NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Heahh, Education, and Welfare Public Health Serrice 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. Cftitb 3&ra3icai ant) €jcplanatorp ^otcs, b£ JOHN ROTHERAM, M.D. VOLUME IL PHILADELPHIA: PRINTED AND SOLD BY FARS.T HALLy NO. I49, CHESNWT STREET} BETWEEN FOURTH AND FIFTH STREETS. M. DCC. XCII. CONTENTS. BOOK IV. CHAPTER. VI. Page L/F *fhe Menorrhagia, or the Immoderate Flow of the Menfes — — o CHAP. VII. @f the Leucorrhdea, Fluor AIbus, or W-hiSes 17 CHAP. VIII. Of the Amenorrhoea, or Interrnption of the Menjlrual Flux — 21 CHAP. IX. 0/Symptomatic Hemorrhagies 30 Se£l. I. Of the Hematemesis, or Vomiting of Blood — — 30 Seel. II. 0/M« Hematuria, or the Void- ing of Blood from the Urinary Paffage 39 BOOK V. Of PROFLUVIA, or FLUXES with PY- REXIA — — — — 47 CHAP. I. Of the Catarrh — —- 48 CHAP. 445^10 iv CONTENTS. Page, CHAP. II. Of the Dysentery —■ -*- 5^ P A R T II. Of NEUROSES, or NERVOUS DIS- EASES — — — 67 BOOK I. Of COMATA, or the LOSS of VO- LUNTARY MOTION — 68 CHAP. I. Of Apoplexy —■ — — 68 CHAP. II. Of Palsy — — —- 90 BOOK II.. Of ADYNAMIC, or DISEASES con- sisting in a WEAKNESS or LOSS of MOTION in either the VITAL or NATURAL FUNCTIONS — 104 CHAP, L Qf Syncope, or Fainting —? 104 CHAP. II. ^/Dyspepsia, or Indigeflion — 113 CHAP. III. Of Hypochondriasis, or the Hypochondriac Affection, CONTENTS. v Page. Affection, commonly called Vapours or Low Spirits — — — 129 BOO K III. Of SPASMODIC AFFECTIONS, with- out FEVER — — 141 SECT. I. Of the Spasmodic Affections of the Ani- mal Functions — — *42 Chap. I. Of Tetanus — — *44 Chap. II. Of Epikpfy — *58 Chap. III. Of the Chorea, or Dance of St, Vitus — — — l85 SECT. II. Of the Spasmodic Affections qftheViTAL Functions — — !°7 Chap, IV*. Of the Palpitation of the Heart 187 Chap. V. Of Dyfpncea, or Difficult Breath- ing — — — 191 Chap. VI. Of AJlhma — — 194 Chap. VII. Of the Chincough, or Hooping- cough — — — 206 SECT. III. Of the Spasmodic Affections in the Na- tural Functions — — 217 Chap. VIII. Of the Pyrofis, or what is named in Scotland the Water Brafh 217 Chap. IX. Of the Colic — 220 Chap. X. Of the Cholera — 231 Chap. XI. Of Diarrhoea, or Loofenefs 235 Chap. * Though I have thought it proper to divide this book into fecYions, I thinlf. it neceffary, for the convenience of rcterence*, to number the chapters from the be- ginning.—Author. vi CONTENT S. Page. Ch^p. XII. Of the Diabetes —- 252 Chap XIII. Of the Hyjlefia* or the Hyfle- ric Difeafe — — 257 Chap. XIV. Of Canine Madnefs and Hy- drophobia — — 264 BOOK IV. Of VESANItE, on of t^ie DISOR- DERS of the INTELLECTUAL FUNCTIONS — — 266 € H A P. I. Of Ves an 1 m in -general — 266 CHAP. II. Of Mania, or Madness — 281 CHA.P. III. 0/"Melancholy, and other Forms of Infanity 292 PART III. Of CACHEXIES — — 302 BOOK I. Of EMACIATIONS — 3^3 BOOK II. Of INTUMESCENTI^E, or GENERAL SWELLINGS — — 315 CHAP. I. Of Adipose Swellings — 315 CHAP. CONTENTS. vii Page. CHAP. II. Of Flatulent Swellings — 319 CHAP. III. Of Watery Swellings, or Dropsies 329 Sect. I. Of Anafarca — — 342 Seel. II. Of the Hydrothorax, or Dropjy of the Breafl — — — 357 Se£t. III. Of Afcites r or Dropfy of the Low- er Belly — — — 363 CHAP. IV. Of General Swellings, arifing from an increafed Bulk of the whole Substance of particular Parts — 368 Of Rachitis, or Rickets — — 368 BOOK III. Of the IMPETIGINES, or deprav- ed HABIT, with AFFECTIONS of the SKIN — — 381 CHAP. I. Of Scrophula, or the King's Evil 381 CHAP. II. Of Siphylis, or the Venereal Disease 392 CHAP. III. Of Scurvy — — — 408 CHAP. IV. 0/" Jaundice — — 4.1% C 9 3 FIRST LINES O t THE PRACTICE of PHYSIC. --------- ^^ ------- BOOK IV, CHAP. VI. Of the MENORRHAGIA, or the IMMO- DERATE FLOW of the MENSES. 96^. BLOOD difcharged from the Vagina may pro- ceed from different fources in the internal parts : But I here mean to treat of thofe dilcharges only, in which the blood may be prefumed to flow from the fame fources that the menles in their na- tural ftate proceed from; and which difcharges alone, are thofe properly comprehended under the prefent title. The title of Metrorrhagia, or hcemor- rhagia uteri, might comprehend a great deal more. 966* The menorrhagia may be confidered as of two kinds; either as it happens to pregnant and lying Vol. II. B ' in io PRACTICE in women, or as it happens to women neither preg- nant nor having recently born children. The nrft kind as connected with the circumftances of preg- nancy and childbearing, (which are not to be treat- ed of in the prefent co'urfe), I am not to confider here, but fhall confine myfelf to the fecond kind of menorrhagia only. 967. The flow of the menfes is confidered as immode- rate, when it recurs more frequently*, when it continues longer, or when, during the ordinary continuancet, it is more abundant^ than is ufual with the fame perfon at other times. ' ' 968. As the mod part of women are liable to fome in* equality with refpeel to the period, the duration, and the quantity of their menfes; fo it is not every inequality in t.hefe refpects that is to be confidered as a difeafe; but only thofe deviations, which are exceflive in degree, which are permanent, and which induce a manifeft date of debility. 969. The circumftances (967. 968.) are thofe wlikh chiefly conditute the menorrhagia : But it is proper to obferve, that although I allow the frequency, duration, and quantity of the menfes to be judged of by what is ufual with the lame individual at other times ; yet there is, in Lhefe particulars, fo much * The ufual period is from twenty-feven to thirty days. + The time of its continuance is very various in different people; it feldom Continues longer than eight days or fhorter than two. In general, women of a lax and delicate conftitution have a more copious and a longer continued difcharge than robuft people. % It is extremely difficult to afcertain precifely what quantity is ufually difcharg- ed ; but the women themlelves can jjrenejally inlorni the ph\lician with fufEtient exadtnefs for regulating the praftice whether the difchaige be immoderate. OF PHYSIC. 11 much uniformity obfervable in the whole of the fex, that in any individual in whom there occurs a conflderable deviation from the common mea- fure, fuch a deviation, if condantly recurring, may be confidered as at lead approaching to a mor- bid date, and as requiring mod of the precautions which I (hall hereafter mention as neceflary to be attendedto by thofe who are actually in fuch a date. 970. However we may determine with refpect to the circumftances (967. 968.), it mud dill be allowed, that the immoderate flow of the menfes is efpecial- jy to be determined by thofe fymptoms affecting other functions of the body, which accompany and follow the dilcharge. When a larger flow than ufual of the menfes has been preceded by headach, giddinefs, or dyfpncea, and has been umeredin by a cold dage, and is at- tended with much pain of the back and loins, with a frequent pulfe, heat, and third, it may then be confidered as preternaturally large. 971- When, in confequence of the circumdances (967.—970.), and the repetition of thefe, the face becomes pale; the pulfe grows weak; an unufual debility is felt in exercife; the breathing is hurri- ed by moderate exercife; when, alfo, the back be- comes pained from any continuance in an ereft podure ; when the extremities become frequently cold; and when in the evening the feet appear af- fected with cedematous fwelling; we may from thefe fymptoms certainly conclude, that the flow of the menfes has been immoderate, and has already induced a dangerous date of debility. 972. The Xt PRACTICE 972. The debility thus induced, does often difcover itfelfalfo by affeftions of the domach, as anorexia and other fymptoms of dyfpepfia; by a palpitation of the heart, and frequent faintings j byaweaknefs of mind liable to drong emotions from flight caufes4 efpecially when fuddenly prefented, 973« That flow of the menfes, which is attended with barrennefs in married women, may be generally confidered as immoderate and morbid. 974- Generally, alfo, that flow of the menfes may be confidered as immoderate, which is preceded and followed by a leucorrhcea, 975- I treat of menorrhagia" here as an active hemor-. rhagy, becaufe I confider mendruation, in its na- tural date, to be always of that kind; and although there mould be cafes of menorrhagia which might be confidered as purely paflive, it appears to me that they cannot be fo properly treated of in any Other place. 976. The menorrhagia (967. et feq.) has for its prox-> imate caufe, either the hemorrhagic effort of the uterine veflels prcternaturally increafed, or a pre- ternatural laxity of the extremities of the uterine arteries, the hemorrhagic effort remaining as in the natural date. 977. Ths OF PHYSIC. *3 977- The remote caufes of the menorrhagia may be, l/l, Thofe which increafe the'plethoric date of the Uterine veftels ; fuch as a full and nourifhing diet, much drong liquor, and frequent intoxication. idly, Thofe which determine the blood more copi- oufly and forcibly into the uterine veffels ; as vio- lent drainings of the whole body; violent fhocks of the whole body from falls ; violent drokes or contufions on the lower belly ; violent exercife, particularly in dancing; and violent paflions of the mind. %dly, Thofe which particularly irritate: the veffels of the uterus; as excefs in venery ; the exercife of venery in the time of mendruation ; a a coftive habit, giving occafion to violent drain- ing at dool ; and cold applied to the feet*. 4thlyt Thofe who have forcibly overdrained the extre- mities of the uterine veffels; as frequent abortions? frequent childbearing without nurfingf; and diffi-. Cult tedious labours. Or, lajlly, Thofe which in- duce a general laxity ; as living much in warm chambers, and drinking much of warm epervating liquors, fuch as tea and coffee, 978. The * It is difficult to account for this caufe of menorrhagia: It may perhaps be ow- ing to the circulation through the lower extremities being obftructed or impeded, and Consequently a greater flow of blood to the uterus. The fadt, however, is certain ; for experience fufficiently evinces that menorrhagia frequently follows an imprudent cxpofqre of the feet to cold, efpecially damp cold. Sitting in wet fhoes, or in a damp cold room with a Hone floor, ought to be carefully avoided by ladies of a delicate con- stitution. t By nurfing, the fluids are determined to the bread, and in a peculiar manner derived from the uterus. This part of the economy of nature phyfiologills have not yet fufficiently explained, but the fait is well afcertained. Nurfing is not only ufeful in preventing menorrhagia, but, as it derives the fluids from the uterus, it pievents alfo frequent child-bearing; and confequently, which is the greateft advantage of all others, time is allowed to the uterus for regaining itsi r- mer tone and ftrength : The fubfequsnt child-births arealfo rendered moie eafy l',i:d they would otherwife be, and the children more healthy. It would be improper to enumerate all the advantages of nurfing in. this pk.ee, j. Cort. Pcruv. §i. Syr. fimpl. q. s. M. f. Eleft. The dofe of tliistlectuary is to be varied according to the conftitution; the fize of a nutmeg twice a day is ufually given. The belt forms of chalybeates, in thefe cafes, are the mineral waters which contain iron diffolved by fixed air. Chalybeate waters mould not, in this difeafe, be drank in fuch large quantities as to pafs off by ftool. A gill taken every three or four hours throughout the day, with a fpoonful of Port wine, is more efficacious than a pint or even a quart, taken at once in the morning. The dofe, however, of jhefe waters, varies according to the ftrength of the particular water we ufe. Along with the chalybsate water, a fcruple or half a dram of Peruvian bark may be given twice a-day. The following form is very agreeable, and is at the fame time Angularly efficacious I ft. Extraft. cort. Peruv. §i. Extraft. Campechenf. Extraft. Glychrrh. aa §fs. Mucilag. gum. Arab. q. s. M. f. Eleft. The dofe iv half a dram or two fcruples twice a-day. o fr physic, *7 983^ The remedies mehtianed in thefe two laft para* graphs, may be employed in all cafes of menor- rhagia, from whatever caufe it may have proceeded, if the difeafe fhall have already induced a confider- able degree of debility in the body. CHAP. VIL Of the LEUCORRHCEA, FLUOR ALBUS, or WHITES. 984; EVERY ferous or puriforrri difcharge from the vagina, may be, and has been compre- hended under one or other of the appellations I have prefixed to this chapter. Such dilcharges, however, may be various; and may proceed from various fources, not yet well afcertained; but I confine myfelf here to treat of that difcharge alone which may be prefumed to proceed from the fame veffels, which, in their natural date, pour out the menfes* 985. I conclude a difcharge from the vagina to be of this kind*; 1. From its happening to women who are fubject to an immoderate flow of the menfes, and liable to this from caufes weakening the veffels of the Uterus. 2. From its appearing chiefly, and often only, a little before, as well as immediately after, the flow of the menfes. 3. From the flow of the menfes being diminifhed, in proportion as Vol. II. C the * The young practitioner ought to pay great attention to the diagnoftics of tha leucorrhoea delivered in this article* 18 PRACTICE the leucorrhcea is increafed. 4. From the leu- corrhcea continuing after the menfes have entirely ceafed, and with fome appearance of its obferving a periodical recurrence. 5. From the leucorrhcea being accompanied with the effects of the menor- rhagia (971. 972.) 6. From the difcharge having been neither preceded by, nor accompanied with, fymptoms of any topical affections of the uterus. 7. From the leucorrhcea not having appeared foon after communication with a perfon who might be fufpecled of communicating infecjtion, and from the firft appearance of the difeafe not being ac- companied with any inflammatory affe&ion of the pudenda*. 986. The appearance of the matter difebarged in the" leucorrhcea, is very various with refpect. to confid- ence and colour; but from thefe appearances, it is not always poffible to determine concerning its nature, or the particular fource from whence it proceeds. 987. The leucorrhcea, of which I am to treaty as af- certained by the feveral circumdances (985.), feems to proceed from the fame caufes as that fpecies of menorrhagia which I fuppofe to arile from the lax- ity of the extreme veffels of the uterus. It accord- ingly often follows or accompanies fuch a menor- rhagia ; * Nothing is more frequent with ignorant practitioners than to miftake a gonor- rhoea for a leucorrhcea. Women Ift.general giv£ the^ame of whites to a gonorrhoea, au4'therefore the unwary practitioner may the more eafily be mifled. The diftinguifh- ir.g chura&eriftic of gonorrhea is, as the Author fays, an inflammatory affection of the pudenda ; but, als few women willfuffer an infpeclion of the partsi we mult pay fome attention to the concomitant fymptoms. The.running in a gonorrhoea is con., fc. nt, and only m fmall quantities; In a leucorrhcw the difcharge is inconftant, and in k'n;e quantities. The other diflinguifliirlg marks of a gonorrhoea' are, fm.mirie in making water, itching of the pudenda, increafed inclination for venery, afweUin» of the labia and of the glands about the groin. Some authors mention the colour oi the difcharged nutter as s dlftinguifhing majk; th'u, however, i* inconftaut„ OF PHYSIC. 10 rhagia; but though the leucorrhcea depends chiefly upon the laxity mentioned, it may have proceeded from irritations inducing that laxity, and feems to be always increafed by any irritations applied to the uterus. 988. Some authors have alleged, that a variety of circumftances in other parts of the body may have a fhare in bringing on and in continuing this affec- tion of the uterus now under confederation ; but I cannot difcover the reality of thgfe caufes ; and it feems to me, that this leucorrhcea, excepting in fo far as it depends upon a general debility of the fyf- tem, is always primarily an affection of the uterus; and the affections of other parts of the body which .may happen to accompany it, are for the mod part to be confidered as effefts, rather than as caufes. 989. The effects of the leucorrhcea are much the fame with thofe of menorrhagia: inducing a general de- bility, and in particular, a debility in the functions of the domach. If, however, the leucorrhcea be moderate, and be not accompanied with any con- fiderable degree of menorrhagia, it may often con- tinue long without inducing any great degree of debility, and it is only when the difcharge has been very copious as well as condant, that its effects in that way arc very remarkable. 99O. But, even when-its effects upon the whole body are not very confiderable, it may dill be fuppofcd to weaken the genital fydem ; and it feems fuffu i cntly probable that this difcharge may often have a fhare in occafioning barrennefs. 991. The 20 PRACTICE 991. The matter difcharged in the leucorrhcea, is at fird generally mild ; but after fome continuance of the difeafe, it fometimes becomes acrid*; and by irritating, or perhaps eroding, the iurfaces over which it paffes, induces various painful disorders, 992. As I have fuppofed that the leucorrhcea pro* ceeds from the fame caufes as that fpecies of me- norrhagia which is chiefly owing to a laxity of the uterine veffels, it mud be treated, and the cure atr tempted, by the fame means as delivered in (981.), for the cure of menorrhagia, and with lets relerve in refpe6l of the ufe of aflringentst, 993- As the leucorrhcea generally depends upon a great lofs of tone in the veffels of the uterus, the difeafe has been relieved, and fometimes cured by certain dimulant medicines, which are commonly determined to the urinary paflages, and from the vicinity of thefe are often communicated to the uterus. Such, for example, are cantharides, tur- pentine^ and other balfams of a fimilar nature^. CHAP. * The young practitioner muft not conclude too haftily that an ulcer exifts ir. the uterus when the nntter difcharged is acrid. Practice has afforded many inltan- ces .-.here the matter h?s excoriated the pudenda, and yet no ulcer exifted. ■f The electuary mentioned at the end of the laft note on Article 982. has been found efficacious in fome cafes of leucarrhoe.-!. Its dofe may be increafed to a dram rhricc a-day, either fwallowcd as a bolus, or diffolved in an ounce of pure water, and l;alf an ounce of fimple cinnamon vv;.tcr. The chalyb:ate w^ter- .reufeful in this, as well as in the former difeafe; and tbey may be ufcd in the manner above mentioned. Prn^rif ioner« rrcorr.mrr.d, in thefe cafe?, a nutritive but not a heating diet, as mu- riheinous b:•■•>!'is made with rice, efpecially veal-broth, jellies of all kinds,, jexcept tlufe that are high-feafono.J. Port wine muft be prefcribed in a moderate quantity, .ccon-ing to tin h ibits of the patient. + The pra^ice here re~ommcnded b not without darker, and muft not be fallow, f.i •—:;?* vith gre.'.t unison and t'.icunfpjdlion. When the other means fail pro- OF PHYSIC. 31 CHAP. VIII. Of the AMENORRHOEA, or INTERRUP- TION of the MENSTRUAL FLUX. 994. WHATEVER, in a fydem of methodical no- fology, may be the fitted place for the amc- norrhcea, it cannot be improper to treat of it here as an object, of practice, immediately after having confidered the menorrhagia, 995- The interruption of the mendrual flux is to be confidered as of two different kinds; the one being when the menfes do not begin to flow at that peri- od of life at which they ufually appear; and the other being that when, after they have repeatedly taken place for fome time, they do, from other cau- fes than conception, ceafe to return at their ufual periods : The former of thefe cafes is named the retenfion, and the latter the Jupprejfwn, of the men- fes, 996. As ducing relief, we may then have recourfe to thefe balfamics, or join them to the to. ■ic aftringents, as, R. Gum. oliban. Terebinth, venet. Alum. Terr, japonic, aa. 3i. Sal. martis 3fs. M. f. mafia, in pilulas aequales No. 60. dividecd. Two or three of thefe pills may be given twice a day or oftener. Some practitioners have ftrongly recommended the following emulfion. J3<. Balfam. copaivi. 51. Vitel. ovi No. 1. Tore in mortar, marmor. et adde gradating Aq. font. §vii. Syr. Simpl. *i. A/, f. Emulf. The dofe of this emulfion is 2 or 3 fpoonfuh three or four times a day. 22 PRACTICE 996. As the flowing of the menfes depends upon the force of the uterine arteries impelling the blood in- to their extremities, and opening thefe fo as to pour out red blood; fo the interruption of themendrual flux mud depend, either upon the want of due force in the action of the uterine arteries, or upon fome preternatural refidance in their extremities. The former I fuppofe to be the mod ufual caufe of re- tention, the latter the mod common caufe of fup- preflion; and of each of thefe I fhall now treat more particularly. 