, the disease sometimes goes entirely off, not to
return till after a long interval.
510. When 

243 OF PHYSIC.
510.
When the disease, after having thus remained
for some time in a joint, ceases very entirely, it
generally leaves the person in very perfect health,
enjoying greater ease and alacrity in the functions
of both body and mind, than he had for a long
time before experienced.
511.
At the beginning of the disease, the returns of it
are sometimes only once in three or four years; but,
after some time, the intervals become shorter, and
the attacks become annual; afterwards they come
twice each year, and at length recur several times
during the whole course of autumn, winter, and
spring; and as it happens, that, when the fits are
frequent, the paroxysms become also longer, so, in
the advanced stage of the disease, the patient is
hardly ever tolerably free from it, except perhaps
for two or three months in summer.
512.
The progress of the disease is also marked by the
parts which it affects. At first, it commonly af—
fects one foot only, afterwards every paroxysm af—
fects both feet, the one after the other; and, as
the disease continues to recur, it not only affects
both feet at once, but after having ceased in the
foot which was secondly attacked, returns again
into the foot first affected, and perhaps a second
time also into the other. Its changes of place are
not only from one foot to the other, but also from
the feet into other joints, especially those of the
upper and lower extremities; so that there is hard—
ly a joint of the body that is not, on one occasion
or other, affected. It sometimes affects two differ—
ent 

244 PRACTICE
ent joints at the same time; but more commonly
it is severe in a single joint only, and passes suc—
cessively from one joint to another; so that the pa—
tient's affliction is often protracted for a long time.
5l3.
When the disease has often returned, and the
paroxysms have become very frequent, the pains
are commonly less violent than they were at first;
but the patient is more affected with sickness, and
the other symptoms of the atonic gout, which shall
be hereafter mentioned.
514.
After the first paroxysms of the disease, the joints
which have been affected are entirely restored to
their former suppleness and strength; but after the
disease has recurred very often, the joints affected
do neither so suddenly nor so entirely recover their
former state, but continue weak and stiff; and
these effects at length proceed to such a degree,
that the joints lose their motion altogether.
515.
In many persons, but not in all, after the disease
has frequently recurred, concretions of a chalky
nature are formed upon the outside of the joints,
and for the most part immediately under the skin.
The matter seems to be deposited at first in a fluid
form, but afterwards becomes dry and firm. In
their dry state, these concretions are a friable
earthy, substance, very entirely soluble in acids.
After they have been formed, they contribute,
with other circumstances, to destroy the motion of
the joint.
516. In

245 OF PHYSIC.
516.
In most persons who have laboured under the
gout for many years, a nephritic affection comes
on, and discovers itself by all the symptoms which
usually attend calculous concretions in the kidneys,
and which we shall have occasion to describe in
another place. All that is necessary to be observ—
ed here is, that the nephritic affection alternates
with paroxysms of the gout; and that the two affec—
tions, the nephritic and the gouty, are hardly ever
present at the same time. This also may be observ—
ed, that children of gouty or nephritic parents,
commonly inherit one or other of these diseases;
but which ever may have been the principal dis—
ease of the parent, some of the children have the
one, and some the other. In some of them the
nephritic affection occurs alone, without any gout
supervening; and this happens to be frequently
the case of the female offspring of gouty parents.
517.
In the whole of the history already given, I have
described the most common form of the disease;
and which, therefore, however diversified in the
manner I have said, may be still called the regular
state of the gout. Upon occasion, however, the
disease assumes different appearances; but as I sup—
pose the disease to depend always upon a certain
diathesis or disposition of the system; so every ap—
pearance which we can perceive to depend upon
that same disposition, I still consider as a symptom
and case of the gout. The principal circumstance
in what we term the Regular Gout, is the inflamma—
tory affection of the joints; and whatever symptoms
we can perceive to be connected with, or to de—
pend upon, the disposition which produces that in—
flammatory affection, but without its taking place,
or 

246 PRACTICE
or being present at the same time, we name the
Irregular Gout.
518.
Of such irregular gout there are three different
states; which I name the atonic, the retrocedent,
and the misplaced gout.
5l9.
The atonic state is when the gouty diathesis pre—
vails in the system, but, from certain causes, does
not produce the inflammatory affection of the joints.
In this case, the morbid symptoms which appear,
are chiefly affections of the stomach; such as, loss
of appetite, indigestion, and its various circumstan—
ces of sickness, nausea, vomiting, flatulency, acid
eructations, and pains in the region of the stomach.
These symptoms are frequently accompanied with
pains and cramps in several parts of the trunk, and
the upper extremities of the body, which are reliev—
ed by the discharge of wind from the stomach. To—
gether with these affections of the stomach, there
commonly occurs a costiveness; but sometimes a
looseness with colic pains. These affections of
the alimentary canal are often attended with all
the symptoms of hypochondriasis; as dejection of
mind, a constant and anxious attention to the
slightest feelings, an imaginary aggravation of these,
and an apprehension of danger from them.
In the same atonic gout, the viscera of the tho—
rax also are sometimes affected, and palpitations,
faintings, and asthma, occur.
In the head also occur, headachs, giddiness,
apoplectic and paralytic affections.
520.
When the several symptoms now mentioned oc—
cur in habits having the marks of a gouty disposi—
tion, 

247 OF PHYSIC.
tion, this may be suspected to have laid the founda—
tion of them; and especially when either, in such
habits, a manifest tendency to the inflammatory af—
fection has formerly appeared; or when the symp—
toms mentioned are intermixed with, and are re—
lieved by, some degree of the inflammatory gout.
In such cases there can be no doubt of considering
the whole as a state of the gout.
521.
Another state of the disease I name the retroce—
dent gout. This occurs when an inflammatory
state of the joints has, in the usual manner, come
on, but which, without arising to the ordinary
degree of pain and inflammation, or, at least, with—
out these continuing for the usual time, and reced—
ing gradually in the usual manner, they suddenly
and entirely cease, while some internal part be—
comes affected. The internal part most common—
ly affected is the stomach, which is then affected
with anxiety, sickness, vomiting, or violent pain;
but sometimes the internal part is the heart, which
gives occasion to a syncope; sometimes it is the
lungs which are affected with asthma; and some—
times it is the head, giving occasion to apoplexy or
palsy. In all these cases, there can be no doubt
of the symptoms being all a part of the same disease,
however different the affection may seem to be in
the parts which it attacks.
522.
The third state of irregular gout, which we name
the misplaced, is when the gouty diathesis, instead
of producing the inflammatory affection of the
joints, produces an inflammatory affection of some
internal part, and which appears from the same
symptoms that attend the inflammation of those
parts arising from other causes.
Whether 

248 PRACTICE
Whether the gouty diathesis does ever produce
such inflammation of the internal parts, without
having first produced it in the joints, or if the in—
flammation of the internal part be always a transla—
tion from the joints previously affected, I dare not
determine; but, even supposing the latter to be al—
ways the case, I think the difference of the affec—
tion of the internal part must still distinguish the
misplaced from what I have named the retrocedent
gout.
523.
What internal parts may be affected by the mis—
placed gout, I cannot precisely say, because I have
never met with any cases of the misplaced gout in
my practice; and I find no cases of it distinctly
marked by practical writers, except that of a pneu—
monic inflammation.
524.
There are two cases of a translated gout; the one
of which is an affection of the neck of the bladder,
producing pain, strangury, and a catarrhus vesicæ;
The other is an affection of the rectum, sometimes
by pain alone in that part, and sometimes by he—
morrhoidal swellings there. In gouty persons, I
have known such affections alternate with inflam—
matory affections of the joints: But whether to re—
fer those affections to the retrocedent, or to the
misplaced gout, I will not presume to determine.
525.
From the history which I have now delivered of
the gout, I think it may be discerned under all its
various appearances. It is, however, commonly
supposed, that there are cases in which it maybe
difficult to distinguish gout from rheumatism, and
is 

249 OF PHYSIC.
it is possible there may be such cases; but, for the
most part, the two diseases may be distinguished
with great certainty by observing the predisposition,
the antecedents, the parts affected, the recurrences
of the disease, and its connection with the other parts
of the system; which circumstances, for the most
part, appear very differently in the two diseases.
526.
With respect to the gout, our next business is to
investigate its proximate cause; which must be a
difficult task, and I attempt it with some diffidence.
527.
Upon this subject, the opinion which has gene—
rally prevailed is, that the gout depends upon a
certain morbific matter, always present in the bo—
dy; and that this matter, by certain causes, thrown
upon the joints or other parts, produces the seve—
ral phenomena of the disease.
528.
This doctrine, however ancient and general, ap—
pears to me very doubtful; for,
First, There is no direct evidence of any morbi—
fic matter being present in persons disposed to the
gout. There are no experiments or observations
which show that the blood, or other humours of
gouty persons, are in any respect different from
those of other persons. Previous to attacks of the
gout, there appear no marks of any morbid state
of the fluids; for the disease generally attacks those
persons who have enjoyed the most perfect health,
and appear to be in that state when the disease comes
on. At a certain period of the disease, a peculiar
matter indeed appears in gouty persons (515.);
but this, which does not appear in every instance
VOL. I. I i and 

250 PRACTICE
and which appears only after the disease has subsist—
ed for a long time, seems manifestly to be the ef—
fect, not the cause, of the disease. Further, though
there be certain acrids which, taken into the body,
seem to excite the gout (503.), it is probable that
these acrids operate otherwise in exciting the dis—
ease, than by affording the material cause of it. In
general, therefore, there is no proof of any morbid—
fic matter being the cause of the gout.
Secondly, The suppositions concerning the par—
ticular nature of the matter producing the gout,
have been so various and so contradictory to each
other, as to allow us to conclude, that there is tru—
ly no proof of the existence of any of them. With
respect to many of these suppositions, they are so
inconsistent with chemical philosophy, and with the
laws of the animal economy, that they must be en—
tirely rejected.
Thirdly, The supposition of a morbific matter be—
ing the cause of the gout, is not consistent with the
phenomena of the disease, particularly with its fre—
quent and sudden translations from one part to
another.
Fourthly, The supposition is further rendered
improbable by this, that, if a morbific matter did
exist, its operation should be similar in the several
parts which it attacks; whereas it seems to be very
different, being stimulant, and exciting inflamma—
tion in the joints, but sedative and destroying the
tone in the stomach: Which, upon the supposition
of particular matter acting in both cases, is not to
be explained by any difference in the part affected.
Fifthly, Some facts, alledged in proof of a mor—
bific matter, are not sufficiently confirmed, such as
those which would prove the disease to be contagi—
ous. There is, however, no proper evidence of this,
the facts given being not only few, but exceptiona—
ble; and the negative observations are innumerable.
Sixthly, Some arguments brought in favour of a
morbific matter, are founded upon a mistaken ex—
planation. 

251 OF PHYSIC.
planation. The disease has been supposed to de—
pend upon a morbific matter, because it is heredi—
tary: But the inference is not just; for most he—
reditary diseases do not depend upon any morbific
matter, but upon a particular conformation of the
structure of the body, transmitted from the parent
to the offspring; and this last appears to be parti—
cularly the case in the gout. It may be also ob—
served, that hereditary diseases, depending upon a
morbific matter, always appear much more early in
life than the gout commonly does.
Seventhly, The supposition of a morbific matter
being the cause of the gout, has been hitherto use—
less, as it has not suggested any successful method
of cure. Particular suppositions have often cor—
rupted the practice, and have frequently led from
those views which might be useful, and from that
practice which experience had approved. Further,
though the supposition of a morbific matter has been
generally received, it has been as generally neglec—
ed in practice. When the gout has affected the
stomach, nobody thinks of correcting the matter
supposed to be present there, but merely of restor—
ing the tone of the moving fibres.
Eighthly, The supposition of a morbific matter
is quite superfluous; for it explains nothing, with—
out supposing that matter to produce a change in
the state of the moving powers; and a change in
the state of the moving powers, produced by other
causes, explains every circumstance, without the
supposition of a morbific matter; and, to this pur—
pose, it may be observed, that many of the causes
(503.) exciting the gout, do not operate upon the
state of the fluids, but directly and solely upon that
of the moving powers.
Lastly, The supposition of a morbific matter is
also superfluous; because, without any such suppo—
sition, I think the disease can be explained in a
manner more consistent with its phenomena, with
the 

252 PRACTICE
the laws of the animal economy, and with the me—
thod of cure which experience has approved.
I now proceed to give this explanation; but, be—
fore entering upon it, I must premise some gene—
ral observations.
529.
The first observation is, that the gout is a disease
of the whole system, or depends upon a certain ge—
neral conformation and state of the body; which
manifestly appears from the facts mentioned from
(493. to 496.) But the general state of the system
depends chiefly upon the state of its primary mov—
ing powers; and therefore the gout may be sup—
posed to be chiefly an affection of these.
530.
My second observation is, that the gout is mani—
festly an affection of the nervous system; in which
the primary moving powers of the whole system are
lodged. The occasional or exciting causes (503.)
are almost all such as act directly upon the nerves
and nervous system; and the greater part of the
symptoms of the atonic or retrocedent gout are ma—
nifestly affections of the same system (519. and 521.)
This leads us to seek for an explanation of the
whole of the disease in the laws of the nervous sys—
tem, and particularly in the changes which may
happen in the balance of its several parts.
531.
My third observation is, that the stomach, which
has so universal a consent with the rest of the sys—
tem, is the internal part that is the most frequent—
ly, and often very considerably, affected by the
gout. The paroxysms of the disease are common—
ly preceded by an affection of the stomach (506.);
many 

253 OF PHYSIC
many of the exciting causes (503.) act first upon the
stomach; and the symptoms of the atonic and re—
trocedent gout (519. 521.) are most commonly and
chiefly affections of the same organ. This observa—
tion leads us to remark, that there is a balance sub—
sisting between the state of the internal and that of
the external parts; and, in particular, that the
state of the stomach is connected with that of the
external parts (44.); so that the state of tone in
the one may be communicated to the other.
532.
These observations being premised, I shall now
offer the following pathology of the gout.
In some persons, there is a certain vigorous and
plethoric state of the system (495.) which, at a cer—
tain period of life, is liable to a loss of tone in the
extremities (498. 505.) This is in some measure
communicated to the whole system, but appears more
especially in the functions of the stomach (506.)
When this loss of tone occurs while the energy of the
brain still retains its vigour, the vis medicatrix na—
turæ is excited to restore the tone of the parts; and
accomplishes it by exciting an inflammatory affec—
tion in some part of the extremities. When this
has subsisted for some days, the tone of the extre—
mities, and of the whole system, are restored, and
the patient returns to his ordinary state of health.
(5l0.)
533.
This is the course of things, in the ordinary form
of the disease, which we name the regular gout;
but there are circumstances of the body, in which
this course is interrupted or varied. Thus when
the atony (505. 506.) has taken place, if the reaction
(508.) do not succeed, the atony continues in the
stomach, or perhaps in other internal parts, and
produces 

254 PRACTICE
produces that state which we have, for reasons now
obvious, named the atonic gout.
534.
A second case of variation in the course of the
gout is, when, to the atony, the reaction and in—
flammation have to a certain degree succeeded;
but, from causes either internal or external, the
tone of the extremities, and perhaps of the whole
system, is weakened; so that the inflammatory
state, before it had either proceeded to the degree,
or continued for the time, requisite for restoring
the tone of the system, suddenly and entirely ceas—
es. Hence the stomach, and other internal parts,
relapse into the state of atony; and perhaps have
this increased by the atony communicated from
the extremities : All which appears in what we have
termed the retrocedent gout.
535.
A third case of variation from the ordinary course
of the gout, is, when, to the atony usually preced—
ing, an inflammatory reaction fully succeeds; but
has its usual determination to the joints by some
circumstances prevented; and is therefore directed
to an internal part, where it produces an inflamma—
tory affection, and that state of things which we
have named the misplaced gout.
536.
We have thus offered an explanation of the cir—
cumstances of the system in the several states of the
gout; and this explanation we suppose to be con—
sistent with the phenomena of the disease, and with
the laws of the animal economy. There are in—
deed, with respect to the theory of the disease, se—
veral questions which might be put, to which we
have 

255 OF PHYSIC.
have not given any answer. But, though perhaps
we could give an answer to many of these questions,
it does not here appear necessary; as at present
we intend only to establish such general facts with
regard to this disease, as may lay a foundation for
the cure of it, so far as experience has enabled us
to prosecute it. Proceeding, therefore, upon the
several parts of the pathology given, as so many
matters of fact, I shall now consider what may be
attempted towards the cure of the disease.
537.
In entering upon this, I must observe, in the
first place, that a cure has been commonly thought
impossible; and we acknowledge it to be very pro—
bable, that the gout, as a disease of the whole ha—
bit, and very often depending upon original con—
formation, cannot be cured by medicines, the ef—
fects of which are always very transitory, and sel—
dom extend to the producing any considerable
change of the whole habit.
538.
It would perhaps have been happy for gouty
persons, if this opinion had been implicitly receiv—
ed by them; as it would have prevented their hav—
ing been so often the dupes of self—interested pre—
tenders, who have either amused them with inert
medicines, or have rashly employed those of the
most pernicious tendency. I am much disposed to
believe the impossibility of a cure of the gout by
medicines; and more certainly still incline to think,
that—whatever may be the possible power of medi—
cines, yet no medicine for curing the gout has
hitherto been found. Although almost every age
has presented a new remedy, yet all hitherto offered
have very soon been either nested as useless, or
condemned as pernicious.
539. Though 

256 PRACTICE
539.
Though unwilling to admit the power of medi—
cines, yet I contend, that a great deal can be done
towards the cure of the gout by a regimen: and
from what has been observed (497.), I am firmly
persuaded, that any man who, early in life, will
enter upon the constant practice of bodily labour,
and of abstinence from animal food, will be pre—
served entirely from the disease.
Whether there be any other means of radically
curing the gout, I am not ready to determine.
There are histories of cases of the gout, in which
it is said, that by great emotions of mind, by
wounds, and by other accidents, the symptoms
have been suddenly relieved, and never again re—
turned; but how far these accidental cures might
be imitated by art, or would succeed in other cases,
is at least extremely uncertain.
540.
The practices proper and necessary in the treat—
ment of the gout, are to be considered under two
heads; first, As they are to be employed in the
intervals of paroxysms; or, secondly, As during the
time of these.
541.
In the intervals of paroxysms, the indications are,
to prevent the return of paroxysms, or at least to
render them less frequent, and more moderate.
During the time of paroxysms, the indications are,
to moderate the violence, and shorten the duration
of them as much as can be done with safety.
542.
It has been already observed, that the gout may
be entirely prevented by constant bodily exercise,
and 

257 OF PHYSIC. 
and by a low diet; and I am of opinion, that this
prevention may take place even in persons who have
a hereditary disposition to the disease. I must add
here, that, even when the disposition has discover—
ed itself by several paroxysms of inflammatory gout,
I am persuaded that labour and abstinence will ab—
solutely prevent any returns of it for the rest of life.
These, therefore, are the means of answering the
first indication to be pursued in the intervals of pa—
roxysms; and I must here offer some remarks upon
the proper use of these remedies.
543.
Exercise, in persons disposed to the gout, is di—
rected to two purposes: One of these is the strength—
ening of the tone of the extreme vessels; and the
other, the guarding against a plethoric state. For
the former, if exercise be employed early in life,
and before intemperance has weakened the body,
a very moderate degree of it will answer the pur—
pose; and for the latter, if abstinence be at the
same time observed, little exercise will be necessary.
544. 
With respect to exercise, this in general is to be
observed, that it should never be violent; for, if
violent, it cannot be long continued, and must al—
ways endanger the bringing on an atony in propor—
tion to the violence of the preceding exercise.
545.
It is also to be observed, that the exercise of
gestation, though considerable and constant, if it be
entirely without bodily exercise, will not answer the
purpose in preventing the gout. For this end,
therefore, the exercise must be in some measure
that of the body; and must be moderate, but at
the same time constant, and continued through life.
VOL. I. K k 546. In 

258 PRACTICE
548.
In every case and circumstance of the gout in
which the patient retains the use of his limbs, bo-
dily exercise, in the intervals of paroxysms, will
always be useful; and, in the beginning of the dis-
ease, when the disposition to it is not yet strong,
exercise may prevent a paroxysm which otherwise
might have come on. In more advanced states of
the disease, however, when there is some disposition
to a paroxysm, much walking will bring it on; ei-
ther as it weakens the tone of the lower extremities,
or as it excites an inflammatory disposition in them;
and it is probable, that in the same manner strains
or contusions often bring on a paroxysm of the gout.
547.
Abstinence, the other part of our regimen (539.)
for preventing the gout, is of more difficult appli-
cation. If an abstinence from animal food be en-
tered upon early in life, while the vigour of the
system is yet entire, we have no doubt of its being
both safe and effectual; but if the motive for this
diet shall not have occurred till the constitution
shall have been broken by intemperance, or by the
decline of life, a low diet may then endanger the
bringing on an atonic state.
548.
Further, if a low diet be entered upon only in
the decline of life, and be at the same time a very
great change in the former manner of living, the
withdrawing of an accustomed stimulus of the sys-
tem may readily throw this into an atonic state.
549. The

259 OF PHYSIC.
549.
The safety of an abstemious course may be great-
er or less according to the management of it. It
is animal food which especially disposes to the ple-
thoric and inflammatory state, and that food is to
be therefore especially avoided; but, on the other
hand, it is vegetable aliment of the lowest quality
that is in danger of weakening the system too much,
by not affording sufficient nourishment; and more
particularly of weakening the tone of the stomach
by its acescency. It is therefore a diet of a mid-
dle nature that is to be chosen; and milk is precise-
ly of this kind, as containing both animal and ve-
getable matter.
As approaching to the nature of milk, and as be-
ing a vegetable matter containing the greatest por-
tion of nourishment, the farinaceous seeds are next
to be chosen, and are the food most proper to be
joined with milk.
550. 
With respect to drink, fermented liquors are
useful only when they are joined with animal food,
and that by their acescency; and their stimulus is
only necessary from custom. When, therefore,
animal food is to be avoided, fermented liquors are
unnecessary; and, by increasing the acescency of
vegetables, these liquors may be hurtful. The sti-
mulus of fermented or spirituous liquors, is not ne-
cessary to the young and vigorous; and, when much
employed, impairs the tone of the system. These
liquors, therefore, are to be avoided, except so
far as custom and the declining state of the system
may have rendered them necessary. For prevent-
ing or moderating the regular gout, water is the on-
ly proper drink.
551. With 

260 PRACTICE
551.
With respect to an abstemious course, it has been
supposed, that an abstinence from animal food and
fermented liquors, or the living upon milk and
farinacea alone for the space of one year, might
be sufficient for a radical cure of the gout; and
it is possible, that, at a certain period of life, in
certain circumstances of the constitution, such a
measure might answer the purpose. But this is
very doubtful; and it is more probable that the
abstinence must, in a great measure, be continued,
and the milk diet be persisted in, for the rest of life.
It is well known, that several persons who had en-
tered on an abstemious course, and had been there-
by delivered from the gout, have, however, upon
returning to their former manner of full living,
had the disease return upon them with as much
violence as before, or in a more irregular and more
dangerous form.
552.
It has been alledged, that, for preventing the
return of the gout, bloodletting, or scarifications
of the feet, frequently repeated, and at stated times,
may be practised with advantage; but of this I have
had no experience.
553.
Exercise and abstinence are the means of avoid-
ing the plethoric state which gives the disposition to
the gout ; and are therefore the means proposed
for preventing paroxysms, or at least for rendering
them less frequent, and more moderate. But many
circumstances prevent the steadiness necessary in 
pursuing these measures; and therefore, in such ca-
ses, unless great care be taken to avoid the excit- 
ing

261 OF PHYSIC.
ing causes, the disease may frequently return; and
in many cases, the preventing of paroxysms is chief-
ly to be obtained by avoiding those exciting causes
enumerated in (503.) The conduct necessary for
avoiding them, will be sufficiently obvious to per-
sons acquainted with the doctrines of the Hygieine,
which I suppose to have been delivered in another
place.
554.
A due attention in avoiding those several causes
(502. 503.) will certainly prevent fits of the gout;
and the taking care that the exciting causes be ne-
ver applied in a great degree, will certainly render
fits more moderate when they do come on. But,
upon the whole, it will appear, that a strict atten-
tion to the whole conduct of life, is in this matter
necessary; and therefore, when the predisposition
has taken place, it will be extremely difficult to a-
void the disease.
555.
I am indeed firmly persuaded, that, by obviat-
ing the predisposition, and by avoiding the exciting
causes, the gout may be entirely prevented: But
as the measures necessary for this purpose, will in
most cases, be pursued with difficulty, and even
with reluctance, men have been very desirous to
find a medicine which might answer the purpose
without any restraint on their manner of living.
To gratisy this desire, physicians have proposed,
and, to take advantage of it, empirics have feign-
ed, many remedies, as we have already observed.
Of what nature several of these remedies have been,
I cannot certainly say; but, of those which are
unknown, we conclude, from their having been
only of temporary same, and from their having
soon fallen into nelect, that they have been either
inert 

262 PRACTICE
inert or pernicious, and therefore I make no in-
quiry after them; and shall now remark only upon
one or two known remedies for the gout, which
have been lately in vogue.
556.
One of these is what has been named in England
the Portland Powder. This is not a new medicine,
but is mentioned by GALEN, and, with some little
variation in its composition, has been mentioned
by the writers of almost every age since that time.
It appears to have been at times in fashion, and to
have again fallen into neglect; and I think that this
last has been owing to its having been found to be,
in many instances, pernicious. In every instance
which I have known of its exhibition for the length
of time prescribed, the persons who had taken it
were indeed afterwards free from any inflammatory
affection of the joints; but they were affected with
many symptoms of the atonic gout; and all, soon
after finishing their course of the medicine, have
been attacked with apoplexy, asthma, or dropsy,
which proved fatal.
557.
Another remedy which has had the appearance
of preventing the gout, is an alkali in various forms,
such as the fixed alkali both mild and caustic, lime
water, soap, and absorbent earths. Since it be-
came common to exhibit these medicines in nephri-
tic and calculous cases, it has often happened that
they were given to those who were at the same time
subject to the gout; and it has been observed, that
under the use of these medicines, gouty persons
have been longer free from the fits of their disease.
That, however, the use of these medicines has en-
tirely prevented the returns of gout, I do not know;
because I never pushed the use of those medicines 
for

263 OF PHYSIC. 
for a long time, being apprehensive that the long
continued use of them might produce a hurtful
change in the state of the fluids.
558.
With respect to preventing the gout, I have on-
ly one other remark to offer. As the preventing
the gout depends very much on supporting the tone
of the stomach, and avoiding indigestion; so cos-
tiveness, by occasioning this, is very hurtful to gouty
persons. It is therefore necessary for such persons
to prevent or remove costiveness, and by a laxative
medicine, when needful; but it is at the same time
proper, that the medicine employed should be such
as may keep the belly regular, without much purg-
ing. Aloetics, rhubarb, magnesia alba, or slow-
ers of sulphur, may be employed, as the one or the
other may happen to be best suited to particular
persons.
559.
These are the several measures (from 541. to 558.)
to be pursued in the intervals of the paroxysms;
and we are next to mention the measures proper
during the time of them.
560.
As during the times of paroxysms the body is in
a feverish state, no irritation should then be added
to it; and every part, therefore, of the antiplogis-
tic regimen, (130. to 133.) except the application
of cold, ought to be strictly observed.
Another exception to the general rule may oc-
cur when the tone of the stomach is, weak, and
when the patient has been before much accustomed
to the use of strong drink; for it then may be al-
lowable, and even necessary, to give some animal
food, and a little wine.
561. That 

264 PRACTICE.
561.
That no irritation is to be added to the system
during the paroxysms of gout, except in the cases
mentioned, is entirely agreed upon among physi-
cians: But it is a more difficult matter to determine
whether, during the time of paroxysms, any mea-
sures may be pursued to moderate the violence of
reaction and of inflammation. Dr. Sydenham has
given it as his opinion, that the more violent the
inflammation and pain, the paroxysms will be the
shorter, as well as the interval between the present
and next paroxysm longer; and, if this opinion be
admitted as just, it will forbid the use of any reme-
dies which might moderate the inflammation; which
is, to a certain degree, undoubtedly necessary for
the health of the body. On the other hand, acute
pain presses for relief; and, although a certain de-
gree of inflammation may seem absolutely necessa-
ry, it is not certain but that a moderate degree of
it may answer the purpose: And it is even proba-
ble, that, in many cases, the violence of inflamma-
tion may weaken the tone of the parts, and there-
by invite a return of paroxysms. It seems to me to
be in this way, that, as the disease advances, the
paroxysms become more frequent.
562.
From these last considerations, it seems probable,
that, during the time of paroxysms, some measures
may be taken to moderate the violence of the in-
flammation and pain; and particularly, that in first
paroxysms, and in the young and vigorous, blood-
letting at the arm may be practised with advantage:
But I am persuaded, that this practice cannot be
repeated often with safety; because bloodletting
not only weakens the tone of the system, but may
also contribute to produce plethora. I believe,
however, 

265 OF PHYSIC.
however, that bleeding by leeches on the foot, and
upon the inflamed part, may be practised, and re-
peated with greater safety; and I have known in-
stances of its having been practised with safety, to
moderate and shorten paroxysms; but how far it
may be carried, we have not had experience
enough to determine.
563.
Besides bloodletting, and the antiphlogistic re-
gimen, it has been proposed to employ remedies
for moderating the inflammatory spasm of the part
affected, such as warm bathing and emollient poul-
tices. These have sometimes been employed with
advantage and safety; but at other times, have been
found to give occasion to a retrocession of the gout.
564.
Blistering is a very effectual means of relieving
and discussing a paroxysm of the gout; but has also
frequently had the effect of rendering it retroce-
dent.
565.
The stinging with nettles I consider as analogous
to blistering; and I think it probable that it would
be attended with the same danger.
566.
The burning with moxa, or other substances, I
consider as a remedy of the same kind. I have had
indeed no evidence of this proving hurtful; but
neither have I had any proper evidence of its hav-
ing proved a radical cure.
VOL. I. L l 567. Camphire, 

266 PRACTICE
567.
Camphire, and some aromatic oils, have the pow-
er of allaying the pain, and of removing the inflam-
mation from the part affected; but these remedies
commonly make the inflammation only shift from
one part to another, and therefore with the ha-
zard of its falling upon a part where it may be
more dangerous; and they have sometimes render-
ed the gout retrocedent.
568.
From these reflections (563. et seq.) it will ap-
pear, that some danger must attend every external
application to the parts affected during a paroxysm;
and that therefore the common practice of commit-
ting the person to patience and flannel alone, is
established upon the best foundation.
569.
Opiates give the most certain relief from pain;
but, when given in the beginning of gouty parox-
ysms, occasion these to return with greater violence.
When, however, the paroxysms shall have abated
in their violence, but still continue to return, so as
to occasion painful and restless nights, opiates may
be then given with safety and advantage, especially
in the case of persons advanced in life, and who
have been often affected with the disease.
570.
When, after paroxysms have ceased, some swel-
ling and stiffness shall remain in the joints, these
symptoms are to be discussed by the diligent use of
the flesh brush.
571. Purging, 

267 OF PHYSIC. 
571.
Purging, immediately after a paroxysm, will be al-
ways employed with the hazard of bringing it on again.
572.
I have now finished what has occurred to be said
upon the means of preventing and curing the regu-
lar gout; and shall now consider its management
when it has become irregular; of which, as I have
observed above, there are three different cases.
573.
In the first case, which I have named the Atonic
Gout, the cure is to be accomplished by carefully
avoiding all debilitating causes; and by employing,
at the same time, the means of strengthening the
system in general, and the stomach in particular.
574.
For the avoiding debilitating causes, I must re-
fer to the doctrines of the Hygieine, as in (553.).
575.
For strengthening the system in general, I must
recommend frequent exercise on horseback, and
moderate walking. Cold bathing also may answer
the purpose, and may be safely employed, if it ap-
pear to be powerful in stimulating the system, and
be not applied when the extremities are threatened
with any pain.
For supporting the tone of the system in general,
when threatened with atonic gout, some animal
food ought to be employed, and the more acescent
vegetables ought to be avoided. In the same case,
some 

268 PRACTICE
some wine also may be necessary; but it should be
in moderate quantity, and of the least acescent
kinds; and if every kind of wine shall be found to
increase the acidity of the stomach, ardent spirits
and water must be employed.
576.
For strengthening the stomach, bitters and the
Peruvian bark may be employed; but care must be
taken that they be not constantly employed for any
great length of time. Compare (556.)
The most effectual medicine for strengthening the
stomach is iron, which may be employed under va-
rious preparations; but, to me, the best appears to
be the rust in fine powder, which may be given in
very large doses.
For supporting the tone of the stomach, aroma-
tics may be employed; but should be used with
caution, as the frequent and large use of them may
have an opposite effect; and they should therefore
be given only in compliance with former habits, or
for palliating present symptoms.
When the stomach happens to be liable to indi-
gestion, gentle vomits may be frequently given;
and proper laxatives should be always employed to
obviate, or to remove, costiveness.
577.
In the atonic gout, or in persons liable to it, to
guard against cold is especially necessary; and the
most certain means of doing this is, by repairing
to a warm climate during the winter season,
578.
In the more violent cases of the atonic gout,
blistering the lower extremities may be useful; but
that remedy should be avoided when any pain
threatens 

269 OF PHYSIC. 
threatens the extremities. In persons liable to the
atonic gout, issues may be established in the extre-
mities, as, in some measure, a supplement to the
disease.
579.
A second case of the irregular gout, is that which
I have named the Retrocedent. When this affects
the stomach and intestines, relief is to be instantly
attempted by the free use of strong wines, joined
with aromatics, and given warm; or if these shall
not prove powerful enough, ardent spirits must be
employed, and are to be given in a large dose. In
moderate attacks, ardent spirits impregnated with
garlic, or with asafœtida, may be employed; or,
even without the ardent spirits, a solution of asa-
fœtida with the volatile alkali may answer the pur-
pose. Opiates are often an effectual remedy, and
may be joined with aromatics, as in the Electuari-
um Thebaicum; or they may be usefully joined
with volatile alkali and camphire. Musk has like-
wise proved useful in this disease.
When the affection of the stomach is accompa-
nied with vomiting, this may be encouraged, by
taking draughts of warm wine, at first with water,
and afterwards without it; having at length recourse
if necessary, to some of the remedies above men-
tioned, and particularly the opiates.
In like manner, if the intestines be affected with
diarrhœa, this is to be at first encouraged, by tak-
ing plentifully of weak broth; and when this shall
have been done sufficiently, the tumult is to be
quieted by opiates.
580.
When the retrocedent gout shall affect the lungs,
and produce asthma, this is to be cured by opiates,
by antispasmodics, and, perhaps, by blistering on the
breast or back.
581. When 

270 PRACTICE, &c.
581.
When the gout, leaving the extremities, shall
affect the head, and produce pain, vertigo, apo-
plexy, or palsy, our resources are very precarious.
The most probable means of relief is, blistering the
head; and if the gout shall have receded entirely
from the extremities, blisters may be applied to
these also. Together with these blisterings, aroma-
tics, and the volatile alkali, may be thrown into the
stomach.
582.
The third case of the irregular gout is what I have
named the Misplaced; that is, when the inflamma-
tory affection of the gout, instead of falling upon
the extremities, falls upon some internal part. In
this case, the disease is to be treated by bloodletting,
and by such other remedies as would be proper in
an idiopathic inflammation of the same parts.
583.
Whether the translation so frequently made from
the extremities to the kidneys, is to be considered
as an instance of the misplaced gout, seems, as we
have said before, uncertain; but I am disposed to
think it something different; and therefore am of
opinion, that, in the Nephralgia Calculosa produc-
ed upon this occasion, the remedies of inflamma-
tion are to be employed no farther than they may
be otherwise sometimes necessary in that disease,
arising from other causes than the gout.
BOOK 

[271]
BOOK III.
OF EXANTHEMATA, OR ERUP-
TIVE FEVERS.
584.
THE diseases comprehended under this title,
which make the third Order of Pyrexiæ in our
Nosology, are in general such as do not arise but
upon occasion of a specific contagion applied, which
first produces fever, and afterwards an eruption
upon the surface of the body; and which diseases,
for the most part, affect persons but once in the
course of their lives.
585.
Whether the character of the Order may be thus
limited, or if the Order may be allowed to compre-
hend also the eruptive fevers produced by a matter
generated in the body itself, and likewise those ca-
ses of eruption which do not depend upon conta-
gion, or upon 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 dis-
eases enumerated by the Nosologists as Exanthema-
ta, there are certainly three different kinds, which
may be distinguished by the circumstances mention-
ed in this and the preceding 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 

272 PRACTICE
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 exan—
themata enumerated by preceding Nosologists, with
only some difference in the arrangement from what
it was in my former editions.
CHAP. I.
OF THE SMALL POX.
586.
THE small pox is a disease arising from a con—
tagion of a specific nature, which first pro—
duces a fever; and on the third or fourth day there—
of, produces an eruption of small red pimples.
These are afterwards formed into pustules, con—
taining 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.
587.
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.
588.
In the former, or the distinct small pox, the e—
ruptive fever is moderate, and appears to be evi—
dently 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 common—
ly with a considerable languor and drowsiness. A
hot stage is soon formed, and becomes more consi—
derable 

273 OF PHYSIC. 
derable 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 affected with one of
two epileptic fits. Towards 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 eruption appears
first in small red spots, hardly eminent, but by de—
grees rising into pimples. These are generally up—
on 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,
containing an almost colourless or whey coloured
fluid, appears upon the top of each pimple. 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 pustules.
These vesicles or pustules, from their first forma—
tion, continue to be surrounded with an exactly
circular inflamed margin, which, when the pustules
re numerous, diffuses some inflammation over the
neighbouring skin, so as to give somewhat of a da—
mask rose colour to the spaces between the pustules.
As the pustules increase in size, if they be numer—
ous on the face, against the eighth day the whole of
the face becomes considerably swelled; and in par—
ticular, 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,
VOL. I. M m on 