997- The retention of the menfes, the emanjio men- Jium of Latin writers, is not to be confidered as a difeafe merely from the menfes not flowing at that period which is ufual with mod other women. This period is fo different in different women, that no time can be precifely afligned as proper to the fex in general. In this climate, the menfes ufually ap- pear about the age of fourteen ; but in many, thejr appear more early, and in many not till the fix- teenth year ; in which lad cafe it is often without any diforder being thereby occafioned. It is not therefore from the age of the perfon, that the re- tention is to be confidered as a difeafe; and it is only to be confidered as fuch, when, about the time the menfes ufually appear, fome diforders a- rife in other parts of the body which may be imput- ed to their retention j being fuch as, when arifing at this period, are known from experience to be re- moved by the flowing of the menfes. 998. Thefe diforders are, a fluggifhnefs, and frequent fenfc of laflitude and debility, with various fymp- toms O F P H Y S I C. j3 toms of dyfpepfia ; and fometimes with a preterna- tural appetite*. At the fame time the face lofesits vivid colour, becomes pale, and fometimes of a yellowifh hue ; the whole body becomes pale and flaccid ; and the feet, and perhaps alfo a great part of the body, become afie&eci, with cedematous fvyel- lings. The breathing is hurried by any quick or laborious motion of the body, and the heart is lia- ble to palpitation and fyncope. A headach fome- times ocpurs ; but more certainly pains of the Ipack, loins and haiwehesf. 999. Thefe fymptoms, when occurring in a higb de- gree, conflitute.the chkrojis of authors, hardly ever appearing feparate from the retention of the men- . fes ; and, attending to thefe fymptoms, the cauf'9 of this retention may, I think, be perceived. Thefe fymptoms manifeftly (how a confiderable laxity and flaccidity of the whole fydem ; ana therefore give reafon to conclude, that the reten- tion of the menfes accompanying them, is owing to a weaker action of the veffels of-the uterus; which therefore do not impel the bipod into their extre- mities with a force fufneient to open thefe, and pour out blood by them. ,., , ;i: ,. .'.;-. IOOO. How it happens that at a certain period of life a ftaccidjty of t;he fydem arifes in yoyng women not ..originally affected, w^th any fuch weaknefs or laxity, and of which, but a little time before, they had given * This is a very extraordinary fymptom, which has not hitherto been explained. It fometimes accompanies every cellation of the uterine difcharge, but frequently ap- pears' in the raoft violent degree, 'irt pregnancy. la young women, the appetite for chalk, lime-rubbifh, charcoal, and varioui •abforbe'nrs', is'fhe'rrioft prevalent. St'ahl, and his followers, made great ufe ofthti circuinftance infupporting their favourite opinion of the vis medicatrix nature. \ Theft pains' are not properly fymptoms of the difeafe, but' prognoftic'r of the >«il»tt* nature makes to remove the difeafe: Tkey are fymptoms of the vit mediatrix* H PRACTICE given no indication, may be difficult to explairi j but I would attempt it in this way. As a certain date of the ovaria in females, pre-* pares and difpofes them to the exercife of venery, about the very period at which the menfes fird ap- pear, it is to be prefumed that the date of the ova^- ria and that of the uterine veffels are in fome mea- fure connected together ; and as generally fymp- toms of a change in the date of the former appear before thofe of the latter, it may be inferred, that the date of the ovaria has a great fhare in exciting the aclion of the uterine veflels, and producing the menftrual flux. But, analogous to what hap- pens in the male fex, it may be prefumed, that in females a certain date of the genitals is neceffary to give tone and tenfion to the whole fydem ; and therefore that, if the dimulus arifing from the geni- tals be wanting, the whole fydem may fall into a torpid and flaccid date, and from thence the chlo- rofis and retention of the menfes may arife. I0OI. It appears to me, therefore, that the retention of the menfes is to be referred to a certain date or affection of the ovaria: But what is precifely the nature of this affection, or what are the caufes of it, I will not pretend to explain ; nor can I ex- plain in what manner that primary caufe of reten- tion is to be removed. In this, therefore as in many other cafes, where we cannot affign the proxi- mate caufe of difeafes, our indications of cure mud be formed for obviating and removing the morbid effects or fymptoms which appear. 1002. The effects, as has been faid in (999), confid in - a general flaccidity of the fydem, and confequent- ly in a weaker action of the veffels of the uterus: to O F P H Y S I C. 25 fo that this debility may be confidered as the more immediate caufe of the retention. This, therefore, is to be cured by redoring the tone of the fydem in general, and by exciting the action of the ute- rine veflels in particular. 1003. The tone of the fydem in general is to be r7eftor- ed by exercife, and, in the beginning of the dif- eafe, by cold bathing. At the fame time, tonic medicines* may be employed ; and of thefe the cha- lybeateshave been chiefly recommended. 1004* The action of the veffels of the Uterus may be excited : id, By determining the blood into them more copioufly j which is to be done by determining the blood into the defcending aorta, by purging, by the exercife of walkingt, by friction, and by warm bathing of the lower extremities. It is alfo proba- ble that the blood may be determined more copiouf- ly into the hypogadric arteries which go to the uterus, by a Compreflion of the iliacs ; but the trials of this kind hitherto made have feldom fucceeded. IOO5. 2dly, The action of the uterine veflels may be excited by dimulants applied to them. Thus, thofe Vol. II. D purgatives * Forms of the tonic medicines have been given in fome of the preceding note?, The eledluary in the note on article 982. is frequently ufed with fuccel's. In this •afe, we mult not ufe aftringents, but tonics, and confequently only fuch tonics as are not aftringents, at lead in a high degree. The fimple bitter tonics frequently anfwer where the fymptoms are not fevere. The Infufum gentians compolitum of the new London Pharmacopoeia is a good formula. The dofe of it is two ounces twice a-day, or oftener, if the ftomach can bear it. Chalybeates are abfolutely neceffary if the difeafe withilands the ufe of bitters j they may be given in any of the forms mentioned in the precedii'j note*. t Dancing is alfo » proper exercife in this difeafe. 16 PRACTICE purgatives which particularly dimulate the intefti- num recium*, may alfo prove dimulant to the uterine veffels connected with thofe of the re&um. The exercife of venery certainly proves a ftimulus to the veffels of the uterus; and therefore may be ufeful when, with propriety, it can be employed. The various medicines recommended as dimulants of the uterine veffels, under the title of Emena- gogues, have never appeared to me to be effectual; and I cannot perceive that any of them are poffeff- ed of a fpecific power in this refpeft. Mercury, as an univerfal dimulant, may aft upon the uterus, but cannot be very fafely employed in chlorotic perfons. One of the mod powerful means of ex- citing the action of the veffels in every part of the fydem is, the electrical fhock; and it has often been employed with fuccefs for exciting the vefieli of the uterus. 1006. The remedies (1002.—1005.) now mentioned, are thofe adapted to the retention of the menfes; and * Thefe flimulant purges are in general the draftic refir.i, as Scammony, Aloes, &c. Various formula; of them have been recommended in thefe cafes ; the Pilula: Rufi is commonly ufed with good effeft. It may be -given in the quantity of half a dram, or, in ftrong conftitutions, two fcruples. It ought not to be repeated above twice a wick; and, in the intermediate days, we may employ the tonic medicines above mentioned. The Pilulse ecphracYicae of the Edinburgh Pharmacopoeia is another very effectu- al medicine in thefe cafes. Its dofe is half a dram twice a week, if we intend to purge brifkly ; but, by giving a fmaller quantity, as ten, twelve, or fifteen grains Mice a-day, a conftant ftimulus is preferved, which fome practitioners prefer. The following pills are alfo much recommended: R. Pil. Gummof. Aloes Socotorin. aa Sii. Vin. Aloet. q. s. A/, f. Mafia in piluhs 48. dividend. The dofe is 3 or 4 pills at bed time. The Tinctura facra is alfo frequently ufed as a brifk purge in theft cafes; its dofe for this purpofe muft not be lefs than an ounce and a half in moft habits; but a ftrong conftitution will require two ounces or more. Oth*r ftimulants than purges have been employed in amenorrhoea, as the Tinc- tura fabina compofita of the new London Pharmacopoeia ; its dofe is thirty or forty i'.op;, in any fuitable vehicle. The Tinctura myrrhae of the fame Pharmacopoeia, in dofes of twenty or thirty drops, is often recommended «» the authority of Botr- hfeve. O F P H Y S I C. fl7 and I am next to confider the cafe of fuppreffion. In entering upon this, I mud obferve, that every interruption of the flux, after it has once taken place, is not to be confidered as a cafe of fuppref- fion. For the flux, upon its fird appearance, is not always immediately edablifhed in its regular courfe ; and therefore, if an interruption happen foon after the fird appearance, or even in the courfe of the fird, or perhaps fecond year after, it may often be confidered as a cafe of retention, efpecial- ly when the difeafe appears with the fymptoms pe- culiar to that date. IOO7. Thofe which may be properly confidered as ca- fes of fuppreffion, are fuch as occur after the flux has been for fome time, edablifhed in its regular courfe, and in which the interruption cannot be re- ferred to the caufes of retention (100.1. 1002.), but mud be imputed to fome refidance in the extremi- ties of the veffels of the uterus. Accordingly, we often find the fuppreffton induced by cold, fear, and other caufes which may produce a conduction of thefe extreme veffels. Some phyficians have fup- pofed an obdructing, lentor of the fluids to occafi- on the refidance now mentioned : But this is pure- ly hypothetical, without any proper evidence of the fact; and it is befides, from other, confiderati- pns, improbable. IO08. There are indeed fome cafes of fuppreffion that feemto depend upon a general debility of the fyf- tem, and confequently of the veffels of the uterus. But in fuch cafes, the fuppreffion always appears as fymptomatic of other affections, and U therefore not to he confidered here. 1009. The 2$ PRACTICE IOO9. The idiopathic cafes of fuppreffion (1007.) feldom continue long without being attended with various- fymptoms or diforders in different parts of the bo- dy ; very commonly arifing from the blood which mould have palled by the uterus, being determined more copioufly into other parts, and very often with fuch force as to produce hemorrhagies in thefe. Hence hemorrhagies from the nofe, lungs, ftomach, and other parts, have appeared in confequence of fupprefled menfes. Befides thefe, there are com- monly hyfleric and dyfpeptiG fymptoms produced by the fame caufe; and frequently colic pains, with. a bound belly. IOIO, In the idiopathic cafes of fuppreffion, (1007.), the indication of cure is to remove the conduction af- fecting the extreme veffels of the uterus ; and for this purpofe the chief remedy is warm bathing ap- plied to the region of the uterus. This, however* is not always effectual, and I do not know of any other remedy adapted to the indication. Betide* this, we have perhaps no other means of removing the condriction in fault, but that of increafing the action and force of the veffels of the uterus, fo as thereby to overcome the refidance or condriction. of their extremities. This therefore is to be at- tempted by the fame remedies in the cafe of fup- preffion, as thofe prefcribed in the cafes of reten- tion (1003. 1005.). The tonics, however, and cold bathing (1003.), feem to be lefs properly adapted to the cafes of fuppreffion, and have ap- peared to me of ambiguous effectA 101.1. It * The Emenagogues enumerated in the note on Article 1005. are more efficaci- ous in thele cale. than the tonics and chalybeatcs mentioned in the note on Article iooj. for this reafcn, that the fuppreffion of the menfes depends Kore on {he con- viction,. OF PHYSIC. 29 IOII. It commonly happens in the cafes of fuppreffion, that though the menfes do not flow at their ufual periods, there are often at thofe periods fome marks of an effort having a tendency to produce the difcharge. It is therefore at thofe times espe- cially when the efforts of the fydem are concurring, that we ought to employ the remedies for curing a fuppreffion j and it is commonly fruitlefs to employ them at other times, unlefs they be fuch* as require fome continuance in their ufe to produce their ef- feOs. IOI2. Nearly fimilar to the cafes of fuppreffion, are thofe cafes in which the menfes flow after long intervals and in leffer quantity than ufual; and when thefe cafes are attended with the diforders in the fydem (1009.), they are to be cured by the fame remedies as the cafes of entire fuppreffion. IOI3. It may be proper in this place to take notice of the dyfmenorrhea, or cafes of mendruation in which the menfes feem to flow with difficulty, and are accompanied with much pain in the back, loins, and lower belly. We impute this diforder partly to fome weaker action of the veffels of the uterus, and partly, perhaps more efpecially, to a fpafm of its extreme veffels. We have commonly found the difeafe relieved by employing fome of the ftriclion, than on a laxity of the extreme veffels. Some cafes, indeed, occur, where a lax habit is the caufe of fuppreffion, but they are rare: The phyfician ought to be attentive in difcriminating fuch cafes, becaufe a liberal ufe of forcing emeiu*jogues is always hurtful 1.1 them; they cu» only be relieved by toiiics, and efptcUUy by chalybeate*. + Via. tonks or alterants. 8o PRACTICE the remedies of fuppreffion immediately before the approach of the period, and at the fame time em- ploying opiates. CHAP. IX. Or SYMPTOMATIC HEMORRHAGIES. IO14. I HAVE thought it very improper, in thii work, to treat of thofe morbid affections that are al- inod always fymptomatic of other more primary difeafes j and this for feveral reafons, particularly becaufe it introduces a great deal of confufion in directing practice, and leads phyficians to employ palliative meafures only. I fhall here, however, deviate a little from my general plan, to make fome reflections upon fymptomatic hemorrhagies. IOI5. The hemorrhagies of this kind that efpecially de- ferve our notice, are the Hematemefis, or Vomit- ing of Blood; and the Hematuria, or the Voiding of Blood from the urinary paffage. Upon thefe I am here to make fome remarks; becaufe, though they are very generally fymptomatic, it is poffible they may be fometimes primary and idiopathic af- fections; and becaufe they have been treated of as primary difeafes in almod every fyftem of the practice of phyfic. Sect. I. Of the Hematemesis, or Vomiting of Bloo*. IOl6. I HAVE faid above (in 944.) in what manner blood thrown out from the mouth may be known to OF PHYSIC. S» to proceed from the domach, and not from the lungs; but it may be proper here to fay more par- ticularly, that this may be certainly known, when the blood is brought up manifedly by vomiting without any coughing; when this vomiting hag been preceded by fome fenfe of weight, anxiety^ and pain, in the region of the domach; when the blood brought up is of a black and grumous ap-» pearance, and when it is manifedly mixed with other contents of the domach ; we can feldom have any doubt of the fource from whence the blood proceeds, and therefore of the exiflence of the difeafe we treat of. IOI7. We muft allow it to be poffible that a plethoric ftate of the body from general caufes may be ac- companied with caufes of a peculiar determination and afflux of blood to the domach, fo as to otcafi- on an hemorrhagy there, and thence a vomiting of blood ; and in fuch a cafe this appearance might be confidered as a primary difeafe. But the hifto- ry of difeafes in the records of phyfic, afford little foundation for fuch a fuppofition ; and on the con- trary, the whole of the indances of a vomiting of blood which have been recorded, are pretty mani- fedly fymptomatic of a more primary affection. Of fuch fymptomatic vomitings of blood, the chief indances are the following. IOl8. One of the mod frequent is that which appears in confequence of a fuppreffion of an evacuation of blood which had been for fome time before edablifhed in another part of the body, particular- ly that of the menftrual flux in women. 101 q. There 3* PRACTICE IOI9. There are indances of a vomiting of blood hap- pening from the retention of the menfes : But fuch indances are very uncommon; as retention of the menfes rarely happens in confequence of, or even with, a plethoric date of the body; and as rarely does it produce that, or the hemorrhagy in quedion. There are indances of a vomiting of blood hap- pening to pregnant women; that might therefore alfo be imputed to the fuppreffion of the menfes, which happens to women in that date. There have indeed been more indances of this than of the for- mer cafe; but the latter are dill very rare ; for al- though the blood which ufed to flow monthly be- fore impregnation, is, upon this taking place, re- tained, it is commonly fo entirely employed in di- lating the uterine veflels, and in the growth of the foetus, that it is feldom found to produce a pletho- ric date of the body, requiring a vicarious outlet. The vomiting of blood, therefore, that is vica- rious of the mendrual flux, is that which common- ly and almod only happens upon a fuppreffion of that flux, after it had been for fome time eda- blifhed. 1020. When fuch a fuppreffion happens, it may be fup- pofed to operate by inducing a plethoric date of the whole body, and thereby occafioning hemor- rhagy from other parts of it; and hemorrhagies from many different parts of the body have been obferved by phyficians as occurring in confe- quence of the fuppreffion we fpeak of. It is, how- ever, the great variety of fuch hemorrhagies that leads me to think, that, with the plethoric date of the whole body, there muft be always fome peculiar circumftances OF PHYSIC. 33 circumftances in the part from which the blood flows, that determines its afflux to that particular, often Angularly odd, part; and therefore, that fuch hemorrhagies may from thefe circumftances occur without any confiderable plethora at the fame time prevailing in the whole fydem. 102 I. It is to be obferved, that if we are to expeft an hemorrhagy in confequence of a fuppreffion of the menfes inducing a plethoric date of the fydem, we fhould expect, efpecially an hemoptyfis, or hemor-. rhagy from the lungs, as a plethora might be ex- pected to fhow its effects efpecially there; and ac- cordingly, upon occafion of fuppreffed menfes, that hemorrhagy occurs more frequently than any- other : But even this, when it does happen, nei- ther in its circumflances nor in its confequences, leads us to fuppofe, that at the fame time any confi- derable or dangerous plethora prevails in the body. 1022. Thefe considerations (in 1020. 1O21.) will, I ap- prehend, apply to ourprefentfubject.; and I would therefore allege, that a hematemefis may perhaps depend upon particular circumdances of the fto- ,mach determining an afflux of blood to that organ, and may therefore occur without any confiderable or dangerous plethora prevailing in the fydem. What are the circumdances of the domach, which, upon the occafion mentioned, may determine an afflux of blood to it, I cannot certainly or clearly explain ; but prefume that it depends upon the con- nexion and confent which we know to lubfid be- tween the uterus and the whole of the alimentary canal, and efpecially that principal part of it the domach. Vol. II. E 1023. From 34 PRACTICE IO23. From thefe reflections, we may, I think, draw the following conclusions. I. That the hematemefis we fpeak of is hardly ever a dangerous difeafe. II. That it will hardly ever require the reme- dies fuited to the cure of active hemorrhagy ; and at lead that it will require thefe only in thofe unu- fual cafes in which there appear ftrong marks of a general plethora, and in which the vomiting of blood appears to be considerably active, very pro- fufe, and frequently recuning. III. Tl at a vomiting of blood from fuppreffed menfes, ought feldom to prevent the ufe of thefe remedies of amenhorrhcea, which might be impro- per in the cafe of an active idiopathic hemorrhagy. IO24. Another cafe of fymptomatic hematemefis quite analogous to that already mentioned, is the hema- temefis following, and feemingly depending upon, the fuppreffion of an hemorrhoidal flux, which had been eftablifhed and frequent for fome time before. This may perhaps be explained by a general ple- thoric date induced by fuch a fuppreffion ; and in- deed fome degree of a plethoric date mud in fuch a cafe be fuppofed to take place; but that fuppofi- tion alone will not explain the whole of the cafe; for a general plethora would lead us to expect, an hemoptyfis (1021.) rather than an hematemefis; and there is therefore fomething dill wanting, as in the former cafe, to explain the particular deter- mination to the domach. Whether fuch an explanation can be got from the connexion between the different parts of the fanguiferous veffels of the alimentary canal, or from the connexion of the whole of thefe veflels with OF PHYSIC. 35 with the vena portarum, I fhall not venture to de- termine. But in the mean time I imagine, that the explanation required is rather to be obtained from that connexion of the domach with the he- morrhoidal affection that I have taken notice of in (945.). IO25. How we may explain the hematemefis occasion- ed by a fuppreffion of the hemorrhois, the consi- derations in (1020. 102i.) will apply here as in the analogous cafe of hematemefis from fuppreffed menfes; and will therefore allow us alfo to con- clude here, that the difeafe we now treat of will feldoin be dangerous, and will feldom require the fame remedies that idiopathic and active hemorrha- gy does. IO26. The cafes of hematemefis already mentioned, may be properly fuppofed to be hemorrhagies of the arterial kind; but it is probable that the do- mach is alfo liable to hemorrhagies of the venous kind (767.). In the records of phyfic there are many indan- ces of vomiting blood, which were accompanied with a tumefied fpleen, which had comprefied the vas breve, and thereby prevented the free return of venous blood from the domach. How fuch an interruption of the venous blood may occafion an hemorrhagy from either the extremities of the veins themfelves, or from the extremities of their correlpondent arteries, we have explained above in (768.), and the hidories of tumefied fpleens compreiling the vafa brevia, afford an excellent illudration and confirmation of our doctrine on that fubject, and render it fufficiently probable that vomitings of blood often arife from fuch a caufe. 1027. It 36 PRACTICE 1027. It is alfo poffible, that an obdruction of the liver refiding the free motion of the blood in the vena portarum, may fometimes interrupt the free return of the venous blood from the veflels of the domach, and thereby occafion a vomiting of blood ; but the indances of this are neither fo frequent nor fo clear- ly explained as thofe of the former cafe. 1028. Besides thefe cafes depending on the date of the liver or fpleen, it is very probable that other he- morrhagies of the domach are frequently of the ve- nous kind. The difeafe named by Sauvages Melsena, and by other writers commonly termed the Morbus Niger (771.), confiding in an evacuation either by vomiting or by dool, and fometimes in both ways, of a black and grumous blood, can hardly be other- wife occafioned, than by a venous hemorrhagy from fome part of the internal furface of the ali- mentary canal. It is, indeed, poffible, that the bile may fome- times put on a black and vifcid appearance, and give a real foundation for the appellation of an Atra Bilis : But it is certain, that indances of this are very rare ; and it is highly probable, that what gave occafion to the notion of an atra bilis among the ancients, was truly the appearance of blood poured into the alimentary canal in the manner I have mentioned; and which appearance, we know, the blood always puts on when it has dagnated there for any length of time. I fuppofe it is now generally thought, that Boerhaave's notion of fuch a matter cxiding in the mafs of blood, is without any foundation ; whild, by diffections in modern times, it appears very clearly, that the morbus niger OF PHYSIC. 37 niger prefenting fuch an appearance of blood, al- ways depends upon the eftufion and llagnation I have mentioned. IO29. From this account of the melaena it will appear, that vomitings of blood may arife in confequence of blood being poured out in the manner I have mentioned, either into the cavity of the domach itfelf, or into the fuperior portions of the inteftines, from whence matters often pal's into the domach. IO3O. Both in the cafe of the melaena, and in the ana- logous cafes from affections of the fpleen or liver, it will appear, that the vomitings of blood occur- ring mud be confidered as fymptomatic affections, not at all to be treated as a primary active hemor- rhagy, but by remedies, if any fuch be known, that may refolvethe primary obdructions*. 1031. I believe * This is doubtlefs the moft rational practice, namely to refolve the obftru^ion, which has occafioned the blood to be thrown or driven to the inteftincs. To dilea- ver this primary obftruftion is, however, fometimes extremely difficult; and, eve:: when it is difcovered, it is frequently not eafily refolved; in fuch cafes, therefore. we muft ufe the general remedies for removing the plethora, except laxatives, the operations of which, in general, derive the fluids to the inteftines. Sweating is perhaps the beft general evacuation for determining the fluids from the inteftines; but its ufe ought to be preceded by bleeding; and it ou<*ht not, in thde cafes, to be excited by naufeating dofes of emetics, as thefe produce the lame effect as laxatives; we muft therefore have recourfe to the light aromatics, fage, mirr. balm, wine-whey, &c. Camphor and opium are alfo proper fudorifks in thefe cafe*. They may be given together, as in the following bolus: R. Camphor, gr. vi. Spir. vini gutt. x. Opii pur. gr. i. Conf. card. 3fs. vel q. s. M. f. bolus. Some practitioners have recommended large quantities of fpermaceti incafes of he- matemefis, and not without reafon. It m jy he given in emuhiom, with yolks of egg., or in an clecluary. 1 fhall therefore add a formula of each. ft. Spermat. cet. §fs. Vitel. ovi q. s. Tere in mortar, mormorco, et add* Aq. font. |vii, Syr. 3* PRACTICE 1031. I believe I have now mentioned almod the whole of the caufes producing an hematemefis; and cer- tainly the caufes mentioned, are thofe which mod commonly give occafion to that fymptom. Poffi- bly, however, there may be fome other caufes of it, fuch as that fingular one mentioned by Sauvage of an aneurifm of the aorta burding into the domach ; and it is poffible, that fome difeafes of other con- tiguous parts, which have become clofely adhering to the domach, may fometimes, by a rupture into the cavity of the domach, pour blood into it, which is afterwards rejected by vomiting. It is poffible alfo, Syr. fimpl. |i. M. f. Emulf. The dofe of this emulfion is two or three table-fpoonfuls every three hours. ft. Spermat. cet. §i. Conferv. rofar. §ii. Syr. Simp. 3L M. f. Eleft. The dofe of this ele&uary is a tea-fpoonful or two every two or three hours. If the hematemefis be violent, we muft have recourfe to fome of the ftyptics and aftringents mentioned before in the cure ofthe hemorrhagy in general, as alum, ca- techu, kino, &c. of which I fhall fubjoin fome formula. ft. Alum. uft. gr. iii. Kino Bfs. M. f. Pulvis. This powder may be repeated every two hoars, and three table-fpoonfuls of the tincture of rofes may be given to wafh it down. The elecluarium japonicum of the Edinburgh Pharmacopoeia is well calculated for thefe cafes ; its dofe is a dram and a half or two drams. The extract of logwood is fometimes ufed in thefe cafes with confiderable fuccefs. It may either be given alone in dofes of a fcruple each every three hours, or joined with alum, as in the following formula : ft. Extraft. lign. Campechcnf. 9fs. Alum. uft. gr. iii. M. f. pulvis. This powder may be repeated every three hours; drinking after it three table- fpoonfuls ofthe tin&ureof rofes; or a tea-cupful of cold water, with twenty or thirty drops of the acidum vitriolicum dilutum, or as much as fuificient to give an agreea- ble acidity. All thefe ftyptics and aftringents are apt to produce coftivenefs, which muft be removed by emollient glyfters, as laxative medicines are, for the reafons above men- tioned, generally hurtful in thefe cafes. The young practitioner muft not truft to thefe medicines for completely curing a he- morrhage from the inteftines; they are only palliatives, and are of no other ufe than to check the violence of the difcharge until the true caufe of the difeafe be difcovcr- ed j and the difcovery of this caufe muft be left to the fagacity of the phyfici%n. OF PHYSIC. 39 alfo, that abfcedes and ulcerations of the domach itfelf, may fometimes pour blood into its cavity to be thrown up by vomiting. I did not think it neceffary, among the fympto- matic vomitings of blood, to enumerate thofe from external violence, nor, what is analogous to it, that which arifes from violent draining to vomit; which lad, however, is much more rare than might be expected. In either of thefe cafes the nature of -the difeafe cannot be doubtful, and the manage- ment of it will be readily underdood from what has been delivered above with refpect. to moderating and retraining hemorrhagy in general. Sect. II. Of the Hematuria, or the Voiding 0/ Bloob from the Urinary Passage, IO32. IT is alleged, that an hematuria has occurred without any other fymptom of an affection of the kidneys or urinary paffages being prefent at the fame time ; and as this happened to plethoric per- sons, and recurred at fixed periods, fuch a cafe has been fuppofed to be an indance of idiopathic hematuria, and of the nature of thofe active he- morrhagies I have treated of before. I cannot positively deny the exiftence of fuch a cafe ; but mud oblerve, that there are very few indances of fuch upon the records of phyfic ; that none have ever occurred to my obfervation, or to that of my friends; and that the obfervations ad- duced may be fallacious, as I have frequently ob- ferved an hematuria without fymptoms of other af- fection 40 PRACTICE feciion of the kidney or urinary paffages being, for the time, prefent; whild, however, fits of a neph- ralgia calculofa having, before or foon after, hap- pened, rendered it to me fufficiently probable, that the hematuria was owing to a wound made by a done prefent in fome part, of the urinary paffages. IO34. The exidence of an idiopathic hematuria is fur- ther improbable, as a general plethora is more like- ly to produce an hemoptysis (1021.), and as we do not well know of any circumdance which might determine more particularly to the kidneys. An idiopathic hematuria, therefore, mud certainly be a rare occurrence ; and indances of fymptomatic aflections of the fame kind are very frequent. One ofthe mod frequent is, that hematuria which attends the nephralgia calculofa, and feems mani- feflly to be owing to a done wounding the internal furface of the pelvis of the kidney or of the ureter. In fuch cafes, the blood difcharged with the urine is fometimes of a pretty florid colour, but for the mod part is of a dark hue; the whole of it is fome- times diifufed or diffolved, and therefore entirely fufpended in the urine ; but if it is in any large quantity, a portion of it is depofited to the bottom ofthe vcffel containing the voided blood and urine. On different occasions the blood voided puts on different appearances. If the blood poured out in the kidney has happened to dagnate for fome time in the ureters or bladder, it is fometimes coagulat- ed, and the coagulated part is afterwards broken down into a grumous mafs of a black or dark co- lour, and therefore gives the fame colour to the urine voided; or if a quantity of broken down blood is fmall, it gives only a brownifli urine refembling codec. It OF PHYSIC. 41 It fometimes alfo happens, that the blood dag- nating and coagulating in the ureters, takes the form of thefe veffels, and is therefore voided un- der the appearance of a worm ;' and if the coagu- lated blood happens to have, as it may fometimes have, the gluten feparated from the red globules, thefe worm-like appearances have their external furface whitifh, and the whole feemingly forming a tube containing a red liquor. I have fometimes obferved the blood which had feemingly been co- agulated in the ureter, come away in an almod dry date, refembling the half burnt wick of a candle*. IO36. Thefe are the feveral appearances of the blood voided in the hematuria calculofa, when it pro- ceeds efpecially from the kidneys or ureter ; and many ofthe fame appearances are obferved when the blood proceeds only from the bladder when a done is lodged there j but the attending fymptoms will commonly point out the different feat of the difeafe. In one cafe, when a quantity of blood from the kidney or ureter is coagulated in the bladder, and is therefore difficultly thrown out from this, trie pain and uneafinefs on such an occafion may ap-« pear chiefly to be in the bladder, though it con- tains no done ; but the antecedent symptoms will commonly difcover the nature ofthe difeafe. »°37- In any of the cafes ofthe hematuria calculofa, it will hardly be necefiary to employ the remedies Vol. II. F fuited * In genera!, the blood is coagulated and grumcus; hence the urice depofits a dark brown fubftnnce fomewhat refembling coffee-grounds. As the grumous blood is fpecifically heavier than the urine, it falls to the bottom of the bladder, and is consequently voided in greater quanfity in the beginning than towards the end of making water, the urine that comes oflflirft being very deep colour- ed and muddy, but bco'mir.,;, while it flows, gradaally more tranfparent and pure* until at laft it is perfectly of a natui.il appearance. The patient generally mention* this circumflance in defcribinp- his complaints, with this addition, that he has in the beginning fom<- difficulty of making water, but that thiS difficulty decreafes in prtfr portion as the uriue becomes more tranfparent, 42 PRACTICE fuited to an active hemorrhagy. It will be proper only to employ the regimen fit for moderating he* morrhagy in general, and particularly here to a- void every thing or circumdahce that might irri- tate the kidneys or ureters. Of fuch cafes of irri- tation, there is none more frequent, or more confi- derable, than the prefence of hardened faeces in the colon ; and thefe therefore are to be frequent- ly removed, by the frequent ufe of gentle laxatives*. IO38. The hematuria calculofat may be properly con- fidered as a cafe of the hematuria violenta; and therefore I fubjoin to that the other indances of hematuria from external violence; fuch as that from external contusion on the region of the kid- ney+, and that from the violent or long continued exercife of the mufcles incumbent on the kidneys. An indance of the latter caufe occurs efpecially in riding||. 1039. It may alfo be confidered as a cafe ofthe hema- turia violenta, when the difeafe occurs in confe- quence * Glyfters are preferable to purgatives in thefe cafes; becaufe they are lefs ftimu- lating ; and the emollient glyfters are peferable to all others, for their only intention is to fofjen the hardened faeces. The only purgatives to be ufed are thofe of the mildeft kind, as manna, oil, caf- fia, &c. The intention of purgatives, in thefe cafes, is only to remove the hardened faeces; and this intention-can often be fufficiently anfwered by a proper choice of food, as broths, efpecially thofe made with barley and young animal flefh; barley gruel, with piunts boiled in it; ftewed endive, lettuce, andotheroleraceousdifh.es. + The hematuria calculofa being fymptomatic, can only be cured by removing the caufe; it may, however, he greatly relieved by demulcents, as lintfeed tea, deco- tion of manh mallows, mucilage of gum Arabic, thick barley-water, &c. I 1 he hematuria proceeding from a contufion of the region of the kidneys requires general and topical bleeding, with purges, and an attention to the antiphlogiftic re- gimen. Some practitioners recommend the warm balfams in thefe cafes ; but, on account of their heating quality, tlieir ufe is fomewhat doubtful. Nitre is not always. adniiCIde, on account of its irritating the kid;:eys; but it is a powerful antiphlogif- tic ; and, if it is ufed in thefe cafes, it muft be well diluted: the mucilaginous. drink e-.re abfolutely r.cc;ffary, and oupht to be ufed plentifully. || The only method of ireating this kind «,, hematuria is by reft. A perfoa fub. jedt to i: ought never u ride. OF PHYSIC. 43 quence ofthe taking in of certain acrid fubfiances, which pafs again efpecially by the urinary pafl'ages ; and, by inflaming and Swelling the neck of the bladder, bring on a rupture of the over-didended bloodveffels, and give occafion to a bloody urine. The mod noted indance of this is in the effed of cantharides in a certain quantity, any way intro- duced into the body. And pofiibly fome other a- crids may have the fame effect*. IO4O. Befide thefe mod frequent indances of hematu- ria, which cannot be confidered as idiopathic he- morrhagies, there are fome other indances of he- maturia mentioned by authors, that are dill how- ever manifedly fymptomatic ; fuch as a difcharge of blood from the urinary paffages, in confequence of a fuppreffion of either the mendrual or hemor- rhoidal flux. Thefe may be confidered as analo- gous to the hematemefis produced by the like cau- fes ; and the feve'ral reflexions made above on that fubjeft, will, I think, apply here, and particu- larly the conclufions formed in (1023.) Indances, however, of either of thefe cafes, ^and efpecially of the fird, have been extremely rare. 1041. Of * This fpecies of hematuria is cured by evacuating the acrid fubftance, and by the ufe of the mucilaginous drinks before mentioned. The acrid fubftance may be evacuated by antiphlogiftic purges, or by the milder diuretics, as nitre, decoclioi.s of parfley roots, cream of tartar, whey, &c. The action of cantharides on the urinary paffages is not well explained. We can fcarcely believe that any part of the cantharides is abforbed from the bliftering plaif- ter; yet its effe&s are the fame with thofe produced by taking the cantharides inter- nally. Ths ftrangury, and its concomitant fymptoms, may be relieved by large and plentiful dilution, and a free ufe of the mucilaginous drinks. Camphor has been thought to have fome fpecific quality in preventing and curing the ftrangury produced by blifters, and experience warrants the conclufion : efpeci- ally if the camphor is Joined with opium, as in the following formula: ft. Camphor, gr. vi. Spir. vini gutt. x. Opii pun gr. i. Conferv. rofar. 5i> A/, f. bolus, u PRACTICE 1041. Of fuch fymptomatic hematuria there is however one indance deferving notice; and that is, when a fuppreffion of the hemorrhoidal flux, either by a communication of veflels, or merely by the vicinity of parts, occafions a determination of the blood in- to the veflels of the neck of the bladder, which in confequence of a rixis or anadomofis, pour out blood to be voided either with or without the urine. This cafe is what has been named the He- morrhoides Veficas ; and with fome propriety, when it is manifedly an evacuation vicarious of what had before been ufually made from the rec- tum. With refpect to the management ofthe he- morrhoides vesicae, I would apply the whole of the doctrines that 1 have delivered above, with refpeft to the cure ofthe proper hemorrhoidal affection*. IO42., There remains dill to be mentioned one other indance of fymptomatic hematuria, which is that which happens in the cafe of confluent and putrid fmall pox, as well as in feveral other indances of putrid difeafes. The blood, in fuch cafes, may be prefumed to come from the kidneys; and I appre- hend that it comes from thence in confequence of that fluidity which is always produced in the blood approaching to a putrid date. Such hematuria, therefore, is not to be confidered as a symptom of any affection ofthe kidneys, but merely as a mark of the putrefcent date of the blood. IO43, In certain difeafes the urine is difcharged of fuch a deep red colour, as to give a fufpicipn of its be- ing * Articles 946. et fe«]uent. O F P H Y S I C. 45 ing tinged by blood prefent in it; and this has giv- en occafion to Sauvages, amongd the other fpe- cies of hematuria, to mark the hematuria fpuria, and the hematuria lateritia; both of which, how- ever, he fuppofes to be without any blood prefent in the urine. In many cafes it is of importance, in afcertaining the nature of the difeafe, to deter- mine whether the red colour of urine be fromblood prefent in it, or from a certain date of the falts and oils which are always in greater or letfer proportion condiment parts of the urine; and the quedion may be commonly determined by the fol- lowing confide rations. It has been obferved above, that when any con- fiderable quantity of blood is voided with the urine, there is always a portion of it depofited at the bottom of the veffel containing the voided blood and urine : and in fuch a cafe there will be no doubt in attributing the colour of the urine floating above to fome part of the blood diffufed in it. The quedion, therefore, with refpcft to the prefence of blood in the urine can only oc- cur when no fuch deposition as I have mentioned appears; and when the blood that may be fuppofed to be prefent is diffolved or diffufed, and there- fore entirely fufpended in the urine. In this cafe the prefence of the blood may be commonly known, jd, By the colour, which blood gives, different from any urine without blood that I have ever feen; and I think a little experience will enable mod perfons to make this diftinclion. 2dly, By this, that the prefence of blood always diminifhes the tranfparency of the urine with which it is mixed; and it is very feldom that urine, though very high coloured, lofes its tranfparency; at lead this hard- ly ever appears, if the urine is examined when re- cently voided. 