274 PRACTICE
on the eleventh day, or soon after, is spontaneous—
ly broken and a portion of the matter oozes out;
in consequence of which, the pustule is shrivelled,
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 re—
mains in the pustule becomes thick, and even hard.
After some days, both the crusts and the hardened
pustules fall off, leaving the skin which they cover—
ed of a brown red colour; and it is only after ma—
ny days that the skin in these places resumes its na—
tural colour. In some cases, where the matter of
the pustules has been more liquid, the crusts form—
ed 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 pustules, 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 numerous,
some degree of pyrexia appears on the tenth and ele—
venth days, but disappears again after the pustules
are fully ripened; or perhaps remains in a very
slight degree till the pustules on the feet have fi—
nished their course. It is seldom that in the dis—
tinct small pox the fever continues longer.
When the pustules on the face are numerous,
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 symptoms increase with the swelling of the
face; and the liquids of the mouth and throat be—
coming thicker, are more difficultly thrown out.
There is, at the same time, some difficulty of swal—
lowing; 

275 OF PHYSIC. 
lowing; so that liquids taken in to be swallowed are
frequently rejected, or thrown out by the nose.
But all these affections of the fauces abate as the
swelling of the face subsides.
589.
In the other form of small pox, or what is called
the Confluent, the course of the disease is, in ge—
neral, the same with that we have described; 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, ap—
proaching 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 symptom, especially at the coming on of
the disease. In very young infants, epileptic fits are
sometimes frequent on the first days of the disease,
and sometimes prove fatal before any eruption ap—
pears; or they usher in a very confluent and pu—
trid small pox.
590.
The eruption appears more early on the third day,
and it is frequently preceded or accompanied with
an erysipelatous efflorescence. Sometimes the
eruption appears in clusters, like that of the mea—
sles. When the eruption is completed, the pimples
are always more numerous upon the face, and at
the same time smaller and less eminent. After the
eruption, the fever suffers some remission, but ne—
ver 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 increase in breadth,
do not retain a circular, but are every way of an
irregular 

276 PRACTICE
irregular figure. Many of them run into one ano-
ther, insomuch that very often the face is covered
rather with one vesicle than with a number of pus—
tules. The vesicles, so far as they are any wife se—
parated, do not arise to a spheroidical form, but
remain 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 becomes
whitish or brownish, but never acquires the yellow
colour and thick consistence that appear in the dis—
tina small pox.
591.
The swelling of the face which attends the dis—
tinct small pox, when they are numerous, and al—
most then only, always attends the confluent, 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 shrivelling pour out a liquor that is formed in—
to 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 desquama—
tion, 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 attends the
distinct small pox, very constantly attends the con—
fluent; and both the salivation and the affection of
the fauces above mentioned are, especially in adults,
in a higher degree. In infants, a diarrhœa comes
frequently in place of the salivation. 
In

277 OF PHYSIC. 
In the confluent small pox, there is often a con—
siderable putrescency of the fluids, as appears from
petechiæ, from serous vesicles, under which the
skin shows a disposition to gangrene, and from
bloody urine or other hemorrhagy, all which symp—
toms frequently accompany 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 vio—
lence. This is what has been called the Seconda—
ry Fever; and is, in different cases, of various du—
ration and event.
592.
We have thus endeavoured to describe the vari—
ous 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 he nearly comprised in the following
propositions.
The more exactly the disease retains the form of
the distinct kind, it is the safer; and the more com—
pletely 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 otherwise, by
fever or putrescency, approaches to the circum—
stances of the confluent, that it is attended with
any danger.
In the confluent small pox there is always dan—
ger; and this is always more considerable and cer—
tain, according as the fever is more violent and
permanent, and especially as the marks and symp—
toms of putrescency are more evident.
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 

278 PRACTICE
Though the small pox should not be immediately
fatal, the more violent kinds are often followed by
a morbid state of the body, of various kind and
event. These consequences, as I judge, may be
imputed sometimes to an acrid matter produced by
the preceding disease, and deposited in different
parts; and sometimes to an inflammatory diathesis
produced, and determined to particular parts of
the body.
593.
It is, I think, agreed among practitioners, that,
in the different cases of small pox, the difference
chiefly depends upon the appearance of distinct or
confluent; and, from the above description of
these kinds, it will appear, 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.
594.
Upon inquiring into the causes of these differen—
ces, we might readily suspect, that they depended
upon a difference of the contagion producing the
disease. This, however, is not probable; for
there are innumerable instances of the contagion,
arising from a person labouring under the small pox
of the distinct kind, producing the confluent; and
on the contrary. Since the practice of inoculation
became frequent, we have known the same vario—
lous 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 conta—
gion, but upon some difference in the state of the
persons to whom it is applied, or in the state of
certain 

279 OF PHYSIC. 
certain circumstances concurring with the applica—
cation of the contagion.
595.
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 differ—
ence between the distinct and confluent small pox
consists especially in the number of pustules produc—
ed; which, in the distinct, are generally few; in
the confluent, always many. If, therefore, we
shall be able to discover what, in the state of dif—
ferent persons, can give occasion to more or fewer
pustules, we shall probably be able to account for
all the other differences of the distinct and conflu—
ent small pox.
596.
It is evident, that the contagion of the small pox
is a ferment with respect to the human fluids, and
assimilates a great part of them to its own nature;
and it is probable, that the quantity thus assimilated,
is, in proportion to the bulk of their several bodies,
nearly the same in different persons. This quan—
tity passes again out of the body, partly by insensi—
ble perspiration, and partly by being deposited in
pustules; but if the quantities generated 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 cau—
ses 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.
597.
The causes which determine more of the vario—
lous matter to pass by perspiration, or to form pus—
tules,

280 PRACTICE
tules, are probably certain circumstances of the
skin, that determine more or less of the variolous
matter to stick in it, or to pass freely through it.
598.
The circumstance of the skin, which seems to de—
termine the variolous matter to stick in it, is a cer—
tain state of inflammation, depending much upon
the heat of it: Thus we have many instances of
parts of the body, from being 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 circumstances, such as adult age,
and full living, determining to a phlogistic diathe—
sis, seem to produce a greater number of pustules;
while the contrary circumstances have contrary
effects.
599.
It is therefore probable, that an inflammatory
state of the whole system, and more particularly of
the skin, gives occasion to a greater number of pus—
tules; and the causes of this may likewise produce
most of the other circumstances of the confluent
small pox; such as the period of eruption; the
continuance of 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
other circumstances of the pustules.
600.
Having thus attempted to account for the chief
difference which occurs in the state of the small
pox,

281 OF PHYSIC.
pox, we shall now try the truth of our doctrine, by
its application to practice.
601.
In considering the practice, we view it first, in
general, as suited to render the disease more gene—
rally benign and safe, and this by the practice of
inoculation.
602.
It is not necessary here to describe the operation
of inoculating; and what we name the practice of
inoculation, comprehends all the several measures
which precede or follow that operation, and are sup—
posed to produce its salutary effects.
These measures are chiefly the following.
1. The choosing for the subject of inoculation
persons otherwise free from disease, and not liable,
from their age or other circumstances, to any inci—
dental disease.
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 inoculated,
by abstinence from animal food for some time before
inoculation.
5. The preparing the person by Courses of mer—
curial and antimonial medicines.
6. The taking care, at the time of inoculation,
to avoid cold, intemperance, fear, or other cir—
cumstances which might aggravate the future disease.
7. After these preparations and precautions, the
choosing a fit matter to be employed in inocula—
tion, by taking it from a person of a sound constitu—
tion, and free from any disease or suspicion of it;
by taking it from a person who has had the small
pox of the most benign kind; and, lastly, by tak—
VOL. I. N n ing 

282 PRACTICE
ing the matter from such persons, as soon as it has
appeared in the pustules, either in the part inoculat—
ed, 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 vegeta—
ble diet, as well as the employment of mercurial
and antimonial medicines; and, at the same time,
frequently employing purgatives.
10. Both before and after inoculation, taking
care to avoid external heat, either from the sun,
artificial fires, warm chambers, much clothing, or
being much in bed; and, on the contrary, expos—
ing the person to a free and cool air.
11. Upon the appearance of the eruptive fever,
the rendering that moderate by the employment of
purgatives; by the use of cooling and antiseptic
acids; and especially by exposing the person fre—
quently to a cool and even a cold air, at the same
time giving freely of cold drink.
12. After the eruption, the continuing the ap—
plication of cold air, and the use of purgatives, du—
ring the course of the disease, till the pustules are
fully ripened.
603.
These are the measures proposed and practised
in the latest and most improved state of inoculati—
on; and the advantages obtained by the whole of
the practice, or at least by most of the measures a—
bove mentioned, are now ascertained by a long ex—
perience to amount to this, That, in ninety nine
cases of the hundred, inoculation gives a distinct
small pox only, and that also very generally of the
mildest form; but it will still be useful, for the pro—
per conduct of inoculation, to consider the impor—
tance and utility of the several measures above
mentioned, that we may thereby more exactly de—
termine upon what the advantages of inoculation
more certainly depend. 
604. As

283 OF PHYSIC. 
604.
As the common infection may often seize per—
sons 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 concurrence. 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 remarked, that the small
pox have often occurred with a diseased state of the
body, without being thereby rendered more vio—
lent. In particular, we have observed, that a scro—
phulous 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 opinion, that they
are the diseases of the febrile kind, or ailments rea—
dy to induce or aggravate a febrile state, that espe—
cially give the concurrence which is most danger—
ous 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
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 per—
son to take them by the common infection.
605.
Though inoculation has been practised with safe—
ty upon persons of all ages; yet, from what has
actually occurred in the cases of common infection,
and 

284 PRACTICE
and from several other considerations, there is rea—
son to conclude, that adults are more liable to a
violent disease than persons of younger years. At
the same time, it is observed, that children, in the
time of their first dentition, are liable, from this
irritation, to have the small pox rendered more vi—
olent; and that infants, before the time of dentiti—
on, 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 circumstances may ad—
mit, and even render inoculation at any age proper;
yet, for the most part, it will be still more advisable
to choose persons at an age, after the first dentition
is over, and before the time of puberty,
606.
Though inoculation has been practised with safe—
ty at every season of the year; yet, as it is certain
that the cold of winter may increase the inflamma—
tory, and the heats of summer increase the putres—
cent state of the small pox, it is highly probable
that inoculation may have some advantage, from
avoiding the extremes either of heat or cold.
607.
Although the original temperament and consti—
tutions of men are not to be readily changed; it is
sufficiently certain, that the conditions of the hu—
man body may, by various causes, in many respects
be occasionally very much changed; and therefore,
as the use of animal food may increase both the in—
flammatory and putrescent state of the human body,
so it must render persons, on receiving the conta—
gion of the small pox, less secure against a violent
disease; and, therefore, inoculation may derive
some advantage from abstinence from animal food
for some time before the inoculation is performed;
but 

285 OF PHYSIC. 
but I am of opinion, that a longer time than that
usually 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.
608.
I cannot deny that mercurial and antimonial me—
dicines may have some effect in determining to a
more free perspiration, and therefore may be of
some use in preparing a person for the small pox;
but there are many observations which render me
doubtful as to their effect. The quantity of both
these medicines, particularly of the antimony,
commonly employed, is too in considerable to pro—
duce any effect. It is true, that the mercurials
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 pre—
paratory courses of medicines.
609.
As it has been often observed, in the case of al—
most all contagions, that cold, intemperance, fear,
and some other circumstances, concurring with the
application of the contagion, have greatly aggra—
vated the future disease, so it must be the same in
the case of the small pox; and it is undoubted, that
inoculation must derive a great, and perhaps its
principal, advantage, from avoiding the concur—
rences above mentioned.
6lO.
It has been commonly supposed, that inoculation
has derived some advantage from the choice of the
matter 

286 PRACTICE
matter employed in it; but, from what has been
observed in (594.), it must appear very doubtful if
any choice be necessary, or can be of any benefit,
in determining the state of the disease.
611.
It has been supposed by some, that inoculation
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 larger than that thrown in by inoculation, it is
not ascertained that the circumstance of quantity
would have any effect. A certain quantity of fer—
ment may be necessary to excite fermentation in a
given mass; but, that quantity given, the fermen—
tation and assimilation are extended to the whole
mass; and we do not find that a greater quantity
than is just necessary, either increases the activity
of the fermentation, or more certainly secures the
assimilation 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.
6l2.
Purging has the effect of diminishing the activity
of the sanguiferous system, and of obviating its in—
flammatory state. It is therefore probable, that
the frequent use of cooling purgatives is a practice
attending inoculation which may be of considera—
ble advantage; and, probably, it is also useful by
diminishing the determination to the skin. It ap—
pears to me, that mercurials and antimonials, as
they are commonly managed, are useful only as
they make a part of the purging course.
613. It 

287 OF PHYSIC. 
613.
It is probable, that the state of the small pox de—
pends very much upon the state of the eruptive fe—
ver, and particularly upon moderating the inflam—
matory state of the skin; and, therefore, it is pro—
bable, 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 tenden-
cy of purging, and the use of acids, for this pur—
pose, is sufficiently obvious; and upon the same
grounds, we should suppose that bloodletting might
be useful; but probably this has been omitted, for
the same reason that perhaps might have led to the
omission of other remedies also; which is, that we
have found a more powerful and effectual one in
the application 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 Indostan had
long ago, and the practice of this country has late—
ly, by a large and repeated experience, ascertained
the safety and efficacy of this remedy; and as it
may and can be more certainly employed with the
practice of inoculation, than it can be in cases of
common infection, it must give a singular advan—
tage to the former.
614.
After the eruption, when a few pimples only have
appeared on the face, the continuing the applica—
tion of cold air, and the employment of purgatives,
has indeed been the practice 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
number of pustules is very small, and the fever has
entirely 

288 PRACTICE
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 unneces—
sary, but that they may be often hurtful.
615.
I have thus considered the several circumstances
and practices accompanying inoculation, and have
endeavoured to ascertain the utility and importance
of each. Upon the whole, I hope I have suffici—
ently ascertained the general utility and great ad—
vantage of this practice, especially consisting in
this, that if certain precautions, preparations, and
remedies, 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 remarks
on the conduct of the small pox, as received by in—
fection, or even when, after inoculation, the symp—
toms shall prove violent. The latter sometimes
happens, although every precaution and remedy
have been employed. The cause of this is not well
known; but it appears to me to be commonly ow—
ing 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 occasion for
studying the conduct of this disease, in all its possi—
ble varying circumstances.
616.
When, from the prevailing of small pox as an epi—
demic, and more especially when it is known that
a person not formerly affected with the disease has
been exposed to the infection, 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 

289 OF PHYSIC. 
and therefore he is to be treated in every respect
as if the disease had been received by inoculation.
He is to be freely exposed to a cool air, to be purg—
ed, and to have cooling acids given liberally.
617.
If these measures moderate the fever, nothing
more is necessary: But if the nature of the fever
attacking a person be uncertain; or, if, with su—
spicions of the small pox, the symptoms of the fe—
ver be violent; or even if, knowing the disease to
be small pox, the measures mentioned (596.), shall
not moderate the fever sufficiently; it will be pro—
per to let fome blood ; and this will be more espe—
cially proper, if the person be an adult, of a ple—
thoric habit, and accustomed to full living.
618.
In the same circumstances, we judge it will be
always proper to give a vomit, as useful in the com—
mencement of all fevers, and more especially in
this, where a determination to the stomach appears
from pain and spontaneous vomiting.
619.
It frequently happens, especially in infants, that,
during the eruptive fever of the small pox, convul—
sions occur. Of these, if only one or two fits ap—
pear on the evening preceding the eruption, they
give a favourable prognostic of a mild disease, and
require no remedy; but if they occur more early,
and be violent 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 re—
medy I have found effectual is an opiate given in a
large dose.
VOL. I. O o 620. These 

290 PRACTICE
620.
These are the remedies necessary during the e—
ruptive fever; and if, upon the eruption, the pim—
ples upon the face be very few and distinct, the dis—
ease is no further of any danger, requires no reme—
dies, 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 considerable remission;
the disease will still require a great deal of attention.
621.
If, after the eruption, the fever shall continue,
the avoiding heat, and continuing to expose the
body to a cool air, will still be proper. If the fe—
ver be considerable, with a full and hard pulse, in
an adult person, a bleeding will be necessary; and,
more certainly, a cooling purgative. It is, how—
ever, seldom 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 purgative, or the
frequent use of laxative glysters, is commonly useful.
622.
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 nitre, is useful; and it is com—
monly proper also to give wine very freely.
623. From 

291 OF PHYSIC.
623.
From the fifth day of the disease, onward through
the whole course of it, it is proper to give an opi—
ate once or twice a day; taking care, at the same
time, to obviate costiveness by purgatives or laxa—
tive glysters.
624.
In a violent disease, from the eighth to the ele—
venth day, it is proper to lay on blisters successive—
ly on different parts of the body, and that without
regard to the parts being covered with pustules.
625.
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 blisters to the external
fauces, and to employ diligently detergent gargles.
626.
During the whole course of the disease, when
any considerable fever is present, the frequent ex—
hibition of antimonial medicines, in nauseating
doses, has been found useful; and these, for the
most part, sufficiently answer the purpose of pur—
gatives.
627.
The remedies mentioned from (621. to 625.)
are those frequently necessary, from the fifth day
till the suppuration is finished. But as, after that
period, the fever is sometimes continued and in—
creased; or, as sometimes, when, after there has
been 

292 PRACTICE
been little or no fever before, a fever now arises,
and continues with considerable danger; this is
what is called the Secondary Fever, and requires
particular treatment.
628.
When the secondary fever follows the distinct
small pox, and the pulse is full and hard, the case
is to be treated as an inflammatory affection, by
bleeding and purging. But, if the secondary fe—
ver follow the confluent small pox, and be a con—
tinuance or exacerbation of the fever which had
subsisted before, it is to be considered as of the pu—
trid kind; and in that case, bleeding is improper.
Some purging 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 antimonial emetic in nau—
seating doses, but in such manner as to produce
some vomiting.
629.
For avoiding the pits which frequently follow the
small pox, many different measures have been pro—
posed; but none of them appear to be sufficiently
certain.
CHAP. II.
Of the CHICKEN POX.
630.
THIS disease seems to depend upon a specific
contagion, and to affect persons but once in
their lives. It is hardly ever attended with any
danger; 

293 OF PHYSIC. 
danger; but as it seems frequently to have given
occasion to the supposition 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.
631.
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 fever of no
determined duration.
The pimples of the chicken pox, more quickly
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 appearance, form—
ed into crusts.
See Dr. Heberden in Med. Transact. Vol. I.
art. xvii.
CHAP. III.
OF THE MEASLES.
632.
THIS disease also depends upon a specific con—
tagion, and affects persons but once in their
lives.
633.
It occurs most frequently in children; but no
age is exempted from it, if the persons have not
been subjected to it before.
634. It 

294 PRACTICE
634.
It commonly appears as an epidemic, first in the
month of January, and ceases soon after the sum—
mer solstice; but various accidents, introducing
the contagion, may produce the disease at other
times of the year.
635.
The disease always begins with a cold stage, which
is soon followed by a hot, with the ordinary symp—
toms of thirst, heat, anorexia, anxiety, sickness,
and vomiting; and these are more or less consider—
able in different cases. Sometimes from the be—
ginning, 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.
636.
This eruptive fever, from its commencement, is
always attended with hoarseness, with a frequent
hoarse dry cough, and frequently with some diffi—
culty of breathing. At the same time, the eyelids
are somewhat swelled, the eyes are a little inflamed,
and pour out tears; and, together with these symp—
toms, there is a coryza, and frequent sneezing.
For the most part, a constant drowsiness attends
the beginning of this disease.
637.
The eruption, as we have said, commonly appears
upon the fourth day; first on the face, and succes—
sively on the lower parts of the body. It discovers
itself first in small red points; but, soon after, a
number of these appear in clusters, which do not
arise 

295 OF PHYSIC 
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 meally desquamation takes place. During the 
whole time of the eruption, the face is somewhat
turgid, but seldom considerably swelled.
638.
Sometimes, after the eruption has appeared, the
fever ceases entirely; but this is seldom the case;
and more commonly the fever continues, or is in—
creased after the eruption, and does not cease till
after the desquamation. Even then the fever does
not always cease, but continues with various dura—
tion and effect.
639.
Though the fever happen to cease upon the erup—
tion's taking place, it is common for the cough to
continue till after the desquamation, and sometimes
much longer.
In all cases, while the fever continues, the cough
also continues, generally with an increase of the
difficulty of breathing; and both of these symp—
toms sometimes arise to a degree that denotes a
pneumonic affection. This may arise at any peri—
od 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 frequent—
ly comes on, and continues so some time.
640. It 

296 PRACTICE
640.
It is common for the measles, even when they
have not been of a violent kind, to be succeeded
by inflammatory affections, particularly ophthal—
mia and phthisis.
641.
If the blood be drawn from a vein, during the
measles, with the circumstances necessary to favour
the separation of the gluten, this always appears
separated, and lying on the surface of the crassa—
mentum, as in inflammatory diseases.
642.
For the most part, the measles, even when vio—
lent, are without any putrid tendency; but in some
cases such a tendency appears, both in the course
of the disease, and especially after the ordinary
course of it is finished. See Dr. Watson, in Lon—
don Med. Observations, Vol. IV. art. xi.
643.
From what is delivered (from 636. to 641.) it
will appear, that the measles are distinguished by a
catarrhal affection, and by an inflammatory diathe—
sis to a considerable degree; and therefore the dan—
ger attending them arises chiefly from the coming
on of a pneumonic inflammation.
644.
From this consideration it will be obvious, that
the remedies especially necessary are those which
may obviate and diminish the inflammatory diathe—
sis; and therefore, in a particular manner, blood—
letting. 

297 OF PHYSIC. 
letting. This remedy may be employed at any
time in the course of the disease, or after its ordi—
nary 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 dur—
ing the eruptive fever; and as this fever is some—
times violent immediately before the eruption,
though a sufficiently mild disease be to follow; so
bleeding is seldom very necessary during the erup—
tive fever, and may often be reserved for the peri—
ods of greater danger which are perhaps to ensue.
645.
In all cases of measles, where there are no marks
of putrescency, and where there is no reason, from
the known nature of the epidemic, to apprehend
putrescency, bleeding is the remedy to be depend—
ed upon; but assistance may also be obtained from
cooling purgatives; and particularly from blistering
on the sides, or between the shoulders.
646.
The dry cough may be alleviated by the large
use of demulcent pectorals, mucilaginous, oily, or
sweet. It may, however, be observed, with re—
spect to these demulcents, that they are not so pow—
erful 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 distilling
from the head.
647.
For moderating and quieting the cough in this
disease, opiates certainly prove the most effectual
VOL. I. P p means, 

298 PRACTICE
means, whenever they can be safely employed. In
the measles, in which an inflammatory state pre—
vails in a considerable degree, opiates may be sup—
posed to be inadmissible; 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 watch—
fulness are the urgent symptoms, I think that opi—
ates may be safely exhibited, and with great advan—
tage. I think, further, that, in all the exanthe—
mata, there is an acrimony diffused over the system,
which gives a considerable irritation; and, for ob—
viating the effects of this, opiates are useful, and
always proper, when no particular contraindica—
tion prevails.
648.
When the desquamation of the measles is finish—
ed, though there should then be no disorder re—
maining, physicians have thought it necessary to
purge the patient several times, with a view to
draw off the dregs of this disease, 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 re—
mains of 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 removing the inflamma—
tory 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 dispo—
sition, is yet more so.
649. From 

299 OF PHYSIC.
649.
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 measles; but we have
not yet had trials sufficient to ascertain this.
There is no doubt that external heat may be very
hurtful in the measles, as in most other inflamma—
tory 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 safety,
we are yet uncertain. Analogy, though so often
the resource of physicians, is, in general, falla—
cious; and further, though the analogy with the
small pox might lead to the application of cold air
during the eruptive fever of the measles, the ana—
logy with catarrh seems to be against the practice.
After the eruption had appeared upon the skin, we
have had many instances of cold air making it dis—
appear, and thereby producing much disorder in
the system; and have also had frequent examples
of such disorder being removed by restoring the
heat of the body, and thereby again bringing forth
the eruption.
CHAP. IV.
OF THE SCARLET FEVER.
650.
IT may be doubted if the Scarlet Fever be a dis—
ease specifically different from the Cynanche
Maligna above described. The latter is almost al—
ways attended with a scarlet eruption; and, in all
the instances I have seen of what may be called the
Scarlet

300 PRACTICE
Scarlet Fever, the disease, in almost every person
affected, has been attended with an ulcerous sore
throat.
651.
This view of the matter may create some doubt;
but I am still of opinion, that there is a scarlet fe—
ver which is a disease specifically different from the
Cynanche Maligna.
Doctor Sydenham has described a scarlet fever,
which he had seen prevailing as an epidemic, 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 observ—
er could not fail to have done, if any such symp—
tom, as we have commonly seen making a princi—
pal part of the disease, had attended those cases
which he had observed. Several other writers have
described 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 connected with
an ulcerous sore throat, and therefore a disease
different from the Cynanche Maligna.
652.
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 pre—
vailing as an epidemic in Scotland) the disease,
in almost all the persons affected, was attended
with an ulcerous sore throat, or was what Sauva—
ges 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 disease in all its symptoms resembled very
exactly the Cynanche Maligna; yet I am still per—
suaded, 

301 OF PHYSIC.
suaded, that not only the Scarlatina of Sydenham,
but that even the Scarlatina Anginosa of Sauva—
ges is a different disease from the Cynanche Ma—
ligna; and I have formed this opinion from the
following considerations.
653.
1st, There is a scarlet fever entirely free from
any affection of the throat, which sometimes pre—
vails as an epidemic; and therefore there is, a spe—
cific contagion producing a scarlet eruption with—
out any determination to the throat.
2dly, The Scarlatina, which, from its matter be—
ing 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 contagion may be
supposed to be more especially determined to pro—
duce the eruption only.
3dly, Though in all the epidemics that I could
allege to be those of the Scarlatina Anginosa, there
have been some cases, which, in the nature of the
ulcers, and in other circumstances, exactly resem—
bled the cases of the Cynanche Maligna; yet I
have as constantly remarked, that these cases have
not been above 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 de—
scribed, somewhat different from those of the Cy—
nanche Maligna.
4thly, On the other hand, as I have two or three
times seen the Cynanche Maligna epidemically
prevailing; so, among the persons affected, I have
seen instances of cases as mild as those of the Scar—
latina Anginosa usually are; but here the propor—
tion was reversed; 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 instan—
ces

302 PRACTICE
ces terminate fatally; while, on the other hand,
that is the event of very few of the cases of the
Scarlatina Anginosa.
654.
From these considerations, though it may ap—
pear that there is some affinity between the Cynan—
che Maligna and Scarlatina Anginosa, it will still
remain probable that the two diseases are specifi—
cally different. I have been at some pains to esta—
blish this opinion; for, from all my experience, I
find, that those two diseases require a different
treatment; and I therefore now proceed to men—
tion more particularly the circumstances of the
Scarlatina Anginosa.
655.
This disease commonly appears about the begin—
ning of winter, and continues throughout that sea—
son. It comes on with some cold shivering, and
other symptoms of the fever which usually introduc—
es the other exanthemata. 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
Cynanche Maligna.
Early in the disease some uneasiness is felt in the
throat; and frequently the deglutition is difficult,
generally more so than in the Cynanche Maligna.
Upon looking into the fauces, a redness and swel—
ling appear, in colour and bulk approaching to the
state of these symptoms in the Cynanche Tonsilla—
ris; but in the Scarlatina, there is always more or
less of sloughs, which seldom appear in the Cynan—
che Tonsillaris; and the sloughs are commonly
whiter than those in the Cynanche Maligna.
While these appearances are discovered in the
fauces, upon the third or fourth day a scarlet erup—
tion 

303 OF PHYSIC. 
tion appears on the skin, in the same form as de—
scribed in (314.) This eruption is commonly more
considerable and universal than in the Cynanche;
but it seldom 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 meally desquamation.
At this time the fever usually subsides; and, gene—
rally, at the same time, some degree of sweat
comes on.
The sloughs, on the fauces, which appeared ear—
ly in the disease, continue for some days; but then
falling off, discover the swelling abated, and an
ulcer formed on one or both tonsils showing a laud—
able pus; and soon after 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 discharg—
ed is less acrid, and has not the fetid smell which
it has in the other disease.
In the Scarlatina, when the eruption has entire—
ly disappeared, it frequently happens, that, in a few
days after, the whole body is affected with an ana—
sarcous swelling; which, however, in a few days
more, gradually subsides.
We have thus described the most common cir—
cumstances of the Scarlatina Anginosa; and have
only to add, that, during the time of its being epi—
demic, and especially upon its first setting in, there
are always a few cases in which the circumstances
of the disease approach very nearly to those of the
Cynanche Maligna; and it is only in these instan—
ces that the disease is attended with any danger.
656.
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 exactly the
same treatment as directed in (317.)
657. When 

304 PRACTICE
657.
When the scarlet fever appears without any af—
fection of the throat, the treatment of it is very
simple, and is delivered by Dr. Sydenham. An
antiphlogistic regimen is commonly all that is requi—
site; avoiding, on one hand, the application of cold
air; and, on the other, any increase of external heat.
658.
In the ordinary state of the Scarlatina Anginosa,
the same treatment is, in most cases, sufficient; but
as here the fever is commonly more considerable,
and there is likewise an affection of the throat, some
remedies may be often necessary.
659.
When there is a pretty high degree of fever, with
a full pulse, and a considerable swelling of the ton—
sils, bleeding is very proper, especially in adults;
and it has been frequently practised with advantage;
but as, even in the Cynanche Tonsillaris, much
bleeding is seldom necessary (305.); so, in the
Scarlatina, when the state of the fever and the ap—
pearances of the fauces render the nature 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.
660.
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 dis—
ease; and when the nauseating doses of emetics ope—
rate a little downwards, they are more serviceable.
661. In 

305 OF PHYSIC.
661.
In every form of the Scarlatina Anginosa, through
the whole course of it, detergent gargles should be
employed, and more or less as the quantity of sloughs
and the viscid mucus in the fauces may seem to re—
quire.
662.
Even in the milder states of the Scarlatina An—
ginosa, it has been common with practitioners to
exhibit the Peruvian bark through the whole course
of the disease; but we are assured, by much expe—
rience, that in such cases it may be safely omitted,
though in cases any ways ambiguous it may not be
prudent to neglect, this remedy.
663.
The anasarcous—swelling, which frequently fol—
lows the Scarlatina Anginosa, seldom requires any
remedy; and, at least the purgatives so much in—
culcated, and so commonly exhibited, soon take
off the anasarca.
CHAP. V.
OF THE PLAGUE.
SECT. I.
Of the PHENOMENA of the PLAGUE.
664.
THE Plague is a disease which always arises
from contagion; which affects many persons
VOL. I. Q q about 

306 PRACTICE
about the same time; proves fatal to great num—
bers; generally produces fever; and, in most per—
sons, is attended with buboes or carbuncles.
665.
These are the circumstances which, taken toge—
ther, give the character of the disease; but it is
accompanied with many symptoms almost peculiar
to itself, that in different persons are greatly diver—
sified in number and degree, and should be parti—
cularly studied. I would with to lay a foundation
for this; but think it unfit for a person who has
never seen the disease to attempt its particular his—
tory. For this, therefore, I must refer to the au—
thors, who have written on the subject; but allow—
ing those only to be consulted, who have them—
selves seen and treated the disease in all its differ—
ent forms.
666. 
From the accounts of such authors, it appears to
me, that the circumstances which particularly dis—
tinguish this disease, and especially the more vio—
lent and dangerous states of it, are,
1st, The great loss of strength in the animal
functions, which often appears early in the disease.
2dly, The stupor, giddiness, and consequent stag—
gering, which resembles drunkenness, or the head—
ach, and various delirium; which are all of them
symptoms denoting a great disorder in the func—
tions of the brain.
3dly, The anxiety, palpitation, syncope, and
especially the weakness and irregularity of the
pulse, which denote a considerable disturbance in
the action of the heart.
4thly, The nausea and vomiting, particularly
the vomiting of bile, which shows an accumulation
of vitiated bile in the gall bladder and biliary ducts,
and 

307 OF PHYSIC.
and from thence derived into the intestines and
stomach; all of which symptoms I suppose to de—
note 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 colli—
quative diarrhœa, which denote a putrescent ten—
dency prevailing to a great degree in the mass of
blood.
667.
From the consideration of all these symptoms, 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 putrescency in the fluids; and it is from
the consideration of these circumstances as the
proximate cause, that I think both the prevention
and cure of the plague must be directed.
668.
If this disease should revisit the northern parts
of Europe, it is probable, that, at the time, there
will be no physician then alive, who, at the first ap—
pearance 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,
therefore, I hope, allowable for me, upon the same
grounds, to offer here my opinion with respect
to both the prevention and cure of this disease.
This paragraph was written before I had any no—
tice of the plague of Moscow anno 1771; but I
think it will still apply to the case of Great Britain
and of many other northern states.
SECT. 