3fe ii the fi« ef a nutmeg ihr»c or four limcj a-Juy. 56 PRACTICE) expeding the fecretion of mucus in the lungs, which may take off the inflammation of its membrane, vo- miting is the mod effectual means. For the latter purpofe, it has been fuppofeda that fquills, gum ammoniac*, the volatile alkali, and fome other medicines, might be ufeful : But their efficacy has never appeared to me to be confidera- ble ; and, if fquills have ever been very ufeful, it feems to have been rather by their emetic, than by their expectorant powers. When the inflammatory affections of the lungs feem to be confiderable, it is proper, befide bloodletting, to apply bliders on fome part of the thorax. As a cough is often the mod troublefome cir- cumdance of this difeafe, fo demulcents may be employed to alleviate it. See (373.) But, after the inflammatory fymptoms have much abated, if the cough fhould dill continue, opiates afford the mod effectual means of relieving it; and, in the circumdancesjud now mentioned, they may be very fafely employed. See (375.) After the inflammatory and febrile dates of thii difeafe are almod entirely gone, the mod effectual means of difcuffing all remains of the catarrhal af- fection, is by fome exercife of gedation diligently employed. C H A P. II. Of the DYSENTERY, 1066. THE dyfentery is a difeafe in which the patient has frequent dools, accompanied with much griping, * Tlie ammoniac and fquills may be joined together in the following form: Be. Lac ammoniac siv. Syr. fcillit. §iii. M. TLW mixture muft be acknowledged to he fomewrut naufeoirs, but it has confider- able efficacy. The dofe of it is two, or, if (he Lbaiaeh can bear it, three ublci fpo3:ifuls twice a-day, OFPHYStC. 57 griping, and followed by a tenefmus. The (tools* though frequent, are generally in fmall quantity; and the matter voided is chiefly mucus, fometimes mixed with blood. At the fame time, the natural faeces feldom appear; and, when they do, it is ge* nerally in a compact, and hardened form. I067. This difeafe occurs efpecially in fummer and au- tumn, at the fame time with autumnal intermittent and remittent fevers ; and with thefe it is fometimes combined or complicated** 1068, The difeafe comes on fometimes with cold Ihiver- ings, and other fymptoms of pyrexia; but more commonly the fymptoms of the topical affection ap- pear fird. The belly is codive, with an unusual flatulence in the bowels. Sometimes, though more rarely, fome degree of diarrhoea is the fird appear- ance. In mod cafes the difeafe begiris with grip- ing, ahd a frequent inclination to go to dool. In indulging this, little is voided ; but fome tenefmus attends it. By degrees, the dools become more fre- quent, the griping more-fevere, and the tenefmus more confiderable. Along with thefe fymptoms there is a lofs of appetite ; and frequently fickneis, naufea, and vomiting, alfo affecting the patient. At the fame time, there is always more or lefs of pyrexia prefent, which is fometimes of the remit- tent kind, and obferves a tertian period. Some- times the fever is manifedly inflammatory, and ve- ry often of a putrid kind. Thefe febrile dates continue to accompany the difeafe during its whole Courfe, efpecially when it terminates foon in a fa- tal manner. In other cafes, the febrile date al- Vol. II. H mod * It appears more efpecially in armies encamped in low fwampy grounds} ahdj» Without proper management, is highly deftrufitive. 5* PRACTICE mod entirely difappears, while the proper dyfen- teric fymptoms remain for a long time after. 1069. In the courfe ofthe difeafe, whether of a fhort- cr 01 longer duration, the matter voided by (tool is verv vaiious. Sometimes it Is merely a mucous matter, without any blood, exhibiting that difeafe which Dr. Roderer has named the morbus mucojus, and others the dyfnteria alba. For the mod part, however, the mucus difcharged is more or lefs mixed with blood. This fometimes appears only in dreaks amongd the mucus ; but at other times is more copious, tinging the whole of the matter difcharged ; and, upon fome occafions a pure and unmixed blood is voided in confiderable quantity. In other refpefts, the matter voided is varioufly changed in colour and confidence, and is common- ly of a ftrong and unulually fetid odour. It is pro- bable, that fometimes a genuine pus is voided ; and frequently a putrid fanies, proceeding from gan- grenous parts. There are very often mixed with the liquid matter fome films of a membranous ap- pearance, and frequently fome fmall maffes of a feemingly febaceous matter. IO7O. While the flools confiding of thefe various mat- ters are, in many indances, exceedingly frequent, it is feldom that natural faeces appear in them ; and, when they do appear, it is, as I have mentioned, in the form of fcybala, that is, in fomewhat hard- ened, feparate balls. When thefe are voided, whether by the efforts of nature, or as folicited by art, they procure a remifiion of all the fymptoms, and more efpecially ofthe frequent dools, griping, and tenefmus. 1071. Accom- OF PHYSIC. 59 IO71. Accompanied with thefe circumdances, the dif- eafe proceeds for a longer or a fhorter time. When the pyrexia attending it is of a violent inflammato- ry kind, and more efpecially when it is of a very putrid nature, the dileafe often terminates fatally in a few days, with all the marks of a fiipera- vening "gangrene. When the febrile date is more moderate, or difappears altogether, the difeafe is often protra&ed for weeks, and even for months ; but, even then, after a various duration, it often terminates fatally, and generally in confequence of a return and confiderable aggravation of theinflam- matory and putrid dates. In fome cafes, the difeafe ceafes fpontaneoufly ; the frequency of dools, the griping, and tenefmus, gradually diminifhin^, while natural dools return. In other cafes, the difeafe, with moderate fymptoms, continues long, and ends in a diarrhoea, fometimes accompanied with fienteric fymptoms. IO72. The remote caufes of this difeafe have been va- rioufly judged of. It generally arifes in fummer or autumn, after confiderable heats have prevailed for fome time, and efpecially after very warm, and, at tiie fame time, very dry dates ofthe weather; and the difeafe is much more frequent in warm, than in cooler climates. It happens, therefore, in the fame circumdances and feafons which con- Fiderably affect the date of the bile in the human body ; but as the cholera is often without any ciy- fenteric fymptoms, and copious dilcharges of bile have been found to relieve the fymptoms of dyfen- tery, it is difficult to determine what connexion this difeafe has with the date ofthe bile. 1073. It 60 PRACTICE IO73. It has been obferved, that the effluvia from very putrid animal fubdances, readily affect, the alimen- tary canal; and upon fome occafions they certain- ly produce a diarrhoea; but, whether they ever produce a genuine dyfentery, I have not been able to learn with certainty, ' 1074, The dyfentery does often manifedly arife from the application of cold, but the difeafe is always contagions; and, by the propagation of fuch con- tagion, independent of cold, or other exciting caufes, it becomes epidemic in camps and other places. It is, therefore, to be doubted, if the ap- plication of cold does ever produce the difeafe, un- Icfs where the fpecific contagion has beenprevioufly received into the body: And upon the whole, it is probable, that a fpecific contagion is to be con- fidered as always the remote caufe of this difeafe. IO75, Whether this contagion, like many others, be of a permanent nature, and only fhows its effects in certain circumdances which render it active, or if it be occasionally produced, I cannot determine. Neither, if the latter fuppofition be received, can I fay by what means it may be generated. As lit- tle do we know any thing of its nature, considered in itfelf; or at mod this only, that, in common with many other contagions, it appears to be com-* monly of a putrid nature, and capable of inducing a putrefcent tendency in the human body. This, however, does not at all explain its peculiar power in inducing thofe fymptoms which properly and ef- fentially conditute the difeafe of dyfentery. (1066.) 1076. Of OF PHYSIC. 61 IO76. Of thefe fymptoms the proximate caufe is ft ill obfcure. The common opinion has been, that the difeafe depends upon an acrid matter received into, or generated in the inteftines themfelves, exciting their peridaltic motion, and thereby producing the frequent dools which occur in this difeafe. But this fuppofition cannot be admitted; for in all the indances known of acrid fubftances applied to the intedines and producing frequent dools, they at the fame time produce copious dools, as might be expected from acrid fubdances applied to any length of the intedines. This, however, is not the cafe in dyfentery ; in which the dools, however fre- quent, are generally in very fmall quantity, and fuch as may be fuppofed to proceed from the low- er parts of the rectum only. With refpeet to the fuperior portions ofthe intedines, and particularly thofe of the colon, it is probable they are under a preternatural and confiderable degree of condric- tion : For, as I have obferved above, the natural faeces are feldom voided; and when they are, it is in a form which gives reafon to fuppofe, they have been long retained in the cells of the colon, and confequently that the colon had been affefted with a preternatural condriction. This is confirmed by almod all the diffections which have been made of the bodies of dyfenteric patients, in which, when gangrene had not entirely dedroyed the texture and form of the parts, confiderable portions ofthe great guts have been found affected with a very confider- able conftriftion. IO77. I apprehend, therefore, that the proximate cauk cf dyfentery, or at lead the chief part of the prox- imate caufe, confids in a preternatural conihiciion oi 62 PRACTICE of the colon, occasioning at the fame time thofe spasmodic efforts which are felt in fevere ^ripings, and which efforts, propagated riownwa-ds to the rectum, occafion there the frequent mucous dools and tenefmus. But, whether this explanation fhall be admitted or not, it will dill remain certain, that hardened feces retained in the culon are the caufe of the griping, frequent dools, and tenefmus; for the evacuation of thefe faeces, whether by nature or by art, gives relief from the fymotons mentionT ed; and it will be more fn!iy and ufe fully confirm- ed by this, that the mod immediate and fuccefsful cure of dyfentery* is obtained by an early and con,. dant attention to the preventing the condriction, and the frequent dagnation of faeces in the colon. IO78. In this manner I have endeavoured to afcertain the proximate caufe of dyfentery, and therefore to point out alio the principal part of the cure, which, from want of the proper view ofthe nature of the difeafe, feems to have been in feveral refpects fluc- tuating and undetermined among practitioners, IO79. The mod eminent of our late practitioners, and of greated experience in this difeafe, feem to be of opinion, that the difeafe is to be cured mod effec- tually by purging affiduoufly employed. The means may be various; but the mod gentle laxatives are ufually fufficient; and as they mud be frequent- ly repeated, the mod gentle are the mod fafe; the more efpecially as an inflammatory date fo fre- quently accompanies the difeafe. Whatever laxa- tives produce an evacuation of natural faeces, and a consequent remiffion of the fymptoms, will be fuf- ficient to effectuate the cure. But if gentle laxa- tives fhall not produce the evacuation now men- tioned, O F P H Y S I C. 63 tfioned, fome more powerful medicines muft be em- ployed*; and I have found nothing more proper or convenient than tartar emetic, given in fmall dofes, and at fuch intervals as may determine their ope- ration to be chiefly by ftool. Rhubarb, fo fre- quently employed, is in feveral refpecls amongd the mod improper purgatives. IO80. Vomiting has been held a principal remedy in this difeafe ; and may be ufefully employed in the beginning of it, with a view to both the date ofthe ftomach and ofthe fever ; but it is not neceffary to repeatitof.n; and unlefs the emetics employed operate alio by ftool, they are of little fervice. I- pecacuanha feems to poflefs no fpecific power ; and it proves only ufefui when fo managed as to operate chiefly by ftool . 1081. For relieving the conftriction ofthe colon, and evacuating the retained faecest, glyfters may fome- times be ufeful; but they are feldom fo effectual as laxatives * I fhall fubjoin fome formulas fuitable for procuring a paffage in the dyfentery, ft. Infill", fenn. |ii. Mannae opt. %i. M. f. hauft. ft. Mannae ^i. Sal. glauber. §fs. Solve in aq. bullient. §iii.; et adde Tinft. Cardamomi 5i. Where ftronger purgatives are requifite, ft. Reiin. Jalap, gr. x. vel xv. Tere in mortario marmoreo, cum Amygdal. dulc. decort. No. iii. Sacch. alb. 3i.; Dein adde Aq. cinnamom. fimpl. §ifs. M. t Glyfters in thefe cafes ought to be made very large, and they ou^ht alfo to ut Irery mili ; as a pint and a hilt, or even two pints, of t!iin lint-feed f.u, or decoc* tio-i of uiirlh rrullows, without any other addition. 64 PRACTICE laxatives given by the mouth ; and acrid glyfters, if they be not effectual in evacuating the colon, may prove hurtful by ftimulating the rectum too much. I082. The frequent and fevere griping attending this difeafe, leads almod. neceffarily to the ufe of opi- ates, and they are very effectual for the purpofe of relieving from the gripes ; but by occafioning an interruption ofthe action of the fmall guts, they fa- vour the condriction of the colon, and thereby. fometimes aggravate the difeafe ; and if at the fame time the ufe of them fuperfede in any meafure the employing of purgatives, it commonly does much nuTchief ; I believe it indeed to be only the neglect, of purging that renders the ufe of opiates very neceffary*. I083. When the gripes are both frequent and fevere, they may fometimes be relieved by the employ- ment of a femicupium, or by a fomentation of the abdomen, continued for fome time. In the fame cafe, the pains may be relieved, and, as I think, the condriction of the colon may be taken off, by bliders applied to the lower bellyt. I084. At the beginning of this difeafe, when the fever is any way confiderable, bloodletting, in patients of tolerable vigour, may be proper and neceffary i and, * The griping is much relieved, and fometimes prevented, by drinking plenti- fully of any mucilaginous warm liquors during the operaticn ofthe purges ; as bar- ley water, with bruifed prunes boiled in it. + Blifters applied to the abdomen, befides being exceffively troublefome, muft neceffarily be extremely painful, PracYuionsrs OF PHYSIC. 65 and, when the pulfe is full and hard, with other fymptoms of an inflammatory difpofition, blood- letting ought to be repeated. But, as the fever attending dyfentery is often of a putrid kind, or does, in the courfe of the difeafe, become foon of that nature, bloodletting mud be employed with great caution. I085. From the account now given of the nature of this difeafe, it will be fufficiently obvious, that the ufe of adringents in the beginning of it mud be abfo- lutely pernicious. 1086. Whether an acrid matter be the original caufe of this difeafe, may be uncertain ; but from the indi- gedion and the dagnation of fluids in the domach which attend the difeafe, it may be prefumed, that fome acrid matters are condantly lifte»- tliat might have happened to have been applied at the time when thefe other remedies were ufed. Too ftrict an attention to the falfe axiom, poji hoc ergo propter lv,c, has been the fource of numerous errors in the practice of phyfic, and has raifed the reputation ofthe phyfician and his remedies, when the merit was only due to nature. * Some forms of thefe demulcents are given in the Pharmacopoeias. The follow- ing may be added, for the fake of variety, as the patient frequently loaths Lmctufss. ft. Mann. opt. 01. amygdal. recent, aa. §i, Syr. e Cort. aurant. %k. M. R. Syr, 66 PRACTICE 1087. As this difeafe is fo often of an inflammatory or of a putrid nature, it is evident that the diet em- ployed in it fhould be vegetable and acefcent. Milk in its entire date is of doubtful quality in many cafes; but fome portion of the cream is often al- lowable, and whey is alwavs proper. In the fird dages of the difeafe, the fweet and fubacid fruits are allowable, and even proper. It is in the more advanced dages only that any mor- bid acidity feems to prevail in the domach, and to require fome referve in the ufe of acefcents. At the beginning of the difeafe, abforbents feem to be fuperfluous; and by their adringent and feptic powers they may be hurtful. 1088. When this difeafe is complicated with an inter- mittent fever, and is protracted from that circum- dance chiefly, it is to be treated as an intermittent, by adminidering the Peruvian bark, which, how- ever, in the earlier periods of the difeafe, is hardly to be admitted. PART R. Syr. althaea*. 01. amygdal. Eleft. lenitiv. aa. 31. M. ft. Conferv. cynoibat. %i. Syr. rofar. 01. amygdal. aa. %\\. M. Two tea-fpoonfuls of any of the above tinctures may be given every hour, or every other hour, drinking, at the fame time, barley-water with bruifed prunes boiled in it. The cure of the dyfentery is briefly comprehended in keeping the belly open, an* .ufmg mucilaginous diluents and lubricants. PART II. Of Neurofes, or Nervous Difeafes. 1089. IN a certain view, almod the whole ofthe difeafes ofthe human body might be called Nervous: But there would be no ufe for fuch a general ap- pellation ; and, on the other hand, it feems impro- per to limit the term, in the loofe inaccurate man- ner in which it has been hitherto applied, to hyderic or hypochondriacal diforders, which are themfelves hardly to be defined with fufricient precifion. IO9O. In this place I propofe to comprehend, under the title of Neuroses, all thofe preternatural af- fections of fenfe or motion which are without py- rexia, as a part of the primary difeafe; and all thofe which do not depend upon a topical affection of the . organs, but upon a more general affection of the nervous fydem, and of thofe powers of the fydem upon which fenfe and motion more efpecially de- pend. 1091. Of fuch difeafes I have edablifhed a clafs, under the title of Neuroses, or Nervous Diseases. Thefe I again diitinguifh, as they confid, either in the interruption and debility of the powers of fenfe and motion, or in the irregularity with which thefe powers are exercifed; and have accordingly arrang- ed them under the four orders of Comata, Adyna- mia;, Spafmi, and Vefanioe, to be defined as we pro- ceed to treat of them more particularly. BOOK [ 68 ] BOOK I. Of COMATA, or the LOSS of VOLUN- TARY MOTION. 1092, UNDER this title are comprehended thofe af- fections which have been commonly called the Soporofe difeafes; but they are mod properly didinguifhed by their confiding in fome interrupti- on or fuppreffion of the powers of fenfe and volun- tary motion, or of what are called the animal func- tions. Thefe are indeed ufually fufpended in the time of natural deep: But of all the difeafes to be comprehended under our title, deep, or even the appearance of it, is not condantly a fymptom. Of fuch difeafes I can mark and properly explain two genera only, which come under the titles of Apo- plexy and Palfy. CHAP. I. Or APOPLEXY. IO93. APOPLEXY is that difeafe in which the whole of the external and internal fenfes, and the whole of the voluntary motions, are in fome de- gree abolifhed; while refpiration and the action of the O F P H Y S I C. 69 the heart continue to be performed*. By its be-1 ing an affePtion of the whole of the powers of fenfe and of voluntary motion, we didinguifh it from Palfy; and by its being with the continuance of refpiration and the action of the heart, it is didin- guifhed from Syncope. I have further added to the ordinary definition of apoplexy, that the abo- lition of the powers of fenfe and motion is in fome degree only ; meaning by this to imply, that, un- der the title of Apoplexy, are here comprehended thofe difeafes which, as differing from it in degree only, cannot, with a view either to pathology or practice, be properly didinguifhed from it : Such are the difeafes fometimes treated of under the names of Car us, Cataphora, Coma, and Lethargus. IO94. Apoplexy, in all its different degrees, mod com- monly affecis perfons advanced in life, and efpeci- ally thofe above fixty years of age. It mod ufu- ally affetts perfons of large heads and fhort necksf, perfons of a corpulent habit, perfons who have paffed an indolent life and ufed a full diet, and efpecially thofe who have indulged in frequent in- toxication. Men who have long laboured under a frequent and copious difcharge of blood from the hemorrhoidal veffels, upon either the fuppreffion or fpontaneous ceasing of that difcharge, are parti- cularly liable to be affected with apoplexy. 1095. This * " The appearance of a profound and continual fleep" is by Boerhaave judici-* oufly added to the definition of Apoplexy. To diftinguifh between a profound fleep and apoplexy", which very much referable each other, is, however, extremely eafy. A man in a profound fleep may in ge« neral be roufed by the application of ftrong {Simulants to the organs of fenfe, which produce no effect on an apopleftic patient. To diftinguifh between apoplexy and a fit of drunkennefs, is not fo eafy; for drunken people are fometimes incapable of being roufed by any ftimuhnts, 1-inrJa- ing totally infenfible and motionlefs. The fumes of the liquor with wM-.h they have been intoxicated may fometimes be difcovered by fmelling: A drunke; "t may alfo be known by the palenefs of the drunken man's face, and by his ki . .cr of living. t Different authors, one of whom is Boerhaave, have fuppofcd t"-.ic a verii "4 il fometimes wanting, the neck confifting only of fix inftead of ieven y :.«;> brre, 70 PRACTICE IO95. This difeafe frequently comes on very fuddenly : But in many cafes it is preceded by various fymp- toms, fuch as frequent fits of giddinefs, frequent headachs, a hemorrhagy from the nofe, fome tran- fitory interruption of feeing and hearing, fome falfe vifion and hearing, fome tranfitory degree of numbnefs or lofs of motion in the extremities, fome faltering of the tongue in fpeaking, a lofs of me- mory, a frequent drowfinefs, and frequent fits of incubus. IO96. An attention to thefe fymptoms, and to the pre- difponent circumdances (1094.), will often enable lis to forefee the more violent attacks of this difeafe. IO97. When the difeafe comes on fuddenly to a confi- derable degree, it has been frequently obferved to have been immediately induced by violent exercife; by a full and long continued infpiration ; by a fit of anger ; by much external heat, efpecially that arifing from a crowded affembly of people ; by warm bathing; by intoxication; by long dooping with the head down ; and by a tight ligature about the neck. The difeafe has been remarked to make its attacks mod frequently in the fpring feafon, and efpecially when the vernal heat fuddenly fucceeds to the winter cold. IO98. The fymptoms denoting the prefence of this dif- eafe will be fufficiently known from the definition given (1093.) Although the whole of the body is affeaed OF PHYSIC. 7» affe&ed with the lofs of fenfe and motion, it fome- times takes place more upon one fide of the body than the other; and, in that cafe, the fide lead af- fected with palfy is fometimes affefted with con- vulfions. In this difeafe there is often a ftertor- ous breathing; and this has been faid to be a mark of the mod violent date of the difeafe : But it is not always prefent even in the mod complete form or mod violent degree of the difeafe. IO99. The proximate caufe of this difeafe may be, in general, whatever interrupts the motion of the ner- vous power from the brain to the mufcles of vo- luntary motion; or, in fo far as fenfe is affe&ed, whatever interrupts the motion of the nervous pow- er from the fentient extremities of the nerves to the brain. 11OO. Such an interruption of the motions of the ner- vous power may be occafioned, either by fome com- preffion of the origin of the nerves, or by fomething dejtroying the mobility of the nervous power. Both thefe caufes we mud treat of more particularly ; and, fird, of that of compreffion, feemingly the mod frequent occafion of apoplexy, and perhaps the occafion of all thofe apoplexies arifing from in- ternal caufes. I IOI. The lofs of fenfe and motion in particular parts of the body, may be occafioned by a compreffion, either of the origin of certain nerves only, or of the fame nerves in fome part of their courfe from the brain to the organs of fenfe and motion. "Such cafes of partial compreffion will be more properly confidered 72 PRACTICE confidered hereafter ; and the affection I am now to treat of being general, it mud depend upon a ve- ry general compreffion of the origin of the nerves, or medullary portion of the brain ; and therefore, this more general compreffion only is to be confi- dered here. I 102. This compreffion of the origin of the nerves, or medullary portion of the brain, may be produced in different ways ; as, 1. By external violence fracturing and preffing in a part of the cranium. 2. By tumors, fometimes foft, fometimes bony, formed in different parts of the brain, or in its membranes, and becoming of fuch a bulk as to comprefs the medullary fubftance of the brain. 3. By the blood being accumulated in the blood- veffels of the brain, and didending them to fuch a degree as to comprefs the medullary portion of the fame. 4. By fluids effufed in different parts of the brain, or into the cavity of the cranium, and ac- cumulated in fuch quantity as to occafion the com- preffion we treat of. And, as to this lad, it is to be remarked here, that the fluids effufed may be of two kinds; that is, they may be either a portion of the common mafs of blood, poured out from red veffels; or a portion of ferum or colourlefs fluid, poured out chiefly by exhalants. IIO3. Of thefe feveral caufes of compreffion, the firft is not to be confidered here, becaufe the removing it does not belong to our province; and the consi- deration of the lecond may be omitted, as in mod ii.iLuices it is neither to be difcerned nor cured by OF PHYSIC. 7S by any means yet known. The third and fourth caufes of compreffion, as they are the mod fre- quent, and are alio mod properly the fubjects of our art, fo they are thofe which deferve our parti- cular attention ; and we fhall therefore endeavour to trace them further back in the feries of caufes which may produce them. I 104. Both the dates of over didention and of effufion, may be produced by whatever increafes the afflux and impetus of the blood in the arteries of the head ; fuch as violent exercife, a violent fit of an- ger, external heat applied, or any drong preffure upon the defcending aorta. I 105. But both thefe dates of over didention and of effufion, may alfo and feem to be more frequently produced by caufes that operate by preventing the free return of the venous blood from the veffels of the head to the right ventricle of the heart. I 106. The venous veflels of the brain are of a confor- mation and didribution fo peculiar, as to lead us to believe, that Nature intended to retard the motion of the blood, and accumulate it in thefe veffels; and therefore, even very fmall additional refid- ances to the motion of the blood from thefe to- ward the right ventricle of the heart, may dill more readily accumulate the blood in them. Such accumulation will mod readily happen in advanc- ed life, when the venous fydem in general is in a plethoric date, and when this plethora takes place efpecially in the venous veffels of the brain. . It will, in like manner, be mod apt to occur in per- Vol. II. K fons 74 PRACTICE fons whofe heads are large with refpect to the reft ofthe body; and in perfons of a fliort neck, which is unfavourable to the return of the venous blood from the head. The accumulation of blood in the venous veffels ofthe brain, will alfo be mod likely to occur in perfons of a corpulent habit, either be- caufe thefe may be confidered to be in a plethoric ftate, or becaufe obefity, by occasioning a compref- fion of the blood-veffels in other parts of the body, more readily fills thofe of the brain, which are en- tirely free from any fuch compreffion. I IO7. Thefe are the circumdances in the conditution of the body, which, producing a flower motion and return of the venous blood from the veffels of the head, favour an accumulation and didention in them ; and we now proceed tc* mention the feveral occasional caufes, which, in every perfon, may di- rectly prevent the free return of the blood from the veffels of the head towards the heart. Such are, 1. Stooping down with the head, or other situa- tions of the body in which the head is long kept in a depending date, and in which the gravity of the blood increafes the afflux of it by the arteries, and oppofes the return of it by the veins. 2. A tight ligature about the neck, which com- preffes the veins more drongly than the arteries. 3. Any obdruction of a confiderable number of the veins carrying the blood from the head, and more efpecially any confiderable obdruction of the afcending vena cava. 4. Any confiderable impediment ofthe free paf- fage of the blood from the veins into the right ven- tricle of the heart; and it is commonly by this, and the immediately preceding circumdances, that po- lypous concretions in the cava, or right ventricle, are found to occafion apoplexy. 5. The return of blood from the veins of the head towards OF PHYSIC. 75 towards the heart, is efpecially interrupted by every circumdance that produces a more difficult tranf- miffion of the blood through the veffels ofthe lungs. It is well known, that, at the end of every expirati- on, fome interruption is given to the free tranfmif- fion ofthe blood through the lungs; and that this at the fame time gives an interruption to the motion ofthe blood from the veins into the right ventricle of the heart. This clearly appears from that re- gurgitation ofthe blood in the veins which occafions the alternate heaving and fubfiding that is perceiv- ed in the brain of living animals when the cranium is removed, and which is obferved to be synchro- nous with the alternate motions of refpiration. From this we readily perceive, that whatever occafions a difficulty in the tranfmiffion of the blood through the lungs, mud alfo interrupt the free return ofthe venous blood from the veffels of the head; and mud therefore favour, and perhaps produce, an ac- cumulation of blood, and an over didention in thefe veffels. It is further to be obferved, that as a very full infpiration, continued for any length of time, oc- cafions fuch an interruption of the free tranfmiffion of the blood through the lungs, as produces a dif- fusion of face, and a manifed turgefcence of the blood-veffels of the head and neck ; fo every full and long continued infpiration may occafion an ac- cumulation of blood in the veffels of the head, to a very confiderable degree. Thus, as every drong exertion of the mufcular force of the body requires,, and is attended with, a very full and long conti- nued infpiration, we thence learn why the violent exertions of mufcular force have been fo often the immediate or exciting caufes of apoplexy. It may alfo be remarked, that corpulency and obefity feem to operate very much, by occasioning a more difficult tranfmiffion of the blood through the veffels of the lungs. It appears, that in fat perfons, from the compreffion of the blood-vef- fels 76 PRACTICE fels in many parts of the body, the veffels of the lungs are thereby kept very full; fo that upon the lead increafe of bodily motion, which fends the blood fader into the lungs, a more frequent and laborious refpiration becomes in fuch perfons immediately neceffary. This fhows, that, in fuch perfons, the blood is not freely transmitted through the lungs; a circumdance which, as in other in- dances, mud give a condant refidance to the re- turn of blood from the veffels of the head, and therefore favour or occafion an accumulation of blood in them. Is the motion of the blood in the veffels of the head rendered flower by dudy, care, and anxiety ? I I 08. It is to be obferved further, that thefe feveral caufes (1104.—1107-) of a preternatural fulnefs in the blood-veflels of the brain, may produce apo- plexy in different ways, according as the fulnefs takes place in the arteries or in the veins. I IO9. Accordingly, frjl, the increafed afflux of blood into the arteries ofthe brain, and an increafed ac- tion in thefe, may either occafion a rupture of their extremities, and thereby an effufion of red blood producing compreffion ; or the fame afflux and increafed action may occafion an increafed ex- halation from their extremities, of a ferous fluid, which, if not as quickly reabforbed, may foon ac- cumulate in fuch quantity as to produce compref- fion. I I IO. Secondly, The plethoric date of the venous vef- fels of the brain, may operate in three different OF PHYSIC. 77. 1. The fulnefs of the veins may give fuch refid- ance to the blood flowing into them from the arte- ries, as to determine the impetus of the blood to be fo much greater upon the extremities of the ar- teries as to occafion a rupture of thefe, and confe- quently an effufion of red blood, or the Hcemor- rharia cerebri, which Ho f f m an considers as a fre- quent caufe of apoplexy, and which we have before explained in (771-). 2. Whild the fame refidance to the blood flow- ing from the arteries into the veins, increafes the impetus of the blood to the former, this may, without occafioning rupture, increafe the exhala- tion from their exhalant extremities, and produce an effufion of a ierous fluid; in the fame manner as fuch refidance in the veins produces hydropic effufions ir< other parts ofthe body. 3. If we may fuppofe, as no lymphatics have been yet difcovered in the brain, that the ordinary abforbents are not prefent there, and that the ex- haled fluids are abforbed or taken up by the extre- mities of the veins ; this will fhow dill more clear- ly that a refidance to the motion ofthe blood in the veins of the brain, may readily produce an accu-* mulation of ferous fluid in its cavities, and confe- quently a compreffion producing apoplexy. mi. Befides thefe cafes of apoplexy from afflux in the arteries, or refidance in the veins, an effufion of ferum may happen from two other caufes. The one is a relaxation of the exhalants, as in other ca- fes of hydropic diathesis prevailing in the body ; and it is not unufual for a general dropfy to end in apoplexy. The fecond is an over proportion of watery parts in the mafs of blood, which is there- fore ready to run off by the exhalants, as in the cafe of an ifchuria renalis ; which when it proves incurable, very commonly terminates in apoplexy. 1112. We 78 PRACTICE I I 12. We have now mentioned the feveral caufes of apoplexy depending upon compreffion ; and from the whole it will appear, that the mod frequent of all thefe caufes is a plethoric date, or an accumula- tion and congedion of blood in the venous veffels ofthe head, operating, according to iis degree, in producing over didention or effufion. The fre- quent operation of fuch a caufe will efpecially ap- pear from a consideration of the predifponent cir- cumdances (1094.), and from the antecedent fymp- toms (1095.). III3. From the view I have now given of the caufes of apoplexy arifing from compreffion, it will readily appear that there is a foundation for the common didinction of this difeafe into the two kinds of San- guine and Serous. But this didinction cannot be Very ufefully applied in practice, as both kinds may often depend on the fame caufe, that is, a venous plethora, and therefore requiring very nearly the fame method of cure. The only didinction that can beproperly made of apoplexies from compreffion, is perhaps the didinction of ferous apoplexy, into that depending on the plethora mentioned (1112.), and that depending on hydropic diathefis or an over proportion of water in the blood (1111.) j the for- mer caufes giving a proper idiopathic, the latter only a fymptomatic, difeafe. I I 14. Befide the caufes now mentioned, occasioning apoplexy by compreffion, I allege there are other caufes producing the fame difeafe, by directly de- droying the mobility ofthe nervous power. Such caufV." OF PHYSIC. 73 caufes feem to be the mephitic, arifing from fer- menting liquors, and from many other fources ; the fumes arifing from burning charcoal; the fumes of mercury, of lead, and of fome other me- tallic fubdances; opium, alcohol, and many other narcotic poifons: To all which I would add the power of cold, ofconcuffion, of electricity, and of certain paflions of the mind. I I 15. None of thefe poifons or noxious powers feem to kill by acting fird upon the organs of refpiration, or upon the fanguiferous fydem ; and I believe their immediate and direct action to be upon the nervous power, dedroying its mobility, becaufe the fame poifons fhow their power in dedroying the irritability of mufcles and of the nerves con- nected with them, when both thefe are entirely fe- parated from the red of the body. I I 16. It appears to me probable, that the apoplectic date in fome degree accompanying, and almod al- ways succeeding, an epileptic paroxysm, does not depend upon compreffion, but upon a certain date of immobility of the nervous power, produced by certaig circumdances in the nervous fydem itfelf, which fometimes feem to be communicated from one part of the body to another, and at length to the brain. I 117. The fame obfervation may be made with refpect to many indances of hyderic paroxyfm; and the cir- cumdances, both of epileptic and hyderic paroxysms, ending in coma, or a degree of apoplexy, lead me to think, that alfo the apoplexy proceeding from re- trocedent 8o PRACTICE trocedent or atonic gout is of the fame kind, or that it depends upon an immobility of the nervous pow- er, rather than upon compreffion. IIl8. : It may indeed happen, that as the apoplectic and gouty predifpofitions do often concur in the fame perfon ; fo it may confequently happen that the apo- plexy coming upon gouty perfons, may fometimes depend upon compreffion ; and diffections may, ac- cordingly, difcover that the circumftances of fuch a caufe had preceded. But, in many cafes of the apoplexy following a retrocedent or atonic gout, no fuch antecedent or concomitant circumdances, as commonly occur in cafes of compreffion, do diilinctly or clearly appear; while others prefent themfelves, which point out an affection of the nervous power alone. I I 19. With refpect, however, to the circumdances which may appear upon the diffection of perfons dead of apoplexy, there may be fome fallacy in judging, from thofe circumdances, ofthe caufe of the difeafe. Whatever takes off or diminifhes the mobility of the nervous power, may very much re- tard the motion of the blood in the veffels of the brain ; and that perhaps to the degree of increasing exhalation, or even of occasioning rupture and ef- fufion; fo that, in fuch cafes, the marks of com- preffion may appear, upon diffection, though the difeafe had truly depended on caufes dedroying the mobility of the nervous power. This feems to be illudrated and confirmed from what oc- curs in many cafes of epilepfy. In fome of thefe, after a repetition of fits, recovered from in the ufual manner, a fatuity is induced, which com- monly depends upon a watery inundation of the brain: O F P H Y S I C. &x brain : And in other cafes of epilepfy, when fits have been often repeated without any permanent confequence, there happens at length a fatal pa- roxyfm ; and upon diffection it appears, that an effufion of blood had happened. This, I think, is to be confidered as a caufe of death, not as a caufe of the difeafe; for in fuch cafes, I fuppofe that the difeafe had diminiflfed the action ofthe veflels of the brain, and thereby given occafion to a flag- nation, which produced the appearances mentioned. And I apprehend the fame reafoning will apply to the cafes of retrocedent gout, which, by dedroy- ing the energy of the brain, may occafion fuch a dagnation as will produce rupture, effufion, and death ; and in fuch a cafe, the appearances upon diffection might lead us to think that the apoplexy had depended entirely upon compreffion. 