308 PRACTICE
SECT. II.
Of the PREVENTYION of the PLAGUE.
669.
WITH respect to the prevention: As we are
firmly persuaded that the disease never arises 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 ge—
nerally be done by a due attention to bills of health,
and to the proper performance of quarantines.
67O.
With respect to the latter we are persuaded, that
the quarantine of persons may safely be much less
than forty days; and, if this were allowed, the ex—
ecution of the quarantine would be more exact and
certain, as the temptation to break it would be in
a great measure removed.
671.
With respect to the quarantine of goods; it can
not be perfect, unless the suspected goods be un—
packed and duly ventilated, as well as the other
means employed for correcting the infection they
may carry; and, if all this were properly done, it
is probable that the time commonly prescribed for
the quarantine of goods might also be shortened.
672.
A second measure, in the way of prevention, be—
comes requisite, when an infection has reached and
prevailed in any place, to prevent that infection
from 

309 OF PHYSIC. 
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 undergone a proper quarantine.
673.
The third measure for prevention, to be employ—
ed with great care, is to hinder the infection from
spreading among thee inhabitants of the place in
which it has arisen. The measures necessary for
this, are to be directed by the doctrine laid down
in (82.); and from that doctrine we infer, that all
persons who can avoid any near communication
with infected persons, or goods, may escape the
infection.
674.
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 infecti—
on, and not necessary to the service of the place,
to go out of it. 2. By prohibiting all assemblies,
or unnecessary intercourse, of the people. 3. By
taking care that necessary communications be per—
formed without contact. 4. By making such ar—
rangements and provisions as may render it easy
for the families remaining to shut themselves up in
their own houses. 5. By allowing persons to quit
houses in which an infection appears, upon condi—
tion that they go into lazarettoes. 6. By ventilat—
ing and purifying, or destroying at the public ex—
pence, all infected goods. Lastly, By avoiding
hospitals, and providing separate apartments for in—
fected persons.
The execution of these measures will require
great authority, and much vigilance and attention,
on the part of the magistrate; but it is not our pro—
vince to enter into any detail on this subject of the
public police.
675. The 

310 PRACTICE
675.
The fourth and last part of the business of pre—
vention, respects the conduct of persons necessarily
remaining in infected places, especially of those
obliged to have some communication with persons
infected.
676.
Of those obliged to remain in infected places, but
not obliged to have any near communication with
the sick, they may be preserved from the contagion
by avoiding all near communication with other per—
sons, or their goods; and, it is probable, that a
small distance 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.
677.
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 con—
tagions do not operate, but when the bodies of men
exposed to the contagion are in certain circumstan—
ces 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 cir—
cumstances and causes, they may often escape in—
fection.
678.
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 nourishment; by
intemperance in drinking, which, when the stupor 
of

311 OF PHYSIC. 
of intoxication is over, leaves the body in a weak—
ened state; by excess in venery; by great fatigue;
or by any considerable evacuation.
679.
The causes which, concurring with contagion,
render it more, certainly active, are cold, fear, and
full living.
The several means, therefore, of avoiding or
guarding against the action of cold (94. to 96.) are
to be carefully studied.
680.
Against fear the mind is to be fortified as well
as possible, by inspiring a favourable idea of the
power of preservative means; by destroying the
opinion of the incurable nature of the disease; by
occupying men's minds with business or labour;
and by avoiding all objects of fear, as funerals,
passing bells, and any notice of the death of parti—
cular friends.
68l.
A full diet of animal food increases the irritabi—
lity of the body, and favours the operation of con—
tagion; and indigestion, whether from the quanti—
ty or quality of food, has the same effect.
682.
Besides giving attention to obviate the several
circumstances (609. 678. to 681.) which favour the
operation of contagion, it is probable that some
means may be employed for strengthening the bo—
dies of men, and thereby enabling them to resist
contagion.
For 

312 PRACTICE
For this purpose, it is probable, that the mode—
rate 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 neither heat—
ing nor fatiguing to the body, may be employed
with advantage.
Persons who have tried cold bathing, and com—
monly feel invigorating effects from it, if they are
anywise secure against having already received in—
fection, 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 a—
mongst these I can hardly admit the numerous alex—
ipharmics formerly proposed; or, at least, very
few of them, and those only of tonic power. A—
mongst 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 internally 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 directly 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.
683.
As neither the atmosphere in general, nor any
considerable portion of it, is tainted or impregnat—
ed 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.
684. It 

313 OF PHYSIC. 
684.
It would probably contribute much to check the
progress of infection, if the poor were enjoined to
make a frequent change of clothing, and were suit—
ably provided for that purpose; and if they were
at the same time induced to make a frequent venti—
lation of their houses and furniture.
SECT. III.
Of the CURE of the PLAGUE.
685.
In the cure of the plague, the indications are the
Same as those of fever in general (126); but here
they are not all equally necessary and important.
686.
The measures for moderating the violence of re—
action, which operate by diminishing the action of
the heart and arteries (128.), have seldom any place
here, excepting so far as the antiphlogistic regimen
is generally proper. Some physicians, indeed, have
recommended 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 frequently present
in the intestines; but a large evacuation this way
may certainly be hurtful.
687.
The moderating the violence of reaction, so far
as it can be done by taking off the spasm of the ex—
VOL. I. R r treme 

314 PRACTICE
treme vessels (151.), is a measure of the utmost ne—
cessity in the cure of the plague; and the whole of
the means (152. to 200.) suited to this indication
are extremely proper.
688.
The giving an emetic at the very first approach
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 evacuat—
ing bile abundant in the alimentary canal, and by
taking off the spasm of the extreme vessels.
689.
From some principles with respect to fever in ge—
neral, and with respect to the plague in particular,
I am of opinion, that, after the exhibition of the
first vomit, the body should be disposed to sweat;
which ought to be raised to a moderate degree on—
ly, but continued for at least twenty four hours, or
longer if the patient bear it easily.
69O.
This sweating should be excited and conducted
agreeably to the rules laid down in (168.) It is to
be promoted by the plentiful use of diluents, ren—
dered more grateful by vegetable acids, or more
powerful by being impregnated with some portion
of neutral salts.
691.
To support the patient under the continuance of
the sweat, a little weak broth, acidulated with juice
of lemons, may be given frequently; and some—
times a little wine, if the heat of the body be not
considerable.
692. If

315 OF PHYSIC.
692.
If sudorific medicines are judged to be necessary,
opiates are the most effectual and safe; but they
should not be combined with aromatics; and pro—
bably may be more effectual, if joined with a por—
tion of emetics and of neutral salts.
693.
If, notwithstanding the use of emetics and sudo—
rifics, the disease should still continue, the cure
must depend upon the employment of means for
obviating debility and putrescency; and, for this
purpose, the various remedies proposed above (from
201. to 227.) may all be administered, but especi—
ally the tonics; and of those the chief are cold
drink and the Peruvian bark.
694.
In the cure of the plague, some attention is due
to the management of buboes and carbuncles; but
we do not touch this, as it belongs to the province
of surgery.
CHAP. VI.
OF ERYSIPELAS, OR ST. ANTHONY'S
FIRE.
695.
IN (274.) I mentioned the distinction which I
proposed to make between the diseases to be
named the Erythema and the Erysipelas; and from
thence it will appear, that Erysipelas, as an Ery—
thema following fever, may have its place here.
696. I sup—

316 PRACTICE
696.
I suppose the Erysipelas to depend on a matter
generated within the body, and which, analogous
to the other cases of exanthemata, is, in conse—
quence of fever, thrown out upon the surface of
the body. I own it may be difficult 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 erysipelas of the face; which I shall
therefore consider here.
697.
The Erysipelas of the face comes on with a cold
shivering, and other symptoms of pyrexia. The
hot stage of this is frequently attended with a con—
fusion of head, and some degree of delirium; and
almost always with drowsiness, or perhaps coma.
The pulse is always frequent, and commonly full
and hard.
698.
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 (275.) as the appearance of Erythema. This
redness, at first, is of no great extent; but gradu—
ally spreads from the part it first occupied to the
other parts of the face, commonly till it has affect—
ed 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 com—
monly 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 swelling, which continues for some time
after the redness has abated. The whole face be—
comes 

317 OF PHYSIC. 
comes considerably turgid; and the eyelids are oft—
en so much swelled, as entirely to shut up the eyes,
699.
When the redness and swelling have proceeded
for some time, there commonly arise, sooner or
later, blisters of a larger or smaller size, on seve— 
ral parts of the face. These contain a thin yellow—
ish or almost colourless liquor, which sooner or
later runs out. The surface of the skin, in the bli—
stered places sometimes becomes livid and black—
ish; but this livor seldom goes deeper than the sur—
face, or discovers any degree of gangrene affect—
ing the skin. On the parts of the face not affected
with blisters, the cuticle suffers, towards the end
of the disease, a considerable desquamation.
Sometimes the tumour of the eyelids ends in a
suppuration.
700.
The inflammation coming upon the face does
not produce any remission of the fever which had
before prevailed; and sometimes the fever increas—
es with the increasing and spreading inflammation.
7O1.
The inflammation usually continues for eight or
ten days; and for the same time, the fever and
symptoms attending it also continue.
702.
In the progress of the inflammation the delirium
and coma attending it sometimes go on increasing
and the patient dies apoplectic on the seventh, ninth,
or eleventh day of the disease. In such cases, it
has been commonly supposed that the disease is
translated 

318 PRACTICE
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.
When the fatal event does not take place, the
inflammation, after having affected a part, common—
ly the whole of the face, and perhaps the other ex—
ternal parts of the head, ceases. With the inflam—
mation, the fever also ceases; and, without any
evident crisis, the patient returns to his ordinary
state of health.
704.
This disease is not commonly contagious; but
as it may arise from an acrid matter externally ap—
plied, so it is possible that the disease may some—
times be communicated from one person to another.
Persons who have once laboured under this dis—
ease are liable to returns of it.
705.
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 co—
ma come on, the disease is seldom attended with
any danger; but when these symptoms appear ear—
ly in the disease, and are in a considerable degree,
the utmost danger is to be apprehended.
706.
As this disease often arises in the part, at the
same time with the coming on of the pyrexia; as I
have 

319 OF PHYSIC. 
have known it, with all its symptoms, arise from
an acrimony applied to the part; as it is common—
ly 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 phlegma—
siæ; and, lastly, as the swelling of the eyelids, in
this disease, frequently ends in a suppuration; so,
from these considerations, it seems doubtful 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.
707.
Upon this conclusion, the Erysipelas of the face
is to be cured very much in the same manner as
phlegmonic inflammations, by bloodletting, cool—
ing purgatives, and by employing every part of the
antiphlogistic regimen; and our experience has
confirmed the fitness of this method of cure.
708.
The evacuations of bloodletting and purging are
to be employed more or less according to the ur—
gency of symptoms, particularly those of the py—
rexia, and of those which mark an affection of the
brain. As the pyrexia continues, and often in—
creases with the inflammation of the face; so the
evacuations mentioned may be employed at any
time in the course of the disease.
709.
In this, as in other diseases of the head, it is pro—
per to put the patient, as often as he can easily
bear it, into somewhat of an erect posture.
710. As 

320 PRACTICE
710.
As in this disease there is always an external af—
fection, and as in many instances there is no other;
so various external applications to the part affect—
ed have been proposed; but almost 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 appli—
cations seem to occasion its spreading. The appli—
cation that seems most safe, and which is now most
commonly employed, is that of a dry mealy pow—
der frequently sprinkled upon the inflamed parts.
711.
An Erysipelas Phlegmonodes frequently appears
on other parts of the body beside the face; and
such other erysipelatous inflammations frequently
end in suppuration. These cases are seldom dan—
gerous. At coming on, they are sometimes at—
tended with drowsiness, and even with some deli—
rium; but this rarely happens; and these symp—
toms do not continue after the inflammation is
formed. I have never seen an instance of the
translation of this inflammation 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 applica—
tions, 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.
712. We 

321 OF PHYSIC.
712.
We have hitherto considered erysipelas as in a
great measure of a Phlegmonic nature; and, agree—
ably to that opinion, We have proposed 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 explicit upon this subject, as such putrid cases
have not come under my observation.
CHAP. VII.
OF THE MILIARY FEVER.
7l3.	
THIS disease is said to have been unknown to
the ancients, and that it appeared, for the first
time, in Saxony, about the middle of the last cen—
tury. 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.
714.
From the time of its having been first particular—
ly observed, it has been described and treated of
by many different writers; and by all of them, till
very lately, has been considered as a peculiar idio—
pathic 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 anxiety, and fre—
Vol. I. S s quent 

322 PRACTICE
quent sighing. The heat of the body becomes great,
and soon produces 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 de—
termined 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.
715.
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 commonly allowed to be a symp—
tomatic 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
particularly describe and treat of in the present
chapter.
716.
What then is called the White Miliary eruption,
appears at first like the red, in very small red pim—
ples, for the most part distinct, but sometimes clus—
tered together. Their slight prominence is distin—
guished better by the singer than by the eye. Soon
after the 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 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 pimples takes this course, another set suc—
ceeds; so that the disease often continues upon
the 

323 OF PHYSIC. 
the skin for many days together. Sometimes when
one crop of this eruption has disappeared, another,
after some interval, is produced. And it has been
further observed, that in some persons there is
such a tendency to this disease, that they have been
affected with it several times in the course of their
lives.
717.
This disease is said to affect both sexes, and per—
sons of all ages and constitutions; but it has been
observed, at all times, to affect especially, and
most frequently, lying in women.
718.
This disease is often accompanied with violent
symptoms, and has frequently proved fatal. The
symptoms attending it, are, however, very various.
They are, in one or other instance, all the several
symptoms attending febrile diseases; but I cannot
find that any symptom or concourse of symptoms
are steadily the same in different persons, so as to
furnish any specific character to the disease. When
the disease is violent, the most common symptoms
are phrenitic, comatose, and convulsive affections,
which are also symptoms of all fevers treated by a
very warm regimen.
719.
While there is such a variety of symptoms ap—
pearing in this disease, it is not to be expected that
any one particular method of cure can be proposed;
and accordingly we find, in different writers, dif—
ferent methods and remedies prescribed; frequent
disputes about the most proper; and those receiv—
ed and practised by some, opposed and rejected by
others. 
720. I have

324 PRACTICE
720.
I have thus given an account of what I have
found delivered by authors who have considered
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 supposed; and I suspect that
there is much fallacy in what has been written on
the subject.
721.
It seems to me very improbable, that this should
have been really a new disease when it was first con—
sidered 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
affections; whilst we know also very well, that
those affections which usually appeared as sympto—
matic only, were commonly neglected, or con—
founded together under a general appellation.
722.
The antecedent symptoms of anxiety, sighing,
and pricking of the skin, which have been spoken
of as peculiar to this disease, are however, com—
mon to many others; and, perhaps, 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 sweating. This,
indeed, always precedes and accompanies the erup—
tion; and, while the miliary eruption attends ma—
ny different diseases, it never, however, appears
in any of these, but after sweating; and, in per—
sons

325 OF PHYSIC.
sons labouring under these diseases, it does not ap—
pear if sweating be avoided. It is therefore pro—
bable, that the eruption is the effect of sweating; and
that it is the produce of a matter, not before pre—
vailing in the mass of blood, but generated, under
particular circumstances, in the skin itself. That
it depends upon particular circumstances of the
skin, appears further from hence, that the eruption
seldom or never appears 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 applications.
723.
It is to be observed, that this eruptive disease
differs from the other exanthemata in many cir—
cumstances; in its not being contagious, and there—
fore never epidemic; that the eruption appears at
no determined period of the disease; that the erup—
tion has no determined duration; that successive
eruptions frequently appear in the course of the
same fever; and that such eruptions frequently re—
cur in the course of the same person's life.
All these circumstances render it extremely pro—
bable, that, in the miliary fever, the morbific mat—
ter is not a subsisting contagion communicated to
the blood, and thence, in consequence of fever
and assimilation, thrown out upon the surface of the
body; but a matter occasionally produced in the
skin itself, by sweating.
724.
This conclusion is further rendered probable
from hence, that, while the miliary eruption has
no peculiar symptoms, or concourse of symptoms,
belonging to it; yet, upon occasion, it accompa—
nies almost all febrile diseases, whether inflamma—
tory 

326 PRACTICE
tory or putrid, if these happen to be attended with
sweating; and from thence it may be presumed,
that the miliary eruption is a symptomatic affection
only, produced in the manner we have said.
725.
But, as this symptomatic affection does not al—
ways accompany every instance of sweating, it may
be proper to inquire, what are the circumstances
which especially determine this eruption to appear?
To this, however, I can give no full and proper
answer. I cannot say that there is any one cir—
cumstance 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 purpose of
this inquiry; and it is, that, of the persons sweat—
ing under febrile diseases, those are especially lia—
ble to the miliary eruption, who have been previ—
ously weakened by large evacuations, particularly
of blood. This will explain why it happens to ly—
ing in women more frequently than to any other
persons; and to confirm this explanation, I have
remarked, that the eruption happened to women
not in childbed, but who had been much subjected
to a frequent and copious menstruation, and to an
almost constant fluor albus. I have also had oc—
casion 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 cer—
tain state of debility, will appear probable, from its
often occurring in fevers of the putrid kind, which
are always attended with great debility. It is true,
that it also sometimes attends inflammatory diseas—
es, when it cannot be accounted for in the same
manner; but I believe it will be found to attend
especially those inflammatory diseases in which the
sweats have been long protracted or frequently re—
peated, 

327 OF PHYSIC.
peated, and which have thereby produced a debi—
lity, and perhaps a debilitating putrid diathesis.
726.
It appears so clearly to me that this eruption is
always a symptomatic and factitious affection, that
I am persuaded it may be in most cases prevented
merely by avoiding sweats. Spontaneous sweatings,
in the beginning of diseases, are very rarely critical;
all sweatings, not evidently critical, should be pre—
vented; and the promoting them, by increasing ex—
ternal 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 cham—
ber; 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.
727.
But it may happen, when these precautions have
been neglected, or from other circumstances, 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 vi—
rulence which produces those symptoms mentioned
in (718.), and proves certainly fatal.
It has been an unhappy opinion with most phy—
sicians, that eruptive diseases were ready to be hurt
by cold; and that it was therefore necessary to co—
ver up the body very closely, so as thereby to in—
crease 

328 PRACTICE
crease 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 several eruptions not only admit, but re—
quire the application of cold air. We are now per—
suaded, that the practice which formerly prevailed,
in the case of miliary eruptions, of covering up the
body close, and both by external means, and in—
ternal remedies, encouraging the sweatings which
accompany this eruption, was highly pernicious,
and commonly fatal. I am therefore of opinion,
even when a miliary eruption, has appeared, that in
all cases where the sweating is not manifestly criti—
cal, we should employ all the several means of stop—
ping it that are mentioned above; and I have some—
times had occasion to observe, that even the ad—
mission. of cool air was safe and useful.
728.
This is, in general, the treatment of miliary
eruptions; but, at the same time, the remedies suit—
ed to the primary disease are to be employed; 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 treat—
ed by bloodletting, purging, and other antiphlo—
gistic remedies.
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 antiseptic remedies, particur—
larly the Peruvian bark, cold drink, and cold air.
I shall conclude this subject with mentioning,
that the venerable octogenarian practitioner, de
Fischer, when treating of this subject; in laying
down the indications of cure, has given this as one
of them: ' Excretionis periphericæ non primariam
' habere rationem.'
 CHAP. 

329 OF PHYSIC.
CHAP. VIII.
OF THE REMAINING EXANTHEMATA.
URTICARIA, PEMPHIGUS, and APHTHA.
729.
THE Nettle Rash is a name applied to two dif—
ferent diseases. The one is the chronic erup—
tion described by Dr. Heberden in the Medical
Transactions, Vol. I. art. xvii. which, as not be—
ing 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.
730.
I have never observed this disease as contagious
and epidemic; and the few sporadic cases of it
which have occured 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 consistent, I cannot en—
ter further into the consideration 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 suffi—
cient to observe an antiphlogistic regimen, and to
keep the patient in a temperature that is neither
hot nor cold.
731.
The Pemphigus, or Vesicular fever, is a rare
and uncommon disease, and very few instances of
it are recorded in the writings of physicians. As I
Vol. I. T t have 

330 PRACTICE
have never had occasion to see it, it would be im—
proper 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 Helve—
tica, vol. ii. p. 260. Synops. Nosolog. vol. ii. p. 149.
732.
The Aphtha, or Thrush, is a disease better
known; and, as it commonly appears in infants, it
is so well understood, as not to need our treating
of it here. As an idiopathic disease, affecting
adults, I have not seen it in this country; but it
seems to be more frequent in Holland; and, there—
fore, for the study of it, I refer to Dr. Boerhaave,
and his commentator Van Swieten, whose works
are in every body's hands.
733.
The Petechia has been, by all our Nosologists,
enumerated amongst the exanthemata; but as, ac—
cording to the opinion of most physicians, it is
very justly held to be always a symptomatic affec—
tion only, I cannot give it a place here.
BOOK

[331]
BOOK IV.
OF HEMORRHAGIES.
CHAP. I.
OF HEMORRHAGY IN GENERAL.
734.
IN establishing a class or order of diseases, under
the title of Hemorrhagies, Nosologists have em—
ployed 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 me—
thodical distribution, such arbitrary and unnatural
associations should be avoided as much as possible.
Further, by that management Nosologists have sup—
pressed or lost sight of an established and well
founded distinction of hemorrhagies into Active
and Passive.
735.
It is my design to restore this distinction; and I
shall therefore here, under the title of Hemorrha—
gies, comprehend those only which have been com—
monly called Active, that is, those attended with
some degree of pyrexia; which seem always to de—
pend upon an increased impetus of the blood in
the vessels pouring it out, and which chiefly arise
from an internal cause. In this I follow Dr.
Hoffman, who joins the active hemorrhagies with
the 

332 PRACTICE
the febrile diseases; and have accordingly establish—
ed these hemorrhagies as an order in the class of
pyrexia. From this order I exclude all those effu—
sions of red blood that are owing entirely to exter—
nal violence; and all those which, though arising
from internal causes, are, however, not attended
with pyrexia, and which seem to be owing to a pu—
trid 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.
736.
Before proceeding to treat of those proper he—
morrhagies which form an order in our Nosology,
I shall treat of active hemorrhagy in general; and
indeed the several genera and species, to be treat—
ed of particularly afterwards, have so many cir—
cumstances 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. 
737.
THE phenomena of hemorrahgy are generally
the following.
Hemorrhagies happen especially in plethoric ha—
bits, and to persons of a sanguine temperament.
They appear most commonly in the spring, or in
the beginning of summer.
For some time, longer or shorter in different
cases, before the blood flows, there are some symp—
toms 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

333 OF PHYSIC.
and sense of heat or of itching; and in the internal
parts, from which blood is to slow, there is a sense
of weight and heat; and, in both cases, various
pains are often felt in the neighbouring parts.
738. 
When these symptoms have subsisted for some
time, some degree of a cold stage of pyrexia comes
on, and a hot stage is formed; during which, the
blood flows of a florid colour, in a greater or less—
er quantity, and continues to flow for a longer or
shorter time; but commonly, after some time, the
effusion spontaneously ceases, and together with it
the pyrexia also.
739.
During the hot stage which precedes an hemor—
rhagy, the pulse is frequent, quick, full, and often
hard; but, as the blood flows, the pulse becomes
softer and less frequent.
740.
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.
741.
Hemorrhagies, from internal causes, having
once happened, are apt, after a certain interval,
to return; in some cases very often, and frequent—
ly at stated periods.
742.
These are, in general, the phenomena of hemor—
rhagy; and if in some cases all of them be not ex—
quisitely 

334 PRACTICE 
quisitely marked, or if perhaps some of them do
not at all appear, it imports only, that, in differ—
ent cases, the system is more or lefs generally af—
fected; and that, in some cases, there are purely
topical hemorrhagies, as there are purely topical in—
flammations.
SECT. II.
Of the PROXIMATE CAUSE of HEMORRHAGY. 
743.
THE pathology of hemorrhagy seems to be suffi—
ciently obvious. Some inequality in the distribu—
tion of the blood occasions a congestion in particu—
lar parts of the sanguiferous system; that is, a great—
er quantity of blood is poured into certain vessels
than their natural capacity is suited to receive.
These vessels become thereby preternaturally dis—
tended; and this distention, proving a stimulus to
them, excites their action to a greater degree than
usual, which, pushing the blood with unusual force
into the extremities of these vessels opens them by
anastomosis, or rupture; and, if these extremities
be loosely situated on external surfaces, or on the
internal surfaces of certain cavities that open out—
wardly, a quantity of blood flows out of the body.
744.
This reasoning will, in some measure, explain
the production of hemorrhagy. But it appears to
me, that, in most cases, there are some other cir—
cumstances that concur to produce it; for it is pro—
bable, that in consequence of congestion, a sense
of resistance arises, and excites the action of the
Vis Medicatrix Naturæ; the exertions of which
are usually made by the formation of a cold stage
of pyrexia, inducing a more vigorous action of
the 

335 OF PHYSIC.
the vessels; and the concurrence of this exertion
more effectually opens the extremities, and occa—
sions the flowing out of the blood.
745.
What has been delivered in the two preceding
paragraphs, seems to explain the whole phenomena
of hemorrhagy, except the circumstance of its fre—
quent recurrence, which I apprehend may be ex—
plained in the following manner. The congestion
and consequent irritation being taken off by the
flowing of the blood; this, therefore, soon after,
spontaneously ceases; but, at the same time, the
internal causes which had before produced the un—
equal distribution of the blood, commonly remain,
and must now operate the more readily, as the over—
stretched and relaxed vessels of the part will more
easily admit of a congestion of blood in them, and,
consequently, produce the same series of pheno—
mena as before.
746.
This may sufficiently explain the ordinary return
of hemorrhagy; but there is still another circum—
stance, which, as commonly concurring, is to be
taken notice of; and that is, the general plethoric
state of the system, which renders every cause of
unequal distribution 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 effect, it is ne—
cessary that the whole system should be at least in
its natural plethoric condition; 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 certainly
occasioned, 

336 PRACTICE
occasioned, if the system becomes preternaturally
plethoric; but hemorrhagy has always a tendency
to increase the plethoric state of the system, and,
consequently, to occasion its own return.
747.
To show hemorrhagy does contribute to produce
or increase the plethoric state of the system, it is
only necessary to observe, that the quantity of fe—
rous fluids being given, the state of the excretions
depends upon a certain balance between the force
of the larger arteries propelling the blood, and the
resistance of the excretories; but the force of the
arteries depends upon their fulness and distention,
chiefly given to them by the quantity of red glo—
bules and gluten, which are, for the greatest part,
confined to the red arteries; and therefore, the
spoliation made by an hemorrhagy, being chiefly of
red globules and gluten, the effusion of blood must
leave the red arteries more empty and weak. In
consequence of the weaker action of the red arteries,
the excretions are in proportion diminished; 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 hemorr—
hagies, whether artificial 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 continue long,
these vessels will become more rigid, and will not
yield to the same impelling force as before. Al—
though the arteries, therefore, by new blood col—
lected in them, shall have recovered 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 ex—
cretion; and, consequently, a further accumulati—
on 

337 OF PHYSIC.
on will take place in the arteries, and an increase
of their plethoric state be thereby induced. In this
manner, we perceive more clearly, that hemorrha—
gy, as producing a more plethoric state of the sys—
tem, has a tendency to occasion its own recurrence
with greater violence; and, as the renewal and sur—
ther accumulation of blood require a determinate
time, so, in the several repetitions of hemorrhagy,
that time will be nearly the same; and therefore
the returns of hemorrhagy will be commonly at
stated periods, as has been observed frequently to
happen.
748.
I have thus explained the nature of hemorrhagy
in general, as depending upon some inequality in
the distribution of the blood, occasioning a con—
gestion of it in particular parts of the sanguiferous
system. It is indeed probable, that, in most persons,
the several parts of the sanguiferous system are in
balance with one another; and that the density,
and consequently the resistance, in the several ves—
sels, is in proportion to the quantity of blood which
each should receive; from whence it frequently
happens, that no inequality in the distribution of
the blood takes place in the course of a long life.
If, however, we consider that the sanguiferous sys—
tem 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 ves—
sels are elastic, so as to be under a constant ten—
dency to contract upon the withdrawing of any part
of the distending force; and, on the other hand,
are not so rigid but that, by an increase of the im—
petus of the blood in them, they may be more than
ordinarily distended; so we can easily understand
how, in most persons, causes of an increased con—
VOL. I. U u traction 

338 PRACTICE
traction or distention may arise in one part or other
of the system, or that an unequal distribution may
take place; and how, in an exquisitely distended
or plethoric system, a small inequality in the distri—
bution of the blood may form those congestions
which give occasion to hemorrhagy.
749.
In this manner I endeavour to explain how he—
morrhagy may be occasioned at any period of life,
or in any part of the body; but hemorrhagies hap—
pen in certain parts more frequently than in others,
and at certain periods of life more readily than at
others; and therefore, in delivering the general
doctrine of hemorrhagy, it may be required that I
should explain those circumstances which produce
the specialities mentioned; and I shall now at—
tempt it.
750.
The human body, from being of a small bulk at
its first formation, grows afterwards to a consider—
able size. This increase of bulk consists, in a great
measure, in the increase of the quantity of fluids,
and a proportional enlargement of the containing
vessels. But, at the same time, the quantity of so—
lid matter is also gradually increased; and, in what—
ever 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 exten—
sion of the arterial system; and such is the consti—
tution of the sanguiferous system, that the motion
of the blood in the arteries has a constant tendency
to extend them in every dimension.
751.
As the state of the animal solid is, af the first
formation of the body, very lax and yielding; so
the 

339 OF PHYSIC. 
the extension of the system proceeds, at first, very
fast; but, as the extension gives occasion to the ap—
position of more matter to the solid parts, these are,
in proportion to their extension, constantly acquir—
ing a greater density, and therefore giving more
resistance to their further extension and growth.
Accordingly, we observe, that as the growth of
the body advances, its increase, in any given time,
becomes proportionally less and less, till at length
it ceases altogether.
752.
This is the general idea of the growth of the hu—
man body, till it attain the utmost bulk which it is
capable of acquiring; but it is to be remarked, that
this growth does not proceed equally in every part
of the body; it being requisite for the economy of
the system, that certain parts should be first evolv—
ed, and should also acquire their full bulk sooner
than others. This appears particularly with respect
to the head; the parts of which appear to be first
evolved, and soonest to acquire their full size.
753.
To favour this unequal growth, it is presumed,
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 (751.), it will also certainly fol—
low, that as the vessels of the head grow fastest, and
soonest 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 fluids, with re—
spect to the whole system, remain the same, the
distending and extending powers will be directed
to such parts as have not yet acquired the same den—
sity and dimensions as those first evolved; and thus
the 

340 PRACTICE
the distending and extending powers will proceed
to operate till every part of the system, in respect
of density 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 particu—
lar part, unless some preternatural circumstance
shall happen to arise.
754.
In this process of the growth of the body, as it
seems in general to depend upon a certain balance
between the force of the heart or distending pow—
er, and the resistance of the solids; so it will ap—
pear, that, while the solids remain very lax and
yielding, some occasional increase of the distending
power may arise without producing any very per—
ceptible disorder 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
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.
755.
From all this, it must follow, that the effects 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 determina—
tion 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 determination of the blood will
most 

341 OF PHYSIC.
most readily produce in that part a rupture of the
vessels, or an hemorrhagy. Hence it is, that he—
morrhagies of the nose so frequently happen in
young persons; and in these more readily, as they
approach nearer to their acme, or full growth; or,
it may be said, perhaps mere properly, as they ap—
proach nearer to the age of puberty, when perhaps,
in both sexes, but especially in the female, a new
determination arises in the system.
756.
The determination of a greater quantity of blood
to the vessels of the head, might be supposed to oc—
casion 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 vessels expanded on the internal surface of
the nostrils, and covered only with thin and weak
teguments. From this circumstance it is, that up—
on any increased impetus of the blood in the ves—
sels of the head, those of the nose are most easily
broken; and the effusion from the nose taking place,
it not only relieves the other extremities of the ex—
ternal 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 ex—
ternal carotid; so that, whichsoever of the extre—
mities are broken, the vis derivations of Haller
will take place; the effusion will relieve the whole
sanguiferous system of the head; and the same ef—
fusion will also commonly prevent an hemorrhagy
happening at the same time in any other part of
the body.
757. From 

342 PRACTICE.
757.
From these principles, it will appear why hemor—
rhages of the nose, so frequent before the period
of puberty, or of the acme, seldom happen after
these periods; and I must observe further, that al—
though they should occur, 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.
758.
When the process of the growth of the body
goes on regularly, and the balance of the fyftem is
properly adjusted to the gradual growth of the
whole, as well as to the successive growth of the
several parts, even a plethoric state does not pro—
duce any hemorrhagy, or at least any after that of
the nose; but if, while the plethoric state continues,
any inequality shall also subsist in any of the parts
of the system, congestions, hemorrhagic or inflam—
matory, may be still readily formed.
759.
In general, it may be observed, that, when the
several parts of the system of the aorta have attain—
ed their full growth, and are duly balanced with
one another, if then any considerable degree of
plethora remain or arise, the nicety of the balance
will be between the systems of the aorta and pulmo—
nary 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 com—
monly compensated by the greater velocity of the
blood in them; yet if this velocity be not always
adjusted 

343 OF PHYSIC.
adjusted to the necessary compensation, it is pro—
bable that a plethoric state of the whole body will
always be especially felt in the lungs; and there—
fore, that an hemorrhagy, as the effect of a general
plethora, may be frequently occasioned in the lungs,
even though there be no fault in their conformation.
760.
In some cases, perhaps, an hemorrhagy from the
lungs, or an hemoptysis, does arise from the gene—
ral plethoric state of the body; but an hemoptysis
more frequently does, and may be expected to hap—
pen, from a faulty proportion between the capacity
of the lungs and that of the rest of the body.
761.
When such a disproportion takes place, it will
be evident that an hemoptysis will especially happen
about the time that the body is approaching to its
acme; that is, when the system of the aorta has ar—
rived at its utmost extension and resistance, and
when, therefore, the plethoric state of the whole
must especially affect the lungs.
762.
Accordingly it has been constantly observed,
that the hemoptysis especially occurs about the time
of the body's arriving at its acme; but I must re—
mark also, that the hemorrhagy may occur sooner
or later, according as the balance between the ves—
sels of the lungs, and those of the system of the
aorta, happens to be more or less exactly adjusted
to one another; 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 concurring causes
are necessary to give it effect.
763. It 

344 PRACTICE 
763.
It was anciently remarked by Hippocrates, and
has been confirmed by modern observation, 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 pe—
riods; but that it seldom happens before the for—
mer, or after the latter; and it may be proper here
to inquire into the reason of these two limitations.
764.
With respect to the first, the reason of it has been
already explained in (761. and 762.)
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 extension
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 exha—
lants and excretories through which the fluids might
pass out of the red arteries; and partly, but espe—
cially, by a resistance in the veins to the free pas—
sage of the blood into them from the arteries.
765.
With respect to this last and chief circumstance,
it appears from the experiments of Sir Clifton Win—
tringham, in his Experimental 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: From which it may be pre—
sumed, that the resistance to the passage of the
blood 

345 OF PHYSIC. 
blood from the arteries into the veins, is greater in
young animals than in old; and, while this resist—
ance continues, the plethoric state of the arteries
must be constantly continued and supported. As
however the density of the coats of the vessels, con—
sisting chiefly of a cellular texture, is increased by
pressure; so, in proportion as the coats of the ar—
teries are more exposed to pressure by distention
than those of the veins, the former, in the progress
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 re—
sistance, must come in time, not only to be in ba—
lance 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 quantities 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 quantity than that
in the arteries. When this change happens in the
proportional quantities of the blood in the arteries
and veins, it 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 ple—
thoric state afterwards take place in the system, it
must especially appear in the veins.
766.
The change I have mentioned to happen in the
state of the arterial and venous systems, is properly
supposed to take place in the human body about
VOL. I. X x the 

346 PRACTICE
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 hemor—
rhagy, hemoptysis, hardly ever appears. It is true
there are instances of the hemoptysis happening at
a later period; but it is for the reasons given (757),
which show that an hemorrhagy may happen at any
period of life, from accidental causes forming con—
gestions, independent of the state of the balance of
the system at that particular period.
767.
I have said (765.), that if after the age of thirty
live, a general and preternatural plethoric state oc—
cur, it must especially appear in the venous system;
and I must now observe, that this venous plethora
may also give occasion to hemorrhagy.
768.
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 system of the vena
portarum, in which the motion of the venous blood
is more slow than elsewhere; in which the motion
of the blood is little assisted by external compressi—
on; and in which, from the want of valves in the
veins that form the vena portarum, the motion of
the blood is little assisted by the compression that is
applied; while, from the same want of valves in
those veins, the blood is more ready to regurgitate
in them. Whether any regurgitation of the blood
can produce an action in the veins, and which in—
verted or directed towards their extremities, can
force these, and occasion hemorrhagy, may perhaps
be disputed: But it appears to me, that an hemor—
rhagy, produced by a plethoric state of the veins,
may 

347 OF PHYSIC.
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 ac—
cumulation must resist the free passage of the blood
from the arteries into the veins. This, again, must
produce some congestion in the 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 arte—
ries, and upon the exhalants proceeding from them;
and this force may occasion an effusion of blood,
either by anastomosis or rupture.
769.
In this manner I apprehend the hemorrhoidal
flux is to be explained, so far as it depends upon
the state of the whole system. It appears most com—
monly to proceed from the extremities of the he—
morrhoidal 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 sys—
tem of veins, and consequently by any general
plethora in the venous system.
770.
It is here to be observed, that I have spoken of
this hemorrhagy as proceeding from the hemor—
rhoidal vessels only, as indeed it most commonly
does; but it will be readily understood, that the
same accumulation and resistance to the venous
blood may, from various causes, affect many of the
extremities of the vena portarum, which lie very su—
perficially upon the internal surface of the alimen—
tary canal, and give occasion to what has been
called the Morbus Niger or Melœna.
771. Another 

348 PRACTICE
771.
Another part, in which an unusually plethoric
state of the veins may have particular effects, and
occasion hemorrhagy, is the head. In this, the
venous system is of a peculiar conformation, and
such as seems intended by nature to give there a
flower motion to the venous 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
produce 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 cranium. The special ef—
fect of the latter effusion will be to produce the
disease termed Apoplexy; and which, therefore,
is properly named by Doctor HOFFMAN, Hœmor—
rhagia Cerebri: And the explanation of its cause,
which I have now given, explains well why it hap—
pens 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.
772.
I have thus attempted to give the history of the
plethoric and hemorrhagic states of the human body,
as they occur at the different periods of life; and
hope I have thereby explained, not only the nature
of hemorrhagy in general, but also of the particular
hemorrhagies which most commonly appear, and
as they occur successively at the different periods
of life.
SECT. 

349 OF PHYSIC.
Sect. III.
Of the REMOTE CAUSES of HEMORRHAGY.
773.
IN the explanation hitherto given, I have espe—
cially 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 predisponent, in exciting hemor—
rhagy, but may also sometimes be the sole causes
of it.
774.
These occasional causes are,
l. External heat, which, by rarifying the blood,
produces or increases the plethoric state of the bo—
dy; and the same heat, as giving a stimulus to the
whole system, must urge any particular determina—
tions before established, 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 predis—
position; or may form congestions where there were
none before, and thereby occasion hemorrhagy.
2. A considerable and sudden diminution of the
weight of the atmosphere, which seems to occasion
the same effects as heat, by producing also an ex—
pansion of the blood.
3. Whatever increases the force of the circula—
tion, and thereby the velocity of the blood, may
operate in the same manner as heat, in urging not
only previous determinations with violence, but al—
so in urging to excess inequalities, otherwise inno—
cent. All violent exercise, therefore, and especi—
ally all violent efforts, which, not only by a larger
and longer inspiration, but also, by the simulta—
neous 

350 PRACTICE 
neous action of many muscles interrupting the free
motion of the blood, impel it with unusual force in—
to the extreme vessels more generally, and, accord—
ing to the different postures of the body, and mode
of the effort, into certain vessels more particularly.
Among the causes increasing the force of the cir—
culation, 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 conges—
tions, or liable to them, such exercise may be con—
sidered as a stimulus applied to the vessels of that
particular part. Thus, any violent exercise of re—
spiration may excite hemoptysis, or occasion its
return.
5. The postures of the body increasing determi—
nations, or ligatures occasioning accumulations of
the blood in particular parts of the body.
6. A determination into certain vessels rendered
habitual by the frequent repetition of hemorrhagy
from them.
7. Cold, externally applied, as changing the dis—
tribution of the blood, and determining it in great—
er quantity into the internal parts.
SECT. IV.
Of the CURE of HEMORRHAGY.
775.
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 he—
morrhagies ought to be attempted by art, or if they
should be left to the conduct of Nature?
776. The 

351 OF PHYSIC. 
776.
The latter opinion was the favourite doctrine of
the celebrated Dr. STAHL, and his followers. They
maintained, that the human body is much disposed
to a plethoric state; and, consequently, to many
disorders which nature endeavours to obviate and
relieve by exciting hemorrhagy: That this, there—
fore, is often necessary to the balance and health
of the system: That it is accordingly to be general—
ly 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.
777.
Much of this doctrine may be admitted. The
human body, upon many occasions, becomes pre—
ternaturally plethoric ; and the dangerous conse—
quences which might from thence be apprehended,
seem to be obviated by an hemorrhagy taking place:
And, further, 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 conclusion
drawn from it there is a fallacy.
778.
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, ex—
cepting upon the supposition, that the plethoric state
which seems to require the evacuation, cannot be
otherwise prevented or removed; and as I imagine
it possible by other means to prevent or remove a
plethoric state, so I do not think that hemorrhagy
is, in all cases, necessary. In general, I am of opi—
nion that hemorrhagy is to be avoided.
1. Because 

352 PRACTICE 
1. Because it does not always happen in parts
where it is safe.
2. Because often, while it does relieve a pletho—
ric state, it may, at the same time, induce 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 relieve; to oc—
casion its own recurrence (720.), 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.
779.
It is further to be considered, that hemorrhagies
do not always arise from the necessities of the sys—
tem, but often proceed from incidental causes.
It appears to me that all hemorrhagies of the latter
kind may be immediately suppressed, and the repe—
tition of them, as it induces a plethora, and a ha—
bit not otherwise necessary, may be prevented with
great advantage.
780.
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 especially the returns of it pre—
vented; and I therefore now proceed to mention,
how hemorrhagy, and its recurrences, may, and
should be prevented.
781.
From the principles delivered above, it will im—
mediately appear, that the prevention, either of the
first attacks, or of the returns of hemorrhagy, will
chiefly, 

353 OF PHYSIC. 
chiefly, and in the first place, depend upon the pre—
venting or removing any considerable degree of a
plethoric state which may happen to prevail in the
body. It is true, that, where the hemorrhagy de—
pends upon the particular conformation of certain
parts, rather than upon the general plethoric state
of the whole; the measures for removing or pre—
venting the latter, may not always be sufficient for
preventing hemorrhagy: 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 great—
er or letter degree of the plethoric state of the
whole system; and, therefore, that, even in the
cases depending upon particular conformation, the
preventing or removing an unusually plethoric
state, will always be a chief means of preventing
hemorrhagy. It is further to be attended to, that
there may be several inequalities in the balance of
the system, which may have little or no effect un—
less when the system becomes preternaturally ple—
thoric; and therefore, that in cases, the prevent—
ing or removing of the plethoric state of the system.
will be a chief means of preventing the first attacks,
or the returns of hemorrhagy. It now, therefore,
remains to explain, how the plethoric state of the
system is to be prevented or removed.
782.
The fluids of the human body are in continual
waste by the excretions, but are commonly replac—
ed by the aliments taken in; and if the quantity of
aliments in any measure exceed that of the excre—
tions, 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 re—
quisite for the growth of the body: But even then,
if the proportion of the aliments to the excretions
be greater than is suited to the growth of the body;
VOL. I. Y y and 

354 PRACTICE 
and more certainly still, if, after the growth is com—
pleted, 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 pletho—
ra 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 ef—
fected by the management of diet, the latter by the
management of exercise.
783.
The ingesta may be diminished, either by giving
aliment in less quantity than usual, or by giving ali—
ments 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 consequent—
ly less of a matter to be retained and accumulated
in the vessels.
The choice of aliments suited to these purposes,
must be left to be directed by the doctrines of the
Materia Medica.
784.
The increasing of the excreta, and thereby dimi—
nishing the plethoric state of the system, is to be
obtained by increasing the exercise of the body;
and generally for adjusting the balance between
the ingesta and excreta, and thereby obviating the
plethoric state, it is necessary that exercise, in a
due measure, be very constantly employed.
785.
The observing abstinence, and the employment
of exercise, for obviating or removing the pletho—
ric 

355 OF PHYSIC. 
ric state of the body, were formerly considered
pretty fully, when treating of the gout, (547. to 551.);
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 measures, which,
in a plethoric state of the body disposing to hemor—
rhagy, are always admissible and proper. Here, how—
ever, it is to be observed, that some choice in the
mode of exercise is necessary, and that it should be
different according to the particular determinati—
ons which may happen to prevail in the system. In
general, in the case of plethora disposing to hemor—
rhagy, bodily exercise will always be hazardous,
and gestation more commonly safe.
786.
Artificial evacuations may be employed to dimi—
nish the plethoric state of the body; and when, at
any time, it has become considerable, and imme—
diately 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 pre—
vent a plethora, as they have a tendency to in—
crease it (720.); and as they require to be often
repeated, and are thereby apt to induce a habit
which may be attended with much danger.
787.
While a plethora, and thereby the predisposition
to hemorrhagy, is avoided, or removed, the other
measures necessary for preventing the occurrence
of this, are those for avoiding the remote causes.
These have been enumerated in (774.); and the
means of avoiding them, so far as within our pow—
er, are sufficiently obvious.
788. Having 

356 PRACTICE
788.
Having thus mentioned the means of preventing
either the first attacks, or the recurrence of hemor—
rhagy; I must next say how it is to be managed
when it has actually come on.
789.
When an hemorrhagy has come on which ap—
pears to have arisen from a preternaturally pletho—
ric state, or from some change in the balance of
the sanguiferous system, no measures are to be im—
mediately taken for suppressing it; as we may ex—
pect, that, when the quantity of blood necessary
for the relief of the system is poured out, the effu—
sion will spontaneously cease.
790.
In many cases, however, it may be suspected,
that the quantity of blood poured out, is not ex—
actly in proportion to the necessities of the system,
either for relieving a general plethora or a parti—
cular congestion, but that it is often to a greater
quantity than these require. This we suppose to
happen in consequence of an inflammatory diathe—
sis 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 evacua—
tion; and when it threatens to go to excess, to
suppress it altogether.
791.
An hemorrhagy may be moderated by avoiding
any irritation that might concur to increase it; so
that every part of the antiphlogistic regimen is to be
observed; in particular external heat, both as it
rarefies 

357 OF PHYSIC. 
rarefies the fluids, and stimulates the solids, is to
be carefully avoided: And it is probable, that in
all cases an hemorrhagy may be safely moderated
by cool air applied, and cold drink exhibited.
792.
A second means for the same purpose, is the use
of refrigerant medicines, and particularly of acids
and nitre.
793.
A third means which has been frequently em—
ployed, is that of bloodletting. The propriety of
this practice may be doubtful, as the quantity of
blood poured out by the hemorrhagy may be sup—
posed 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 practised in the cure of he—
morrhagy; but that it is further necessary for tak—
ing off the inflammatory diathesis which prevails,
and the febrile spasm that has been formed. Ac—
cordingly, 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 effusion 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 circumstances of venesection may render
it more powerful for taking off the tension and in—
flammatory irritation of the system, than any grad—
ual flow from an artery.
794. That 

358 PRACTICE 
794.
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.
795.
Do emetics and vomiting contribute to the cure
of hemorrhagy? See Dr. BRYAN ROBINSON on
the Virtues and Power of Medicines.
796.
When an hemorrhagy is very profuse, and seems
to endanger life, or even threatens to induce a
dangerous infirmity, it is agreed on all hands, that
it is to be immediately suppressed by every means
in our power; and particularly, that, besides the
means above mentioned for moderating the disease,
astringents, internal or external where the latter
can be applied, are to be employed for suppres—
sing it.
797.
The internal astringents are either vegetable or
fossil.
The vegetable astringents are seldom very pow—
erful 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 quality, that
they 

359 OF PHYSIC.
they should not be employed except in cases of the
utmost danger. The Tinctura Saturnina, or Anti—
phthisica, as it has been called, appears to be of
little efficacy; 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.
798.
External astringents, when they can be applied,
are more effectual than the internal. The choice
of these is left to the surgeons.
799.
The most powerful of all astringents appears to
me to be cold, which may be employed, either by
applying cold water to the surface of the body, or
by throwing it into the internal parts.
800.
For suppressing hemorrhagies, many superstitious
remedies and charms have been recommended,
and pretended to have been employed with success.
The seeming success of these, however, has been
generally owing to the bystanders' mistaking a spon—
taneous ceasing of the hemorrhagy for the effect of
the remedy. At the same time, I believe, that
those remedies may have been sometimes useful,
by impressing the mind with horror, awe, or dread.
801.
Upon occasion of profuse hemorrhagies, opiates
have been employed with advantage; and, when
the fulness and inflammatory diathesis of the system
have 

360 PRACTICE
have been previously taken off by the hemorrhagy
itself, or by bloodletting, I think opiates may be
employed with safety.
802.
For restraining hemorrhagy, ligatures have been
applied upon the limbs, in ihe view of retarding
the return of the venous blood from the extremi—
ties; but they appear to me to be of uncertain and
ambiguous use.
803.
In the case of profuse hemorrhagies, no pains are
to be taken to prevent a Deliquium Animi, or faint—
ing, as the happening of this is often the most cer—
tain means of stopping the hemorrhagy.
804.
Having thus delivered the general doctrine of
hemorrhagy, I proceed to consider the particular
cases of it. It may perhaps be remarked, that I
have marked fewer of these than are commonly e—
numerated by the nosologists; but my reasons for
differing from these authors, must be left to a no—
sological discussion, to be entered into elsewhere
more properly than here.
CHAP. II.
OF THE EPISTAXIS, OR HEMORRHAGY
OF THE NOSE.
805.
THE state of the vessels upon the internal sur—
face of the nose being such as already men—
tioned 

361 OF PHYSIC.
tioned (756.), renders an hemorrhagy from that
more frequent than from any other part of the body.
806.
The blood commonly flows from one nostril on—
ly; and probably because an hemorrhagy from one
vessel relieves the congestion in all the neighbour—
ing vessels.
The blood flowing from both nostrils at the same
time, shows commonly a more considerable disease.
807.
This hemorrhagy happens to persons of every
constitution and temperament, but most frequently
to those of a plethoric habit and sanguine tempera—
ment. It happens to both sexes, but most frequent—
ly to the male.
808.
This hemorrhagy may occur at any time of life;
but most commonly happens to young persons,
owing to the state of the balance of the system pe—
culiar to that age, as mentioned in (755.)
8O9.
Although generally it happens to persons before
they have arrived at their full growth, and more
rarely afterwards; yet sometimes it happens to per—
sons after their acme, and during the state of man—
hood: And it must then be imputed to an unusual—
ly plethoric state of the system; to an habitual de—
termination of the blood to the vessels of the nose;
or to the particular weakness of these.
8l0.
In all these cases the disease may be considered
VOL. I. Z z as 

362 PRACTICE 
as an hemorrhagy purely arterial, and depending
upon an arterial plethora; but it sometimes occurs
in the decline of life, when probably it depends
upon, and may be considered as, a mark of a ve—
nous plethora of the vessels of the head. See (771.)
8ll.
This hemorrhagy happens also at any period of
life, in certain febrile diseases, which are altogether
or partly of an inflammatory nature, and which
show a particular determination of the blood to the
vessels of the head. These diseases often admit of
a solution by this hemorrhagy, when it may be pro—
perly termed critical. 
8l2.
The disease sometimes comes on without any
previous symptoms; particularly when some ex—
ternal violence has a share in producing it. But
when it proceeds entirely from an internal cause,
it is commonly preceded by headachs, redness of
the eyes, a florid colour of the face, an unusual
pulsation in the temples, a sense of fulness about
the nose, and an itching of the nostrils. A bound
belly, pale urine, coldness of the feet, and cold
shivering over the whole body, are also sometimes
among the symptoms that precede the disease.
813.
From the weakness of the vessels of the nose, the
blood often flows from them without any considera—
ble effort of the whole system, and therefore with—
out any observable febrile disorder; which, how—
ever, in many cases, is, in all its circumstances,
very discernible.
814. An 

363 OF PHYSIC.
814.
An hemorrhagy of the nose happening to young
persons, is, and may generally be, considered as a
slight disease of little consequence, and hardly re—
quiring any remedy. But, even in young persons,
when it recurs very frequently, and is very copi—
ous, 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 pletho—
ric state; which, in a more advanced stage or life,
may give the blood a determination to parts from
which the hemorrhagy would be more dangerous.
All this will more particularly require attention,
according 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 considerable degree of fe—
brile disorder.
815.
When the epistaxis happens to persons after
their acmè, returning frequently, and flowing co—
piously, it is always to be considered as a danger—
ous disease, and as more certainly threatening the
consequences mentioned in the last paragraph.
8l6.
When this hemorrhagy happens in the decline
of life it may be considered as in itself very salu—
tary: But at the same time, it is to be considered
as a mark of a very dangerous state of the system;
that is, as a mark of a very strong tendency to a
venous plethora in the vessels of the head: And I
have accordingly observed it often followed by apo—
plexy, palsy, or such like diseases.
817. When 

364 PRACTICE 
817.
When an hemorrhagy from the nose happens in
febrile diseases, as mentioned in (811.), and is in
pretty large quantity, it may be considered as cri—
tical and salutary; but it is very apt to be profuse,
and even in this way dangerous.
It upon some occasions occurs during the erup—
tive fever of some exanthemata, and is in such cases
sometimes salutary; but if these exanthemata be
accompanied with any putrid tendency, this he—
morrhagy, like artificial bloodlettings, may have
very bad effects.
818.
Having thus explained the several circumstan—
ces of epistaxis, I proceed to consider the ma—
nagement and cure of it. I use the expression of
management, because it has been usually thought
to require no cure, but that nature should be al—
lowed to throw out blood in this way very frequent—
ly; and as often as it appears to arise from internal
causes, that is a state of the system supposed to re—
quire such evacuation.
819.
I am however of opinion, for the reasons given
in (778.), that this disease is very seldom to be left
to the conduct of nature; and that in all cases it
should be moderated 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 show—
ing any tendency to cease, a profuse bleeding is to
be prevented by measures employed to stop it, such
as pressing the nostril from which the blood flows,
washing the face with cold water, or applying this
to other parts of the body.
820. Even 

365 OF PHYSIC.
820.
Even in the case of young persons, where the
disease is least hazardous, and even in the first at—
tacks, I judge such measures to be proper: But
they will be still more proper if the disease fre—
quently recurs without any external violence; if
the returns shall happen to persons of a habit dis—
posed to be plethoric; and more particularly, if
the marks of a plethoric state appear in the prece—
dent symptoms (812.)
821.
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 appre—
hend it will be proper to suppress the hemorrhagy
by every means in our power. See (796.) and
following paragraphs.
822.
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, (782. 786.) 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 derivation from them.
823.
In adult persons, liable to frequent returns of
the epistaxis, the whole of the measures proposed
(822.) are more certainly and freely to be employed.
When 

366 PRACTICE 
When with the circumstances mentioned in (812.),
the tendency to a profuse hemorrhagy appears, a
bleeding at the arm may be proper, even in young
persons; but in the case of adults, it will be still
more allowable, and even necessary.
824.
In persons of any age liable to frequent returns
of this hemorrhagy, when the measures proposed
in (816. et seq.) shall have been neglected, or from
peculiar circumstances in the balance of the system,
shall have proved ineffectual, and the symptoms
threatening hemorrhagy (837.) shall appear, it
will then be proper, by bloodletting, cooling pur—
gatives, and every part of the antiphlogistic regi—
men, to prevent the hemorrhagy, or at least to
prevent its being profuse when it does happen.
825.
In the circumstances just now mentioned (824.),
the measures proposed are proper, and even ne—
cessary; but it should at the same time be observ—
ed, that these are practised with much less advan—
tage than those pointed out in (823.): Because,
though those suggested here may prevent the com—
ing on of the hemorrhagy for the present, they cer—
tainly, however, dispose to the return of that ple—
thoric state which required their being used; and
there can be no proper security against returns of
the disease, but by pursuing the means proposed in
(822.)
826.
When the hemorrhagy of the nose happens to
persons approaching to their full growth, and when
its returns have been preceded by the symptoms
(812.), it may be supposed, that, if the returns can
be 

367 OF PHYSIC.
be prevented by the measures proposed in (824.),
these may be safely employed; as the plethoric
state induced will be rendered safe, by the change
which is soon to take place in the balance of the
system. This, however, cannot be admitted; as
the evacuations practised upon this plan will have
all the consequences which, I have already observ—
ed, may follow the recurrence of the hemorrhagy
itself.
827.
When the hemorrhagy of the nose shall be found
to make its returns at nearly stated periods, the
measures for preventing it (824.) may be practised
with great certainty; and, upon every repetition of
bloodletting, by diminishing the quantity taken
away, its tendency to induce a plethora may be in
some measure avoided. When indeed, the repeti—
tion of evacuations is truly unavoidable, the dimi—
nishing them upon every repetition is properly prac—
tised: But it is a practice of nice and precarious
management, and should by no means be trusted
to, so far as to supersede the measures proposed in
(824.), wherever these can be admitted.
828.
When the hemorrhagy of the nose happens in
consequence of a venous plethora in the vessels of
the head, as in (771.), the flowing of the blood
pretty largely may be allowed, especially when it
happens after the suppression or ceasing of the men—
strual or hemorrhoidal flux. But though the flow—
ing of the blood is, on its first occurring, to be al—
lowed, there is nothing more proper than guarding
against its returns. This is to be done not only by
the measures proposed in (782. 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

368 PRACTICE 
and especially upon any threatening of hemorrhagy,
the plethora is to be removed, and the hemorrhagy
to be obviated immediately by proper evacuations,
as bloodletting, purging, and issues; or by restoring
suppressed evacuations, where this can be done.
CHAP. III.
OF THE HEMOPTYSIS, OR HEMORRHAGY
FROM THE LUNGS.
SECT. I.
Of the PHENOMENA and CAUSES of HEMOPTYSIS.
829.
WHEN, after some affection 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
therefore some other considerations, to be men—
tioned hereafter, are often necessary to ascertain
the existence of an hemoptysis.
830.
The blood—vessels of the lungs are more nume—
rous than those of any other part of the body of the
same bulk. These vessels of the largest size, as
they arise from the heart, are more immediately
than in any other part subdivided into vessels of
the smallest size; and these small vessels spread out
near to the internal surfaces of the bronchial cavi—
ties, are situated in a loose cellular texture, and
covered by a tender membrane only: So that,
considering 

369 OF PHYSIC.
considering how readily and frequently these ves—
sels 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 particu—
larly, why any violent shock given to the whole
body so readily occasions an hemoptysis.
831.
An hemoptysis may be occasioned by external
violence, at any period of life; and I have ex—
plained above (759.), 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 thir—
ty, an hemoptysis may at any time be produced,
merely by a plethoric state of the lungs.
832.
But it has been also observed above, (760.), that
an hemoptysis more frequently arises from a faulty
proportion between 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 conformation. And
the disease also happens especially 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
having been long liable to a difficult respiration.
833.
With these circumstances also the disease hap—
pens especially to persons of a sanguine tempera—
ment; in whom particularly, the arterial plethora
prevails. It happens likewise to persons of a slen—
der 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 general—
VOL. I. 3 A ly 

370 PRACTICE
ly of a delicate structure; to persons who have been
formerly liable to frequent hemorrhagies of the
nose; to persons who have suffered a suppression
of any hemorrhagy they had formerly been liable
to, the most frequent instance of which is in females
who have suffered a suppression of their menstrual
flux; and, lastly, to persons who have suffered the
amputation of any considerable limb.
834.
In most of these cases (833.), the disease happens
especially to persons about the time of their coming
to their full growth, or soon after it, and this for the
reasons fully set forth above.
835.
From all that has been said from (830. to 834.), the
predisponent cause of hemoptysis will be sufficiently
understood, and the disease may happen from the
mere circumstance of the predisponent cause arising
to a considerable degree. In the predisposed, how—
ever, it is often brought on by the concurrence of
various occasional and exciting causes. One of these,
and perhaps a frequent one, is external heat; which,
even when in no great degree, will bring on the dis—
ease in spring, and the beginning of summer, while
the heat rarefies the blood more than it relaxes the
solids which had been before contracted by the cold
of winter. Another exciting cause is a sudden di—
minution of the weight of the atmosphere, especial—
ly when concurring with any effort in bodily exer—
cise. This effort, too, alone, may often, in the pre—
disposed, be the exciting cause; and more particu—
larly, any violent exercise of respiration. In short,
in the predisposed, any degree of external violence
also may bring on the disease.
836. Occasioned 

371 OF PHYSIC.
836.
Occasioned by one or other of these causes
(835.), the disease comes on with a sense of weight
and anxiety in the chest, some uneasiness in breath—
ing, 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 salt—
ish taste is perceived in the mouth.
837.
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 irritation 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.
838.
This is commonly the manner in which the he—
moptysis begins; but sometimes at the very first
the blood comes up by coughing, or at least some—
what of coughing accompanies the hawking just
now mentioned.
839.
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 toge—
ther. It is sometimes profuse; but rarely in such
quantity as either by its excess, or by its sudden
suffocation, to prove immediately mortal. It com—
monly 

372 PRACTICE
monly either ceases spontaneously, or is stopped by
the remedies employed.
840.
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 cases; and, in most instances, it may
be done by attending to the following considerations.
841.
When the blood spit out proceeds from some part
of the internal surface of the mouth itself, it comes
out without any hawking or coughing: And gene—
rally, upon inspection, the particular source of it
becmes evident.
842.
When blood proceeds from the fauces, or adjoin—
ing cavities of the nose, it may be brought out by
hawking, and sometimes by coughing, in the man—
ner we have described in (836. and 838.); so that,
in this way, a doubt may arise concerning its real
source. A patient often lays hold of these circum—
stances to please himself with the opinion of its
coming from the fauces, 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 for—
mer 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 fauces, the distillation
of the blood, if it comes from thence, will be per—
ceived,
843. When 

373 OF PHYSIC.
843.
When blood proceeds from the lungs, the man—
ner in which it is brought up will commonly show
from whence it comes: But independent of that,
there are many circumstances which may occur to
point it out, such as the period of life, the habit of
body, and other marks of a predisposition (832.
834.); and, together with these, the occasional
causes (835.) having been immediately before ap—
plied.
844.
When vomiting accompanies the throwing out
of blood from the mouth, as vomiting and cough—
ing often mutually excite each other; so they may
be frequently joined, and render it doubtful, whe—
ther the blood thrown out proceeds from the lungs
or from the stomach. We may, however, gene—
rally 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 pro—
ceeding from the lungs is usually of a florid colour,
and mixed with a little frothy mucus only; where—
as 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 sometimes 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 enumerat—
ed in (836.), are most of them evident marks of an
affection of the lungs. And, on the other hand,
the

374 PRACTICE
the hematemesis, or issuing of blood from the sto—
mach, has also its peculiar symptoms and circum—
stances preceding it; as, for instance, some mor—
bid affection of this organ, or at least some pain,
anxiety, and sense of weight, referred distinctly to
the region of the stomach. To all this may be ad—
ded, that the vomiting of blood happens more fre—
quently to females than to males; and to the for—
mer, in consequence of a suppression of their men—
strual flux: and, by attending to all these consider—
ations (841.—844.), the presence of the hemopty—
sis may commonly be sufficiently ascertained.
SECT. II.
Of the CURE of HEMOPTYSIS.
845.
THIS disease is sometimes attended with little
danger; as, when it happens to females in conse—
quence of a suppression of the menses; when, with—
out any marks of a predisposition, it arises from
external violence; 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 being left to stagnate
in the cavity of the bronchiæ; and particularly
from any determination of the blood being made
into the vessels the lungs, which, by renewing
the hemorrhagy, may have dangerous consequen—
ces. In every instance therefore of hemoptysis,
the effusion is to be moderated by the several
means mentioned (791. to 794)
846. These 

375 OF PHYSIC.
846.
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 frequent—
ly returns, the effusion is not only to be moderat—
ed, but to be entirely stopped, and the returns of
it prevented by every means in our power. See
(796.) and following. 
847.
To stop an hemoptysis, or prevent the returns of
it, two medicines have been frequently 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 system, they can hardly be safe in any case
of active hemorrhagy, and I have frequently found
them hurtful.
848.
As the hemoptysis, which happens in conse—
quence of predisposition, is always attended with
a phlogistic diathesis; and, as the bad consequen—
ces 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 great—
er or smaller quantity, and more or less frequently
repeated, according as the symptoms shall direct.
At the same time, cooling purgatives are to be
employed, and every part of the antiphlogistic re—
gimen is to be strictly enjoined. The refrigerants
may also be administered; taking care, however,
that the acids, and more especially the nitre, do
not excite coughing.
849. From

376 PRACTICE
849.
From what was observed in (794.) it will appear
that blistering upon the breast or back may be a re—
medy of hemoptysis, when it is present; and that
issues in the same places may be useful in prevent—
ing the recurrence of it when it has ceased.
85O.
The avoiding of motion is generally a proper
part of the antiphlogistic regimen; and in the he—
moptysis, nothing is more necessary than avoiding
bodily exercise: But some kinds of gestation, as
failing, and travelling in an easy carriage on smooth
roads, have often proved a remedy.
851.
Such is the treatment I can propose for the he—
moptysis, considered merely as an hemorrhagy:
But when, in spite of all our precautions, it conti—
nues to recur, it is often followed by an ulceration
of the lungs, and a phthysis pulmonalis. This,
therefore, I must now proceed to consider; but, as
it arises also from other causes besides the hemop—
tysis, it must be treated of with a more general
view.
CHAP. 

377 OF PHYSIC. 
CHAP. IV.
OF THE PHTHISIS PULMONALIS, OR
CONSUMPTION OF THE LUNGS.
SECT. I.
Of THE PHENOMENA and CAUSES of the
PHTHISIS PULMONALIS.
852.
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.
853.
I have met with some instances of an expectora—
tion 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 en—
tirely free from symptoms of hectic, as to form
any exception to the general definition.
854.
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 another opinion, and has suppos—
ed that pus may be formed in the blood—vessels,
and be from thence poured into the bronchiæ.
Admitting his fact, I have attempted an explana—
VOL. I 3 B tion 

378 PRACTICE
tion of the appearance of pus without ulceration in
(349.): But, after all, I cannot help suspecting the
accuracy of his observations; must entirely reject
his explanation of them; must however allow, that
we still want facts to support the explanation I have
offered; and doubt much if it will apply 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 our definition depend always upon an
ulceration formed in the lungs.
855.
It has sometimes happened, that a catarrh was
attended with an expectoration of a matter so much
resembling pus, that physicians have been often un—
certain whether it was mucus or pus, and therefore
whether the disease was a catarrh or a phthisis. It is 
often of consequence to determine these questions;
and it appears to me that it may be generally done,
with sufficient certainty, from the following consi—
derations, 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 mucus is
naturally transparent, and pus always opaque.
When mucus becomes opaque, as it sometimes
does, it becomes white, yellow, or greenish; but
the last mentioned colour is hardly ever so remark—
able in mucus as in pus.
2. From the consistence; as mucus is more vis—
cid and coherent, and pus less so, and may be said
to be more friable. When mucus is thrown into
water, it is not readily diffused, but remains unit—
ed in uniform and circular masses: But pus, in the
same circumstances, though not readily diffused,
does not remain so uniformly united, and by a lit—
tle agitation is broken into ragged fragments.
3. From the odour; which is seldom perceived
in 

379 OF PHYSIC. 
in mucus, but frequently in pus. It has been pro—
posed 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 small,
and it is not easy to distinguish between them.
4. From the specific gravity compared with wa—
ter; 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 de—
ceived; 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 if a yellow or greenish
matter appears surrounded with a quantity of trans—
parent or less opaque and less coloured matter, the
more strongly coloured matter may be generally
considered as pus; as it is not easy to understand
how one portion 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 experiments of
the late Mr. Charles Darwin: a. That the vitriolic
acid dissolves both mucus and pus, but most readi—
ly the former: That, if water be added to such a
solution of mucus, this is separated, and either
swims on the surface, or, divided into flocculi, is
suspended in the liquor; whereas, when water is
added to a like solution of pus, this falls to the bot—
tom, or by agitation is diffused so as to exhibit an
uniformly turpid liquor. b. That a solution of the
caustic fixed alkali, after some time, dissolves mu—
cus and generally pus; and, if water be added to
such solutions, the pus is precipitated, but the mu—
cus is not. From such experiments it is supposed,
that pus and mucus may be certainly distinguished
from each other.
From the expectoration's being attended with a
hectic 

380 PRACTICE
hectic fever. A catarrh, or expectoration of mu—
cus, is often attended with fever; but never, so far
as I have observed, with such a fever as I am present—
ly 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 mortal nature of a
confirmed or purulent phthisis, they have consider—
ed every case in which a recovery happened, as a ca—
tarrh only: But, that they may have been mistaken
in this, shall be shown hereafter.
856.
Having thus considered the first part of the cha—
racter of the phthisis pulmonalis as a mark of an ul—
ceration of the lungs; and having 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 (74.)
857.
A hectic fever has the form of a remittent,
which has exacerbations twice every day. The
first of these occurs about noon, sometimes a little
sooner or later; and a slight remission of it happens
about five afternoon. This last is soon succeed—
ed by another exacerbation, gradually increasing
till after midnight: 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 attend—
ed 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 preternaturally warm. Of these exacerba—
tions 

381 OF PHYSIC. 
tions, that of the evening is always the most con—
siderable.
858.
It has commonly been given as a part of the cha—
racter of a hectic fever, that an exacerbation of it
commonly appears, after the taking food; and it
is true that dinner, which is taken at noon or af—
ter it, does seem to occasion some exacerbation.
But this must not make us judge the midday exa—
cerbation 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 indeed to be observed, that
in almost every person, the taking food occasions
some degree 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.
859.
I have thus described the general form of hectic
fever; but many circumstances attending it are
further to be taken notice of.
The fever I have described does not commonly
subsist long, till the evening exacerbations 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 deposits a copious
branny red sediment, which hardly ever falls close
to the bottom of the vessel.
In the hectic, the appetite for food is generally
less impaired than in any other kind of fever.
The thirst is seldom considerable; the mouth is
commonly 

382 PRACTICE
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 in—
flamed, and become more or less covered with
aphthæ.
As the disease advances, the red vessels of the
adnata of the eye disappear, and the whole of the
adnata becomes of a pearly white.
The face is commonly pale; but during the ex—
acerbations, a florid red, and an almost circum—
scribed 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 debility,
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 the end of the disease, the feet are
often affected with œdematous swellings.
The exacerbations of the fever are seldom at—
tended with any headach, and scarcely ever with
delirium.
The senses and judgment commonly remain en—
tire 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 dilirium comes on,
and commonly continues to the end.
860.
The hectic fever now described (857. 858.) as
accompanying a purulent state of the lungs, is per—
haps 

383 OF PHYSIC. 
haps 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 ul—
ceration in some external or internal part. It was
for this reason that in (74.), 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 scor—
butic and cancerous kinds often subsist long in the
body without producing a hectic. What is the pre—
cise state of the acrimony producing this, I cannot
determine, but it seems to be chiefly that of a vi—
tiated purulency.
86l.
However this may be, it appears, that the hec—
tic's depending in general upon an acrimony, ex—
plains its peculiar circumstances. The febrile state
seems to be chiefly an exacerbation of that frequen—
cy of the pulse, which occurs twice every day to
persons in health, and may be produced by acri—
mony alone. These exacerbations, indeed, do not
happen without the proper circumstances of pyrex—
ia; but the spasm of the extreme vessels in a hec—
tic does not seem to be so considerable as in other
fevers; and hence the state of sweat and urine
which appears so early and so constantly in hectics.
Upon the same supposition of an acrimony corrupt—
ing the fluids and debilitating the moving powers,
I think that most of the other symptoms may also
be explained.
862.
Having thus considered the characteristical symp—
toms and chief part of the proximate cause of the
phthisis pulmonalis, I proceed to observe, that an
ulcer 

384 PRACTICE
ulcer of the lungs, and its concomitant circum—
stance of hectic fever, may arise from different
previous affections of the lungs; all of which how—
ever may, in my opinion, be referred to five heads;
that is, 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 order mentioned.
863.
It has been commonly supposed, that an hemop—
tysis was naturally, and almost necessarily, follow—
ed 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 instances 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 seve—
ral times, but when it has often recurred during
the course of a long life. It is indeed easy to con—
ceive, 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 intenti—
on. It is probable therefore, that it is an hemop—
tysis in particular circumstances only, which is ne—
cessarily followed by an ulcer; but what these cir—
cumstances are, it is difficult to determine. It is
possible, that merely the degree of rupture, or fre—
quently repeated rupture 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 e—
rode the parts. These however are but suppositi—
ons, not supported by any clear evidence. And,
if 

385 OF PHYSIC. 
if we consider that those cases of hemoptysis which
follow the predisposition (831.—884.) are those e—
specially which end in phthisis, we shall be led to
suspect that there are some other circumstances
which concur here to determine the consequence
of hemoptysis, as I shall hereafter endeavour to
show.
864.
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 fore—
see what may be the consequences of such an acci—
dent, and because the measures above suggested
are safe; for, upon every supposition, it is a dia—
thesis phlogistica that may urge on every bad conse—
quence to be apprehended. 
865. 
The second cause of an ulceration of the lungs, 
to be considered, is a suppuration formed in con—
sequence of pneumonia.
866.
From the symptoms mentioned in (857. and 858.),
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 portion
of it investing the lungs. Here purulent matter
frequently remains for some time, as if inclosed in
a cyst; but commonly it is not long before it comes
to be either absorbed, and transferred to some other
part of the body; or that it breaks through into the
cavity of the lungs, or into that of the thorax. In
the latter case, it produces the disease called em—
pyema; but it is only when the matter is poured in—
VOL. I. 3 C to 

386 PRACTICE
to the cavity of the bronchiæ, that it properly con—
stitutes the phthisis pulmonalis. In the case of em—
pyema, the chief circumstances of a phthisis are in—
deed also present; but I shall here consider that
case only in which the abscess of the lungs gives
occasion to a purulent expectoration.
867.
An abscess of the lungs, in consequence of pneu—
monia, 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 frequently coughed up very readily,
and spit out; and, though this purulent expectora—
tion 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 constant motion of the
lungs, will prevent an ulcer of these parts from
healing, if the matter of it be well conditioned.
An abscess of the lungs, therefore, does not neces—
sarily produce the phthisis pulmonalis; and if it be
followed by such a disease, it must be in conse—
quence 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, being absorbed,
produces a hectic and its consequences.
868.
The corruption of the matter of such abscesses
may be owing to several causes; as, 1. That the
matter effused during the inflammation, had not
been a pure serum fit to be converted into a laud—
able pus, but had been united with other matters
which prevented that, and gave a considerable acri—
mony to the whole; Or, 2. That the matter effused,
and 

387 OF PHYSIC. 
and converted into pus, either merely by a long
stagnation in a vomica, or by its connection with
an empyema, had been so corrupted as to become
unfit for the purpose of pus, in the healing of the
ulcer. These seem to be possible causes of the cor—
ruption of matter 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 per—
sons previously disposed to that disease, and there—
fore only as it concurs with some other causes of it.
869.
The third cause supposed to produce phthisis, in
a catarrh; which in many cases seems, in length of
time, to have the expectoration of mucus proper to
it, gradually changed 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 supposition, how—
ever, 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 tonsilla—
ris, which very seldom terminate in suppuration.
And although a catarrh should be disposed to such
termination, yet the ulcer produced might readily
heal up, as it does in the case of a cynanche tonsil—
laris; and therefore should not produce a phthisis.
870.
Further, the catarrh, as purely the effect of cold,
is generally a mild disease, as well as of short du—
ration; 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 persons affected were peculiarly predispos—
ed 

388 PRACTICE
ed 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 frequent cause of catarrh,
is also frequently the exciting cause of the cough
which proves the beginning of phthisis.
871.
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 pos—
sible 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 presently to be mentioned as
the most frequent cause of phthisis.
872.
It must be particularly observed here, that no—
thing said in (871.) 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 (871.)
873.
Many physicians have supposed an acrimony 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 

389 OF PHYSIC. 
the vessels. It is true, indeed, that in many cases
an acrimony 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 direct erosion.
874.
It has been mentioned in (862.), 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 dis—
ease frequently subsists very long without producing
any other, and may have its own peculiar fatal ter—
mination, 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 tuber—
cles, and their consequences, which shall be pre—
sently mentioned.
875.
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 indu—
rated glands. Dissections have frequently shown
such tubercles formed in the lungs; and although
at first indolent, yet at length they become inflam—
ed, and are thereby changed into little abscesses,
or vomicæ, which breaking, and pouring their
matter into the bronchiæ, give a purulent expecto—
ration, and thus lay the foundation of phthisis.
876.
Though the matter expectorated upon these occa—
sions has the appearance of pus, it is seldom that of
a laud—

390 PRACTICE
a laudable kind; and, as the ulcers do not readily
heal, but are attended with a hectic fever, for the
most part ending fatally, I presume that the matter
of the ulcers is imbued with a peculiarly noxious
acrimony, which prevents their healing, and pro—
duces a phthisis in all its circumstances, as men—
tioned above.
877.
It is very probable that the acrimony which thus
discovers itself in the ulcers, existed before 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 acri—
mony is, probably, in different cases, of different
kinds; and it will not be easy to determine its va—
rieties: But to a certain length I shall attempt it.
878.
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 concluded from observing,
that a phthisis, at its usual periods, frequently at—
tacks 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 lymphatic 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 scrophulous affection has either ma—
nifestly preceded or accompanied a phthisis, this
last, however, most commonly affects persons of a
habit resembling the scrophulous; that is, persons
of a sanguine, or of a sanguineo—melancholic tem—
perament, who have very fine skins, rosy complex—
ions,

391 OF PHYSIC. 
ions, 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 hav—
ing tubercles, as shall be immediately explained.
879.
Another species of acrimony producing tuber—
cles 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 foundation of phthisis. It is pro—
bable also, that other exanthemata have the same
effect; and from the phenomena of the disease, and
the dissections of persons who have died of it, it is
probable, that all the exanthemata may occasion a
phthisis, by affording a matter which in the first
place produces tubercles.
880.
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 disposed, does not ap—
pear to me certain.
88l.
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 tubercles and phthisis, I
cannot now decide, but must leave to be determin—
ed by those who have had experience of such cases.
882.
There is one peculiar case of phthisis, which from
my own experience I can take notice of. This is
the 

392 PRACTICE.
the case of phthisis from a calcerous matter formed
in the lungs, and coughed up, frequently with a
little bloody sometimes with mucus only, and some—
times with pus. How this matter is generated, or
in what precise part of the lungs it is seated, I ac—
knowledge myself ignorant. In three cases of this
kind which have occurred to me, there was at the
same time no appearance of stony or earthy concre—
tions 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.
883.
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 stone—
cutters, 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.
884.
Besides these now mentioned, there are probably 
some other causes producing tubercles, which have 
not yet been ascertained by observation: and it is
likely, that in the state of tubercles there is a vari—
ety not yet accounted for: But all this must be left
to future observation and inquiry.
885.
It has been frequently supposed by physicians,
that 

393 OF PHYSIC. 
that the phthisis is a contag disease; and I dare
not assert that it never is such: But in many hun—
dred instances of the disease which I have seen,
there has been hardly one which to me could ap—
pear to have arisen from contagion. It is possible,
that in warmer climates the effects of contagion may
be more discernible.
After having said that a phthisis arises from tu—
bercles more frequently than from any other cause;
and after having attempted to assign the variety of
these, I now proceed to mention the peculiar cir—
cumstances and symptoms which usually accompa—
ny the coming on of the disease from tubercles.
886.
A tuberculous and purulent state of the lungs
has been observed in very young children, and in
some others at several different periods before the
age of puberty and full growth; but instances of
this kind are rare; and the attack of phthisis, which
we have reason to impute to tubercles, usually hap—
pens at the same period which I have assigned for
the coming on of the hemoptysis.
887.
The phthisis from tubercles, does also generally
affect the same habits, as the hemoptysis; that is,
persons of a slender make, of long necks, narrow
chests, and prominent shoulders: But very fre—
quently the persons liable to tubercles, have less
of the florid countenance, and of the other marks
of an exquisitely sanguine temperament, than the
persons liable to hemoptysis.
888.
This disease, arising from tubercles, usually
commences with a slight and short cough, which be—
VOL. I. 3 D comes 

394 PRACTICE
comes habitual, is often little remarked by those af—
fected, and sometimes so little as to be absolutely
denied by them. At the same time their breath—
ing becomes easily hurried by any bodily motion,
their body grows leaner, and they become languid
and indolent. This state sometimes continues for
a year, or even for two years, without the persons
making any complaint of it, excepting only that
they are affected by cold more readily than usual,
which frequently increases their cough, and pro—
duces some catarrh. This, again, however, is
sometimes relieved; is supposed to have arisen
from cold alone; and therefore gives no alarm ei—
ther to the patient or to his friends, nor leads them
to take any precautions.
889.
Upon one or other of these occasions of catch—
ing cold, as we commonly speak, the cough be—
comes more considerable; is particularly trouble—
some 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 continu—
ance of cough come on during the summer season.
890.
The cough which comes on as in (888.), is very
often for a long time without any expectoration;
but when, from repeatedly catching cold, it be—
comes more constant, it is then at the same time
attended with some expectoration, which is most
considerable in the mornings. The matter of this
expectoration becomes by degrees more copious,
more viscid, and more opaque; at length of a yel—
low or greenish colour, and of a purulent appear—
ance. The whole of the matter, however, is not
always at once entirely changed in this manner;
but, 