1120. The feveral caufes mentioned in (1114), are oft- en of fuch power as to occafion immediate death ; and therefore have not commonly been taken no- tice of as affording indances of apoplexy ; but, as the operation of the whole of thefe caufes is simi- lar and analogous, and as in mod indances of the operation of thefe caufes an apoplectic date is ma- nifedly produced, there can be little doubtin con- sidering mod ofthe indances of their effects as ca- fes of apoplexy, and therefore fuch as fall proper- ly under our consideration here. I 121. This difeafe of apoplexy is fometimes entirely re- covered from; but more frequently it ends in death, or in a hemiplegia. Even when an attack ofthe difeafe is recovered from, we generally find it difpofed to return ; and the repeated attack* of it almod always, fooner or later, brin^ on the e- vcnts we have mentioned. Vol. II. L 1122. The %* PRACTICE I 122. The feveral events of this difeafe, in health, death, or another difeafe, may be expected and forefeen from a consideration of the predifponent circumdances (1094.); ofthe antecedent fymptoms (1095.) ; of the exciting caufes (1097.); of the vio- lence and degree ofthe fymptoms when the difeafe has come on (1093.) ; ofthe duration ofthe dif- eafe; and of the effects ofthe remedies employed. II23. From the great danger attending this difeafe when it has come on (1121.), it will readily appear, that our care fhould be chiefly directed to the pre- vention of it. This, I think, may be often done by avoiding the remote and exciting caufes ; and how this may be accomplifhed,- will be obvious from the enumeration of thofe caufes given above (1097.) But it will alfo appear from what is faid above, that the prevention of this difeafe will efpecially depend upon obviating the predifponent caufe ; which, in mod cafes, feems to be a plethoric date of the blood-veffels of the brain. This, I think, may be obviated by different means ; and, in the fird place, by a proper management of exercife and diet. I 124. The exercife ought to be fuch as may fupport the perspiration, without heating the body or hur- rying refpiration ; and, therefore, commonly by fome mode of gedation. In perfons not liable to frequent fits of giddinefs, and who are accudomed to riding on horfeback, this exercife is, of all others, the bed. Walking, and fome other modes of bodily exercife, may be employed with the re- dactions O F P H Y S I C. 8$ ftrictionsjud now mentioned; but in old men, and in men of corpulent habits, bodily exercife ought. always to be very moderate. II25- In perfons who pretty early in life fhow the pre- difpofition to apoplexy, it is probable that a low diet, with a good deal of exercife, might entirely prevent the difeafe; but, in perfons who are ad- vanced in life before they think of taking precau- tions, and are at the fame time of a corpulent ha- bit, which generally fuppofes their having been ac- cudomed to full living, it might not be fafe to put them upon a low diet; and it may be enough that their diet be rendered more moderate than ufual, efpecially with refpect to animal food; and that, at fupper, fuch food fhould be abdained from alto- gether. In drinking, all heating liquors are to be abdain- ed from, as much as former habits will allow; and the fmalled approach to intoxication is to be care- fully fhunned. For ordinary draught, fmall beer is to be preferred to plain water, as the latter is more ready to occafion codivenefs, which in apo- plectic habits is to be carefully avoided. The large ufe of tobacco in any fhape, may be hurtful; and except in cafes where it has been accudomed to occafion a copious excretion from the head, the interruption of which might not be fafe, the ufe of tobacco fhould be avoided; and even in the cir- cumdance mentioned, where it may be in fome meafure neceffary, the ufe of it fhould at lead be rendered as moderate as poffible. I 126. Evacuations by dool may certainly contribute to relieve the plethoric date of the veffels of the head ; and, upon an appearance of any unufuai turgefcencp H PRACTICE turgefcence in thefe, purging will be very properly employed : But, when no fuch turgefcence appears, the frequent repetition of large purging might weak- en the body too much; and, for preventing apo- plexy, it may for the mod part be enough to keep the belly regular, and rather open, by gentle laxa- tives*. In the fummer feafon, it may be ufeful to drink, every morning, of a gentle laxative mineral water, but never in large quantity. I127. In the cafe of a plethoric date ofthe fydem, it might be fuppofed that bloodletting would be the mod effe6tual means of diminifhing the plethora, and of preventing its confequences : And, when an attack of apoplexy is immediately threatened, bloodletting is certainly the remedy to be depend- ed upon ; and blood fhould be taken largely, if it can be done, from the jugular vein, or temporal artery. But, when no threatening turgefcence ap- pears, the obviating plethora is not judieioufly at- tempted by bloodletting, as we have endeavoured to demonftrateabove, (786.) In doubtful circum- ftances, leeches applied to the temples, or fcarifi- cations of the hind head, may be more fafe than general bleedings. I 128. When there are manifed fymptoms of a plethoric date in the veffels ofthe head, a feton, or pea iffue, near the head, may be very ufeful in obviat- ing any turgefcence ofthe blood. 1129. Thefe * Gentle laxatives have been often enumerated in the preceding notes. In thefe eafes, however, there is no danger to be apprehended from the ufe of the refinous draftics, provided that they are not given iq fuch dofes as may weaken the patient too jnuch They ought not to be ufed for the purpofe of purging, but only for keeping the body moderately open ; and this effed may be fafely produced by five or eight grains of Rufus's pills taken occafionally at bed time, or by a tea-fpoonful or two of the Tinft. jalap, or a table-fpoonful of the elixir fennae in the morning. The fame TOdmay, iamany cafes, be anfwered by a due attention to diet. O F P H Y S I C. 85 1129. Thefe are the means to be employed for prevent- ing the apoplexy which might arife from a pletho- ric date of the veffels of the brain ; and if, at the fame time, great care is taken to avoid the exciting caufes (1097.), thefe means will be generally fuc- cefsful. In the cafes proceeding from other caufes (1114.), as their application is fo immediately fucceeded by the difeafe, they hardly allow any opportunity for prevention. II30. For the Cure of apoplexies from internal cau- fes, and which I fuppofe to be chiefly thofe from compreffion, the ufual violence and fatality of it require that the proper remedies be immediately andTargely employed. The patient is to be kept as much as poffible in fomewhat of an erect poflure, and in cool air ; and therefore neither in a warm chamber, nor covered with bed clothes, nor furrounded with a crowd of people. II3I. In all cafes of a full habit, and where the difeafe has been preceded by marks of a plethoric date, bloodletting is to be immediately employed, and very largely. In my opinion, it will be mod effec- tual when the blood is taken from the jugular vein ; but, if that cannotbe properly done, it may be tak- en from the arm. The opening of the temporal artery, when a large branch can be opened, fo as fuddenly to pour out a confiderable quantity of blood, may alfo be an effectual remedy; but, in execution, it is more uncertain, and may be in- convenient* u PRACTICE convenient. It may be in fome meafure fupplied, by cupping and fcarifying on the temples or hind head. This, indeed, fhould feldom be omitted ; and thefe fcarifications are always preferable to the application of leeches. With refpect to every mode of bloodletting, this fs to be obferved, that when in any cafe of apoplexy, it can be perceived that one fide of the body is more affected with the lofs of motion than the other, the bloodletting, if poffible, fhould be made on ihe fide opposite to that mod affected*. 1132. Another remedy to be employed is purging, to be immediately attempted by acrid glyderst; and, at the fame time, if any power of fwallowing re- main, by dradic purgatives given by the mouth. Thefe, however, led they may excite vomiting, fhould be given in divided portions at proper in- tervalsj. 1133. Vomiting * Directions fhew that the congeftions producing apoplexy are always on the fide t<». affected ; and hence the propriety ofthe direction. ♦ Acrid glyfters are, R. Eledt. lenitiv. §i. Sal. cathartic, amar. §iifs. Aq. tepid. §xi. M. f. Enema. R. Sapon. alb. §ifs. Solve in aq. tepid. ?x. ; cui adde Syr. e fpina cerv. §ii. M. f. Enema. R. Pulp, colocynth. 5'ui. Coque per horse quadrantem in aq. font. q. s. ad colaturae |xii.; cui adde Ol. olivar. §i. M. f. Enema. X The draflic purges arc, in thefe cafes, t» be given in draughts^ rather than in frills or bolufes. The following form may be ufed : R. Pulv. jalap. 5i. Rad. zinzib. 9i. Infuf. fem. lini $iii. M. The dofe of this mixture is two fpoonfuls every two hours till it operate, or we inay ufeone of the formula mentioned in the note on article 1075. efpecially the laft, repeating it every two hours till it produces an effeft. OFPHYSIC. 9f "33- Vomiting has been commended by fome practi- tioners and writers : But, apprehending that this might impel.the blood with too much violence into the veffels of the head, I have never employed it. "34- Another remedy to be immediately employed is blidering; and I judge that this is more effectual when applied to the head, or near to it, than when it is applied to the lower extremities. This reme- dy I do not confider as a dimulant, or capable of making any confiderable revulfion : But, applied to the head, I fuppofe it ufeful in taking off the 'hemorrhagic disposition fo often prevailing there. ^35- It has been ufual with practitioners, together with the remedies already mentioned, to employ dimulants of various kinds: But I am difpofed to think them generally hurtful; and they mud be fo, wherever the fulnefs of the veffels, and the impe- tus of the blood in thefe, is to be diminifhed. Up- on this principle it is therefore agreed, that dimu- lants are abfolutely improper in what is fuppofed to be a fanguine apoplexy; but they are commonly fuppofed to be proper in the ferous. If, however, we be right in alleging that this alfo commonly de- pends upon a plethoric date of the blood-veffels of the brain, dimulants mud be equally improper in the one cafe as in the other. II36. It may be argued from the almod univerfal era^ ployment of dimulants, and fometimes with feem- ing 88 PRACTICE ing advantage, that they may not be fo hurtful as my notions of the caufes of apoplexy lead me to fuppofe. But this argument is, in feveral refpects, fallacious ; and particularly in this, that in a dif- eafe which, under every management, often pro- ceeds fo quickly to a fatal termination, the effecta of remedies are not to be easily afcertained. ll37- I have now mentioned the feveral remedies which I think adapted to the cure of apoplexy arifing from compreffion, and fhould next proceed to treat of the cure of apoplexy arifing from thofe caufes that directly dedroy the mobility of the nervous power. But many of thofe caufes are often fo powerful, and thereby fo fuddenly fatal in their effects, as hardly to allow of time for the ufe of remedies; and fuch cafes therefore have been fo feldom the fubjects of practice, that the proper remedies are not to well afcertained as to enable me to fay fo much of them here. 1138. When, however, the application of the caufes (1114.) is not fo powerful as immediately to kill, and induces only an apopleciic date, fome efforts are to be made to obviate the confequences, and to recover the patient; and even in fome cafes where the caufes referred to, from the ceafing of the pulfe and of refpiration, and from a coldnefs coming upon the body, have induced an appear- ance of death; yet, if thefe appearances have not continued long, there may be means of recovering the perfons to life and health. I cannot, indeed, treat this fubject completely ; but for the cure of apoplexy from feveral of the caufes mentioned (1114.), fhall offer the following general directions. 1. When OF PHYSIC. 89 1. When a poifon capable of producing apo- plexy has been recently taken into the domach, if a vomiting fpontaneoudy arifes, it is to be encou-. raged ; or, if it does not fpontaneoufly come on, a vomiting is to be immediately excited by art, in order that the poifon may be thrown out as quick- ly as poffible. If, however, the poifon has been taken into the domach long before its effects have appeared, we judge that, upon their appearance, the exciting of vomiting will be ufelefs, and may perhaps be hurtful. 2. When the poifon taken into the domach, or otherwile applied to the body, has already induced an apoplectic date, as thofe caufes do commonly at the fame time occafion a dagnation or dower motion of the blood in the veffels of the brain and of the lungs, fo it will generally be proper to re- lieve this congedion by taking fome blood from the jugular vein, or from the veins ofthe arm. 3. Upon the fame fuppofition of a congedion in the brain or lungs, it will generally be proper to relieve it by means of acrid glyfters producing fome evacuation from the intedines. 4. When thefe evacuations by bloodletting and purging have been made, the various dimulants which have been commonly propofed in other cafes of apoplexy, may be employed here with more probability and fafety*. One ofthe mod effectual means of roufing apoplectics of this kind feems to be throwing cold water on feveral parts of the bo- dy, or wafhing the body all over with it. 5. Although the poifon producing apoplexy hap- pens to be fo powerful as very foon to occafion the appearances of death above mentioned ; yet if this date has not continued long, the patient may often Voi- II. M be * The ftimulants are various according to the various parts of the body to which they are generally applied, as volatile and vinous fpirits, or vinegar, to the nofe and temples; acrid effential oils, mixed with thrice their weight of hogs-lard, to the bread and back ; blifters, hot finapifms, and warm fomentations, with horfe-radifh, to the extremities ; frictions with warm brufhes ; the actual cautery to the foles ot' the feet, and palms of the hands, with feveral other?, which are more particularly dcfcribcd in the notes on article 1160. tt Jrj. 90 PRACTICE be recoverable; and the recovery is to be attempt- ed by the fame means that are directed to be em- ployed for the recovery of drowned perfons, and which are now commonlv known. CHAP. II. Or PALSY. J3ALSY is a difeafe confiding in a lofs of the power of voluntary motion, but affecting cer- tain parts of the body only, and by this it is didin- guifhed from apoplexy (1093.). One of the mod frequent forms of palfy is when it affects the whole of the mufcles on one fide of the body ; and then the difeafe is named a Hemiplegia. I 14O. The lofs of the power of voluntary motion may be owing either to a morbid affection of the muf- cles or organs of motion, by which they are ren- dered unfit for motion ; or to an interruption of the influx of the nervous power into them, which is always neceffary to the motions of thofe that are under the power of the will. The difeafe, from the fird of thefe caufes, as confiding in an organic and local affection, we refer entirely to the clafs of local difeafes. I am here to confider that difeafe only which depends upon the interrupted influx of the nervous power; and it is to this difeafe alone I would give the appellation of Palfy. A difeafe de- pending on an interrupted influx of the nervous power, may indeed often appear as merely a local affection ; but as it depends upon an affection of the mod general powers of the fydem, it cannot be properly feparated from the fyHematic affections. 1141. In OF PHYSIC. 91 I 141. In palfy, the lofs of motion is often accompani- ed with a lofs of fenfe: But as this is not condant- ly the cafe, and as therefore the lofs of fenfe is not an effential fymptom of palfy, I have not taken it into my definition (1139.); and I fhall not think it neceffary to take any further notice of it in this treatife; becaufe, in fo far as it is in any cafe a part of the paralytic affection, it mud depend upon the fame caufes, and will be cured alfo by the very fame remedies, as the lofs of motion. I 142. The palfy then, or lofs of motion, which is to be treated of here, may be didinguifhed as of two kinds; one of them depending upon an affection of the origin of the nerves in the brain, and the other depending upon an affection of the nerves in fome part of their courfe between the brain and the organs of motion. Ofthe latter, as appearing in a very partial affection, I am not to fpeak par- ticularly here; I fhall only treat of the more gene- ral paralytic affections, and efpecially of the hemi- plegia (1139.). At the fame time I expect, that what I fhall fay upon this subject will readily apply to both the pathology and practice in the cafes of affections more limited. "43- ' The hemiplegia (1139.) ufually begins with, or follows, a paroxysm of apoplexy; and when the hemiplegia, after fubfiffing for fome time, becomes fatal, it is commonly by paffing again into the date of apoplexy. The relation therefore or affinity be- tween the two difeafes, is fufficiently evident; and is further drongly confirmed by this, that the he- miplegia 92 PRACTICE miplegia comes upon perfons of the fame conditu- tion (1094.), and is preceded by the fame fymp- toms (1097.), that have been taken notice of with refpect to apoplexy. I 144. When a fit of apoplexy has gone off, and there remains a date of palfy appearing as a partial affec- tion only, it might perhaps be fuppofed that the origin of the nerves is in a great meafure relieved; but in fo far as commonly there dill remain the fymptoms of the lofs of memory, and of fome de- gree of fatuity, thefe, I think, mow that the organ of intellect, or the common origin ofthe nerves, is dill considerably affected. * I 145. Thus, the hemiplegia, from its evident connec- tion with, and near relation to apoplexy, may be properly confidered as depending upon like caufes; and confequently, either upon a compreffion pre- venting the fl«w of the nervous power from the brain into the organs of motion, or upon the ap- plication of narcotic or other powers (1114.) ren- dering the nervous power unfit to flow in the ufu- al and proper manner. I 146. We begin with considering the cafes depending upon compreffion. The compreffion occasioning hemiplegia may be of the fame kind, and of all the different kinds that produce apoplexy ; and therefore either from tu- mour, over didention, or effufion. The exidence of tumour giving compreffion, may often be better difcerned in the cafe of palfy than in that of apo- plexy, as its effects often appear at fird in a very partial affection. _. r 1147. The OF PHYSIC. 93 1147. The other modes of compreffion, that is, of over didention and effufion, may, and commonly do, take place, in hemiplegia; and when they do, their operation here differs from that producing apo- plexy, by its effects being partial, and on one fide of the body only. It may feem difficult to conceive that an over didention can take place in the veffels on one fide of the brain only; but it may be underdood: And in the cafe of a palfy which is both partial and tran- fitory, it is perhaps the only condition of the vef- fels ofthe brain that can be fuppofed. In a hemi- plegia, indeed, which fubfids for any length of time, there is probably always an effufion, either fanguine or ferous : But it is likely that even the latter mud be fupported by a remaining congedion in the blood-veffels. I 148. That a fanguine effufion can happen without be- coming very foon general, and thereby occafion- ing apoplexy and death, may alfo feem doubtful: But diffections prove that in fact it does happen, occasioning palfy only ; though it is true, that this more commonly depends upon an effufion of ferous fluid, and of this only. I 149. Can a palfy occafioned by a compreffion remain, though the compreffion be removed* ? 1150. From * This queftion may be anfwered in the affirmative; becaufe the frruclure of the, ■erve may be deftroyed by the compreffion, and the nerve may the* tere remain im- pervious to the nervous influence after the compreffion has been removed* 94 PRACTICE I 150. From what has been faid (1143.), it will be ob- vious, that the hemiplegia may be prevented by all the feveral means propofed (1124. et feq.) for the prevention of apoplexy. I 151. Upon the fame grounds, the Cure of palfy mud be very much the fame with that of apoplexy (1129. etfeq.); and when palfy has begun as an apoplexy, it is prefumed, that, before it is to be confidered as palfy, all thofe feveral remedies have been em- ployed. Indeed, even when it happens that on the fird attack of the difeafe the apoplectic date is not very complete, and that the very fird appearance of the difeafe is as a hemiplegia, the affinity be- tween the two difeafes (1143.) is fuch as to lead to the fame remedies in both cafes. This is certainly proper in all thofe cafes in which we can with much probability impute the difeafe to compreffi- on; and it is indeed feldom that a hemiplegia from internal caufes comes on but with a confiderable affe£lion of the internal, and even of the external fenfes, together with other marks of a compreffion of the origin of the nerves. II52. Not only, however, where the difeafe can be imputed to compreffion, but even where it can be imputed to the application of narcotic powers, if the difeafe come on with the appearances menti- oned at the end of the lad paragraph, it is to be treated in the fame manner as an apoplexy by (1130.-1138.). 1153. The OF PHYSIC. 95 ll53- The cure of hemiplegia, therefore, on its firft attack, is the fame, or very nearly the fame, with that of apoplexy ; and it feems requifite that it fhould be different only, 1. When the difeafe has fubfided for fome time; 2. When the apoplectic fymptoms, or thofe* marking a confiderable compreffion of the origin of the nerves, are removed ; and, particularly, 3. When there are no evident marks of com- preffion, and it is at the fame time known that nar- cotic powers have been applied. IIS4. In all thefe cafes, the quedion arifes, Whether dimulants may be employed, or how far the cure may be entirely truded to fuch remedies ? Upon this quedion, with refpect to apoplexy, I have of- fered my opinion in (1135.). And, with refpect to hemiplegia, I am of opinion that dimulants are almod always equally dangerous as in the cafes of complete apoplexy ; and particularly, 1. In all the cafes of hemiplegia fucceeding to a paroxyfm of complete apoplexy ; 2. In all the cafes coming upon perfons of the temperament mentioned in (1094.) and after the fame antecedents as thofe of apoplexy (1115. j; and, 3. In all the cafes coming on with fymptoms of apoplexy from compreffion. 115^. It is, therefore, in the cafes (1153.) only, that dimulants are properly admiffible : And even in the two firft of thefe cafes, in which a plethoric date of the blood-veffels of the brain may have brought * The moft infallible of thefe marks it the intellectual frcultie* not returning. 