395 OF PHYSIC.
but, while one part of it retains the usual form of
mucus, another suffers the changes now described.
891.
When the cough increases, and continues very
frequent through the night, and when the matter
expectorated undergoes the changes I have men—
tioned, 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 pro—
gress, the menses cease to slow; and this circum—
stance is to be considered as commonly the effect,
although the sex themselves are ready to believe it
the sole cause of the disease.
892.
When the cough comes on as in (888.), the
pulse is often natural, and for some time after con—
tinues to be so; but the symptoms have seldom
subsisted long before the pulse becomes frequent,
and sometimes to a considerable degree, without
much of the other symptoms of fever. At length,
however, evening exacerbations become remarka—
ble; and by degrees the fever assumes the exquisite
form of hectic, as described in (857.—859.)
893.
It is seldom that the cough, expectoration, and
fever, go on increasing, in the manner now de—
scribed, 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 occasion 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

396 PRACTICE
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 general—
ly happens that phthisical persons cannot lie easily
on some one of their sides without having their
difficulty of breathing increased, and their cough
excited.
894.
The phthisis begins, and sometimes proceeds to
its fatal issue, in the manner described from (888.
to 894.), 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 evi—
dent purulency and hectic state, without any ap—
pearance of blood in the spitting: So that it may
be affirmed, the disease is frequently not founded
in hemoptysis. At the same time, we must allow,
not only that it sometimes begins with an hemopty—
sis, as is said in (863.); but further, that it seldom
happens that in the progress of the disease more or
less of an hemoptysis does not appear. Some de—
gree of bloodspitting does, indeed, appear some—
times in the state mentioned (888. 892.) but more
commonly in the more advanced stages of the dis—
ease only, and particularly upon the first appear—
ance of purulency. However this may be, it is
seldom, in the phthisis from tubercles, that the he—
moptysis is considerable, or requires any remedies
different from those which are otherwise necessary
for the state of the tubercles.
895.
I have now described a succession of symptoms
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; commonly becoming easier, and some—
times 

397 OF PHYSIC. 
times almost disappearing, during the summer: But
returning again in winter, they at length, after two
or three years, prove fatal, towards the end of
spring or beginning of summer.
896.
In this disease, the prognosis is for the most part
unfavourable. Of those affected with it, the great—
er number die; but there are also many of them
who recover entirely, after having been in very
unpromising circumstances. What are, however,
the circumstances more certainly determining to a
happy or to a fatal event, I have not yet been able
to ascertain.
897.
The following aphorisms are the result of my
observations.
A phthisis pulmonalis from hemoptysis, is more
frequently recovered than one from tubercles.
An hemoptysis not only is not always followed
by a phthisis, as we have said above (863.); but
even when followed by an ulceration, the ulcera—
tion is sometimes attended with little of hectic, and
frequently admits of being soon healed. Even
when the hemoptysis and ulceration have happen—
ed to be repeated, there are instances of persons
recovering entirely after several such repetitions.
A phthisis from a suppuration in consequence
of pneumonic inflammation, is that which most
rarely occurs in this climate; and a phthisis does
not always follow such suppuration, when the ab—
scess formed soon breaks and discharges a laudable
pus: But, if the abscess continue long shut up, and
till after a considerable degree of hectic has been
formed, a phthisis is then produced, equally dan—
gerous as that from other causes.
A phthisis from tubercles has, I think, been re—
covered: But it is of all others the most dangerous:
and, 

398 PRACTICE
and, when arising from a hereditary 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 hectic and its conse—
quences have arrived. From a certain degree of
emaciation, debility, profuse sweating, and diar—
rhœa, no person recovers
A mania coming on, has been found to remove
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 retarded the
progress of a phthisis; but commonly it is only till
after delivery, when the symptoms of phthisis re—
turn with violence, and soon prove fatal.
SECT. II.
Of the CURE of PHTHISIS.
898.
FROM what has been just now said, it will
readily appear, that the cure of the phthisis pulmo—
nalis must be exceedingly difficult; and that even
the utmost care and attention in the employment
of remedies have seldom succeeded. It may be
doubtful whether this failure is to be imputed to the
imperfection of our art, or to the absolutely incu—
rable nature 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 at—
tempted towards either curing or moderating the
violence of this disease.
899. It 

399 OF PHYSIC.
899.
It must be obvious, that, according to the dif—
ferent circumstances of this disease, the method of
cure must be different. Our first attention should
be employed in watching the approach of the dis—
ease, and preventing its proceeding to an incur—
able state.
In all persons of a phthisical habit, and especial—
ly in those born of phthisical parents, the slightest
symptoms of the approach of phthisis, at the phthi—
sical period of life, ought to be attended to.
900.
When an hemoptysis occurs, though it be not
always followed with ulceration and phthisis, these,
however, are always to be apprehended; and eve—
ry precaution is to be taken against them. This is
especially to be done by employing every means of
moderating the hemorrhagy, and of preventing its
return, directed in (891. et seq.) and these precau—
tions ought to be continued for several years after
the occurrence of the hemoptysis.
9O1.
The phthisis which follows a suppuration from
pneumonic inflammation, can only be prevented
with certainty, by obtaining a resolution of such
inflammation. What may be attempted towards
the cure of an abscess and ulcer which have taken
place, I shall speak of hereafter.
902.
I have said, it is doubtful if a genuine catarrh
ever produces a phthisis; but have allowed that it
possibly may; and both upon this account, and
upon 

400 PRACTICE
upon account of the ambiguity which may arise,
whether the appearing catarrh be a primary disease,
or the effect of a tubercle, I consider it as of con—
sequence to cure a catarrh as soon as possible af—
ter 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 men—
tioned afterwards, when we come to treat of ca—
tarrh as a primary disease; but, in the mean time,
the means necessary for preventing its producing a
phthisis shall be mentioned immediately, as they
are the same with those I shall point out as neces—
sary for preventing a phthisis from tubercles.
903.
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 occasions phthisis, by
producing tubercles, the measures necessary for
preventing phthisis from asthma, will be the same
with those necessary in the case of tubercles, which
I am now about to mention.
904.
I consider tubercles as by much the most fre—
quent cause of phthisis; and even in many cases
where this seems to depend upon hemoptysis, ca—
tarrh, 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 requisite for curing phthisis.
905.
When, in a person born of phthisical parents, of
a phthisical habit, at the phthisical period of life,
the

401 OF PHYSIC. 
the symptoms (888.), in the spring and beginning
Of summer, shall appear in the slightest degree, we
may presume 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 immediately, even
although the patient himself should overlook or,
neglect the symptoms, as imputing them to acci-
dental cold.
906.
This is certainly the general indication; but
how it may be executed I cannot readily say. I
do not know that, at any time, physicians have
proposed any remedy capable of preventing the
formation of tubercles, or of resolving them when
formed. The analogy of scrophula gives no as-
sistance in this matter. In scrophula the remedies
that are seemingly of most power are, sea water,
or certain mineral waters ; but these have general-
ly proved hurtful in the case of tubercles of the
lungs. I have known several instances of mercu-
ry very fully employed for certain diseases, in per-
sons who were supposed at the time to have tu-
bercles formed; or forming, in their lungs; but
though the mercury proved a cure for those other
diseases, it was of no service in preventing phthi-
sis, and in some cases seemed to hurry it on.
907.
Such appears to me to be the present state of our
art, with respect to the cure of tubercles; 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 in-
flammation of tubercles. It is probable that tu-
Vol.I, 3E bercles 

402 PRACTICE
bercles may subsist long without producing any dis-
order ; and I am disposed to think, that nature
sometimes resolves and discusses tubercles which
have been formed ; but that nature does this only
when the tubercles remain in an uninflamed state ;
and therefore, that the measures necessary to be
taken are chiefly those for avoiding the inflamma-
tion of the tubercles.
908.
The inflammation of a tubercle of the lungs is to
be avoided upon the general plan of avoiding in-
flammation, by bloodletting, and by an antiphlo-
gistic regimen ; the chief part of which, in this case,
is the use of a low diet. This supposes a total ab-
stinence from animal food, and the using of vegeta-
ble 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 being suf-
ficient that the farinacea be employed, and together
with these, milk.
909.
Milk has been generally considered as the chief 
remedy in phthisis, and in the case of every ten-
dency to it ; but whether from its peculiar quali- 
ties, or from its being of a lower quality, with re-
spect to nourishment, than any food entirely ani-
mal, is not certainly determined. The choice and
administration of milk will be properly directed,
by considering the nature of the milk of the seve-
ral animals from which it may be taken, and the
particular state of the patient with respect to the
period and circumstances of the disease, and to
the habits of his stomach with respect to milk.
910. A second 

403 OF PHYSIC.
910.
A second means of preventing the inflammation
of the tubercles of the lungs, is, by avoiding any
particular irritation, of the affected part, which may
arise from any violent exercise of respiration; from
any considerable degree of bodily exercise; from
any position of the body which straitens the capa-
city 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.
911.
From the last mentioned consideration, the ap-
plication of cold in general, and therefore the win-
ter season, in cold climates, as diminishing the cu-
taneous perspiration, is to be avoided; but more
particularly, that application of cold is to be shun-
ned that may suppress perspiration, to the degree
of occasioning a catarrh, which consists in an in-
flammatory 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 recommended,
and by comparing this with what has been just
now said respecting the avoiding cold, the proper
choice of climates and seasons for phthisical patients
will be readily understood.
912.
A third means of avoiding the inflammation 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.

404 PRACTICE
most safely done by warm clothing, and the fre-
quent use of the exercises of gestation.
9l3.
Every mode of gestation has been found of use
in phthisical cases; but riding on horseback, as
being accompanied with a great deal of bodily ex- 
ercise, is less safe in persons liable to an hemopty-
sis. Travelling in a carriage, unless upon very
smooth roads, may also be of doubtful effect; and
all the modes of gestation that are employed on
land, may fall short of the effects expected from.
them, because they cannot be rendered sufficiently
constant: And therefore it is that sailing, of all
other modes of gestation, is the most effectual in
pneumonic cases, as being both the smoothest and
most constant.
It has been imagined, that some benefit is deriv-
ed from the state of the atmosphere upon the sea :
But I cannot find that any impregnation 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 moderate temperature and greater purity
of the air upon the sea.
914.
In order to take off any inflammatory determi- 
nation of the blood into the vessels of the lungs,
blisters applied to some part of the thorax may of-
ten be of service ; and for the same purpose, as
well as for moderating the general inflammatory
state of the body, issues of various kinds may be
employed with advantage.
915.
The several measures to be pursued in the case
of what is properly called an Incipient Phthisis,
have 

405 OF PHYSIC.
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 inflammation has come upon the tuber-
cle, and an abscess has been formed, which open-
ing into the cavity of the bronchiæ, has produced 
an ulcer, and a confirmed phthisis.
916.
In this state of matters, some new indications,
different from the former may be supposed to arise;
and indications for preventing absorption, for pre-
venting 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 in-
dications, are either probable or have proved ef-
fectual. If, upon some occasions, they have ap-
peared to be useful, it has been probably by an-
swering some other intention.
While no antidote against the poison which espe- 
cially 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 inflam-
mation is certainly 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
(908. et seq.)
917.
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 

406 PRACTICE
no sufficient grounds, and to have proved common-
ly hurtful. The resinous and acrid substance of
myrrh, lately recommended, has not appeared to
me to be of any service, and in some cases to have
proved hurtful.
918.
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 phthi-
sis, or that it proved hurtful because it cannot have
effect without exciting 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 mani-
festly pernicious.
919.
The Peruvian bark has been recommended for
several purposes in phthisical cases ; and is said,
upon some occasions, to have been useful : But I
have seldom found it to be so; and as by its tonic
power it increases the phlogistic diathesis of the sys-
tem, I have frequently 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 stop-
ping these exacerbations, and at the same time of
relieving the whole of the phthisical symptoms ;
but in the cases in which I observed this, the fever
showed a constant tendency to recur ; and at length
the phthisical symptoms also returned, and proved
quickly fatal.
920. Acids 

407 OF PHYSIC.
920.
Acids of all kinds, as antiseptic and refrigerant,
are useful in cases of phthisis ; but the 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 coughing.
921.
Though our art can do so little towards the cure
of this disease, we must, however, palliate the un-
easy symptoms of it as well as we can. The symp-
toms especially urgent, are the cough and diar-
rhœa. The cough may be in some measure reliev-
ed by demulcents (872.) : But the relief obtained
by these is imperfect and transitory ; and very often
the stomach is disturbed by the quantity of oily,
mucilaginous, and sweet substances, which are on
these occasions taken into it.
922.
The only certain means of relieving the cough,
is by employing opiates. These, indeed, 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 giv-
ing 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 seem to
increase the sweatings that occur; but they com-
pensate this, by the ease they afford in a disease
which cannot be cured.
923. The 

408 PRACTICE
923.
The diarrhœa which happens in the advanced
state of this disease, is to be palliated by moderate
astringents, mucilages, and opiates.
Rhubarb, so commonly prescribed in every
diarrhœa, and all other, purgatives, are extremely
dangerous in the colliquative diarrhœa of hectics.
Fresh subacid fruits, supposed to be always lax-
ative, are often, in the diarrhœa of hectics, by their
antiseptic quality, very useful.
CHAP. V.
Of the HEMORRHOIS; or of the HE-
MORRHOIDAL SWELLING and FLUX.
SECT. I.
Of the PHENOMENA, and CAUSES of the
HEMORRHOIS.
924.
A DISCHARGE of blood from small tumours
on the verge of the anus, is the symptom which
generally constitutes the Hemorrhois ; 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 mak-
ing two cases or varieties of it, under the names of
External and Internal Hemorrhois.
925.
In both cases it is supposed that the flow of blood
is from tumours previously formed, which are na-
med 

409 OF PHYSIC.
med Hemorrhoids, or Piles; and it frequently
happens, that the tumours exist without any dis-
charge of blood; in which case, however, they
are supposed to be a part of the same disease, and
are named Hemorrhoides Cæcæ, or Blind Piles.
926.
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.
927.
These tumours, and the discharge of blood from
them, sometimes come on as an affection purely
topical, and without any previous disorder in other
parts of the body ; but it frequently 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, ver-
tigo, stupor, difficulty of breathing, sickness, colic
pains, pain of the back and loins ; and often, toge-
ther with more or fewer of these symptoms, there
occurs a considerable degree of pyrexia.
The coming on of the disease with these symp-
toms, is usually attended with a sense of fullness,
heat, itching, and pain in and about the anus.
Sometimes the disease is preceded by a discharge
of serous 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 mentioned. This serous discharge, therefore,
has been named the Hemorrhois Alba.
Vol. I. 3F 928. In 

410 PRACTICE
928.
In the hemorrhois, the quantity of blood dis-
charged is different upon different occasions.
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 above mentioned,
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 ha-
zard of life. Indeed, though rarely, it has been
so great as to prove suddenly fatal. These consi-
derable discharges occur especially to persons who
have been frequently liable to the disease. They
often induce great debility ; and frequently a leu-
cophlegmatia, or dropsy, which proves fatal.
The tumours and discharges of blood in this dis-
ease, often recur at exactly stated periods.
929.
It often happens, in the decline of life, that the
hemorrhoidal flux, formerly frequent, ceases to
flow; and, upon that event, it generally happens
that the persons are affected with apoplexy or palsy.
930.
Sometimes hemorrhoidal tumours are affected
with considerable inflammation ; which, ending in
suppuration, gives occasion to the formation of fis-
tulous ulcers in those parts.
931.
The hemorrhoidal tumours have been often con-
sidered as varicous tumours, or dilatations of veins;
and 

411 OF PHYSIC.
and it is true, that in some cases varicous dilatati-
ons have appeared upon dissection. These, how-
ever, do not always appear; 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, especially when recently formed, fre-
quently contain fluid blood; but, after they have
remained for some time, they are commonly of a
firmer substance.
932.
From a consideration of their causes, to be here-
after mentioned, it is sufficiently probable, that
hemorrhoidal tumours are produced by some in-
terruption of the free return of blood from the
veins of the lower extremity of the rectum ; and it
is possible, that a considerable 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 pre-
ceded by pain, inflammation, and a febrile state,
as well as by many other symptoms which show a
connection between the topical affection and the
state of the whole system, it seems probable that the
interruption of the venous blood, which we have
supposed to take place, operates in the manner ex-
plained in (768); and therefore, that the discharge
of blood here is commonly from arteries.
933.
Some physicians have been of opinion, that a
difference in the nature of the hemorrhois, and
of its effects upon the system, might arise from the
difference of the hemorrhoidal vessels from which
the blood issued. But it appears to me, that hard-
ly in any case we can distinguish the vessels from
which 

412 PRACTICE.
which the blood flows; and that the frequent inos-
culations of both the arteries and veins which be-
long to the lower extremity of the rectum, will
render the effects of the hemorrhagy nearly the
same, from whichsoever of these vessels the blood
proceed.
934.
In (768.), I have endeavoured to explain the man-
ner in which a certain state of the sanguiferous sys-
tem might give occasion to an hemorrhoidal flux ;
and I have no doubt, that this flux may be produced
in that manner. 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 Stahl-
ians have imagined, and would have us to believe.
It occurs in many persons before the period of life
at which the venous plethora takes place ; it hap-
pens to females, in whom a venous plethora, de-
termined to the hemorrhoidal vessels, cannot be
supposed ; and it happens to both sexes, and to
persons of all ages, from causes which do not affect
the system, and are manifestly suited to produce a
topical affection only.
935.
These causes of a topical affection are, in the first
place, the frequent voiding of hard and bulky fæ-
ces, which, not only by their long stagnation in the
rectum, but especially when voided, must press up-
on 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.
936.
From the causes just now mentioned, the disease
happens especially to persons liable to some degree
of 

413 OF PHYSIC. 
of a prolapaus ani. Almost every person in void-
ing fæces has the internal coat of the rectum more
or less protruded without the body ; and this will be
to a greater or lesser degree, according as the hard-
ness and bulk of the fæces occasion a greater or les-
ser 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 replac-
ed ; and, in consequence thereof, a strong con-
striction is made, which preventing the fallen out
gut from being replaced, and at the same time pre-
venting the return of blood from it, occasions its
being considerably swelled, and its forming a tu-
mid ring round the anus.
937.
Upon the sphincter's being a little relaxed, as it
is immediately after its strong contraction, the fall-
en out portion of the gut is commonly again taken
within the body; but, by the frequent repetition
of such an accident, the size and fulness of the ring
formed by the fallen out gut, is much increased.
It is therefore more slowly and difficultly replaced ;
and in this consists the chief uneasiness of hemor-
rhoidal persons.
938.
As the internal edge of the ring mentioned is ne-
cessarily divided by clefts, the whole often assumes
the appearance of a number of distinct swellings ;
and it also frequently happens, that some portions
of it, more considerably swelled than others, be-
come more protuberant, and form those small tu-
mours more strictly called Hemorrhoids, or Piles.
939.
From considering that the pressure of fæces, and
other causes interrupting the return of venous
blood 

414 PRACTICE
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 happens, that some of the tumours formed
without the anus, as in (938.), may continue when
taken within the body, and even be increased by
the causes just now mentioned. 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 in-
ternal piles are more especially painful, when af-
fected by the hemorrhagic effort described in (744.
and 768.)
940.
The production of piles is particularly illustrated
by this, that pregnant women are frequently affect-
ed 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 preg-
nant women are usually liable. I have known ma-
ny instances 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 com-
monly asserted, that the male sex is more frequent-
ly affected with this disease than the female ; but
in this country I have constantly found it otherwise,
941.
It is commonly supposed, that the frequent use
of purgatives, especially of those of the more acrid
kind, and more particularly of aloetics, is apt to
produce the hemorrhoidal affection ; and as these
purgatives stimulate chiefly the great guts, it seems
sufficiently probable that they may excite this dis-
ease.
942. I have. 

413 OF PHYSIC.
942.
I have now mentioned several causes which may
produce the hemorrhoidal tumours and flux as a
topical affection only ; but must observe farther,
that although the disease appears first as a purely
topical affection, it may, by frequent repetition,
become habitual; and therefore may become con-
nected with the whole system, in the manner alrea-
dy explained, with respect to hemorrhagy in gene-
ral, in (747.)
943.
The doctrine now referred to will, it is appre-
hended, apply very fully to the case of the hemor-
rhoidal flux; and will the more readily apply,
from the person who has been once affected being
much exposed to a renewal of the causes which
first occasioned the disease ; and from many persons
being much exposed to a congestion in the hemor-
rhoidal 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 depending ves-
sels, while at the same time the effects of these cir-
cumstances are much favoured by the abundance
and laxity of the cellular texture about the rectum.
944.
It is thus that the hemorrhoidal flux is so often
artificially rendered an habitual and systematic af-
fection; and I am persuaded, that it is this which
has given occasion to the Stahlians to consider the
disease as almost universally such.
945.
It is to be particularly observed here, that when
the hemorrhoidal disease has either been original- 
ly

416 PRACTICE
ly, or has become, in the manner just now explain-
ed, a systematic affection, it then acquires a par-
ticular connexion with the stomach, so that certain
affections there excite the hemorrhoidal disease,
and certain states of the hemorrhoidal affection
excite disorders of the stomach.
It is perhaps owing to this connexion that the
gout sometimes affects the rectum. See (524.)
Sect. II.
Of the Cure of Hemorrhoidal Affections.
946.
ALMOST at all times it has been an opinion
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 happened; 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 influence upon the practice of physic in Ger-
many.
947.
The question arises with respect to hemorrhagy
in general, and indeed it has been extended so far
by the Stahlians. I have accordingly considered
it as a general question, (766.—779.); but it has
been more especially agitated with regard to the
disease now under consideration : And as to this,
although I am clearly of opinion, that the hemor-
rhois may take place in consequence of the general
state of the system (768.); or, what is still more
frequent, that by repetition it may become connect-
ed with that general state (942.), and in either case
cannot

417 OF PHYSIC.
cannot be suppressed without great caution ; I must
beg leave, notwithstanding this, to maintain, that
the first is a rare case, that generally the disease first
appears as an affection purely topical (934. 941.) 
and that the allowing it to become habitual is ne-
ver proper. It is a nasty disagreeable disease, rea-
dy to go to excess, and to be thereby very hurtful,
as well as sometimes fatal. At best it is liable to
accidents, and thereby to unhappy consequences.
I am therefore of opinion, that not only the first
approaches of the disease are to be guarded 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.
948.
Having delivered these general rules, I proceed
to mention more particularly, how the disease is
to be treated, according to the different circum-
stances under which it may appear.
When we can manifestly discern the first appear-
ance of the disease to arise from causes acting upon
the part only, the strictest attention should be em-
ployed in guarding against the renewal of these
causes.
949.
One of the most frequent of the remote causes of
the hemorrhoidal affection, is a slow and bound
belly (935.): And this is to be constantly obviated
by a proper diet, which each individual's own ex-
perience must direct; or, if the management of di-
et be not effectual, the belly must be kept regular
by such medicines as may prove gently laxative,
without irritating the rectum. In most cases it will
be of advantage to acquire a habit with respect to
time, and to observe it exactly.
Vol. I. 3 G 950. Another 

418 PRACTICE
950.
Another cause of hemorrhois to be especially at-
tended to, is the prolapsus or protrusion of the anus
which is apt to happen on a person's having a stool
(936.). If it shall occur to any considerable degree,
and at the same time be not easily and immediately
replaced, it most certainly produces piles, or in-
creases them when otherwise produced. Persons
therefore liable to this prolapsus, should, upon
their having been at stool, take great pains to have
the gut immediately replaced, by lying down in a
horizontal posture, and pressing gently upon the
anus, till the reduction shall be completely ob-
tained.
951.
When the prolapsus of which I speak is occasion-
ed only by voiding hard and bulky fæces, it should
be obviated by the means mentioned in (949), 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 treated by as-
tringents, as well as by proper artifices for prevent-
ing the falling down of the gut.
952.
These are the means to be employed upon the
first approaches of the hemorrhoidal affection; and
when from neglect it shall have frequently recur-
red, and has become in some measure established,
they are no less proper. In the latter case, how-
ever, 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 

419 OF PHYSIC. 
the use of strong liquor; which, as I should have
observed before, is, in all cases of hemorrhagy,
of the greatest influence in increasing the dispositi-
on to the disease.
953.
I need hardly repeat here, that exercise of all
kinds must be a chief means of obviating and remo-
ving a plethoric state of the body ; but upon occa-
sion of the hemorrhoidal flux immediately approach-
ing, both walking and riding, as increasing the de-
termination 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.
954.
Cold bathing is another remedy that may be em-
ployed to obviate plethora, and prevent hemorrha-
gy ; but it is to be used with caution. When the
hemorrhoidal flux is approaching, it may be dan-
gerous 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.
955.
These are the means for preventing the recur-
rence of the hemorrhoidal flux; and in all cases,
when it is not immediately approaching, they are
to be employed. When it has actually come on,
means are to be employed for moderating it as much
as possible, by the person's lying in a horizontal po-
sition upon a hard bed ; by avoiding exercise in an
erect posture; by using a cool diet ; by avoiding
external

420 PRACTICE
external heat; and by obviating the irritation of
hardened fæces by the use of proper laxatives,
(949.). From what has been said above, as to the
being careful not to increase the determination of
the blood into the hemorrhoidal vessels, the pro-
priety 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.
956.
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 affection is accompanied with much
pain ; and of this there are two cases, according
as the pain happens to attend the external or the in-
ternal piles.
957.
The pain of the external piles arises especially
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 intes-
tine. Sometimes 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 re-
lief is to be obtained by applying leeches to the tu-
mid parts.
958.
The other case in which hemorrhoidal persons
seek assistance, is that of excessive bleeding. Up-
on 

421 OF PHYSIC. 
on 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 various 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.
959.
When the disease occurs as a purely topical af-
fection, there can be no doubt of the propriety of
this rule ; and, even when it has occurred as a cri-
tical 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 he-
morrhois seems to be both safe and proper.
960.
It is only when the disease arises from a pletho-
ric state of the body, and from a stagnation 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 en-
tirely. Even in these cases, however, I appre-
hend it will be always proper to moderate the bleed-
ing ; lest by its continuance or repetition, the ple-
thoric state of the body, and the particular deter-
mination 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.
961. Further, 

422 PRACTICE, &c.
961.
Further, even in the cases stated (960.), in so far
as the plethoric state of the body, and the tenden-
cy 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 entirely
suppressed.
962.
The Stahlian opinion, that the hemorrhoidal flux
is only in excess when it occasions great debility,
or a leucophlegmasia, 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.
963.
In all cases therefore of excess, or of any ap-
proach towards it, and particularly when the disease
depends upon a prolapsus ani (950.), I am of opi-
nion that astringents, both internal and external,
may be safely and properly employed; not indeed
to induce an immediate and total suppression, but
to moderate the hemorrhagy, and by degrees to
suppress it altogether, while at the same time mea-
sures are taken for removing the necessity of its
recurrence.
964.
When the circumstances (945.), marking a con-
nexion between the hemorrhoidal affection and the
state of the stomach occur, the measures necessary
are the same as in the case of atonic gout.
PRACTICAL 

PRACTICAL
AND
EXPLANATORY NOTES*.
PREFACE xi. line 36. causes. ] At this period the medical knowledge of Eu-
rope was chiefly, and, indeed, solely, such as had been derived from the Ara-
bians. At the conquest of Constantinople by the Turks, about the middle of the
fifteenth century, several of the Greeks fled into Italy, and the people of Europe,
communicating with them, found them to be intelligent, and some of them even
learned men : The Europeans were thence led to study the Greek language, in or-
der to read the valuable books which these fugitives had so much extolled ; and
among other works, those of Galen particularly attracted the notice of the physicians,
which, to their great astonishment, contained all the medical knowledge that had
been attributed to the Arabians. To the Greek writers, therefore, the physicians
of those times closely applied their attention, thinking these Looks the only true
fountains of medical knowledge ; and thus it was that the Galenical doctrines be-
came prevalent all over Europe.
Preface xii. line 7. Paracelsus.] The remarkable circumstances in the life of
Aureolus Philippus Theophrastus Bombastus Paracelsus de Hohenheim, as he called
himself, are too numerous for insertion in the narrow limits allotted to these notes.
He was born at the village of Einfidlen, about two German miles from Zurick, in
the year 1493. At three years old he was made an enuch by an accident. He tra-
velled all over the continent of Europe, obtaining knowledge in chemistry and phy-
sic, and then travelled about the country practicing what he had learned. His chief
remedies were opium and mercury, and his great success increased his celebrity.
He cured the famous printer Frobenius of Basil of an inveterate disease; this cure
brought him acquainted with Erasmus, and made him known to the magistracy of
Basil, who elected him professor in 1527. He lectured two hours every day.
While seated in his chair, he burnt, with great solemnity, the writings of Galen
and Avicenna ; and declared to his audience, that if God would not impart the se-
crets of physic, it was not only allowable, but even justifiable to consult the devil.
He soon left Basil, and continued rambling about the country, generally intoxicated,
and never changing his clothes, or even going to bed. He died after an illness of a
few days, in an inn at Saltsburg, in 1541, in his forty-eighth year, though he
had promised himself that, by the use of his elixir, he should live to the age of
Methusalem.
Preface xvii. line 14. Dr. Hoffman.] Frederick Hoffman was born at Hall, in
the year 1660. He graduated in physic in 1681, was made professor of physic
there in 1693, and filled that chair till his death in 1742. A very remarkable cir-
cumstance of his life is, that he never took fees from his patients, but was content
with his stipend. He was in high repute as a practitioner, and curing the Emperor
Charles
* When this American Edition of Dr. Cullen's First Lines of the Practice of
Physic was begun, the Editor was entirely ignorant of an European one publishing in
Edinburgh by Dr. Rotheram ; therefore in order to obviate this, he has added the
Notes in this place, and with such references, as he trusts, will be sufficiently plain.

EXPLANATORY NOTES.
Charles VI. and Empress, and Frederick I. of Prussia, of inveterate diseases, great-
ly increased his reputation. His worse are collected in six volumes folio, published
at different times from 1748 to 1754. They abound with many useful practical
directions ; but at the same time contain many frivolous remarks, and an abund-
ance of conjectural theory.
Preface xviii. line 32. Dr. Willis.] This illustrious physician was born at Great
Bedwin in Wiltshire in 1621. He took the degree of Master of Arts in 1642 at 
Oxford, where he was made professor of natural philosophy in 1660; and that
same year he took the degree of M. D. His practice was extensive and successful ;
he was one of the first members of the Royal Society in London, whither he remov-
ed in 1666 ; and soon made his name as illustrious by his writings, as he had alrea-
dy done by his practice. His works had been often printed separately; but they
were not collected till after his death, which happened on the 11th of November
1675. One edition was published at Geneva in 1676, and another at Amsterdam
in 1682, both in quarto.
Preface xx. line n. Dr. Boerhaave.] Voorhoot, a small village about two miles
from Leyden, save birth to this eminent physician on the last day of the year 1668.
He was educated at Leyden, and took his first degree in philosophy in 1690. His
thesis on this occasion was a confutation of the doctrines of Epicurus, Hobbes, and
Spinosa, in which he shewed great strength of genius and argument. Although he
was at this time well qualified to enter into the church, which was his father's in-
tention, yet he was diffident of his abilities, and chose to attend the lectures of di-
vinity longer. His patrimony wus however now exhausted, and he supported him-
self at the university by teaching mathematics, while he prosecuted his theological
studies. This conduct was much approved by the eminent men both of the univer-
sity and city, and procured for Boerhaave the friendship of Mr. Vandenburg the
burgomaster of Leyden. Under the patronage, and at the persuasion of this gentle-
man, Boerhaave applied himself to the study of physic with great ardor and indefa-
tigable diligence. In a short time he became a proficient in anatomy, chemistry,
and the materia medica, which indeed are the bases of physic. Leaving Leyden,
he went to the university of Harderwick in Guelderland, and there took his degree
of Doctor of Physic in July 1693. On his return to Leyden he still persisted in his
intention of entering into the ministry, which luckily, for the sake of physic, was
frustrated by the following adventure: In a passage boat where Boerhaave was, a
discourse was accidentally started about the doctrines of Spinosa, as subversive of reli-
gion ; and one of the passengers, with vague invectives of blind zeal, opposed this
philosopher's pretended mathematical demonstration. Boerhaave calmly asked him
if he had read Spinosa's work, which he had so much derided. The bigot was sud-
denly struck dumb, and became fired with silent resentment. As soon as he arrived
at Leyden, he spread abroad a rumour that Boerhaave was become a Spinosist.
Boerhaave finding these prejudices to gain ground, thought it more prudent to pur-
sue the science of physic, than rifle the refusal of a licence for the pulpit. He now
joined the practice of physic to the theory. On the 18th of May 1701 he com-
menced his lectures on the Institutes of Physic. In 1709 he was created Professor
of Medicine and Botany ; and in 1718 he succeeded Le Mort in the Professorship
of Chemistry. In August 1722 he was seized with the gout, and was obliged to
resign his professorships of Chemistry and Botany in 1729. He continued for
some time to practice, but was at length obliged to quit that also; and he died on
the 23d of September 1738.
3.] Remote causes are of two kinds, viz. the predisposing and the exciting, or,
as it is sometimes called, the occasional. The predisposing is that which renders
the body liable or capable of being affected by disease when the exciting cause is ap-
plied. No disease can exist without an occasional cause; yet it is necessary, that,
at the same time, the state of the body be such as to admit that cause to take effect,
or act. The predisposing cause is inherent in the body ; but it may nevertheless be
induced or changed by an external cause still more remote. Thus plethora may be
the predisposing cause of many diseases, yet that same plethora may be induced by
various causes previously acting on the body.
The

EXPLANATORY NOTES.
The prevention of diseases is to avoid the exciting cause, and to correct that state
of the body, which renders it Capable of being affected by the exciting cause.
4.] Proximate causes are those which immediately produce the disease, and whose
removal cures the disease.
10.] This description of a paroxysm is truly admirable. The symptoms are most
accurately described, and the order of their succession most strictly attended to by the
author.
15.] The thirst in the cold and hot stages of the paroxysm seems to be a provident
design of nature, and has been held forth as an argument for the existence of the vis
medicatrix naturtæ. The paroxysm concludes with a profuse sweat; the production
of this sweat requires an additional quantity of fluidity ; and nature, by means or the
thirst, seems anxious to supply the quantity of fluid matter necessary for the perspi-
ration that is requisite to remove the disease.
17.] The author's expression is here somewhat aukward ; the meaning of the
passage is, that stools seldom occur in the two first stages of a paroxysm, except in
peculiar cases attended with diarrhœa ; and if a stool happens about the end of the
paroxysm, it is generally of a loose kind.
A spontaneous diarrhœa always increases the violence of the symptoms, and the
obstinacy of the disease. Hence the absurd practice of prescribing purges in agues,
which never fail to exacerbate the paroxysms, and prolong their continuance. If
any uneasiness arises from accumulated fæces in the colon or rectum, they may be
removed by emollient glysters.
25.] Of the quotidian, tertian, and quartan intermittents there are many va-
rieties and forms; as, The double tertian, having a paroxysm every day, with the
alternate paroxysms similar to one another. The double tertian, with two parox-
ysms every other day. The triple tertian, with two paroxysms on one day, and an-
other on the next. The double quartan, with two paroxysms on the first day, none
on the second and third, and two again on the fourth day. The double quartan,
with a paroxysm on the first day, another on the second, but none on the third.
The triple quartan, with three paroxysms every fourth day. The triple quartan,
with a paroxysm every day, every fourth paroxysm being similar.
29. line 3. CONTINUED.] This passage is very obscure: The author's mean-
ing is, that some continued fevers put on the appearance of intermittents ; but, be-
ing different, in some peculiar and material circumstances, from intermittents, are
not to be classed with them.
33. line 1. proximate cause.] The author, in this chapter, delivers his favour-
ite doctrine of universal spasm. It is by no means new, as he himself confesses in
the preface, but borrowed from Hoffman. The author, however, greatly improved
the original idea, and brought the system to a greater degree of perfection than it had
before. That there are weighty objections against it cannot, indeed, be denied;
it contains, however, much ingenuity ; and Dr. Cullen, by introducing it into this
University, raised his name high in the annals of medical fame.
36. line 8. debilitating powers.] A purge administered six or seven days after
the appearance of any paroxysm, has frequently occasioned a relapse, and is a prac-
tice that ought to be carefully avoided. I have generally found that purges given in
the beginning of the disease, increase the difficulty of curing it.
45. line 1. This atony.] The reader will perceive, that the whole of the doc-
trine delivered in this chapter is hypothetical.
55. line 7. general law.] The reader will find entertainment in admiring the
ingenuity of the author, in contriving several artifices for maintaining his doctrine.
One hypothesis piled on the top of another, almost without end.
VOL. I. 3 H 67. line 

EXPLANATORY NOTES.
67. line 8. characters.] These characters are,
Synocha. Calor plurimum auctus; pulsus frequens, validus, et durus; urina
-rubra ; sensorii functiones parum turbatae.
Typhus. Morbus contagiosus ; calor parum auctus; pulsus parvus, debilis. ple-
rumque frequens ; urina parum mutata; sensorii tunctiones plurimum turbatæ;
vires multum imminutæ.
102. line 9. particularly.] No part of medical knowledge is so serviceable in
the practice of physic as prognostics. It wonderfully assists in the cure of all diseases,
but more especially fevers, and other acute disorders. The young reader, therefore,
ought to be particularly attentive to this part of the work. What the author advances
is very different from what has gone before. We have here no hypotheses or fan-
cies —no suppositions unsupported by facts; but, on the contrary, truths deduced
from a careful observation of nature, and arranged in a distinct and perspicuous
manner.
106.] It may not be amiss to explain this circumstance a little more fully.
Coldness of the extremities may alone be sufficient to induce the practitioner to
think the issue of the disease fatal; yet if this symptom be combined with a weak-
ness and irregularity of the intellectual operations, and these two accompanied with
involuntary, loose, and fetid evacuations of stool, and urine, death may be pro-
nounced to be at no great distance.
115.] This idea of the general tendency of nature to preserve a regularity in the
animal motions, is a most ingenious explanation of the apparent irregularities in the
termination of fevers. It is perhaps one of the best defences of the critical days that
ever appeared, because it explains, in a most satisfactory manner, why the termina-
tion on the sixth day should not be salutary. The violence of the disturbing cause
excites motions which nature has not the power of withstanding, and which are ei-
ther the immediate causes of death, or induce such morbid affections as prove ulti-
mately fatal.
116. line 3. Hippocrates.] To enter into a critical inquiry, whether the works
handed down to us as the writings of Hippocrates are really the productions of that
great man, or compilations from various physicians, would be foreign to the design
of this work. The style of them is, if I may be allowed the expression, homoge-
neous ; the same provincial dialect prevails through the whole of them; and they
are extremely remarkable, especially such of them as respect the critical days, for
being rather a detail of observed facts, than reasonings brought to support a favour-
ite hypothesis. It is probable, indeed, that Hippocrates, who has got the credit of
the work, might have been indebted to many of his contemporaries for some of the
materials that compose them ; but the sameness of the style is a strong presumptive
argument that they are the production of one person, or at least of their having been
reduced to their present form by one and the same hand. Dr. Cullen's other suppo-
sition, of their having suffered many, and, he might have added, material corrup-
tions, seems highly probable.
119. line 7. quartan periods.] The author might have added, "or periods
" compounded of these two."
130. 4. line 7. gives the least.] In addition to these directions, it may be men-
tioned that, if the patient have a desire for food, which is seldom the case, he ought
to make very sparing and frequent meals. Much food taken at once proves a greater
stimulus than the same quantity taken at several different times; especially if suffi-
cient quantities of diluting mucilaginous drink, such as lintseed tea, barley-water,
water-gruel, &c. be taken along with it.
130. 4. line 15. abstained from.] Thin liquors are the best in cases of this kind:
Of these we may use either water alone, or weak lintseed tea, thin barley-water,
toast and water, whey, currant jelly dissolved in water, with a variety of such like
mucilaginous acescent drinks. They ought to be taken in small quantities, and
often.
131. line 

EXPLANATORY NOTES.
131 line 4. removed] This passage might have been more clearly expressed
thus : Besides the stimulant powers more constantly applied, others, only occasion-
ally accompanying fevers, must be attended to and removed.
131. line 7. removed.] The drinks mentioned in the former note are best adapt-
ed to this purpose.
131. line 11. acids ] The vegetable acids are the most suitable, especially the
juices of acid fruits, as the juices of oranges, lemons, currants, or apples, diluted
with water. In some cases, the mineral acids have been much extolled, especially
the nitrous, when united with spirit of wine. The spiritus ætheris nitrosi of the
last London Pharmacopœia is used with success in these cases. It may be given in
barley-water, to the quantity of 20 or 25 drops within the hour.
131. line 14. laxative glysters.] The preference of glysters to purging medicines
is obvious. The action even of the most gentle laxatives is always attended with
some degree of stimulus, while, glysters, especially the mild ones, seldom produce
that effect. The best glyster, in these cases, is half a pint of milk, with as much
water, two ounces of oil, and one ounce of brown sugar, or, what is better than su-
gar, two ounces of manna.
131. line 20. antiseptic liquors.] The chief of these are the acid fruits diluted
with water; to which we may add the decoction of malt, of radix graminis (the
Triticum repens of Linne), infusions of sage, mint, and other plants of that natu-
ral order which Linne calls Spirantia.
134.] The vitriolic acid is harsh to the taste, and frequently acts as an astrin-
gent; it is therefore not always admissible. The best vegetable acids for this pur-
pose, are, as we said above, the natural juices of acid fruits. The acid of tartar is
the best refrigerant we have: There is an excellent formula of it in the Swedish
Pharmacopœia, under the title of Pulvis Refrigerans, which consists chiefly of the
essential salt of tartar and sugar. The dose of the acid of tartar, prepared according
to Scheele's prescription, is half a scruple, or fifteen grains, in the hour, largely
diluted with a mucilaginous liquor.
135. ] Nitre has been long used as a refrigerant. In too large quantities, how-
ever, it has often done harm. It may therefore be necessary to guard the young
practitioner against giving nitre in a larger quantity than two drams in the twenty
four hours, nor in doses of above ten grains, well diluted with mucilaginous drink.
142.4. ] The phlogistic diathesis is explained in Art. 247.
149 ] Purges ought to be very cautiously administered in fever ; and such only 
are to be used as operate with the least irritation. In fevers, attended with local in-
flammation, we may be under no apprehension of danger even from the brisker
purges, as Glauber's salt, given in the quantity of an ounce, or an ounce and a
half; or three or four ounces of the infusum sennæ, with half an ounce of Glauber's
salt, and a dram or two of tincture of jalap : But in fevers where no topical inflam-
mation appears, the purges, if necessary, must be of the mildest kind, such as man-
na, cassia, &c. and they must he given in small and often repeated doses. In most
fevers the intestines may be sufficiently evacuated by taking half an ounce of manna,
and a scruple of cream of tartar, every hour till it operates, diluting plentifully at
the same time with barley-water. The phosphorated soda, lately introduced into
practice by the ingenious Dr. Pearson of London, is well calculated for these cases.
The dose of it is an ounce or ten drams in barley-water, or broth.
158 ] Simply as a diluent, water is undoubtedly the best drink that can be used;
but, by adding a small quantity of mucilage to it, two intentions are answered at the
same time, viz. diluting and overcoming the acrimony ; hence the propriety of bar—
ley-water, water-gruel, lintseed tea, all made extremely weak; of very slight de-
coctions of malt, or bread crusts emits or even the gelatinous parts of young animals, as
calf's feet, or the more solid hartshorn shavings, &c. These animal substances must
however, 

EXPLANATORY NOTES.
however, be used in great moderation, and only in those cases where the patient re-
quires nourishment. When this watery regimen is carried to a great length, the
patient turns anasarcous ; but this effect may be prevented by some of the neutral
salts, of which the Kali acetatum of the London Pharmacopœia is most preferable,
on account of its diuretic quality. The dose of it may be carried as far as half an
ounce or six drams in the day. The same intention may also be answered by eating
water-cresses, radishes, it in season, or a little of the outer rind of turnips; all of
which are diuretics.
160. line 3. acid of vegetables.] The following is the usual dose of it every
three or four hours :
Rx. Sal. Absinth. ℈i.
Succ. Limon. ℥ss. vel q. f, ad saturationem;
Adde Aq. Fontanæ ℥iss.
Syrup, commun. ʒii.
M. f. haust.
160. line 6. stronger degree.] The form and dose of this is the same with the
foregoing, only using the volatile alkali instead of the fixed. The aqua ammonia
acetata of the London Pharmacopœia is one of the ammoniacal salts, and may be
given in doses of two drams every four hours, diluted with an ounce and a half of
water.
161.] It is certainly extremely useful in suppressing vomitings in fevers. The
method of producing the effervescence in the stomach is as follows : Let the patient
take the acid first, diluted with a sufficient quantity of water, and immediately after
let him swallow the alkali, also diluted. The proportion of the alkali to the acid
must be learned from chemistry. If the mild fixed alkali is good, it will saturate
about twelve times its weight of lemon-juice.
168. 4.] This direction is not always absolutely necessary.
169. line 6. light aromatic] The light aromatics here mentioned are sage,
mint, balm, &c. For the purpose of sweating, white wines answer best, especially
the thin French wines ; as also Rhenish wines, particularly Hock. They must be
taken warm and plentifully diluted. Wine whey is also a very powerful sudorifc,
as are also wheys made with vinegar, cream of tartar, the juices of acid fruits, or
with dulcified spirit of nitre.
169. line 8. neutral salts.] Neutral salts may be given in the quantity of two
scruples or a dram; but the patient must nevertheless drink large quantities of warm
water. The Tartarus tartarisatus is the neutral most frequently used for producing
sweats ; its dose is generally ℈i. but it may be increased to two drams.
169. line 10. an emetic] This is the well known Dover's powder, now called
in the London Pharmacopœia, Pulvis ipecacuanhæ compositus. It consists of eight
parts of neutral salt, one of opium, and one of ipecacuanha; so that ten grains of it
are an ordinary dose : But it has been given to the quantity of a scruple without any
bad consequences, and that dose repeated every two or three hours till the effect was
produced. In general, however, doses of 12 or 15 grains are the most usual, and
are found by experience to be the best. The Dovers powder, when given in larger
quantities, often nauseates, and is rejected by vomit. In the Edinburgh Pharma-
copœia, the Dovers powder consists ot nine parts of neutral salt, one of opium, and
one of ipecacuanha. The dose of this, therefore, will be nearly the same as the
dose of the former ; eleven grains of the Edinburgh Dovers powder being equivalent
to ten of the London. In administring this powder it may be necessary to observe,
that the patient ought to refrain from drinking for at least an hour after taking it,
because it nauseates more readily if much diluted in the stomach ; and if the nausea
be so great as to produce vomiting, its effects as a sudorific are considerably diminish-
ed. When, however, a sweat is produced, then diluting drinks may, and ought
to be plentifully given ; for, in such cases, it is evident from the effect, that the
medicine has passed out of the stomach, and that no material nausea can then he
produced by it. 171. ] All 

EXPLANATORY NOTES.
171.] All the antimonial emetics are violent in their effects, and are sometimes
attended with disagreeable consequences. Emetic tartar is found from experience to
be the safest of them ; but it is not always of the same strength, unless peculiar at-
tention be paid to the making it. The prescription for it in the last Edinburgh
Pharmacopœia is preferable to that in the London. Some chemists think that it
would be better to use boiling water alone, and omit the alkaline salt; alleging that
the alkali renders the precipitation variable in point of strength : But this opinion is
erroneous. The alkali is used in order to free the precipitate more completely from
any remains of the muriatic acid, making it thereby a milder powder and a more
perfect calx.
183. line 6. James's Powder.] The Pulvis antimonialis of the London Phar-
macopœia is intended as a substitute for, or imitation of, James's powder. The
dose of it is seven or eight grains. It is by no means so sure in its operations as the
emetic tartar; yet it has been much extolled by several eminent modern practitioners.
185. line 5. next accession.] The dose is ten or twelve grains. This calx, how-
ever, is very uncertain in its operations, sometimes acting with great violence, and
sometimes scarcely producing any perceptible effects.
185. line 19. intervals shorter.] The dose of the Antimonium tartarisatum
should never exceed three grains. The best method of giving it is, to dissolve three
grains in six ounces of water, and of this mixture give two table spoonfuls : if no
vomiting ensues within twenty minutes, repeat the dose, and continue to give a table
spoonful every ten minutes till the vomiting is excited, which must be encouraged by
drinking plentifully of camomile tea, or a thin water-gruel. If the Emetic tartar
be intended for a sudorific, two table spoonfuls of the following solution every two or
three hours will perhaps be more proper than small doses of the other.
ꝶ. Antimonii tartarisati gr. ii.
Aq. Cinnamom. simpl. ℥ii.
—. Font. ℥vi.
M. F. julap.
212.] When or how the inhabitants of Peru first discovered the febrifuge pow-
ers of this bark is involved in sable and uncertainty. They appear, however, to
have long known its virtue, although we have no proofs of their revealing it to the
Europeans before the middle of the last century. The Spaniards call the tree which
produces it Palo de Calenturas, or fever tree. Linne calls it Cinchona officinalis, in
memory of the Countess of Cinchon, the Spanish viceroy's lady in Peru, who was
the first European that had been cured by it. It was first brought into Italy by a
Jesuit about the year 1649, and distributed through Europe by the fathers of that
order; hence the names Cortex and Pulvis Jesuiticus, Pulvis Patrum. By Cardi-
nal de Lugo's influence a cargo of it was procured and brought to Rome soon after;
whence it received the name of Pulvis Cardinaiis de Lugo.
As this bark is a medicine of considerable importance, it may not be improper to
join a short description of the external qualities of the best sort. It is in concave
pieces, scarcely ever exceeding the fourth part of a cylinder cut longitudinally. It
breaks short, and when broken evidently appears to be composed of three distinct
and separate coats, viz. one outer thin coat, that is somewhat rugged, often covered
with moss of different kinds, and is of a reddish brown colour like cinnamon. The
middle coat is considerably thicker, of a closer texture and deeper colour than the
first, and is less brittle but more resinous than any other part. The third or inner-
most coat is woody and fibrous, and of a brightish red, at least considerably brighter
than either of the others. From this description of the bark, great care must be
taken in powdering it, not to leave much gross powder, but to pass the whole of it
through the sieve, because the most resinous, and consequently the most effectual,
part of the bark is the longest and most difficult to powder.
With respect to the two kinds of bark so much talked of and noticed a few years
ago, it may be proper to observe, that they seem to be the production of the same
tree. The Spaniards always selected such pieces as those above described out of the
original packages, and rejected the thin, pale, and quilled sort, which the English
preferred. 

EXPLANATORY NOTES.
preferred. It is certain that both the red, pale quilled, and a variety of gradation
between them, all occur in the same chest as originally imported ; and it is ex-
tremely improbable, that the bark of different kinds of trees should be packed to-
gether. Be this matter however as it may, experience gives the preference to what
is called the red bark, and this sort ought surely to be used.
2l6.] The doses of the bark can only be determined from the state of the pa-
tient's stomach and the violence of the disease : It is usual to give a dram of the
powder at a dose, and repeat it every two or three hours, according to the exigency
of the case, or the state of the patient's bowels. It frequently passes off by stool
when given too liberally ; this inconvenience is obviated by giving a few drops,
eight or twelve, of laudanum with each dose.
219.] Wine is a valuable cordial, and is much superior to most other stimulants;
it raises the pulse, supports the vis vitæ, promotes diaphoresis, and resists putrifac-
tion.
With respect to the medical differences of wines, it may suffice to observe, that
the effects of full bodied wines are more lasting than those of the thinner. Red
wines are subastringent, and consequently possess a tonic virtue, and are hence more
proper in fevers of all kinds where wine is at all admissible, than white wines are.
All sweet wines are nutritive and in general more stimulating than others ; but they
heat much, and are apt to turn sour on the stomach.
224. line 3. intestines.] The evacuants to be used in these cases are, the mild-
er purees, such as manna, &c. Rhubarb and senna may also be used ; but we must
avoid the drastic purees, such as jalap, scammony, aloes, and similar resinous
purges. Calomel has been found very useful in these cases : It may be given to the
quantity of eight or ten grains, and three ounces of the Infusum sennæ with half an
ounce of Glauber's salt may be given, about ten or twelve hours after it, to accele-
rate its operation.
224. line 6. diluents.] The diluents necessary in these cases must all be mixt
with a little Port wine or claret. Warm Port wine and water is the best diluent.
225. line 9. acids.] Whether all kinds of acids are to be used as antiseptics is
somewhat doubtful. The mineral acids, especially the vitriolic, have been much
recommended ; but the vegetable acids seem much more efficacious. As their mild-
ness allows us to give them in very large quantities, and as they more easily enter
into a union with the animal fluids than the fossile acids do, they seem more suitable
antiseptics in these cases. Whether there is any difference between the native ve-
getable acids and vinegar, with respect to their antiseptic qualities, was formerly
much disputed by practitioners. Physicians however, have now settled this que-
stion ; and are generally of opinion, that, in cases of putrescence arising from fe-
vers, the fermented acid is most proper; but, in cases of putrescence without fever
they prefer the native acid juices.
225. line 9. neutral salts.] The antiseptic power of the different neutral salts is
extremely various. According to the reasoning in the foregoing note, those consis-
ing of a vegetable acid base ought to be preferred ; and indeed experience confirms
the opinion. The Spiritus Mindereri would perhaps be useful, if it could be pre-
vented from passing too hastily off by sweat and urine. In doses of a dram every two
hours, it is less subject to promote sweat and urine, than when given in the usual
dose of half an ounce. Lemon juice, saturated with volatile alkali, has often been
successfully used in these cases; especially when they are taken either in the act of
effervescence, or separately, the one immediately after the other.
225. line 9. fixed air.] The antiseptic qualities of fixed air are much doubted
by several eminent physicians. The giving it is frequently very difficult, and some-
times even impossible.
The author might have added several other antiseptics to the short list he has giv-
en: What he has mentioned, however, are such as are generally used, or approved
of by practitioners. Camphor is a considerable antiseptic, but it is of too heating a 
quality 

EXPLANATORY NOTES.
quality to be given in such quantities as seem necessary. The common dose of it is
from one to ten grains, and it is best exhibited in the form of a bolus; in which
form it may also be joined with some other antiseptic, as
?. Camphor, gr. viii.
Spt. Vini gutt. x.
Pulv. Rad. Contrayerv. ?ii.
Syr. simpl. q. s.
M. f. bol.
This dose may be repeated every six hours, or oftener, especially if the pulse be
low or weak. In using camphor the practitioner ought; to remember that this me-
dicine, when given in large quantities, frequently occasions delirium. Peculiar at-
tention must therefore be paid to that symptom, and the doses of camphor regulated
with caution.
232. 5.] The quantity of bark to be given in the intermission must be as great
as the stomach can possibly bear. It is very common to give two ounces during the
intermission, in doses of half a dram or two scruples every hour, especially in quar-
tans. But it has been found more successful in its operations, when we begin with
small doses, viz. ?i. in the commencement of the intermissions, and increase
the doses to ?i towards the end of it. The bark sometimes sits better on the sto-
mach by adding to it about an eighth or a fourth of its weight of some aromatic an-
tiseptic. Virginian snake-root answers this intention very well. An ounce of red
bark and two drams of snake-root taken during the intermission of a tertian, if the
stomach can bear it, or if no diarrhœa comes on, generally prevents the next parox-
ysm. In case of diarrhœa being produced by bark, ten or twelve drops of laudanum
are to be given three or four times with each dose of the bark.
The substances generally joined with the bark in prescription, seem calculated ei-
ther to promote its efficacy or reduce it to the intended form, without having regard
to the agreeableness of the composition. This however is a point of great conse-
quence, as the taste of the bark, and the large quantity of it necessary for the cure,
make the patient frequently loath it before its use ought to be discontinue. When
made into an electuary or bolus with syrups, it slicks about the mouth and fauces ;
whence its taste remains a long while ; but, when made into an electuary with mu-
cilage, it passes down freely, scarcely leaving any taste behind it. The taste of the
bark is very effectually concealed by liquorice root in a decoction, or by the extract
in an electuary. The extract of logwood also conceals the taste of the bark, and an
electuary made with it, and a sufficient quantity of mucilage, is a very elegant
form. Decoction, infusions, and tinctures of the bark are much less efficacious
than the substance.
The extract and the resin are seldom employed in the cure of intermittents, ex-
cept when other forms will not sit on the stomach. The formula in the last London
Pharmacopœia is the best, being a compound of both the extract and resin ; for the
watery extract is strong in bitterness, but weak in astringency, and the resin is
strong in astringency, but weak in bitterness, and both qualities are necessary for
curing intermittents. About ten or twelve grains of the extract are equivalent to
half a dram of the powder.
When a paroxysm has been stopped by the bark, it is by no means safe to abandon
the use of this medicine altogether, as a relapse is always to be apprehended. The
doses are to be gradually diminished, and the intervals between the times of giving
them are to be increased : After tertians, we may diminish the quantity daily one
half, till we arrive at two drams; and these two drams ought to be continued in
doses of two scruples thrice a day for eight days ; after which period, two scruples
ought to be given night and morning for a week longer : After quartans, when the
dose is reduced to two drams a day, it will be prudent to continue giving this quan-
tity daily for a fortnight, and half a dram night and morning for a fortnight longer.
In order the more effectually to prevent a relapse, great attention must be paid to
diet and regimen. Patients are generally extremely voracious after the cure of in-
termittents ; and indeed they require considerable nutrition to supply the waste oc-
casioned by the fever. Small quantities of food are to be taken at once and to be
often repeated ; and the most nutritive, and at the same time easily digestable food,
must be chosen, as broths with barley and white flesh meat, roast lamb, veal, chick- 
ens

EXPLANATORY NOTES.
ens, new laid eggs, broiled fresh fish, &c. Acrid, acescent, and irritating aliments,
and acids are to be carefully avoided. The drink ought to be in moderate quantity,
but rich and strong; as mild ale, Port wine and water.
With respect to the regimen proper for convalescents from intermittents, it may
suffice to observe, that sleep may be indulged in. Exercise without fatigue is of great
use, either by walking, by riding on horseback, or in a carriage, according to the
strength of the patient. But, above all, cold must be carefully avoided; for no-
thing more effectually produces a relapse than an imprudent exposure to cold damp
air, or a neglect in keeping the body properly clothed.
The practice of giving purges after the cure of intermittents is highly blameable,
and is frequently the cause of a relapse. Should costiveness be troublesome, it may
be removed by very mild emollient glysters.
233. 2.] This practice, of giving vomits in the end of the cold stage and an
opiate after their operation, is old. It is mentioned by Sydenham, Boerhaave,
Van Swieten, and most practical writers. It must not however be indiscriminately
used. It is seldom attended with any salutary effect, except in vernal intermittents,
end in the earlier periods of the disease ; and it is constantly attended with disad-
vantage when the disease has been of long continuance.
241. ] This is the Boerhaavian doctrine which the author here refutes. Many
objections might be made against several parts of this refutation ; but to examine it
minutely, is foreign to my purpose, and would require more room than the narrow
limits of these notes can possibly allow.
265. line 6. demulcents.] If the matter causing the inflammation be an acid,
then the application of an alkaline substance will be proper: If, on the contrary,
the inflammation be produced by an alkali, then an acid must be applied.
In many cases, however, the acrid substances causing inflammation are neither
alkaline nor acid ; and, in such cases, or when we cannot find a proper corrector,
we must use demulcents, which, by their obtunding quality, sheath the acrimony,
or defend the parts to which they are applied from being irritated or corroded.
266.] The advantages of topical bleedings, in most cases of local inflammation,
are very great. They may be performed by cupping, or, what is in many cases
more preferable, by leeches. Cupping acts sometimes as a stimulus, especially on
parts that are tendinous or fleshy, or where the cellular substance is thin, and thus
frequently increases the inflammation which we would wish to resolve.
267.] The resolution of an inflamed part is considerably assisted by the applica-
tion of discutients; and, in most cases, when the general system is not affected,
these discutients alone frequently succeed in dissolving an incipient phlegmon.
Solutions of lead in vinegar are the applications which the bell modern practi-
tioners generally approve. Goulard's Extract was supposed by the vulgar to be a
new remedy ; and his panegyric on it tended, in a considerable degree, to render
the use of lead more universal than it had been before his time. There are,
however, many weighty objections against the formula used by that gentleman ; the
chief one is, that, on account of the different strength of the vinegar employed,
and of the degree of heat used in the process, we can never accurately ascertain the
quantity of lead dissolved in the acid ; and consequently the efficacy of this prepara-
tion must be uncertain. The Saccharum Saturni, which is always of the same
strength, is therefore preferable to Goulard's Extract; and, as vinegar is a powerful
discutient itself, it has been usual to add a quantity of vinegar to the solution of the
sugar of lead in distilled water. The following proportions have been found in ge-
neral to be the best:
ꝶ. Sacchar. Saturn. ℥i.
Acet. gallic, opt. ℥iv.
Aq. font. distillatæ ℥xxxii.
M.
In the application of this solution, it is of great consequence that the parts affect-
ed should be continually moistened with it. Poultices made of fresh bread crumb,
and 

EXPLANATORY NOTES.
and as much of the above solution as is necessary, are in general preferable to any
other mode of applying it; but it sometimes happens that the inflamed part is so ex-
tremely painful and tender, as not to bear the great weight of a poultice; and in
such cases we must have recourse to pieces of soft linen, moistened with the solution.
Both these applications, viz. poultices, or wet pledgets, must always be applied cold,
and be frequently renewed when they become warm, hard, or stiff.
This is the most approved method of applying lead for the purpose of resolving in-
flammations; yet it frequently happens that practitioners meet with patients whose
prepossessions for a popular remedy are so great, that there is no persuading them
from using it. The method of making Goulard's Extraat and Vegeto-Mineral
Water are therefore subjoined :
Take Litharge of Gold one pound,
French White-wine Vinegar a quart,
Boil them in an earthen vessel, on a slow fire, for an hour and an half, constantly
stirring them with a wooden spathula, and, when cold, pour off the clear liquor,
which must be kept in well stopped glass phials.
The Vegeto-Mineral Water is made by adding a hundred drops of the above Ex-
tract to a quart of water, and four tea-spoonfuls of French brandy.
269.] Poultices of various kinds have been recommended for this purpose. It
is, however, of little consequence what their ingredients are, provided they be emol-
lient, and applied warm. The white bread poultice is in common use, and answers
in general very well; the addition of a little oil keeps it from becoming hard, and
is at the same time serviceable as an emollient. A poultice of bruised lintseed well
boiled with milk and water is strongly recommended by some writers, and indeed
not without reason, on account of its very great emollient quality.
As heat is absolutely necessary for the production of matter in tumors, it is of
great consequence that the poultices should not be suffered to cool on the part, and
that they should be often renewed. Mr. Bell has given excellent directions for ap-
plying poultices, with the intention of promoting suppuration.
'Warm fomentations and poultices,' says that rational practitioner, ' are the
' means usually employed for the application of heat to an inflamed part; and,
' when these are regularly and frequently renewed, nothing, it is probable, can
' more effectually answer the purpose. But, in the ordinary manner in which they
' are applied, and as the cataplasms are renewed only once, or, at most, twice a
' day, they must always, it is imagined, do more harm than good. For, as soon
' as the degree of heat, they at first possessed, is dissipated, the moisture kept up by
' them, with the consequent evaporation that ensues, must always render the part
' much colder than if it had been merely wrapped up in flannel, without the use
' of any such application.
' In order to receive all the advantage of such remedies, the part affected should
' be well fomented with flannels, pressed out of any warm emollient decoction, ap-
' plied as warm as the patient can easily bear them, continued at least half an hour
' at once, and repeated four or five times a day.
' Immediately after the fomentation is over, a large emollient poultice should
' likewise be applied warm, and renewed every second or third hour at farthest.
' Of all the forms recommended for emollient cataplasms, a common bread and
' milk poultice, with a due proportion of butter or oil, is perhaps the most eligible ;
' as it not only possesses all the advantages of the others, but can at all times be
' more easily procured.' Treatise on Ulcers, Edition of 1787, p. 67.
270. line 20. writings on surgery.] For a particular account of knowing when
abscesses are completely formed, at what period they ought to be opened, and the
manner of opening them, the reader can consult no author preferable to Mr. Bell.
271.] The author mentioned in the preceding note treats this subject in his usu-
al rational manner, and with no less perspicuity than judgment. Contrary to the
opinion of all former writers on gangrene, he disapproves of scarifications, and the
subsequent application of antiseptics and stimulants. Mr. Bell's reasoning against
this practice is to the following purport: The degree of inflammation requisite, and
indeed necessary, for the separation of the dead parts, is only very slight, and, when
too violent, it fails to produce the desired effect. Scarifications, and the subsequent
Vol. I. 31 application 

EXPLANATORY NOTES.
application of stimulants, which increase the inflammation too much, are therefore
hurtful. Again, in scarifying, there is a considerable risk of wounding large blood-
vessels, nerves, or tendons ; besides the disadvantage of allowing the putrescent fluids
of the gangrene to enter more freely the found parts, by increasing the surface of the
wound. With respect to the application of antiseptics, it is justly remarked, that,
although these medicines have the quality of preserving dead animal substances from
corruption, they by no means produce the same effect on living animal substances.
But the concluding argument is of much greater weight, viz. that, in a long course
of extensive practice, no advantages ever accrued from scarification.
These objections against promiscuous scarification were first proposed by Mr. Bell
in his Treatise on Ulcers, about twelve years ago ; and the novelty of the opinion
excited the attention of almost every practitioner. At present, however, it is uni-
versally adopted, and would, of itself, independent of the many improvements Mr.
Bell has made in surgery, perpetuate his justly acquired same.
272.] The bark must be given in these cases in large quantities; and, as the
pulse is, in general, very small, Port wine must be used along with it. Beside the
use of these remedies, a good nourishing diet is absolutely requisite, with such a
quantity of strong generous wine as is fully sufficient to keep up the pulse, and in-
duce the necessary slight degree of inflammation. When, indeed, the patient is ex-
tremely languid, and much reduced, the warm stimulating cordials, as camphor,
confectio cardiaca, spiritus aromaticus volatilis, &c. may be used with advantage.
274.] The Erysipelas is particularly described in Articles 695. et seq.
277. line 4. cure.] The method of curing an erysipelas is delivered in Articles
707. et seq.
277. line 9. considered here.] The cure of erythema is chiefly effected by the
antiphlogistic regimen already sufficiently described. Although bleeding, purging,
and the general remedies for resolving an inflammation, will, in most cases, cure an
erythema, yet, as it is a disease frequently depending on a peculiar acrimony, we
shall always find great advantage from the external use of emollients applied cold, or
mucilaginous diluents taken internally. The disease, however, is seldom danger-
ous, and generally terminates favourably.
280. 2. vapours.] Hence chemists, when much employed in processes where
copious noxious vapours arise, ought to be extremely careful to avoid them as much
as possible.
282. line 20. leeches.] Ten or twelve may be applied at once, and, when many
are employed together, they generally produce a better effect, than if fewer be em-
ployed repeatedly : That is, twelve at once are more efficacious than three at a time
repeated four times a day,
282. line 22. scarifying.] Cupping and scarifying the temples ought to be per-
formed with very great caution, because of the numerous ramifications of consider-
able branches of arteries in those places.
282. line 26. adnata itself.] These operations require great nicety. For the
particular method of performing them, the reader is referred to the writers on surgery.
Much harm ensues from these operations when injudiciously performed; they
ought therefore to be refrained from, except when a very skilful and expert surgeon
can be procured. They are seldom serviceable, except they be repeated several times.
Cutting the vessels of the adnata is perhaps the best preventative of an opacity of
the cornea that we know; and, wherever there appears the least tendency towards
an opacity, the practice should be put in execution: The operation ought to be re-
peated daily for two, three, or four weeks, or even longer, if a cure is not accom-
plished sooner.
284.] The part where blisters are usually applied in Ophthalmia are behind the
ear, or the nape of the neck. The blisters ought to be kept open by the subsequent
application 

EXPLANATORY NOTES.
application of the mild blistering ointment, if they assume appearances of healing.
Setons in the neck are sometimes recommended ; but, where speedy relief is re-
quired, they are of little service, because they seldom begin to discharge till the ex-
piration of a few days ; besides, they are extremely troublesome to the patient; and,
if the phlogistic diathesis be considerable, they sometimes become so exceedingly in-
flamed as to produce many disagreeable circumstances that might have been avoided.
286.] A solution of a scruple of sugar of lead in four ounces of distilled water is
a very effectual application ; some authors recommend equal parts of white vitriol
and sugar of lead dissolved in distilled water. These collyria, as they are called, do
infinite mischief if they are too strong.
If, therefore, the patient complain of the least smarting on their application, it
will be necessary to dilute them with the addition of more distilled water. They
ought to he applied cold, and pledgets moistened with them ought to be frequently
renewed when they grow hot or dry. An additional direction may be added, viz.
that the solution of saccharum saturni be always made in distilled water, especially
when it is to be used as a collyrium, because the least impregnation of any mineral
acid, howsoever combined, decomposes the sugar of lead.
Cold poultices of rasped raw potatoes or turnips are sometimes very efficacious.
They may be applied in a fine muslin bag, and aught to be renewed whenever they
grow warm.
288. If the Ophthalmia be venereal, mercury is the only remedy, and external
applications have little effect. If scrophula is the cause, relief is often speedily pro-
cured by an application of the coagulum a luminis, or the unguentum citrinum, now
called unguentum hydrargyri nitratum in the London Pharmacopœia. The un-
guentum tutiæ has been used in many cases, with advantage, as has also the unguen-
tum cerussæ acetatæ. But these topical applications never effect a permanent cure.
290.] Hog's lard, fresh pressed lintseed ail, or oil of almonds, answer this in-
tention very well, or the unguentum spermatis ceti of the London Pharmacopœia.
292. ] This, sentence is very obscure; the author meant to say, that the diagno-
stic symptoms of this disease are uncertain.
294.] Practitioners have in general admitted two kinds of phrensy, viz. the
idiopathic or true phrensy, and the symptomatic. The former is what the author
describes in the text; and, as he has omitted to describe the latter, which, in Arti-
cle 292. he acknowledges to be the more frequent of the two, I shall enumerate its
symptoms.
The symptomatic phrensy is constantly preceded by some very acute inflammatory
fever. Its approach may be suspected by a suppression of the excretions, by colour-
less stools, by a black, dry, and rough tongue, by pale and watery urine, which
sometimes has black or dark brown clouds floating in it, by a desire but inability to
sleep, by picking the bed-clothes, by the eyes appearing fierce, and the vessels of the
albuginea becoming turgid, and by a few drops of blood distilling from the nose.
When most of these symptoms appear in inflammatory fevers, we justly apprehend
an attack of the phrensy, and ought to have immediate recourse to such remedies
as will lessen its violence, or altogether prevent its access. Large bleedings, if the
pulse permits, must be made on the lower extremities, emollient glysters are to be
frequently injected, laxatives administered, fomentations applied to the feet and,legs,
cupping glasses applied on the thighs, and the patient must be forced to drink plen-
tifully, tor he is seldom thirsty in these cases, although his tongue be parched. Be-
side these general remedies, peculiar attention must be paid to the primary disease ;
and the treatment of the symptomatic phrensy will vary according to the nature of
the disease by which it is produced.
No part of the practice of physic requires more judgment and sagacity in the prac-
titioner, than ascertaining the proper mode of treating the symptomatic phrensy in
different fevers. To enter fully into the subject, would require more room than
these notes allow. I can therefore only recommend the young practitioner to pay
great attention to it. He will find many useful practical directions for the treat-
ment of these cases, in most of the medical writers, both ancient and modern, espe-
cially Sydenham and Van Swieten. 297.] It 

EXPLANATORY NOTES.
297.] It has been usual to apply a large blistering plaister over the whole head,
and suffer it to remain on for eight and forty hours. This, however, hinders the
application of other very powerful remedies. Shaving the head of a frantic patient
is always a troublesome operation; but the very great benefit arising from it renders
it absolutely necessary in all cases; and the physician ought therefore to advise it on
the first suspicion of an approaching phrensy.
298.] Many eminent practitioners have dissuaded the use of these refrigerant
applications to the newly shaven head; the immediate relief which the mere shav-
ing generally procures, seems to indicate the propriety of the practice ; and expe-
rience has not discovered any material disadvantages attending it, but, on the con-
trary, much benefit accruing from it.
303. line 2. resolution.] As the most frequent termination of this disease is by
resolution, this mode of cure must always be attempted, and will seldom fail of
proving successful.
306.] The formula of an emetic may be seen in the note on Article 185.
307.] Various have been the opinions of physicians respecting the kind of gar-
gles proper in these cases. A pint of tincture of roses, with two drams of honey,
has often been found serviceable. The following gargle is frequently used with suc-
cess. Boil an ounce of oak bark, bruised in a quart of water, till half is evaporated,
and to the strained liquor add an ounce of honey of roses, and a dram of alum.
Sage tea, with honey, is in common use, and frequently answers every purpose.
308. ] Glauber's salts answer the end of purges in these cases very well, especi-
ally if the patient drinks copiously during the operation.
309.] Dover's powder is an excellent sudorific in these cases. The method of
giving it has been described in a former note on Article 169. Many other sudori-
fics, however, are found to answer tolerably well, as wine whey, whey made with
dulcified spirit of nitre, vinegar whey, sage tea, with several other drinks of a simi-
lar kind. The following bolus is often very efficacious, especially when the patient
drinks largely of sage or balm tea.
ꝶ. Camphor, gr, viii.
Opii pur. gr. i.
Tart, vitriolat. ℈i.
Tere in mortario marmoreo ; et adde
Confect. cardiac. ʒi. vel q. s. ut fiat bolus.
Small doses of tartar emetic taken in such quantities as to produce a slight nausea,
without vomiting, are also good sudorifics. Two table-spoonfuls of the following
julep may be taken every half hour till the effect be produced, drinking, at the same
time, plentifully of some warm diluent.
ꝶ. Tartar, emetic, gr. iii.
Aq. font. ℥vii.
Syr. Papaveris rubri, ℥i.
M. f. julap.
310.] Very convenient apparatus for this purpose are made by most tin-workers.
Beside the steam of warm water here recommended, external applications to the
throat and sides of the neck have a considerable effect in forwarding the suppuration,
as warm poultices, fomentations, &c.
317. line 9. gargles.] When the violence of the symptoms is moderate, and
When the ulceration is slight, sage tea, or tea made of rose leaves, or both together,
may be sufficient. A gargle made of a pint of sage and rose tea, three spoonfuls of
vinegar, and one spoonful of honey, has been found as efficacious as any of the
sharper antiseptics with the mineral acids. Dr. Fothergill's gargle is,
ꝶ. Decoct. 