96 PRACTICE brought on the difeafe, in which a difpofition to that date may dill continue, and in which even fome degree of congedion may dill remain, the ufe of dimulants mud be an ambiguous remedy; fo that perhaps it is in the third of thefe cafes only that dimulants are clearly indicated and admiffiblc. I 156. Thefe doubts with refpect to the ufe of dimu- lants, may perhaps be overlooked or difregarded by thofe who allege that dimulants have been em- ployed with advantage even in thofe cafes (1154.) in which I have faid they ought to be avoided. II57. To compromife this contrariety of opinion, I mud obferve, that even in the cafes of hemiplegia depending upon compreffion, although the origin of the nerves be fo much compreffed as to prevent fo full a flow ofthe nervous power as is neceffary to mufcular motion, yet it appears from the power of fenfe dill remaining, that the nerves are, to a cer- tain degree, dill pervious ; and therefore it is pof- fible that dimulants applied, may excite the ener- gy of the brain fo much, as in fome meafure to force open the compreffed nerves, and to fhow fome return of motion in paralytic mufcles. Nay, further, it may be allowed, that if thefe dimulants be fuch as act more upon the nervous than upon the fanguiferous fydem, they may poffibly be em- ployed without any very hurtful confequence. "58. But dill it will be obvious, that although certain dimulants act chiefly upon the nervous fvftem, yet they alfo act always in fome meafure upon the fan- guiferous ; fo that, when they happen to have the latter OF PHYSIC. 97 latter effect in any confiderable degree, they may certainly do much harm ; and in a difeafe which they do not entirely cure, the mifchief arifing from them may not be difcerned. II59. Whild the employment of dimulants is fo often „ an ambiguous practice, we may perhaps go fome length towards afcertaining the matter, by confider- ing the nature of the feveral dimulants which may be employed, and fome of the circumdances of their adminidration. With this view, therefore, I fhall now mention the feveral dimulants that have been commonly employed, and offer fome remarks upon their nature and ufe. I 160. They are in the fird place to be didinguifhed as external or internal. Of the fird kind, we again didinguifh them as they are applied to particular parts of the body only, or as they are more gene- rally applied to the whole fydem. Of the fird kind are, 1. The concentrated acids of vitriol or nitre; involved, however, in oily or unctuous fubdances, which may obviate their corrofive, without dedroy- ing their dimulant power*. 2. The volatile alkaline fpirits, efpecially in their caudic date ; but involved alfo in oils, for the purpofe jud now mentionedf. Vol. II. N 3. The * Rubifacient ointments are compof.tions like the following: R. Azung. porcin. 311. Acid, vitriol. 3i. M. Or, R. Unguent, bafilic. flav. |ii. Acid, vitriol. 3i. M. They foon redden and inflame the fkin; and, when this effecT: is produced, they muft be taken off, and the part anointed with common ointment, or with oil. + l'h -■ Li ni rac nta volatilia of the Plurmacopccias are not fo ftrong as the following* ft. AlkaL 98 PRACTICE 3. The fame volatile fpirits are frequently em- ployed by being held to the nofe, when they prove a powerful fliinulus to the nervous f)dem ; but it is at the fame time probable; that they may alfo prove a drong dimulant to the blood-veffels of the brain. 4. A brine, or drong folution of fea-falt*. 5. The effential oils of aromatic plantst, or of their parts. 6. The effential oils of turpentine, or of other fuch refinous fubdances. 7. The diddled oils of amber, or of other bitu- minous foffilsj. 8. The rectified empyreumatic oils of animal or vegetable fubftances||. g. Various vegetable acrids, particularly mudard§, 10. The acrid matter found in feveral infects, particularly cantharides 1. Some of thefe dimulants may be either applied in fubitance, or may be diffolved in ardent fpirits, by which their dimulant power may be increafed, or more conveniently applied. 1161. The R. Alkal. volatil. cauftic. §i. 01. olivar. §ii. M. In the new London Pharmacopoeia this compofition is called Linimentum Am- moniac Fortius. * The brine that remains in the falt-pans, after the common fait is cryftallized, is the moft effectual of thefe briny ftimulants. It is called in Edinburgh Oil of Salt. + The 01. Origani is generally ufed. It ought to be mixed with fome unctuous oil, as in the following formula: R. Ol. origan, *ii. Azung. porcin. §iv. M. The aromatic oils diffolved in fpirit make an elegant application, but the diftill- ed fpirits or the plants themfelves are more in ufe. \ They are generally ufed with hogs-lard, in the proportion of eight times their quantity of lard. Some practitioners, however, take only twice the quantity of lard ; but they are not fo effectual as fome of the rubifacients above enumerated. || The ufe of thefe empyreumatic oils is not fo frequent now as formerly ; they are extremely acrid, and, if not ufed with caution, often corrode the fkin. (, The form, in which flour of muftard is ufed, is called a Sinapifm. It is mixed with an equal quantity of bread-crumb or oat-meal, made into a parte with vinegar. Some practitioners add bruifed garlic, in the proportion of one fourth of tha quantity of muftard ; but it is extremely offenfive, and the cataplafmt without it, anfwers fufficiently well. 3 Theft iflie&s arc the boils of the Wittering platters And ointments. O F P H Y S I C. 93 1161. The greater nart of the iubdances now enume- rated fhow then dimulant power by inflaming the {kin of the p^rt to which they are applied ; and when their application is fo long continued as to produce this etfe6t, it interrupts the continuance of their ufe ; and the inflammation of the part does not feem to do fo much good as the frequent repe- tition of a more moderate dimulus. I l62. Analogous to thefe dimulants is the dinging of nettles, which has been frequently commended. Among the external dimulants, the mechanical one of friction with the naked hand, the flefh-brufh, or flannel, is jufily to be reckoned. Can the im- pregnation of the flannels to be employed, with the fumes of burning madic, olibanuni, &c. be of any fervice* ? 1163. With refpect to the whole of thefe external di mulants, it i* to be obferved, that they affeci tl part to which they are applied much more th they do the whole fvffem, and they are theref indeed safer in ambi^uou•; cales; but, for the f reafon, they are of lefs efficacy in curing a ger 1 affection. 116. * Many practitioners have thought that fuch impregnations have 1 tar fervice. 1 he fumes of moft ot thefe refins are either flowers, as t jeen of fingu- in the (hops, or effential oils, both of which are itimulating, and m -hey are called fuppofed to be adive. ay therefore be The impregnating flannels or flefh-bruflies with flour of muftard is gfiiib coufiderably ia bringing on an inflammation. often ufed, and ie an ore "lto PRACTICE I 164. The external applications which may be applied to affeci the whole fydem, are the powers of heat and cold, and of electriciiy. Heat, as one of the mod powerful dimulants of the animal economy, has been often employed in palsies, efpecially by warm bathing. But as, both by dimulating the folids and rarefying the fluids, this proves a drong dimulus to the fanguiferous fy- dem, it is often an ambiguous remedy ; and has frequently been manifedly hurtful in palfies depend- ing upon a congedion of blood in the veflels ofthe brain. The mod certain, and therefore the mod proper ufe of warm bathing in palfies, feems to be in thofe that have been occafioned by the applica- tion of narcotic powers. Are the natural baths more ufeful by the matters with which they may be naturally impregnated* ? H65. Cold applied to the body for any length of time, is always hurtful to the paralytic perfons ; but if it be not very intenfe, nor the application long continued, and if at the fame time the body be ca- pable of a brifk reaction, fuch an application of cold is a powerful dimulant of the whole fydem, and has often been ufeful in curing palfv. But, if the power of rea£tion in the body be weak, any ap- plication of cold may prove very hurtfult. 1166. Electricity, * The mtural baths contain fo fmall a quantity of impreenatine fubftances as in- duces us to fufpect that they cannot have any beneficial powers fuperior to thofe of ordinary warm baths. The ufe of wirm baths ought not to be promifcuous. In cafes of palfies, arifinf from certain poifons, as the fumes of arfenic or metals, and their ores, the warm baths feMom fail of procuring relief; and fome inftances have been given by : u>hor» of complete cures havinr b.-cn performed by the ufe of baths alone. ■+ The very ;.-eat uncertainty of the power of reaction always makes the applica- tion of cold a very doubtful remedy; and, as it is evident'y hurifu! wherever the mHioa is weak, it oj6ht to be ufed with extreme caution. OF PHYSIC. 101 1166. Electricity, in a certain manner applied, is cer- tainly one of the mod powerful ftimulants-that cari be employed to act upon the nervous fydem of ani- mals ; and therefore much has been expected from it in the cure of palfy. But, as it dimulates the fanguiferous as well as the nervous fydem, it has been often hurtful in palfies depending upon a com- preffion of the brain ; and efpecially when it has been fo applied as to act upon the veflels of the head. It is fafer when its operation is confined to particular parts fomewhat remote from the head ; and, further, as the operation of eleclricity, when very drong can deftroy the mobility of the nervous power, I am of opinion, that it is always to be em- ployed with caution, and that it is only fafe when applied with moderate force, and when confined to certain parts of the body remote from the head. It is alio my opinion, that its good effects are to be expected from its repetition rather than from its force, and that it is particularly fuited to the cure of thofe palfies which have been produced by the ap- plication of narcotic powers. I 167. Amongd the remedies of palfy, the ufe of exer- cife is not to be omitted. In a hemiplegia, bodily exercife cannot be employed; and in a more limit- ed affection, if depending upon a compreffion of fome part of the brain, it would be an ambiguous remedy : But, in all cafes where the exercife of gedation can be employed, they are proper; as, even in cafes of compreffion, the dimulus of fuch exercife is moderate, and therefore fafe; and, as it always determines to the furfaee of the body, it is a remedy in all cafes of internal congedion. 1168. The *ce PRACTICE 1168. The internal dimulants employed in palfy are va- rious, but chiefly the following. 1. The volatile alkaline falts, or fpirits, as they «re called, are very powerful and diffuiive dimu- •lants, operating especially on the nervous fydem*; and even although they operate on the fan^uiferous, yet, if given in frequently repeated fin all rather than in large dofes, their operation being tranfito- ry, is tolerably fafe. 2. The vegetables of the clafs named Tetrady- namia, are many of them powerful diffufive dimu- lants; and at the fame time, as quickly pafling out of the body, and therefore a tranfitory operation, they arc often employed with fafetyt. As they commonly prove diuretic, they may in this way al- fo be of fervice in fome cafes of ferous palfy. 3. The various aromatics, whether employed in fubdance, in tincture, or in their effential oils, are often powerful dimulants; but being more adhe- live and inflammatory than thofe laft mentioned, they are therefore, in all ambiguous caies, lei's fafe+* 4. Some * Of thefe there are feveral formula in the fhops, as, Spiritus volatilis aromati- Cus, Spiritus volatilis oleofus, Spiritus falinus aromaticus. Their dofe is from ten to fixty drops. The Eau de Luce ought to be mentioned here, though it isfeldon ufed internally, but only for fuelling to, as it-is extremely penetrating. It is pre- pared thus : Mix together in a retort forty drops of redtitied oil of amber, an ounce of re 3 irk J fpirit of wine, and twelve ounces of the ftron^ut caullic volatile alki'.i. They mult be diftilled with a very moderate fire. It is feldom limpid, but has a jnilky appearance, owing to the imperfect folution of the oil in the fpirit; and, if ' the alkali be not very cauftic, fcarcely any of the oil is diffolved. + White muftard feeds may be given whole, in the quantity of two tea-fpoonfu!s in a half tea-cupful of cold water. They ought to be fwallowed whole, that thc.r acrid tafte may not be perceived. The dofe may be repeated twice or thi^e a-d iv. Horfe-radifh is another plant of this clafs of vegetables that has been much recom- mended ; it muft be given in a cold watery infulion, or in an iniu'.ion in ule. The fcurvy-;»rafs is another of the fame clafs ; it may be eaten raw, or we may give for- ty or liity drops of the Spiritus cochleariae, either on a pier of fugar, or mixed with half an ounce of fyrup, four or five times a-day. This fpirit ought to be kept well Corked, as it foon lofes all its adtivity, if it be expofed to the air. £ The aromatics beft adapted for ftimulating, in thefe cafes, are fuch as Linns Calls Spirantia ; the chiefof them are, Marum, Rofemary, Lavender, &c. Their fpirltous waters are much more efficacious than the plants in fubftance, or in any other form ; and their efficacy is confiderably increafed by uniting them to volatile fpirits, as in fome ofthe furmulje mentioned in the firft note o,i tins article. OF PHYSIC. log 4. Some other acrid vegetables have been em- ployed; but v.e ate not well acquainted with their peculiar \ nht-s, or proper ufe. 5 Son:e -ciinous fubftances, as guaiacum, and the terebimlv.r.ate fubdances, or their effential oils, h<~ve been, with fome probability, employed ; but thcv arc apt to become inflammatory. Decoctions of guaiacum, and fome other fudorifics, have been directed to excite fweating by the application of the fumes of burning fpirit of wine in the laconicum, and have in that way been found ufeful. 6. Many of the fetid antifpafmodic medicines have been frequently employed in palfy ; but I do not perceive in what manner they are adapted to the cure of this difeafe, and I have not obferved their good effe£ts in any cafe of it. 7. Bitters, and the Peruvian bark, have alfo been employed; but with no propriety or advan- tage that I can perceive*. I 169. With refpect to the whole of thefe internal di- mulants, it is to be obferved, that they feldom prove very powerful; and, wherever there is any doubt concerning the nature or date of the difeafe, they may readily do harm, and are often therefore of ambiguous ufe. • In fome cafes, paralytic patients, for want of exercife, fink into a ftate of de* bility, with lois of appetite, and confequent emaciation, in which bitters, l'eru* vian bark, and other tonics, are frequently of fome advantage. BOOK [ 104 ] BOOK II. Of ADYNAMIC, or DISEASES consist- ing in a WEAKNESS or LOSS of MO- TION IN EITHER THE VITAL OR NA- ' TURAL FUNCTIONS. * CHAP. I. Of SYNCOPE or FAINTING. I 170. THIS is a difeafe in which the action ofthe heart and refpiration become considerably weaker than ufual, or in which, for a certain time, thefe functions ceafe altogether. I 17 I. Phyficians having obferved that this affection oc-. curs in different degrees, have endeavoured to dif- tinguifh thefe by different appellations: But, as it is not poffible to afcertain thefe different degrees with any precision, fo there can be no ffrict propri- ety in employing thofe difierent names; and I fhall here comprehend the whole of the affections of this kind under the title of Syncope. 1172., This difeafe fometimes comes on fuddenly to a confiderable degree, but fometimes alfo it comes on OF PHYSIC. 105 on gradually ; and in the latter cafe, it ufually comes on with a fenfe of languor, and of anxiety about the heart, accompanied at the fame time, or immediately after, with fome giddinefs, dimnefs of fight, and founding in the ears. Together with thefe fymptoms, the pulfe and refpiration become weak; and often fo weak, that the pulfe is fcarce- ly to be felt, or the refpiration to be perceived ; and fometimes thefe motions, for a certain time, ceafe altogether. While thefe fymptoms take place, the face and whole furface of the body become pale, and more or lefs cold according to the de- gree and duration of the paroxvfm. Very com- monly, at the beginning of this, and during its continuance, a cold fweat appears, and perhaps continues, on the forehead, as well as on fome other parts of the body. During the paroxyfm, the animal functions, both of fenfe and motion, are always in fome degree impaired, and very oft- en entirely fufpended. A paroxyfin of fyncope is often, after fome time, fpontaneoufly recovered from ; and this recovery is generally attended with a fenfe of much anxiety about the heart. Fits of fyncope are frequently attended with, or end in, vomiting ; and fometimes with convultions, or an epileptic fit. "73- Thefe are the phenomena in this difeafe; and, from every view of the greatedpart of them, there cannot be a doubt that the proximate caufe of this difeafe is a very weak or a total ceafing of the ac- tion of the .heart. But it will be a very difficult matter to explain in what manner the feveral re- mote caufes operate in producing the proximate caufe. This, however, I fhall attempt, though with that diffidence which becomes me in attempt- ing a fubject that has not hitherto been treated with much fuccefs, Vol. II. Q 1174. The 106* PRACTICE I 174. The remote caufe of fyncope may, in the firft place, be referred to two general heads. The one is, of thofe caufes exifting and acting in the brain, or in parts of the body remote from the heart, but acting upon it by the intervention of the brain. The other general head of the remote caufes of fyncope, is of thofe exifting in the heart itfelf, or in parts very immediately connected with it, and thereby acting more directly upon it in producing this difeafe. II75. In entering upon the consideration of the fird fet of thofe caufes (1174.), I mud aflume a propo- iition which I fuppofe to be fully edabliflied in Physiology. It is this: That though the mufcular fibres of the heart be endowed with a certain degree of inherent power, they are dill, for fuch action as is neceffary to the motion of the blood, very condantly dependent upon a nervous power fent into them from the brain*. At lead this is evident, that there are certain powers acting primarily, and perhaps only in the brain, which influence and va- rioufly modify the aBion of the heart. I fuppofe, therefore, a force very condantly during life exert- ed in the brain, with lefpett to the moving fibres ofthe heart, as well as of every part of the body; which force I fliall call the Energy of the Brain ; and which I fuppofe may be, on different occafi- ons, dronger or weaker witb refpect to the heart. 