EXPLANATORY NOTES.
ꝶ. Decoct. pectoral. ℥xii. cui inter coquendum, adde
Rad. contrayerv. contus. ℥ss.
Liquori colato admisce,
Acet. vin. alb. ℥ii.
Tinct. myrrh. ℥i.
Mel. opt. ʒvi.
But he often used it with a dram of the Mel Egyptiacum dissolved in two ounces
of it.
The Mel Egyptiacum is a very harsh application, and ought to be cautiously used.
If the sloughs cast off so slowly as to require a powerful application, it is better prac-
tice to touch them with Mel Egyptiacum by means of an armed probe, than to use
gargles, in which it is an ingredient. In this disease, a strict attention must be
given to the use of gargles and injections for the throat, because the cure seems to
depend in part on procuring a discharge from the glands of the fauces which these
gurgles induce, and also because they are the only means of retarding the progress
of the ulcers.
317. line 14. disease.] The quantity of bark given ought to be very consider-
able, viz. as much as the stomach and intestines can possibly bear; half a dram or
two scruples every hour, with a glass of good Port wine. A scruple of confectio
cardiaca, joined with each dose of the bark, has a double effect of making the bark
less nauseous, and of preventing, in some measure, a tendency to a diarrhœa ; but
opium is a sovereign remedy for removing this symptom when it is actually present.
In administering the bark, great care must be taken to avoid a diarrhœa, which
is a very dangerous symptom in any period of the disease, but especially after the
third or fourth day, when the patient is in a considerable state of debility.
Children are more frequently attacked with this disease than adults; and it is
sometimes extremely difficult to prevail on them to take a sufficient quantity of this
necessary and valuable, though nauseous medicine. In these cases, glysters with
powdered bark have been used with very great success. Two drams of the fine pow-
der may be given in five or six ounces of barley-water, every three or four hours, to
very young children, and half an ounce, or six drams, to children of eight or ten
years old, in three quarters of a pint of barley-water. If the first glyster comes
away too speedily, two or three grains of opium may be added to the subsequent
glysters.
317. line 20. inflammation.] In addition to the method of cure here delivered,
it may be proper to observe, that, as the cure depends much on the removal of every
thing putrid from the patient, it is absolutely necessary to have the room well ven-
tilated, but not with cold air. The reason for this precaution is, that the patient
always complains of the least admission of cold air, becoming sick and oppressed,
probably in consequence of the sudden disappearance of the efflorescence which al-
ways accompanies the disease. The linen ought frequently to be changed, the pa-
tient kept clean, the mouth and throat frequently washed, and great plenty of li-
quid vegetable nutriment must be given, with generous wine.
A hemorrhage from the nose, mouth, or ears, very frequently occurs in the later
stages of a malignant sore throat. This discharge is by no means critical, but al-
ways a dangerous symptom, and must be stopped with the utmost expedition. It is
the consequence of some arterial branch being corroded by the mortification. If the
hemorrhage withstands the usual means of tents dipt in vinegar, or a solution of
alum, &c. recourse must be had to opium and bark; and the Port wine must be
given sparingly.
In the advanced stages, a diarrhœa frequently appears, especially in children; it
proceeds from the putrid and acrid matter of the ulcers being received into the in-
testines. It can only be prevented, or effectually removed, by a careful attention
to keep the mouth as clean as possible.
318. Of the Cynanche Trachealis.] This disease has been supposed to be new,
and confined chiefly to infants. It is, however, described by many of both the an-
cient and modern writers. Boerhaave describes it in his 801st and 802d Aphorism.
It is, indeed, uncommon in adults, and most frequent in infants. It was never
rightly 

EXPLANATORY NOTES.
slightly understood, however, till Dr. Home, the Professor of the Materia Medica
in this University, investigated its nature, and pointed out the only effectual method
of cure.
330. line 5. topical.] The topical bleeding is best performed by leeches. Three
or four may be applied at once on each side of the trachea, or on the trachea itself.
Notwithstanding this recommendation of topical bleeding, previous general bleeding
is absolutely necessary in every case, and ought never to be omitted. It frequently
produces relief even while the blood is flowing from the vein ; but, in these cases,
it is imprudent to stop the evacuation, even on the total removal of the symptoms.
As much blood must be drawn as the infant can bear to lose, and leeches ought
moreover to be applied, as above directed ; for it frequently happens, that, when
all the symptoms suddenly disappear, the disease returns in a few hours with redou-
bled violence, and speedily puts an end to the child's life.
330. line 13. laxative glysters.] Laxative glysters are to be carefully distinguish-
ed from purging glysters, which generally irritate too violently, and thus increase
the inflammatory diathesis. It is of little consequence what the compositions of
glysters be, provided they contain some Glauber's or Epsom salt, and are sufficient-
ly large. The common glyster with milk and water, and a little Epsom salt, an-
swers sufficiently well.
332. line 3. Europe.] It is called here, and in many parts of Great Britain,
The Mumps.
336. line 10. frequent.] A frequent pulse is when there is a great number of
strokes in a given time.
336. line 11. quick.] A quick pulse is when the stroke itself is quick, although
the number in a given time be not very great.
It is therefore no tautology to mention both frequent and quick, as they are really
distinct, and may be both present at once ; but, if the pulse be above an hundred in
a minute, the physician must haves very nice sense of feeling to distinguish between
a quick and a slow beat.
338. line 7. streaked with blood.] Young practitioners should not be alarmed at
this symptom ; nor should they suppose it a dangerous one : it is, on the contrary, a
salutary symptom, and ought not to be restrained, either by too rigorous an adhe-
rence to the antiphlogistic regimen, or by the use of styptics and other astringents.
345. line 15. Injuring.] Violent exertions in speaking, singing, playing on
wind instruments, running up hill, or in short any exercise that increases the action
of the lungs.
345 line 15. injuring.] Receiving noxious vapours into the lungs is sometimes
the cause of pneumonic inflammation ; especially corrosive or other acrid poisonous
vapours, as the fumes of arsenic, of sulphur, of the muriatic acid, and similar cau-
stic and destructive exhalations. Chemists, therefore, in making experiments or
artists who work on substances yielding such vapours, should be careful to avoid
them.
354. line 2. gangrene.] As this termination of Pneumonia is always fatal, it is
highly necessary that the physician should be able to know when a gangrene is to be
suspected, that he may take the proper means for preventing it; or, when it is ab-
solutely formed, that he may save his reputation, by informing the patient's relati-
ons of the impending danger, and the fatal consequences with which such a termi-
nation is attended : I shall therefore add some of the more remarkable diagnostics of
an incipient gangrene in this disease.
A purulent spitting, streaked with deep coloured blood, or with a blackish mat-
ter; a fetid breath; a rattling in the throat; a dejected countenance ; a dim eye;
a languid quick pulse ; the blood drawn from a vein void of the inflammatory crust;
fetid green stools in abundance ; urine of a bright flame colour, or departing a black
sediment of a scaly appearance. More 

EXPLANATORY NOTES.
More symptoms of this fatal termination are unnecessay; for, if most of those
above mentioned be present, the physician has no other duty to perform than warn
the friends of the patient that death may be soon expected.
It may be farther remarked, that, when a gangrene is begun, the patient is con-
siderably freed from pain, and both himself and his attendants have great hopes of
his recovering; a few hours, however, soon undeceives them, and raises the repu-
tation of the physician, who has pronounced a true prognosis.
See some other diagnostics of gangrene in the notes on Article 359.
357.] In all Pneumonic affections, the breathing is generally more difficult
when the patient lies in an horizontal posture; it cannot therefore be admitted as a
diagnostic of an effusion.
359. line 2. remission of the pain.] The young physician must be on his guard
with respect to this symptom ; for it is also a symptom of an incipient, or an already
formed gangrene; he ought therefore to be peculiarly attentive to the concomitant
symptoms which the author enumerates, viz. the continuance or augmentation of
the difficulty of breathing and the cough, both of which either totally disappear, or
are considerably lessened on the supervention of gangrene.
359. line 6. rather increased.] The increased frequency of the pulse is also a
symptom of a gangrene being formed ; but, if that increased frequency be attended 
with febrile exacerbations in the evenings, then and then only can the physician be
sure that the disease has terminated in suppuration, and not in gangrene.
364.] Bleedings produce the best effect when the blood is drawn off as quickly
as possible in a large full stream; and, in order to prevent syncope, the patient
ought to be laid horizontally, or even with his head lower than his trunk.
With respect to the quantity of blood to be drawn at once, or in the whole course
of the disease, no general directions can be given ; it must depend entirely on the
circumstances of the disease and of the patient. In general, it is usual to continue
the discharge until the patient can either breathe more freely, or feels a considerable
abatement of the pain. If, however, the pain does not abate while the blood con-
tinues to flow, but signs of fainting appear, the blood must then be immediately
stopped.
If the pain and other symptoms continue violent, or return after the first bleeding,
it will then be necessary to have recourse to the operation ; and it must be repeated
frequently through the course of the disease ; avoiding, however, so large an evacu-
ation at once as may induce fainting. The reason of this precaution is evident, viz.
that, while the motion of the heart is suspended during fainting, the blood stagnates
in the right side of the heart, and is afterwards thrown with greater impetuosity
through the lungs.
369. line 4. acids.] See the note on Article 131. acids.
369. line 6. neutrals.] See the note on Article 160.
369. line 7. drink.] These salts generally render the drink nauseous ; and, as
plentiful dilution is absolutely necessary in these cases, so far from rendering the pa-
tient's common drink nauseous, by impregnating it with ill flavoured medicines,
we ought, by every possible means, to endeavour to make it as agreeable as we can,
that he may be the more easily prevailed on to take it plentifully.
370.] The cooling laxatives are, salts, manna, &c. but, in these cases, three
or four ounces of infusum sennæ, with half an ounce of Glauber's salt may be given,
without danger.
371.] The tartar emetic is the medicine generally employed for this purpose.
The dose of it in these cases must be very small, and well diluted, as in the follow-
ing formula:
ꝶ. Antimon. tartarisat. gr. ii,
Aq. font. ℥viiss.
Syr. Papaveris rubr. ℥ss.
M. The 

EXPLANATORY NOTES.
The dose of this mixture ought not to exceed three table-spoonfuls, when given
with this intention.
372. line 5. blistering.] The application of a blister to the part affected ought
to be the first prescription in all complaints of the thorax, except some remarkable or
urgent cause forbid the practice, because it is a most efficacious remedy, and is as
necessary as bleeding.
372. line 22. thorax.] They ought, however, to be applied as near to the
pained part as possible.
373. line 9. induce.] All the liquid forms of squills which we have in the shops
are nauseating. Pills made of the dry powder, with any electuary or conserve, or
honey, is the form in which squills affect the stomach least. The dose is four or
five grains of the dry powder; ten grains generally, if not constantly, produce vo-
mitings. To prevent the nauseating effect of squills, the addition of some grateful
aromatic is of material use. The pilulæ siliticæ of the Edinburgh Pharmacopœia
is a good formula, except that the dose of it must be large, in order to take a suffici-
ent quantity of the squills, ten grains of it, containing only one grain of dry squills,
supposing no syrup to be used in making the mass. One convenience, indeed, at-
tends this formula, viz. that we can give small doses with more precision than if we
use the powder alone. The gum ammoniac is an expectorant; and therefore, when
given along with the squills in these pills, may render a less dose of the squills ne-
cessary. If the extract of liquorice be omitted, the proportion of the squills to the
whole will be increased.
373. line 20. promoting expectoration.] Some practitioners propose the steam of
vinegar alone; but it proves in general too irritating. The same objection may be
made against using the steam of wine, which some practitioners have recommended
instead of the steam of vinegar. Plain water is the best, as the warm vapour only
acts by relaxing the internal surface of the lungs.
381. line 10. extremely hurtful.] The intention of bleeding in this disease is
merely to facilitate the circulation through the lungs, and to relieve the oppression
in the breast. When this intention is therefore answered, and when the shortness
of breath and oppression about the breast are removed, there is no farther need of the
lancet.
As this disease chiefly attacks elderly persons, and such as are of a phlegmatic ha-
bit, much harm may be done by repeated bleedings, which always increase debility,
and retard the cure.
381. line 12. vomiting.] Vomiting in this disease has been thought by many
practitioners to be a doubtful remedy. The action of vomiting always oppresses the
breast, and sometimes even increases the symptoms of the disease.
381. line 12. blistering.] This is the chief remedy ; and the blisters ought to
be applied as near the part affected as possible.
381. line 14. nauseating doses.] In several of the former notes we have fully de-
scribed the method of giving the emetic tartar in nauseating doses. Their principal
effect is to procure a perspiration; and, when this effect is produced, the patient
must drink largely of any diluent or attenuating liquor, as thin barley-water, with
the addition of the juice of some of the acid fruits, or infusions of some of the gentle
aromatics, as sage, balm, mint, &c. or even a thin wine whey.
381. line 17. necessary.] Purging is surely hurtful in this disease, by inducing
too great a state of debility; the intestines, however, are to be emptied in the be-
ginning of the disease, which is best done by a purging glyster, and kept open by the
subsequent use of gentle laxatives, or by repetitions of mild emollient glysters. The
purging glyster may be made as follows:
ꝶ. Aq. font. ℔. I.
Fol. senn, ℥ss.
Coque 

EXPLANATORY NOTES.
Coque leniter, et colaturæ adde
Sal. cathart. amar. ℥i.
Mel. ℥ii.
M. f. Enema.
The subsequent glysters ought to consist of nothing more than simple barley-water,
or milk and water. The laxatives, if they are used, should be very gentle and
mild; as cream of tartar whey, manna, tamarinds, &c. Half an ounce of manna
dissolved in half a pint of cream of tartar whey, makes an agreeable opening mix-
ture ; half a tea-cupful of it may be taken three or four times a day, so as to pro-
cure at least two or three stools in the twenty-four hours.
391.] A delirium is one of the most general concomitants of the increasing de-
bility of the system, and may be considered as a diagnostic. 
394.] Chicken broth is extremely mild ; it may be taken in small quantities,
with about eight or ten grains of nitre in every pint of it. Lintseed tea is also a
very mild drink; and, if the inflammation be owing to the presence of any acrid
matter irritating the stomach, it is of great service by its sheathing quality.
408. line 5. laxatives.] In this disease, we ought to be extremely cautious in the
administration either of medicines or diluents. The reason is evident from the fol-
lowing considerations. In every case of inflammation of a canal, the bore of that
canal is diminished, and frequently quite shut. A quantity of any kind of ingesta
being forced against this obstruction, must necessarily increase the irritation, and
consequently aggravate all the symptoms. The same reason may be given for the
caution necessary in prescribing laxatives, which always irritate ; for their action
generally depends upon the irritation they produce.
Large bleedings, emollient glysters frequently repeated, fomentations, the warm
bath, and small anodyne glysters occasionally injected, are the most effectual reme-
dies in the first stage of this violent disease.
When the pain remits, and the violence of the symptoms abates, mild diluents
may then be admitted, as chicken broth, thin lintseed tea, &c.; and, if such li-
quors be retained without aggravating the symptoms, we may then venture to give
an ounce of manna every three or four hours, till it procures a passage.
The internal use of opium has been extolled by several practitioners in these cases;
but experience shews that it generally does harm in every case of inflammation, espe-
cially in the early stages of it.
The anodyne glyster is the safest method of using opium ; but glysters of this kind
are said to obstruct: This objection is, however, ill founded ; for, by diminishing
the irritation, they evidently tend to resolve the inflammation. The following for-
mula of an anodyne glyster is generally used:
ꝶ. Decoct. hord. ℥iv.
Opii puri gr. iv.
M.
In these glysters, particular care must be taken to avoid every thing that has the
least tendency to irritate.
If a gangrene be formed before the physician be called, as is too frequently the
case, then all remedies are in vain.
409. line 3 , colic] See Article 434.
413. ] It is doubtful whether this chronic hepatitis ever exists.
414. line 19. symptom.] This symptom generally appears, however, after the
disease has continued for three or four days; perhaps, indeed, it might have been
present in the beginning, for it is frequently so slight as to escape observation.
419. line 4. right nostril.] And the left also. It was a fancy of Galen's that
inflammatory fevers were only resolved by such hemorrhagies as flowed from the side
affected: Thus, an hemorrhage from the right nostril resolved an inflammation of
the liver; but a discharge from the left, an inflammation of the spleen.
VOL. I. 3 K 429. line 

EXPLANATORY NOTES.
429. line 4. demulcent liquids.] These have all been enumerated in some of the
preceding notes.
429. line 7. cantharides.] This is a very necessary caution. Blisters generally
affect the urinary organs and vessels, occasioning much irritation, and consequently
increasing the inflammation.
As the author is rather short in his directions for the cure of this very troublesome
inflammation, it may be proper to add some particular directions for regulating our
practice in these cases.
An ulcer in the kidneys is extremely difficult to heal; we ought therefore always
to attempt the cure of nephritis by resolution. The general remedies for answering
this intention have been frequently enumerated, especially in the notes on Art. 130.
and 131. The particular remedies more peculiarly adapted to this disease, are de-
mulcent drinks of the softest nature, and such as are least apt to irritate the parts ;
as lintseed tea, decoction of marsh mallows, &c. Nitre has been recommended
among the general antiphlogistic remedies; but, in nephritis, its use is doubtful, on
account of its passing quickly by the kidneys, and irritating them,
A difficulty of making water is one of the symptoms of this disease, and some
practitioners recommend heating diuretics. This practice, however, is extremely
hurtful, and ought to be carefully avoided, because these warm medicines, as tur-
pentines, balsams, &c. always increase the irritation, especially in the urinary
passages.
As the colon presses immediately on the kidneys, especially on the right one, we
should be peculiarly careful to keep it empty, which is best done by glysters. Be-
side the use of glysters in evacuating the contents of the colon, they act as a fomen-
tation to the inflamed part; we ought therefore, in these cases, to prescribe them
larger than usual, and repeat them often. They ought to be extremely emollient,
and void of every ingredient that is any way stimulating. A quart of thin barley-
water or lintseed tea answers the purpose as completely as any of the more compound
emollient glysters of the Pharmacopœias.
With respect to diet and regimen, we may observe that lenient nourishment is
highly proper; for every thing acrid naturally forces itself off by the urine, and con-
sequently increases the irritation. A total abstinence from food is by no means ad-
viseable, because, from abstinence, little urine is secreted, and the smaller the quan-
tity secreted it is generally the more acrid, and consequently noxious.
The patient ought to be made to sit up as much as possible. Warm soft beds,
which are always improper in all inflammatory diseases, are peculiarly hurtful in
nephritis, especially if the patient lies on his back; for in this position the kidneys
are kept very warm, and are at the same time pressed by the superincumbent weight
of the abdominal viscera, all which will contribute to increase the inflammation.
Although lying much in bed be disapproved, the patient ought by no means to be
over fatigued with sitting too long. The room should be moderately cool, and the
bed springy, but not soft.
In addition to what was said above respecting blisters in this disease, it may be
necessary to observe, that other vesicants besides cantharides may be used, such as
mustard poultices, commonly called sinapisms, a poultice of the fresh leaves of the
ranunculus acris, and other acrid plants.
436. ] There are many instances, however, of rheumatism extremely acute in
old people.
453. line 9. diseases.] To distinguish the chronic rheumatism from venereal or
scorbutic pains, is, however, in some cases, extremely difficult, and often requires
the utmost sagacity of the practitioner. A due attention to the causes of rheuma-
tism, recited in the foregoing articles, and a strict examination whether the patient
has been subjected to these causes, will sometimes determine the disease: but it
often happens, that the same causes which produce rheumatism, also exacerbate ve-
nereal and scorbutic pains.
No general rules can be delivered on this subject; and the practitioner must trust
to his own sagacity for direction in this difficult diagnosis.
463.] These topical bleedings, however, have, by repeated experience, been
found 

EXPLANATORY NOTES.
found of essential advantage, especially when the partial inflammation has been very
violent. They are best performed by leeches, many of which ought to be applied
at once all over the inflamed part.
Cupping has long been the favourite practice of many physicians, but it generally
irritates more than the leeches: yet in cases that require immediate relief, it is pre-
ferable to them.
464. line 5. refrigerant power.] The Glauber, or Epsom salts, are the most con-
venient purges in all cases of acute rheumatism. Either of them may be given se-
parately, or joined with the infusum sennæ, as in the following formula :
ꝶ. Infus. Sennæ, ℥iii-
Sal. Glauber. ℥ ß.
Tinct. Jalap. ʒi.
Tinct. Aromat. ʒ ß.
M. f. haust.
The more suddenly purges operate in acute rheumatisms, the more efficacious are
they generally found : and as large diluting warm thin liquors considerably accelerate
the operation of all purges, such practice is never to be neglected in these cases.
Cream of tartar whey, mixed with twice its quantity of warm water, is a very pro-
per drink to assist the operation of purges.
466. ] Sweating is most effectual in this disease, when produced by Dover's
powder. The dose of it is twelve or fifteen grains, repeated at intervals, of two or
three hours, till a sweat be produced. Diluent drinks are to be used with it: and
it may be necessary to observe, that they ought to be such as are bland, and by no
means stimulating; viz. barley-water, lintseed tea, thin water-gruel, &c.
467. ] Notwithstanding this caution, many practitioners use opiates, especially
when joined with camphor, to procure sweats in acute rheumatism. This com-
pound never fails to increase the phlogistic diathesis, and consequently must be hurt-
ful. In the chronic rheumatism, indeed, camphor and opium together form a va-
luable medicine. The dose is the following bolus:
ꝶ. Camphor, gr. vi.
Sp. Vini, gutt. x.
Opii, gr. i.
Tart. Vitriol. gr. xv.
Syr. q. s. M. f. bolus.
468.] Bark is always an ambiguous remedy in rheumatism, and on its first in-
troduction into practice it was thought to occasion or induce the disease. Wherever
an inflammatory diathesis prevails, the Peruvian bark is always an improper medi-
cine, and it has been found by experience to be manifestly hurtful in the beginning,
or inflammatory state of rheumatism.
473. line 8. cold.] This, when compared with Art. 457. and others, seems to
be a typographical error, and the author meant warm. Practice affords many in-
stances of chronic rheumatisms being occasioned by cold bathing.
474. line 3. turpentine] Turpentine is an extremely heating oil, as indeed are
all the essential oils : its use therefore requires the greatest caution. The dose is
from eight to fifteen drops on a piece of sugar. Venice turpentine may be more
conveniently given in the form of an emulsion, by dissolving it in water by means
of yolks of eggs. Two scruples of turpentine is the ordinary dose ; and when given
in this liquid and diluted state, is much preferable to the oil.
474. line 4. gualac] The officinal preparations of guaiacum, are an extract of
the wood, a solution of the gum in rectified spirit, another in volatile alkali, and
an empyreumatical oil. The gum may be given in the quantity of fifteen or twenty
grains for a dose, either in a bolus, or made into an emulsion with yolk of egg and
an ounce or two of water : In larger quantities it is too purgative. The volatile
elixir

EXPLANATORY NOTES.
elixir of the Edinburgh Pharmacopœia is an excellent form, as the volatile spirit
promotes the medicinal virtue of the guaiacum. The dose of it is from a dram to
half an ounce, morning and evening, in any convenient vehicle ; a tea-cupful of
milk is the best, as it sheaths in some measure the pungency of the medicine.
Guaiacum is very conveniently joined with rhubarb and magnesia, when we find that
such a dose of it, as is necessary for procuring a sufficient opening, would be too heat-
ing. A formula of this kind is described in the note on Art. 558.
474. line 6. Calomel.] Calomel, perhaps, has only been serviceable in venereal
cases.
475.] The diet in the cure of chronic rheumatism ought to be generous and full.
In many cases, especially among people in poor circumstances, good living, with two
or three glasses of sherry in the day, has cured the disease without any medicines.
One material circumstance ought not be omitted ; viz. that the cure is much imped-
ed by costiveness : if, therefore, the guaiacum does not procure two motions in the
day, it will be necessary to give along with it some warm laxative. The tincture
sacra is a proper medicine in these cases : its dose is from one to two ounces: As is
also the elixir sacrum of the Edinburgh College Pharmacopœia, its dose may be from
a dram to half an ounce, as occasion may require.
486. line 4. aromatic oils.] The Oleum Origani is the oil generally used for
this purpose. Great care must be taken in using either these acrid essential oils, or
the vitriolic or other mineral acids, that no part of them touch the gums.
489. line 4. conveniently done.] Blisters are applied most successfully behind the
ears. Such applications however are always troublesome ; and their effects are often
doubtful. Other milder stimulants frequently answer all the intentions of blisters,
and by many practitioners are thought to be equally efficacious. The applications
generally used are camphorated spirit, or volatile alkali. This last, either alone,
or mixed with an equal quantity of oil of almonds, rubbed on the jaw, the part be-
ing kept warm by a piece of flannel, has often been found extremely useful.
Warmth, any how produced on the part, always gives relief; while, on the con-
trary, cold always exasperates the symptoms : hence the propriety of covering the
jaws with flannel, and avoiding a cold stream of air.
489. line 8. acrid masticatories.] These are horse-radish, scurvy-grass, the great-
er celandine, with some others; but the radix pyrethri is the best. In some phar-
macopœia, but I do not recollect which, there is a formula, called Trochisci Siala-
gogi, to the best of my remembrance, as follows :
ꝶ. Pulv. Rad. Pyrethri, ℥i.
Gum. Mastich. ℥ß.
Ol. Caryophyll. Aromat.
Ol. Marjoranæ, aa ʒi.
Cera Alb. q. s. ut. f. Trochisci.
One of these held in the mouth, or chewed, promotes a copious discharge of sa-
liva, by warming and stimulating the salivary glands.
493. line 3. female.] Hippocrates says, that women seldom have the gout, and
never before the disappearance of the catamenia. In his time and country, perhaps,
the ladies were more temperate than they were in other ages and in other places.
We find the gout a familiar disease among the Roman ladies ; which Seneca, in his
ninety fifth epistle, justly ascribes to the luxurious living and debaucheries, in which
they indulged without controul.
As the whole of that epistle is an excellent account of the direful effects of high
living and debauchery, it may not be unacceptable to the young practitioner, who,
perhaps, might otherwise be unacquainted with so just a description of luxurious liv-
ing, and its concomitant evils. Independent of its containing a minute relation of
Roman customs, which makes it a valuable morsel for Antiquaries, it may be read
with peculiar advantage by the young physician.
As an apology for giving it in the original, I shall say of Seneca what an elegant
English

EXPLANATORY NOTES.
English writer says of Cicero; That any translation of his nervous language, is like
the faint glimmerings of a taper compared with the blazing light of the meridian sun.
" Medicina quondam paucarum suit scientia herbarum, quibus sisteretur fanguis
" fluens, vulnera colerent paulatim. Deinde in hane pervenit tarn multiplicem
" varietatem. Nec mirum est: tunc illam minus negotii habuiffe, firmis adhuc.
" solidisqæ corporibus, et facili cibo, nee per artem voluptatemque corrupto. Qui
" postquam cœpit, non ad tollendam, fed ad irritandam samem quæri, et inventæ
" sunt mille conditunæ, quibus aviditas excitaretur: quæ desiderantibus alimenta
" erant, onera sunt plenis. Inde pallor, et nervorum vino madeutium tremor, et
" miserabilior ex cruditatibus quam ex same macies. Inde incerti labantium pedes,
" et semper qualis in ipsa ebrietate titubatio. Inde in totam cutem humor admissus,
" distentusque venter, dum male assuescit plus caperc, quam poterat. Inde suffu-
" sio luridæ bilis, et decolor vultus, tabesque in se putrescentium, et retorti digiti
" articulis obrigescentibus, nervorum sine sensu jaceutium, terpor aut palpitatio
" fine intermiflione vibrantium. Quid capitis vertigines dicam ? Quid oculoruni
" auriumque tormenta, et cerebri æstuantis verminationes, et omnia per quæ ex-
" oneramur internis ulceribus affecta ? Innumerabilia praeteræ febrium genera,
" aliarum impetu subeuntium, aliarum tenui peste repentium, aliarum cum hor-
" rore et multa membrorum quassntione venientium ? Quid alios referam innume-
" rabiles morbos, supplicia luxuriæ ? Im'munes erant ab istis malis qui nondum se
" deliciis folverant, qui fibi imperabant, fibi miniftrabant. Corpora opere ac vero
" labore durabant, aut curfu desatigati, aut venatu, aut tellure versata. Excipie-
" bat illos cibus qui nili esurientibus placere non poterat. Itaque nihil opus erat
" tarn magna medicorum supelledtile, nee tot ferramentis atque pyxidibus. Sim-
" plex erat ex simplice causa valetudo. Multos morbos multa sercula secerunt.
" Vide quantum rerum per unam gulam transitur.irum permisceat luxuria, teirarum
" marisque vastatrix. Necesse est itaque inter se tarn diversa diffideant, et hausta
" mali digerantur, aliis alio nitentibus. Nee mirum, quod inconstans variusqua
" ex discordi cibo morbus est, et ilia ex contrariis naturæ partibus in eundem com-
" pulsa redundant. Inde tarn nullo aegrotamus genere quam vivimus. Maximut
" ille medicorum, et hujus scientiæ conditor, seminis nee capillos defluere dixit,
" nec pedes laborare. Atqui hæ jam et capillis destituuntur, et pedibus ægræ sunt.
" Non mutata feminarum natura, sed vita est. Nam cum virorum licentiam æqua-
" verint, corporum quoque virilium vitia æquaverunt. Non minus pervigilant,
" non minus potant, et oleo et mero viros provocant. Æque invitis ingesta visce-
" ribus per os reddunt, et vinum omne vomitu remetiuntur; æque nivem rodunt,
" solatium stomachi æstuantis. Libidini vero nec maribus quidem cedunt, pati
" natæ. Dii illas deæque male perdant: adeo perversum commentæ genus impu-
" dicitiæ viros iheunt. Quid ergo mirandum est, maximum medicorum ac naturæ
" peritissimum, in mendacio prehendi, cum tot feminæ podagricæ calvæque sint.
" Benesicium sexus sui vitiis perdiderunt; et quia feminam exuerunt, damnatæ
" sunt morbis virilibus. Antiqui medici nesciebant dare cibum sæpius, et vino
" fulciri veins cadentes; nesciebant saniem emittere, et diutinam ægrotationem
" balneo sudoribusque laxare; nesciebant crurum vinculo, brachiorumque, laten 
" tern vim, et in medio sedentem, ad extrema revocare. Non erat necesse circum-
" spicere multa auxiliorum genera cum essent periculorum paucissima. Nune au-
" tem quam longe processerunt mala valetudinis ? Has usuras voluptatum pendimus,
" ultra modum sasque concupitarum. Innumerabiles esse morbos miraris ? Coquos
" numera. Cessat omne studium ; et liberalia professi, sine ulla frequentia, deser-
" tis angulis præsident. In rhetorum ac philosophorum scholis solitudo est. At
" quam celebres culinæ sunt? Quanta nepotum focos juventus premit? Transeo
" puerorum inselicium greges ; quos post transacta convivia aliæ cubiculi contume-
" liæ expectant. Transeo agmina exoletorum per nationes coloresque descripta,
" et eadem omnibus levitas sit, eadem primæ mensura lanuginis, eadem species
" capillorum, ne quis cui rectior sit coma, crispulis misceatur. Transeo pistorum
" turbam, transeo ministratorum, per quos signo dato ad inferendam cœnam dis-
" curritur. Dii boni quantum hominum unus venter exercet! Quid tu illos bole-
" tos, voluptarium venenum, nihil oculti operis judicas sacere, etiamsi præsenta-
" nei non surant? Qnid tu illam æstivam nivem non putas callum jecinoribus ob-
" ducere ? Quid ilia ostrea, inertissimam carnem, cœno saginatam, nihil existimas
" limose gravitatis inferre? Quid illud sociorum garum, pretiosam piscium saniem,
"' non credis urere salsa tabe præcordia ? Quid ilia purulenta, et quæ tantum non
"ab 

EXPLANATORY NOTES.
" ab ipso igne in os transseruntur, judicas sine noxa, in ipsis visceribus extingui ?
" Quam fœdi atque pestilentes ructus sunt, quantum sastidium sui, exhalantibus
" crapulam veterem ?"
503. line 2. excess in venery.] Why excess of venery should be a cause of gout,
has much engaged the attention of medical writers, and various reasons have been
given why it should produce such an effect. There is not the least doubt of the fact,
though some authors have ventured to deny it, and have excluded the excess of ve-
nery from being a cause of gout.
It produces gout not primarily, but secondarily, if I may be allowed the expressi-
on, by inducing a general state of debility, and by weakening the power of digesti-
on, both of which circumstances are causes of the gout.
503. line 3. intoxicating liquors.] By intemperate drinking the action of the
stomach and bowels becomes extremely feeble and languid, if it be not wholly de-
stroyed; hence continual indigestions, to which the origin of the gout is attributed.
503. line 5. aliments.] Both the quantity and quality of the aliments may pro-
duce indigestion : and hence the indulging in too great a quantity of aliment, as
well as in that which is of an indigestable nature, are secondary causes of the gout;
viz. causes which induce a state of debility.
503. line 5. business.] Much application to study may doubtless induce indigest-
ion, and thus increase the general state of debility : it is not, however, by intense
study, or deep thinking merely, that men grow pale amid their books, but by the
sedentary life which studious men generally lead, and the untimely lucubrations in
which they inconsiderately indulge.
Much application to business can only be an occasional cause of the gout, when the
business requires a sedentary and inactive life ; but as most business requires activity,
attention to business is seldom the cause of gout.
503. line 6. night watching.] The want of sleep is always a cause of indigestion,
and increases debility more perhaps, when carried to excess, than any other of the
circumstances mentioned by the author.
503. line 6. excessive evacuations.] That large evacuations induce debility it
sufficiently evident.
503. line 7. usual labour.] Nothing more effectually promotes digestion than
proper exercise ; the leaving off accustomed labour must therefore necessarily induce
indigestion, and consequent debility.
503. line 8. spare diet.] Why this induces debility is evident See note on
Article 548.
503. line 8. acescents.] That acids, by impairing the digestive powers of the
stomach, may produce debility, is what every practitioner allows.
503. line 9. cold.] How cold, thus applied, can produce a state of debility, is
not very evident. It is, however, one of the occasional causes of gout, as experi-
ence sufficiently testifies.
517. line 6. different appearances.] These different appearances which the gout
assumes, are extremely unlike the regular gout above described: the young practiti-
oner ought therefore to pay peculiar attention to them, that when he observes them
in patients, he may not think them symptoms of other diseases, or even mistake
them for primary diseases. Errors of this kind are frequently committed by igno-
rant practitioners, to their own discredit and the danger of their patient's life.
530. line 2. nervous system.] Boerhaave, after describing the disease, says,
Aphorism 1262, " From all which it appears that the proximate cause of the gout
" is a vitiated state of the most minute, and consequently nervous vessels of the bo-
" dy ; and also of that fluid which flows through the nerves." 542. 

EXPLANATORY NOTES.
542. line 9. rest of life.] Several cases are to be met with in practical authors,
which confirm this observation. Van Swieten relates the case of a priest, who en-
joyed a rich living, and had long been an old constant sufferer in the gout; but hap-
pening at last to be taken by the pirates of Barbary, was detained there in a state of
slavery for the space of two years, and kept constantly at work in the galleys, with
only a very spare diet. The regimen he there underwent had this good effect, that
after he was ransomed from his captivity, having lost his troublesome and monstrous
fatness, he never once had a fit of the gout, though he lived several years after the
event happened.
548.] A sudden change from a full to a spare diet was justly enumerated among
the occasional causes of the gout in Art. 503.
554. line 8. necessary.] The physician has more difficulty in persuading his pa-
tients to a proper regimen in the gout than in any other disease; and if he would
gain reputation, he ought to pay peculiar attention to this part of practice, and use
his utmost art in convincing his patient of the necessity of an abstemious diet, and a
regular conduct.
Gouty patients are generally the genuine offspring of jolly Bacchus, and prefer
the transient indulgence of their jovial inclinations to the ransom of whole years of
torment at the easy price of a life of sobriety and temperance, until the invincible
Queen of tortures, as Lucian calls her, fully convinces them of their errors. They
are then anxious for medical advice, and after consulting the physician, they are
willing implicitly to obey his strictest injunctions. They seldom, however, then
find much relief; and remain living proofs of the truth of the adage:
-sero medicina paratur,
Cum mala per longas invaluere moras.
556. line 2. Portland powder.] This medicine was so called from one of the 
Dukes of Portland being cured by it of an hereditary and very inveterate gout. It
consists of equal parts of the following bitter aromatics: viz. Rad. aristolochiæ ro-
tundæ, Rad. gentianæ, Summitat. chamedryos, Summitat. chamæpityos, Sum-
mitat. centaur. min. A dram of this powder is ordered to be taken, in any conve-
nient vehicle, as a little wine, broth, tea, &c. in a morning, fasting, the patient
tasting nothing for an hour and an half after it; it must be used in this dose for three
months without the least interruption: Forty-five grains are to be taken daily in the
same manner, for the succeeding three months : half a dram every day, for the
next six months; and half a dram every other day, during the second year. It is
sometimes two years complete before any change be produced, but the patient must
rot therefore abandon the medicine, but continue its use.
These aromatic bitters have been long in use as remedies for the gout. We find
Galen prescribing in this disease the seeds and tops of wild rue, birth-wort, lesser
centaury, gentian, &c. either singly, or mixed in certain proportions. Trallian de-
scribes similar antidotes, which he says, must be continued for a great length of
time, viz. six or seven months, or even for a year and upwards. The tetra-phar-
macon of Aetius, composed of gentian, birth-wort, bay-berries, and myrrh, is a
similar remedy, and is also directed to be used for a great length of time. Cælius
Aurelianus likewise mentions the bitters to be lone used in the gout, and he gives
them the apposite epithet of annalia. The Diatesseron, which has not been long
thrown out of our shops, and is still retained in some of the foreign pharmacopœias,
is of the same kind.
The use of these medicines has doubtless in many cases completely cured the gout;
but in many cases, even in those that have been cured, fatal diseases have superven-
ed. The ancients were well aware of the danger of an indiscriminate use of these
medicines : " Many," says Galen, "of a moderate and slender habit of body, have
" lost their life by the use of drinks composed of these kinds of remedies, their
" blood being dried up. The numerous arthritic cases cured by these medicines,
" encouraged gouty people to have recourse to them indiscriminately, and without
" reflecting that those, who had been cured by them, were of a humid and phleg-
" matic habit, to whom medicines of this sort might be administered with safety."
" Ægineta has a similar passage. "Those," says he, "who endeavour to remove
" the disease entirely by medicines, to be used through the whole year, will doubt- 
" less

EXPLANATORY NOTES.
" less do service to such patients as are infested with pituitous and excrementitious
" humours in their joints, but they will hasten an untimely death in persons of a
" dry and hot habit of body, by forcibly driving the morbific matter on the intestines,
" kidneys, lungs, or some other of the principal bowels."
The ancients, then, were aware of the danger attending the promiscuous use of
these remedies; and the moderns are still more convinced of that danger : hence
these aromatic bitters are entirely laid aside, and in their place the Peruvian bark it
the only tonic now used in these cases.
557. line 10. disease.] Some remarkable cases have lately occurred in this city
of the efficacy of aerated alkaline water, in preventing the returns of the paroxysms
of the gout. It requires to be taken for a great length of time, to insure success;
but the patient is encouraged to persevere in its use, in consequence of a speedy re-
moval of some of the most troublesome symptoms.
The method of making it is described by several authors ; but, for the sake of
those readers who are unacquainted with the process, I shall give an abstract of it.
Dissolve three ounces, Troy weight, of good salt of Tartar in a gallon and a half
of rain water, or good soft spring water; filtre the solution, and put as much of it in-
to the middle glass of Parker's machine as will completely fill the vessel, reserving
the remainder for a subsequent making. The effervescing materials must then be
put into the lower vessel, and a gentle stream of fixed air mull be made to pass through
the liquor, till it tastes evidently acidulous, which will probably require forty-eight
or sixty hours, or in summer more.
The method of managing the effervescence is of considerable consequence ; for, if
it is too violent at first, much air escapes through the vessels without effect. Ascer-
tain, by previous experiment, how much of the vitriolic acid, which you have pro-
cured, for it is of very different strengths in the shops, will saturate a dram of the
chalk. Put four ounces of dry powdered chalk into the lower vessel, and shake it
to one side : under that side put a wedge, so as to raise it about an inch and an half
from the table. With a long funnel, which reaches to the bottom of the vessel,
pour in the quantity of vitriolic acid necessary for the saturation, which will run
down to the other side of the vessel, and not come into contact with the chalk:
through the same funnel, pour very slowly as much water as will be sufficient to co-
ver about a fourth part of the chalk as it then lies. The vessel being gently shaken
occasionally, the effervescence will go on very slowly, and the alkaline liquor will
be sooner and more effectually saturated, than if the effervescence had been too vio-
lent. If the materials are not sufficient for giving an acidulous taste to the liquor,
the lower vessel must be washed, and fresh chalk and acid again put into it.
The dose of this water is half a pint about noon, and another in the evening. In
urgent cases half a pint has been given morning, noon, and night, for a considerable
time together, without disagreeing with the stomach, or injuring the appetite or ge-
neral health of the patient. If it proves flatulent, a tea-spoonful or two, but not
more, of spirituous cinnamon water may be taken in each dose. If it inflames, or
too violently irritates the urinary passages. five or ten, or in urgent cases, twenty
drops of laudanum may be taken with each dose of the water.
558.] The following formula may be used in particular cases:
ꝶ. Aloes Socotorin. ʒii.
Gum. Guaiac. ʒiii.
Tinct. Sacræ, q. s.
M. f. massa, in pilulas equales xv. dividenda ; quarum su-
mat iii. vel iv. pro re nata.
ꝶ. Pulv. Rad. Rhei, ʒiii.
Magnes. alb. ℥ ℔.
Gum. Guaiac. ʒii.
Confect. Aromat. ʒii.
Syrup. comm. q. s.
M. f. Elect. cujus sumat magnitudinem juglandis mane et
vespere, vel pro re nata. 
This

EXPLANATORY NOTES.
This last medicine has been extremely beneficial in removing costiveness, and in
giving a tone to the stomach.
An ounce, or an ounce and a half, or two ounces of the tinctura sacra, is also a
good purge for gouty persons.
The Elixir Sennæ is likewise a good medicine where we cannot use aloetic purges,
as in cases of piles: in these cases also we may use sulphur; of which the following
form is very convenient:
ꝶ. Flor. Sulphuris, ℥ii.
Elect. Lenitivi, ℥ii.
Pulv. Rad. Jalap. ʒii
Zinzib. ʒii
Syr. Simpl. q. s. 
M. f. Elect. cujus sumat quantitatem juglandis pro re nata.
560. line 11. a little wine.] The wine in these cases should be of the best kind,
and such as are not apt to turn sour on the stomach. The dry wines, as Sherry and
Madeira, are most proper, while both the rich sweet wines and the austere thin acid
wines are equally improper.
563.] On this account these topical remedies ought to be used with great cauti-
on : the temporary relief which they afford, by procuring an intermission of the
pain, is agreeable to the patient, but it is frequently the occasion of an exacerbation
of all the symptoms.
564.] This is a very dangerous practice. Blisters are however extremely useful,
in bringing back the retrocedent gout to the part originally affected ; but, the violent
degree of pain that accompanies the gout, when brought to a part already irritated by
the blisters, frequently prevents a patient who has once suffered it, from allowing it
a second time. It is, however, so important and necessary a practice, that it ought
not to be omitted. As soon as the gout has been brought back to its original place,
the blisters must be immediately removed, a piece of soft linen dipped in fresh oil,
applied to the part, and the whole well wrapt up in soft flannel; a moderate degree
of heat must be preserved in the flannel, and the patient must be encouraged to bear
with patience the violent pain which he suffers.
566. line 1. moxa.] Moxa is a soft lanuginous substance prepared in Japan, from
the young leaves of a species of Artemisia, by beating them when thoroughly dried,
and rubbing them between the fingers till nothing but the finest fibres remain.
A little cone of this cottony substance is laid upon the skin, which is previously
moistened to prevent the cone from sliding off: Fire is set to the apex of the cone,
and it is suffered to burn till it extinguishes itself. A small eschar is produced and
the ulcer either healed or kept open as occasion requires.
Cotton impregnated with a small quantity of a solution of nitre, and afterwards
dried, answers the end as effectually as the Japonese moxa.
569. ] The best form for exhibiting opium in these cases, is the Confectio Opiata
of the London Pharmacopœia, or the Electarium Thebaicum of the Edinburgh. The
dose of the former is half a dram, but of the latter a dram and an half.
As opiates ought never to be administered where the inflammation is violent, but
only in such cases as are attended with little or no inflammation, these warm opiates
cannot be improper. If however the practitioner should think either of the above
formulæ too hot, he can have recourse to the Tinctura Thebaica.
575. line 7. pain.] Cold bathing is a doubtful remedy, and ought to be used with
caution. If it does not prove a tonic, it ought to be abandoned ; and we know by
experience that it frequently debilitates.
575. line 9. animal food.] The use of animal food is absolutely necessary, and
such ought to be chosen as is most nutritive. Beef or mutton have been with pro-
priety preferred to all other animal food, and some eminent practitioners have re-
VOL. I 3 L commended

EXPLANATORY NOTES.
commended steaks to every other mode of dressing beef and mutton. Stews, hashes,
pyes, and all high seasoned dishes, ought to be avoided.
575. line 12. some wine.] The wine which a gouty person uses, ought to be
generous and good, as Madeira, sherry, &c. the thin acescent wines, as hock, claret,
&c. always do mischief.
575. line 16. employed.] In order the more effectually to guard against acescen-
cy, the spirits and water ought, if possible, to be taken without sugar, and cold.
No drink is perhaps more prejudicial for gouty patients, than what is called rich
punch, viz. with a large quantity of sugar and lemon, especially when taken warm.
576. line 9. large doses.] The dose must be very small at first, not exceeding
four or five grains in the day ; the doses may be daily increased two grains, till we
arrive at ten or twelve, and after two or three days, ten grains may be given twice a
day. Aromatics always make it sit easier on the stomach than it would do if taken
alone; the most convenient form therefore is the following :
ꝶ. Rubig. Martis, gr. 10.
Confect. Card. ʒ ℔.
Syr. Croci, q. s.
M. f. bolus.
After the patient has taken two of these boluses for three or four days, he may
proceed to take three of them; and after a few more days, if the stomach is not dis-
ordered, each bolus may be daily increased till we arrive at 24, or even 30 grains,
thrice a day.
576. line 18. proper laxatives.] The proper laxatives for gouty constitutions,
are mentioned in a note on Article 558.
579. line 14. Thebaicum.] The following form is extremely efficacious, and at
the same time pleasant to the taste: it may be repeated three or four times, if the
first does not procure relief.
ꝶ. Elect. Thebaic. ʒi.
Aq. Cinnamom. spirituosaæ, ℥i. ℔.
Syr. Croci, ʒii.
M. f. haust.
579. line 15. camphor.] The best way of giving these medicines is in the fol-
lowing form :
ꝶ. Opii purificati, gr. i.
Camphor, gr. xii.
Spt. Vini, q. s.
Confect. Cardiac. ʒii.
M. f. bolus.
Or the camphor may be made into a bolus with a dram of the Elect. Thebaic.
and forty drops of the Spiritus Aromaticus, in a glass of strong wine, as Madeira or
Sherry, may be drank after it.
580. line 3. antispasmodics.] The Spiritus Ethereus Vitriolicus is a medicine
used with much success in these cases. The dose of it is from twenty to thirty drops
in a glass of wine. The ethereal spirit is so very volatile, that it will wholly evapo-
rate, if it be suffered to stand in the wine for a few minutes; it must therefore be
drank speedily : and the dose may be repeated every two hours, in cases of emer-
gency. In most cases laudanum will answer every purpose. Ammoniacum has
been much recommended, and its powers in cases of gouty asthma have frequently
been very conspicuous : It may be given independently of the opiates. Two drams
of it may be made into an emulsion with six ounces of water: and a couple of table-
spoonfuls of this emulsion may be given every two or three hours.
581.] Little 

EXPLANATORY NOTES.
581.] Little relief has ever been obtained in these cases from internal remedies.
Large doses of the Spiritus Aromaticus have been thought serviceable, but the chief
dependence is on the effect of blisters on the extremities, especially the feet, with
warm fomentations to the legs, and rubbing the legs with a flesh brush, impregnated
with plenty of dry flour of mustard.
588. last line, subsides ] The discharge of saliva is always salutary, and ought
to be moderately encouraged. It is probably owing to the morbific matter attacking
the salivary glands, and through them making its exit out of the body.
All the affections of the sauces, and the salivation, gradually abate as the swell-
ing of the face subsides ; but, if these symptoms disappear suddenly, or are not suc-
ceeded by a swelling of the extremities, danger is to be apprehended.
This remark is solely the result of experience, and the explanation of it seems to
be involved in considerable difficulty.
596. line 3. own nature.] This opinion is most probably true, but it is by no
means, as the author says, evident. His reasoning, however, is ingenious and de-
serves attention. The expulsion, or rather evacuation of the morbific matter is ad-
mitted as the cure of the disease, and the difference of the disease to the different
manner in which this evacuation is made : But, the author has not proved either of
the premises he has advanced, viz. that the quantity of human fluids which the fer-
ment assimilates, is nearly the same in different persons, nor that any part of the
morbific matter, or the morbid assimilated fluids pass off by perspiration.
602. 5.] Compare this paragraph with what follows in article 608.
610.] To remove all suspicion, however, it is doubtless better to inoculate with
matter taken from a mild state of the disease.
612.] All purgatives are extremely nauseous to children ; and as it is of little
consequence what purgatives we use, if we only avoid the hot drastic stimulants, we
ought to pay attention to the agreeableness of the form. Children may in general
be deceived by the following device : Put half an ounce of senna leaves (after the
stalks are all picked out) into a tea-pot, with a quarter of an ounce of green tea;
pour on it a quart of boiling water. Let the child see it poured out into a tea-cup,
sweetened with plenty of moist sugar, and cream put to it. The child will drink it
with avidity. A tea-cupful may be given every hour till it begin to operate.
If this device should fail a second time, another may be used in its stead. Two
drams of senna leaves, powdered, may be added to half a pound of ginger-bread
paste ; the mass may be divided into fifteen small cakes to be baked : give the child
one of these cakes every half hour till it begins to operate, or till he has taken a suf-
ficient dose for his age. A dram of jalap may be used instead of the senna.
If neither of these artifices succeed, a dose of powdered senna, with or without a
little ginger, may be given in orange marmalade.
Children will sometimes eat as many tamarinds as will sufficiently answer all the
intentions of a formal purge. A little Cassia-pulp, added so the tamarinds, will in-
crease their activity, and will not be easily perceived by the child.
The empirics have committed many strange chemical blunders in compounding
their purges for inoculation. Dimsdale's powder may serve as an example : it con-
sists of tartar emetic, and crabs claws. The calcareous earth deprives the tartar
emetic of its acid ; in consequence of which, the antimony will be inert, except it
accidentally meets with an acid in the stomach; and even then the acid must be in
such a quantity as to saturate the crabs claws, before it can act on the antimonial calx.
613. line 26. the former.] Notwithstanding the justness of this remark, bleed-
ing ought not to be employed, except in cases where the phlogistic diathesis and symp-
toms are violent: the fright which children suffer in consequence of the operation,
may be productive of much mischief; and purgatives, when properly administered,
supersede the necessity of bleeding, especially when the cold regimen is employed at
the same time.
615. line 10. common infection.] The author seems to have forgotten a frequent
consequence 

EXPLANATORY NOTES.
consequence of inoculation, that demands some attention, viz. an inflammation of
the axillary glands, that often terminates in suppuration. Many cases of this kind
occurred to me in practice, and I attempted several methods of preventing the suppu-
ration ; of which, I found the following the most efficacious : If only one arm had
been punctured,, the gland of that arm, when such an accident happened, and not of
the other, was inflamed. In attempting the resolution, which perhaps some prac-
titioners may think improper, I applied cold compresses, impregnated with a soluti-
on of Saccharum Saturni, to the inflamed gland, and a warm poultice to the ulcer of
the puncture. The consequence was an increased discharge from the puncture, and
a diminution of the axillary swelled gland.
No ill consequences attended any of those cases where the tumour was thus resolv-
ed; but when these tumours suppurate, they are apt to produce sinous ulcers, very
difficult to heal.
616.] The cooling acids have been described in former notes, (Art. 131. and
134.) Whey made with cream of tartar is very useful in the small pox, as it is a
cooling drink, and at the same time laxative. It is made by throwing into a quart
of boiling milk half an ounce or six drams of powdered cream of tartar.
617. line 8. let some blood.] This practice is most judicious, and ought to be
strictly followed.
619.] The doses for children in these cases are as follow: A child of half a year,
five drops of laudanum : From half a year to a year, six drops : From one to two
years, seven or eight: From two to three, nine or ten: Five years, twelve, or at
most fifteen. These are large doses, and are such as are only to be given to robust
children.
620. line 11. considerable remission.] The practitioner ought to be particularly
attentive to the symptoms which appear on the fifth day. The subsequent paragraphs
render any farther remarks needless.
621. line 10. laxative glysters.] Laxative glysters are preferable to repeated pur-
gatives, on account of their not debilitating the patient so much as purgatives. The
following form has been found very effectual:
ꝶ. Fol. Sennæ, ℥ ℔.
Sal. cathartic, amar. ℥i
Aq. bullient. ℔ i.
Colaturæ frigidæ adde.
Syr. e Spin. Cervin. ℥i.
Ol. Olivar. ℥ ℔.
M.
Or even a simple solution of Epsom salt in warm water.
622. line 4. large quantity.] The method of giving the bark in the small pox, is
the same with that mentioned in the note on article 317. For children, the glyster
there mentioned, is extremely convenient, and proves wonderfully efficacious.
622. line 5. of nitre.] The Spiritus Nitri dulcis is the best form in which nitre
can be given to children. See the notes on article 131.
622. line 6. wine very freely.] The wine best suited to these cases is Port wine:
but as children sometimes loath it, good claret may be substituted in its place.
625.] The best detergent gargles in this case are the tincture of roses with honey;
or the gargle of sage and rose-tea, with vinegar and honey, mentioned in the note
on article 317; or Dr. Fothergill's gargle described in that note.
626. ] A solution of two grains of emetic tartar in eight ounces of water answers
this intention very effectually. The dose is to be determined by the nauseating ef-
fect produced : a table-spoonful of the solution may be given occasionally every two
or

EXPLANATORY NOTES.
or three hours. Care, however, must be taken, that vomiting is not produced :
and, at the same time, a sufficient quantity must be given to produce a nausea. Both
these circumstances depend on the age, strength, and constitution of the patient and
on the violence of the disease.
628.] The secondary fever is always the worst, and most dangerous stage of the
disease. In the distinct small pox it seldom occurs; but it is a constant attendant on
the confluent kind. It seems to be owing to the absorption of the matter: for it ne-
ver appears, evidently at least, till after the suppuration : and, ceteris paribus, it is
always more violent in proportion to the quantity of pustules. Some authors recom-
mend opening the pustules, in order to evacuate the matter, as a preventative against
the secondary fever; and when the eruption is large, this practice is advisable.
The Peruvian bark must be given in these cases in the largest quantities that the
stomach can bear, and also in glysters as formerly mentioned. Some practitioners,
beside the internal use of bark, and giving it in glysters, have advised it to be appli-
ed externally by throwing the dry powder on those parts of the body that are the most
exulcerated.
629.] The most effectual means of preventing pits, are to avoid much exposure
to the cold air, to anoint the face with oil, &c.
630.] As this disease is generally mild, and scarcely ever requires the assistance
of art in the cure, the author very properly passes it over in a cursory manner. It
sometimes, however, very much resembles the mild small pox ; and in such cases may
require the treatment which has been recommended as serviceable in that disease.
644. line 10: very freely.] Bleeding ought to be used where it is absolutely ne-
cessary ; but, too free a use of it has been attended with a long continued weakness,
and a very slow recovery.
646. line 3. or sweet.] Two ounces of pearl barley, and four ounces of dried
figs, cut, boiled in a gallon of water to three quarts, is a good drink in these cases.
If the patient loaths this drink, lintseed tea, or a slight infusion of Orrice root in boil-
ing water, may be substituted in its place, or a solution of an ounce of gum arabic
in a pint of water.
Oily emulsions are also recommended; the most usual is the following:
ꝶ. 01. Amygdal. ℥ii.
Aq. Font. ℥vi.
Alkali Caustic. q. s. ut fiat Emuls. cui adde
Syrup. Althasæ, ℥ii.
The patient may take half a tea-cupful of this emulsion occasionally, when the
cough is most troublesome. The cough may also be relieved, by taking now and
then a tea-spoonful of the following Linctus :
ꝶ. Ol. Amygdal.
Syrup. Althææ.
Conserv. Cynosbat. aa. ℥i.
M. f. Linct.
Or the following:
ꝶ. Mel. anglic.
Ol. Amygdal. aa. ℥ii.
Succ. Limon. ℥i.
M. f. Linct.
647. line 15. great advantage.] Opiates, in all inflammatory cases, ought to be
cautiously used. The danger arising from them is considerably obviated, by using
only the gummy part Of the opium, and therefore the watery solution of opium, is
in these cases preferable to any other form.
The Syrupus papaveris albi, is an opiate peculiarly adapted to this disease; the
dose of it is immaterial, provided we do not exceed four ounces in the four and
twenty 

EXPLANATORY NOTES.
twenty hours ; a table-spoonful may be taken when the cough is troublesome, and
may be repeated every two or three hours according to the urgency of the symptoms.
648.] The complaints which the measles leave are chiefly pneumonic. The
cough is the most troublesome symptom, and to relieve the patient from it, not only
Weeding and purging must be used, but expectorants ought also to be administered.
The Lac Ammoniacum, formerly mentioned, has often proved beneficial.
On the supposition, that the cough and pneumonic affection remaining after the
measles are owing to a peculiar acrimony, some practitioners have recommended al-
teratives and demulcents : Experience, however, has found little advantage from
their use. I once saw a body opened, that had died thirty-two days after the erup-
tion : the internal surface of the bronchiæ were covered with small surfuraceous
scales, somewhat like those that appear on the skin when the eruption goes off.
Hence I have been induced to suppose, that expectorants are the bell remedies in
these cases, and indeed, experience confirms the practice. Bleeding and purging
are only to be occasionally used, in order to prevent the inflammation.
The best method of avoiding the ill consequences that follow the disease, is a free
use of demulcent drinks, during the eruption, and of expectorants immediately after
it. The Decoctum hordei compositum, of the London Pharmacopœia, is peculiarly
adapted to these cases, but it is much improved by adding half an ounce of Orrice
root, when it is nearly boiled enough : If the orrice be added too soon, the efficaci-
ous part of it evaporates. The Lac Ammoniacum above mentioned, is a very pro-
per expectorant, but if it should prove too nauseous, or, through use, be loathed by
the patient, recourse may be had to the weak solution of the tartar emetic, so often
mentioned in these notes.
649.] Though the application of cold air be dangerous, yet ventilation is of con-
siderable use in the measles ; as is also a frequent change of linen, and cleanliness.
665. last paragraph, line 8. with any danger.] These cases in which the disease
is attended with danger, are, however, very few, and are only the effect of art.
Teazing the patient by doing too much ; tormenting him with a close confinement to
his bed, well furnished with blankets; and adding fuel to the flame, by forcing him
to swallow large quantities of cordials and alexipharmics, are the sure methods of in-
creasing the disease: and the patient, distressed by the excessive officiousness of his
sage doctor, is obliged to take refuge in the arms of Death.
657. line 4. antiphlogistic regimen.] The antiphlogistic regimen must not how-
ever be carried too far, lest we induce a state of debility that may prove hurtful.
661.] The detergent gargles were described in the note on article 317. Tinc-
ture of roses is generally used, and in most cases answer every intention. If, how-
ever, the ulceration is considerable, and the sloughs do not easily cast off, recourse
must be had to Dr. Fothergill's gargle, described in article 317.
694.] The reader might possibly expect a detail of the medicines used in the
plague, with their doses, and the manner of administering them ; but I thought it
better to refer to the authors who have either seen the disease, or who have expressly
written on it.
On consulting different authors, it appears, that every particular epidemic requires
a different treatment, in some part of the cure at least. Should any young practiti-
oner be unfortunate enough to have occasion to exercise his art in the cure of the
plague, he must chiefly be directed by the general indications of the cure of fevers.
707.] The antiphlogistic regimen, &c. have been described in former notes.
See Art. 129. et seq.
710. line 5. Toe narcotic] The leaves of solanum, of hemlock, of henbane,
and other similar plants applied as fomentations.
710. line 6. astringent.] Solutions of Saccharum Saturni, or Vitriolum album,
applied cold.
710. line 

EXPLANATORY NOTES.
710. line 7. spirituous. ] Especially if they are such as are compounded with aro-
matics or volatile salts, as camphorated spirit of wine, Hungary water, volatile lini-
ment, &c.
710. line 8. watery.] The reason is evident, because they confine the acrimo-
nious liquor discharged from the part affected.
710. line 12. inflamed parts.] Wheat flour is apt to run into hard lumps by the
thin acrimonious liquor which always exhales from parts affected with erysipelas.
Oatmeal not being so liable to this inconvenience, is therefore preferable: it ought
to be wiped off, and a fresh quantity applied twice or thrice a day.
Many practitioners recommend the application of cabbage leaves to erysipelatous
swellings, and their efficacy has been frequently approved, They ought to be re-
moved as soon as they grow warm or uneasy, and fresh cold ones applied.
713. line 4. last century.] Hoffman, Welsch, and several other writers, fix the
first appearance of this disease at Leipsic in the years 1651 and 1652. This opini-
on, however, is false; for descriptions of miliary eruptions are to be found in the
writings of the ancients, and among the moderns we find Riverius describing it in
France, just after the appearance of the comet of the year 1618; to which pheno-
menon that author ascribes the fatal epidemic, as well as the bloody wars that were
at that time making horrid devastations in Europe.
713. line 5. parts of Europe.] We meet with several accounts of the appearance
of the miliary eruption in different parts of Europe soon after the middle of the last
century, not only by medical writers, but by general historians; among the latter
of whom we may mention Robert Sibbald, who takes notice of it in his Scotia illu-
strata, published at Edinburgh in the year 1684. (Sibbald, however, was a physi-
cian.) To enumerate the medical writers who have described the disease in the dif-
ferent parts of Europe, would take more room than the short compass of these notes
admits, the chief of them are Welsch, Hoffman, Langius, Reyger, Bonetus, Grin-
wald, Sydenham, Ramizini, Fuchsius, &c. &c.
The authors above mentioned, and several others about the end of the last and be-
ginning of this century, entertained various opinions concerning the nature of the
miliary eruption, some of them supposing it to be a critical termination of a peculiar
fever, and others on the contrary strenuously insisting that it was only accidental or
symptomatic, and never critical or salutary. The controversy, which was carried
on with some warmth, is now terminated, as will appear by what follows ; but the
inquisitive young physician v. ill find both entertainment and instruction in perusing
it. A very good abstract of it occurs in De Haen's treatise on the division of Fevers.
726. line 2. symptomatic.] As this disease is always symptomatic and never
idiopathic, the method of curing must necessarily vary in different cases ; the chief
attention of the physician must therefore be turned to the primary disease, and to
the means of preventing this symptom from appearing in those diseases which it ac-
companies.
The author judiciously begins his method of cure by giving directions for prevent-
ing the eruption, which he properly supposes to be entirely factitious, and to depend
on the application of too much heat. With a proper attention to the directions giv-
en in the text, we may in general prevent the eruption. If, however, the eruption
is present before the physician is called, those remedies must be used for its removal
that are enumerated in the subsequent articles.
727. line 20. We are now.] The present rational practice has entirely altered
the regimen in fevers ; and instead of macerating the patient in a hot bed, and
obliging him to breathe the corrupt air of a confined chamber, we now cover him
with light bed-clothes, and ventilate his room.
It may, however, be necessary to guard the young physician against the excess of
this practice. The precept, Omne nimium nocet, should always be attended to. If
the patient feels any disagreeable effect?, or if he should suffer rigors, or trembles
from the admission of cold air, it is certainly prejudicial, and its admission ought to
be regulated.  It

EXPLANATORY NOTES.
It may not be improper to mention another caution, viz. That the young practi-
tioner must not, by the means here recommended, check sweats that are really cri-
tical. To determine what sweats are, and what are not, critical, is perhaps, in
some cases, attended with considerable difficulty. In general, however, critical
sweats may be known by their happening on the critical days before mentioned in
articles 107. et seq. and by their always being immediately followed by an abate-
ment of all, or at least the greatest part of the symptoms.
731. line 5. to treat of it.] It appears from the following passage in the author's
Synopsis, that he had afterwards seen it: " Collega noster eximius Franciscus
" Home, mihi hominem leviter febricitantem ostendit, cui, primum in brachiis,
" et successive demum in toto corpore, vesiculæ magnitudine avellanæ obortæ sunt,
" et post duos tresve dies effuso humoris serosi pauxillo, collapsæ sunt. Hæc febris
" autem nullam indolem vel typum peculiarem monstrabat, et cito disparuit ne-
" quaquam contagiosa."
732.] Boerhaave only saw aphthæ twice without, and preceding, fever, and
Van Swieten only once; but Ketelaer says he has frequently seen them. They
sometimes accompany inflammations of the viscera, and other inflammatory fevers,
and are often difficult to remove. They are to be treated in the same manner as the
ulcerations in the Cynanche maligna, by gargles of the detersive kind, until the
aphthous crust separates and falls off; but when that crust has fallen off, the pain-
fulness of the nakedly exposed sensible parts requires emollient applications ; of which
kind a decoction of Rad. Alth. or an infusion of lintseed, are proper gargles alone :
if honey be added, the patient complains of its making the parts smart. The pati-
ent's diet ought to be of the mildest kind, that it may be swallowed without causing
much pain.
The aphthous crust frequently appears at the anus, which symptom generally
leads us to conclude, as is really the case, that aphthæ covers the whole intestinal
canal. Hence considerable danger arises. The absorbents are covered, and refuse
admittance to all nourishment; hence an increased debility, with all its evil conse-
quences. In these cases, a nutritive, liquid, and detersive diet, must be used. For
this purpose a decoction of bread, with wine and honey, is the properest drink.
Such a decoction is extremely nutritive, and also averse to putrefaction, and there-
fore well adapted to the exigency of the case.
739. line 2. quick.] The difference between a frequent and quick pulse was
mentioned in a note on article 336.
774. 3. line 15. anger.] Passionate children frequently bring on a bleeding of
the nose; and when such an accident happens, the child's face, before the blood
breaks out, becomes red, and all the vessels of the head and neck seem distended
and full. 
774. 4. line 5. exercise of respiration.] As playing on the German flute, or any
other wind instrument that requires a great force to blow it.
782. line 19. excreta.] This effect may surely be more speedily produced by
using both these means at once.
784.] The exercise best adapted to these cases is such as does not heat the body
or increase the force of the blood. Hence riding moderately, travelling in a carri-
age, or sailing, are preferable to walking. Young people may use such gentle exer-
cise as may amuse the mind, and at the same time conduce to bodily health, as
gardening, several agricultural labours, or mechanical operations; or some of the
sports that require a gentle bodily exertion, as bowling, archery, &c.
786.] Brisk purges are perhaps preferable to every other mode of evacuating the
ingesta ; and in these cases we may have recourse to drastics without any apprehension
of danger. The following formulæ may serve as specimens of the purges useful in
these cases.
R. Pul.

EXPLANATORY NOTES.
ꝶ. Pulv. Rad. Jalap. ℥ ℔.
Aromat. ʒi.
Sal. Tart. ʒ ℔.
Syr. Simp. q. s.
M. f. Elect.
This electuary may be divided into four doses, one of which may be taken early
in the morning, as occasion may require.
ꝶ. Pilul. Rusi, ʒ ℔.
Calomel, gr. vi.
Syr. Simpl. q. s.
M. f. Massa in pilulas equales sex dividend.
Two of these pills may be taken in the evening, and the remaining four the fol-
lowing morning.
ꝶ. Resin. Jalap. ℈i.
Tere in mortar, cum Sacch. alb. ʒ ℔.
Amygdal. dulc. decorticat. No. ii.
Adde gradatim Aq. Cinnamom. simpl. ℥i.
M. f. haust. mane sumend.
This is a very elegant purge, and has the peculiar advantage of operating power-
fully without griping or occasioning much inconvenience.
789.] The doctrine here delivered, and the practice founded on it, is pure
Stahlianism; and is, doubtless, in these cases the best practice. A patient, how-
ever, is not always satisfied when the physician is inactive, which often obliges him
to prescribe some of the medicamenta inertiora, and the choice of them must be left
to the practitioner's own sagacity.
792.] The refrigerant medicines have been enumerated in former notes, arti-
cles 134. and 135. The Tinctura rosarum is a very proper acid refrigerant in most
hemorrhagies. The dose of it must be proportioned to the exigency of the case; it
ought never to exceed four ounces in the space of an hour; an ounce every half hour
is generally sufficient, and a greater quantity at a time frequently occasions gripes,
and by its irritation increases the disease; especially if it does not produce a diarrhœa
which is seldom the case. With respect to nitre, the precautions, mentioned in the
note on article 135, must be observed. The dulcified spirit of vitriol or of nitre are
not always safe medicines in these cases, as they heat and irritate. The acid of
tartar, in the form described in the note on article 134. answers very well in most
cases.
797. line 16. little efficacy.] It is a very dangerous medicine, and ought to be
used with the utmost caution. But since its efficacy is doubtful, we had better
abandon it altogether, except when every other remedy fails.
797. line 21. alum.] Alum frequently irritates if given in too large doses at first,
proving sometimes a purgative and sometimes an emetic. In cases of great danger,
however, it must be given in large quantities by frequently repeating small doses.
Five grains is a sufficient dose to begin with ; but it may be repeated every hour, or
every half hour. Some authors have given it in doses of a scruple several times a
day; but that is certainly too great a quantity at once.
799. ] Van Swieten relates a case of a bleeding at the nose being stopped by the
application of pledgets, dipped in cold wine and water, to the scrotum ; a shivering
was produced, and the bleeding stopped.
Vol. I. 3 M 800. line 

EXPLANATORY NOTES.
800. line 2. charms.] It is astonishing that these charms should continue in use
in this enlightened age. They are practised among the country people frequently.
Some of them, however, act mechanically, as the application of the great key of
the church door to the nape of the neck, in bleedings at the nose ; drinking large
draughts of cold water out of a human skull, &c. The cold iron and the cold water
were in fact proper remedies.
801.] Opium, however, ought to be cautiously avoided in active hemorrhagies,
which are frequently accompanied with a phlogistic diathesis ; and it is well known,
that in such a diathesis, opium is generally, if not universally, hurtful. But, as the
author observes, when the hemorrhagy has reduced the inflammatory diathesis, we
may then give opium freely; and for this purpose large doses are preferable to small-
er ones.
803.] Attention, however, is necessary in this case, as fainting is frequently
the forerunner of death.
821. line 6. following paragraphs.] Beside the general directions referred to a-
bove, plugs of lint or cotton, impregnated with vinegar and a solution of alum, are
recommended. Thick cotton threads, impregnated with these styptic solutions,
have been passed through the nostril, and brought out by the mouth by means of a
bent probe, with great success.
822. line 9. open belly.] For this purpose Glauber's salt seems peculiarly adapt-
ed. It operates speedily, and without too much irritation ; evacuating, at the same
time, not only the contents of the intestinal canal, but the superfluities of the san-
guiferous system.
845. line 3. the menses.] The author might have added, " And when no symp-
" toms of phthisis have preceded or accompanies the hemorrhage."
846.] The tincture of roses has been frequently employed with success in these
cases: alum, however, is the principal astringent. It may be given, either by it-
self in small and often repeated doses, or combined with terra Japonica. The fol-
lowing formula is very convenient:
ꝶ. Alamin.
Terr. Japonic, aa. ʒi.
Conserv. Rosar. ℥i.
M. f. Elect. cum. syr. commun. q. s.
The dose ought to be proportioned to the exigency of the case: in general, the above
prescribed mass may be divided into ten equal parts; one of which may be given
every two hours, or in urgent cases, every hour. In using this medicine, it will be
necessary to keep the belly open : but for this purpose, purgatives are ill adapted, as
they carry off with them the medicine that is employed : glysters are therefore pre-
ferable ; and in order that they be the more effectual, they ought to be somewhat of
a stimulating nature : as,
ꝶ. Infus. Sennæ, ℥vi.
Sal. Cathartic. Amar. ℥i.
Decoct. Hordei, ℥viii.
M.
Or,
ꝶ. Pulp. Tamarind. ℥ii.
Crem. Tart. ℥ ℔.
Coque in Aq. font. q. s. ad colaturæ ℔xii.
Adde, Mann. ℥ii.
M.
848. line 

EXPLANATORY NOTES.
848. line 13. nitre.] Nitre ought to be cautiously used in all complaints of the
lungs, on account of the irritation which it produces, and the subsequent cough
which it excites.
850. line 5. sailing.] A sea-voyage has often been prescribed for hemoptysis :
it is, nevertheless, a very dangerous practice, on account of the violent agitation
produced by the sea-sickness in the action of vomiting. The violence of the reach-
ings in sea-sickness, especially after the contents of the stomach are throughly evacu-
ated, has been known to cause hemoptysis, by a rupture of some considerable vessel.
The hemorrhagy, indeed, hence proceeding, is not an active hemorrhagy ; but, ne-
vertheless, in a phlogistic diathesis, which predisposes to an active hemorrhagy, we
ought always to be cautious how we employ remedies, which, although they do not
immediately increase the predisposing diathesis, produce the least irritation, or give
any violent shock in their action.
Speaking loud, singing, playing on wind instruments, and whatever requires any
exertion of the lungs, ought to be carefully avoided.
851.] In the cure of the hemoptysis, the patient's drink ought to be of the aci-
dulous kind, or of the acidulous and astringent kinds conjoined. The vitriolic acid
is therefore the most eligible, but it ought to be well diluted. A pleasant drink may
be composed of one part of the tincture of roses, and four of cold water : or the tinc-
ture of roses may be prescribed with five times the quantity of water that is ordered
in the Pharmacopœia. The acid of tartar dissolved in twenty times its weight of
water, and sweetened with a little syrup of roses, is also a suitable drink. A decoc-
tion either of the fresh fruit of quinces, sweetened with sugar, or an infusion of
quince marmalade, is another excellent acid astringent.
In addition to what has been said, it may be proper to observe, that opium is ad-
missible only in very few cases of hemoptysis, viz. when the hemoptysis is the conse-
quence of coughing. These cases are very difficultly distinguished. If the blood be
thrown out into the lungs, a Cough is excited for its discharge, and then the hemop-
tysis is the primary disease : in this case opium does more harm than good. But if
a cough arising from any other irritating cause, than extravasated blood in the lungs,
should by its violence and long continuance, produce an hemoptysis, then opium,
joined with such remedies as are suitable to remove the peculiar irritation, is the on-
ly medicine on which we can have any reliance; and in these cases we must use it
in large doses, such as forty or fifty drops of laudanum.
899. line 10. attended to.] This early attention to the first symptoms of the dis-
ease is of the utmost consequence, for it is only in the early stage that any remedies
can be employed with success, as experience has sufficiently taught. See Article
905. et seq.
912. line 6. warm clothing.] This is a most essential part in the cure of phthi-
sis, and many other diseases prevalent in cold climates.
The warm clothing that is most effectual is flannel shirts next the skin. It feels
a little disagreeable at first to a person unaccustomed to it; but the great relief it af-
fords, and the comfortable sensation it produces, are so strong inducements for con-
tinuing its use, that few people who have once experienced its beneficial effects have
any desire to relinquish it.
917.] From the preceding account of the disease, it is sufficiently evident that
all acrid and hot substances must be hurtful in phthisis. The balsamics have been
long recommended in these cases, even by the best authorities, but on what princi-
ple is not easy to determine.
920. line 3. acid of vegetables.] The acid fruits, acid of tartar, acid of sorrel,
and other plants yielding an acid, but not an acrid, juice. The eating of oranges
is therefore serviceable.
949. line 4. proper diet.] Broths of all kind are proper in these cases: barley
broth is preferable to that which is made with rice. Barley gruel, with prunes, is
an excellent laxative broth.
949. line 

EXPLANATORY NOTES.
949. line 8. irritating the rectum.] The lenitive electuary alone may in many
cases be sufficient, when given in the quantity of half an ounce or six drams. The
following formula may be used where greater costiveness prevails :
ꝶ. Sal. Nitri, ʒii.
Pulv. Jalan. ʒi.
Elect. Lenitivi, ℥i.
M. f. Elect. cujus sumat q. n. m. pro re nata.
951. ] Astringents may be used both internally and externally. The internal
astringents are Alum, Kino, Terra Japonica, &c. But in cases of hemorrhoids
from laxity, nothing produces a better effect than the frequent application of pledg-
ets dipped in a strong infusion of galis, or oak bark.
953.] It is doubtful whether riding is ever adviseable in any period of the dis-
ease. Riding frequently produces Piles, in persons not in the least predisposed to.
them.
END OF THE FIRST VOLUME.