1176. Admitting * The author here differs fomewhat in opinion from phyfiologifts. He allows, indeed, that the heart poffeffes a vis infita in a certain degree, but he will not al- low this vis infita to be fufficiently ftrong for carrying on the circulation ; and he thinks that fome energy muft be imparted to the heart from the brain, in ofder t» enable that important mufcle to perform its office. In fupport of this opinion, we have a plain fact, which the author might have adduced, viz. that a ligatme en ttee nerves going to the heart immediately llo^s lis motions. OF PHYSIC, 107 I 176. Admitting thefe propositions, it will be obvious, that, if I can explain in what manner the fird fct of remote caufes (1174.) diminifh the energy of the brain, I fhall at the fame time explain in what man- ner thefe caufes occafion a fyncope. II77. To do this, I obferve, that one of the mod evi- dent of the remote caufes of fyncope is a hemor- rhagy, or an evacuation of blood, whether fpon- taneous or artificial. And, as it is very manifed that the energy of the brain depends upon a cer- tain fulnefs and tendon of its blood-veffels, for which nature feems to have indudrioufly provided by fuch a conformation of thofe blood-veffels as retards the motion of the blood both in the arteries and veins of the brain ; fo we can readily perceive, that evacuations of blood, by taking off the ful- nefs and tendon of the blood-veffels of the brain, and thereby diminifhing its energy with refpect to the heart, may occafion a fyncope. In many per- fons, a fmall evacuation of blood will have this ef- fect ; and in fuch cafes there is often a clear proof of the manner in which the caufe operates, from this circumfiance, that the effect can be prevented by laying the body in a horizontal podure; which, by favouring the afflux of the blood by the arteries, and retarding the return of it by the veins, preferves the neoeffary fulnefs of the veffels of the brain. It is farther to be remarked here, that, not on- ly an evacuation of blood occafions fyncope, but that even a change in the didribution of the blood, v whereby a larger portion of it flows into one part of the fydem of blood-veffels, and confequently lefs into others, may occafion a fyncope. It is thus I explain the fyncope that readily occurs upon the evacuation joB PRACTICE evacuation of hydropic waters, which had before filled the cavities of the abdomen or thorax. It is thus alfo I explain the fyncope that fometimes hap- pens on bloodletting, but which does not happen till the ligature which had been employed is unti- ed, and admits a larger afflux of blood into the blood-veffels of the arm. Both thefe cafes of fyn- cope fhow that an evacuation of blood does not al- ways occafion the difeafe by any general effect on the whole fydem, but often merely by taking off the requisite fulnefs ofthe blood-veflels ofthe brain. II78. The operation of fome others of the remote caufes of fyncope may be explained on the follow- ing principles. Whild the energy of the brain is, upon different occafions, manifedly dronger or ■weaker, it feems to be with this condition, that a Itronger exertion of it is neceffarily followed by a weaker date of the fame. It feems to depend up- on this law in the conditution of the nervous pow- er, that the ordinary contraction of a mufcle is al- ways alternated with a relaxation ofthe fame ; that, unlefs a contraction proceeds to the degree of fpafm, the contracted date cannot be long continued: And it feems to depend upon the fame caufe that the vo- luntary motions, which always require an unufuai increafe of exertion, occafion fatigue, debility, and at length irrefidible deep. From this law, therefore, ofthe nervous power, we may underdand why a fudden and violent exer- tion of the energy of the brain is fometimes follow- ed by fuch a diminution of it as to occafion a fyn- cope ; and it is thus I fuppofe that a violent fit of joy produces fyncope, and even death. It is upon ihe fame principle alfo, I fuppofe, that an exqui- fite pain may fometimes excite the energy of the brain more drongly than can be fupported, and is therefore followed by fuch a diminution as mud occafion of physic: 109 occafion fainting. But the effect of this principle appears more clearly in this, that a fainting readi- ly happens upon the fudden remiffion of a confider- able pain ; and thus I have feen a fainting occur upon the reduction of a painful diflocation. I I79. It feems to be quite analogous when a fyncope immediately happens on the finifhing of any great and long continued effort, whether depending on the will, or upon a propensity ; and, in this way, a fainting fometimes happens to a woman on the bearing of a child. This may be well illudrated, by obferving, that, in perfons already much weak-* ened, even a very moderate effort will fometimes occafion fainting. Il8o. To explain the operation of fome other caufes of fyncope, it may be obferved, that, as the exertions of the energy of the brain are efpecially under the influence of the will, fo it is well known that thofe modifications of the will which are named Paffions and Emotions, have a powerful influence on the energy of the brain in its action upon the heart, either in increasing or diminifhing the force of that energy. Thus, anger has the former, and fear the latter effect; and thence it may be underdood how terror often occafions a fyncope fometimes of the mod violent kind, named Afphyxia, and fometimes death itfelf. Il8l. As, from what I have jud mentioned, it appears, that the emotions of defire increafe, and thofe of aversion diminifh, the energy of the brain; fo it may be underdood, how a drong averfion, a hor- ror. lis PRACTICE ror> or the feeling which arifcs upon the fight of a very difagreeable object, may occafion fainting. As an example of this, I have known more than one indance of a perfon's fainting at the fight of a fore in another perfon. Il82. To this head of horror and difgud, I refer the operation of thofe odours which in certain perfons occafion fyncope. It may be fuppofed, that thofe odours are endowed with a directly fedative power, and may thereby occafion fyncope; but they are, many of them, with refpect to other perfons, evi- dently of a contrary quality : And it appears to me, that.thofe odours occafion fyncope only in thofe perfons to whom they are extremely difagreeable. 1183. It is, however, very probable, that, among the eaufes of fyncope, there are fome which, analo- gous to all thofe we have already mentioned, a& by a directly fedative power : And fuch may either be diffufed in the mafs of blood, and thereby com? municated to the brain ; or may be only taken in- to the domach, which fo readily and frequently communicates*its affections to the brain. I 184. Having now enumerated, and, as I hope, ex- plained the mod part of the remote caufes of fyn- cope, that either operate immediately upon the brain, or whole operation upon other parts of the body is communicated to the brain, it is proper to obferve, that the mod part of thefe caufes operate Upon certain perfons more readily and more pow- erfully than upon others; and this circumdance, which may be confidered as the predifponent caufe pf fyncope, deferves to be inquired into. It OF PHYSIC. 111 It is in the fird place, obvious, that the opera- tion of fome of thofe caufes depends entirely upon an idiofyncrafy in the perfons upon whom they operate ; which, however, I cannot pretend to ex- plain. But, in the next place, with refpect to the greater part of the other caufes, their effects feem to depend upon a temperament which is in one de- gree or other in common to many perfons. This temperament feems to confift in a great degree of fenfibility and mobility, arifing from a date of de- bility, fometimes depending upon original confor- mation, and fometimes produced by accidental oc- currences in the courfe of life. H85. The fecond fet of the remote caufes of fyncope (1174.), or thofe acting directly upon the heart it- felf, are certain organic affections of the heart it- felf, or ofthe parts immediately connected with it, particularly the great veffels which pour blood in- to, or immediately receive it from, the cavities of the heart. Thus a dilatation or aneurism of the heart, a polypus in its cavities, abfeeffes or ulcera- tions in its fubftance, a dole adherence of the pe- ricardium to the furface of the heart, ancurifins cf the great veffels near to the heart, polypus in thefe, and offifications in thefe or in the valves of the heart, are one or other of them conditions v.hich, upon diffection, have been difcovered in thofe per- fons who had before laboured under frequent fyn- cope. Il86. It is obvious, that thefe conditions are all of them, either fuch as may, upon occasion, difturb the free and regular influx into, or the free egrefs of the blood from, the cavities of the heart; or fucli, as may otherwife didurb its regular action, by fome- times 112 PRACTICE times interrupting it, or fometimes exciting it to more violent and convulsive action. The latter ii what is named the Palpitation ofthe Heart, and it commonly occurs in the fame perfons who are lia- ble to fyncope. H87. It is this, as I judge, that leads us to perceive in what manner thefe organic affections of the heart and great veflels may occafion fyncope : for it may be fuppofed, that the violent exertions made in palpitations may either give occafion to an alter- nate great relaxation (1178.), or to a fpafmodic contraction; and in either way fufpend the action of the heart, and occafion fyncope. It feems to me probable, that it is a fpafmodic contraction of the heart that occafions the intermiffion of the pulfe fo frequently accompanying palpitation and fyn<" cope. Il88. Though it frequently happens that palpitation and fyncope arife, as we have faid, from the or- ganic affections above mentioned, it is pioper to obferve, that thefe difeafes, even when in a vio- lent degree, do not always depend on fuch caufes acting directly on the heart, but are often depend- ent on fome of thofe caufes which we have men- tioned above as acting primarily on the brain. I 189. I have thus endeavoured to give the patholo- gy of fyncope; and of the cure I can treat very fhortly. The cafes of fyncope depending on the fecond let of caufes (1174.), and fully recited in (1185.), I fuppofe to be generally incurable j as our art, fo far O F P H YSI C. 113 far as I know, has not yet taught us to cure any one of thofe feveral caufes of fyncope (1185.). The cafes of fyncope depending on the fird fet of caufes (1174.), and whofe operation I have en- deavoured to explain in (1177. etfeq.), I hold to be generally curable, either by avoiding the feve- ral occafional caufes there pointed out, or by cor- recting the predifponent caufes (1184.). The lat- ter, 1 think, may generally be done by correcting the debility or mobility of the fydem, by the means which I have already had occafion to point out in another place*. CHAP. II. Of DYSPEPSIA, or INDIGESTION. I I96. AW A N T of appetite, a fqueamifhnefs, fome^ times a vomiting, fudden and tranfient dif- tentions of the domach, eructations of various kinds, heartburn, pains in the region ofthe domach, and a bound belly, are fymptoms which frequent- ly concur in the fame perfon, and therefore may be prefumed to depend upon one and the fame proximate caufe. In both views, therefore, they may be confidered as forming one and the fame difeafe, to which we have given the appellation of Dyfpepfia, fet at the head of this chapter. I 191. But as this difeafe is alfo frequently a fecondary and fympathic affection, fo the fymptoms above mentioned are often joined with many others ; and this has given occafion to a very confuted and un- determined defcription. of it, under the general ti- Vol. II. P tie * Sec article i\ 7. |w, 114 PRACTICE tie of Nervous Difeafes, or under that of Chronic Weaknefs. It is proper, however, to didinguifh them; and I apprehend the fymptoms enumerated above are thofe effential to the idiopathic affection I am now to treat of. I 192. It is indeed to be particularly obferved, that thefe fymptoms are often truly accompanied with a certain date of mind which may be confidered as a part of the idiopathic affection: But I fliall take no further notice of this fymptom in the prefent chapter, as it will be fully and more properly con- fidered in the next, under the title of Hypochon- driasis. "93- That there is a didinct difeafe attended always with the greater part of the above fymptoms, is rendered very probable by this, that all thefe fe- veral fymptoms may arife from one and the fame caufe; that is, from an imbecility, lofs of tone, and weaker action in the mufcular fibres of the do- mach : And I conclude, therefore, that this imbe- cility may be confidered as the proximate caufe of the difeafe I am to treat of under the name of Dyfpepfia. I 194. The imbecility of the domach, and the confe- quent fymptoms (1190.), may, however, frequent- ly depend upon fome organic affection of the do- mach itfelf, as tumour, ulcer or fchirrofity ; or up- on fome affection of other parts of the body com* municated to the domach, as in gout, amenorrhoea, and fome others. In all thefe cafes, however, the dvfpeptic fymptoms are to be confidered as fe- cortdary OF PHYSIC. 115 condary or fympathic affections, to be cured only by curing the primary difeafe. Such fecondary and fvn^athic cafes cannot, indeed, be treated of here:' But as I prefume that the imbecility of the domach may often take place without either any organic affection of this part, or any more primary affection in any other part ofthe body; fo I fup- pofe an 1 expect it will appear, from the considera- tion of the remote caufes, that the dyfpepfia may be often an idiopathic affection, and that it is there- fore properly taken into the fydem of methodical Nofology, and becomes the fubject of our confi- deration here. I 195. There can be little doubt, that, in mod cafes, the weaker action of the mufcular fibres ofthe do- mach, is the mod frequent and chief caufe of the fymptoms mentioned in (1190.); but I dare not maintain it to be the only caufe of idiopathic dyf- pepfia. There is, pretty certainly, a peculiar fluid in the domach of animals, or at lead a peculiar quality in the fluids, that we know to be there, up- on which the folution of the aliments taken into the domach chiefly depends : and it is at the fame time probable, that the peculiar quality of the dif- folving or digeding fluids may be varioufly chang- ed, or that their quantity may be, upon occafion, diminifhed. It is therefore fufficiently probable, that a change in the quality or quantity of thefe fluids may produce a confiderable difference in the phenomena of digedion, and particularly may give occafion to many of the morbid appearances men* tioned in (1190.). I 196. This feems to be very well founded, and points out another proximate caufe of dyfpepfia befide that 116 PRACTICE that we have already affigned: But, notwithdand- ing this, as the peculiar nature of the digedive fluid, the changes which it may undergo, or the caufes by which it may be changed, are all matters fo little known, that I cannot found any practical doctrine upon any fuppofition with refpect to them; and as, at the fame time, the imbecility ofthe do- mach, either as causing the change in the digeftive fluid, or as being induced by that change, feems always to be prefent, and to have a great fhare in occasioning the fymptoms of indigedion ; fo I fhall ftill confider the imbecility of the domach as the proximate and almod fole caufe of dyfpepfia. And I more readily admit of this manner of proceeding; as, in my opinion, the doctrine applies very fully and clearly to the explaining the whole of the prac- tice which experience has edablifhed as the mod fuccefsful in this difeafe. H97- Considering this, then, as the proximate caufe pf dyfpepfia, I proceed to mention the feveral re- mote caufes of this difeafe ; as they are fuch, as on different occafions, feem to produce a lofs of tone 5n the mufcular fibres of the domach. They may, I think, be confidered under two heads. Thtfrjl 5s, of thofe which act directly and immediately up- on the domach itfelf: The fecond is, of thofe which act upon the whole body, or particular parts of it, but in confequence of which the domach is chiefly or almod only affected. I 198. Of the fird kind are, 1. Certain fedative or narcotic fubdances taken into the domach ; fuch as tea, coffee, tobacco, ardent fpirits, opium, bitters, aromatics, putrids, and acefcents. 2. The OF P II Y S I C. 117 2. The large and frequent drinking of warm wa- ter, or of warm watery liquids. 3. Frequent furfeit, or immoderate repletion of the domach. 4. Frequent vomiting, whether fpontaneoufly arifing, or excited by art. 5. Very frequent fpitting, or rejection of faliva. II99. Thofe caufes which act upon the whole body, or upon particular parts and functions of it, are, 1. An indolent and fedentary life. 2. Vexation of mind, and diforderly paffions of any kind. 3. Intenfe fludy, or dole application to business too long continued. 4. Excels in venery. 5. Frequent intoxication ; which partly belongs to this head, partly to the former. 6. The being much expofed to moid and cold air when without exercife. 1200. Though the difeafe, as proceeding from the lad fet of caufes, may be confidered as a fymptomatic affection only ; yet as the affection of the domach is generally the fird, always the chief, and often the only, effect which thefe caufes produce or dif- cover, I think, the affection of the domach may be confidered as the difeafe to be attended to in prac- tice ; and the more properly fo, as in many cafes the general debility is only to be cured by reftor- ing the tone of the domach, and by remedies fird applied to this organ. 1201. For the cure of this difeafe, we form three feve- ral indications; a prefervative, a palliative, and a curative. The nS PRACTICE The firft is, to avoid or remove the remote cau- fes juft now enumerated. The fecond is, to remove thofe fymptoms which efpecially contribute to aggravate and continue the difeafe. And, The third is, to redore the tone of the domach; that is, to correct or remove the proximate caufe of the difeafe. 1202. The propriety and neceffity of the fird indicati- on is fufficiently evident, as the continued applica- tion, or frequent repetition of thofe caufes, muft continue the difeafe ; may defeat the ufe of reme- dies ; or, in fpite of thefe, may occafion the recur- rence of the difeafe. It is commonly the neglefil of this indication which renders this difeafe fo fre- quently obdinate. . How the indication is to be executed, will be fufficiently obvious from the con- sideration of the feveral caufes: But it is proper for the practitioner to attend to this, that the exe- cution is often exceedingly difficult, becaufe it is not eafy to engage men to break in upon edablifh- ed habits, or to renounce the purfuit of pleafure; and, particularly, to perfuade men that thefe prac- tices are truly hurtful which they have often prac- ticed with feeming impunity. 1203. The fymptoms of this difeafe which efpecially contribute to aggravate and continue it, and there- fore require to be more immediately corrected or removed, are, fird, the crudities of the domach al- ready produced by the difeafe, and difcovered by a lofs of appetite, by a fenfe of weight and uneafi- nefs in the domach, and particularly by the eructa- tion of imperfectly digeded matters. Another fymptom to be immediately correBed, ;> an unufuai quantity, or a higher degree than ufual, OF PHYSIC. 119 ufual, of acidity prefent in the domach, difcover- cd by various diforders in digedion, and by other effects to be mentioned afterwards. The third fymptom aggravating the difeafe, and otherwife in itfelf urgent, is codivenefs, and there- fore condantly requiring to be relieved. 1204. The Jirjl of thefe fymptoms is to be relieved by exciting vomiting ; and the ufe of this remedy, therefore, ufually and properly begins the cure of this difeafe. The vomiting may be excited by va- rious means, more gentle or more violent. The former may anfwer the purpofe of evacuating the contents of the domach : But emetics, and vomit- ing, may alfo excite the ordinary action of the do- mach ; and both, by varioufly agitating the fydem, and particularly by determining to the furface of the body, may contribute to remove the caufes of the difeafe. But thefe latter effects can only be obtained by the ufe of emetics of the more power- ful kind, fuch as the antimonial emetics efpecially are*. 1205. The fecond fymptom to be palliated, is an exec;* of acidity, either in quantity or quality, in the con- tents of the domach. In man there is a quantity of acefcent aliment almod condantly taken in, and, as I think, always undergoes an acetous fermenta- tion in the domach ; and it is therefore that, in the human domach, and in the ftomachs of all ani- mals ufing vegetable food, there is always found an acid prefent. This acid, however, is generally in- nocent, and occafions no difordei\ unlefs either the quantity of it is very large, or the acidity pro- ceeds • The formulas and *24 PRACTICE curative ; and it is to redore the tone of the do- mach, the lofs of which we confider as the proxi- mate caufe of the difeafe, or at lead as the chief part of it. The means of fatisfying this indication we refer to two heads. One is, of thofe means which operate directly and chiefly on the domach itfelf; and the other is, of thofe means which, ope- rating upon the whole fydem, have their tonic ef- fects thereby communicated to the domach. 1212. The medicines which operate directly on the do- mach are either dimulants or tonics. The dimulants are faline or aromatic. The faline are acids or neutrals. Acids of all kinds feem to have the power of di- mulating the domach, and therefore often increafe appetite : But the native acids, as liable to fermen- tation, may otherwife do harm, and are therefore of ambiguous ufe. The acids, therefore, chiefly and fuccefsfully employed are the vitriolic*, muri- aticf, and the diddled acid of vegetables, as it is found in tar-water, which are all of them antizy- micsj. The neutral falts answering this intention are efpecially thofe which have the muriatic acid in their composition, though it is prefumed that neu- trals of all kinds have more or lefs of the fame virtue||. 1213. The * The dofe of the vitriolic acid ought not to exceed ten drops, and it fhould be well diluted with water. t The Tinctura Martis of the Edinburgh College powerfully ftimulates the fto- mach, and acts at the fame time as a tonic ; its dofe is from ten to twenty drops thrice a-day, in a fufficient quantity of any proper vehicle, and it is a very agreea- ble medicine. J i. e. Refill fermentation. || The Sal digeftivus, i. e^the muriatic acid faturated with vegetable f.xe-.l alka- li, was thought to be preferable to common fait in promoting digeftion. Hence its old name of Sal digeftiyus. Its fuperiority over common fait is however doubtful. OF PHYSIC. 125 1213. The aromatics, and perhaps fome other acrids, certainly dimulate the domach, as they obviate the acefcency and flatulency of vegetable food : But their ftimulus is tranfitory ; and if frequently re- peated, and taken in large quantities, they may hurt the tone of the domach*. I 2 14. The tonics employed to drengthen the domach are bitters, bitters and adringents combined, and chalybeates. Bitters are undoubtedly tonic medicines, both with refpect to the domach and the whole fydem : But their long-continued ufe has been found to de- droy the tone of the domach and of the whole fy- dem ; and, whether this is from the mere repetiti- on of their tonic operation, or from fome narcotic power joined with the tonic in them, I am un- certain. 1215. Bitters and adringents combined are probably more effectual tonics than either of them taken sin- gly ; and we fuppofe fuch a combination to take place in the Peruvian bark ; which therefore proves a powerful tonic, both with refpect to the domach and to the whole fydem. But I have fome ground to fufpect that the long-continued ufe of this bark may, like bitters, dedroy both the tone of the do- mach and of the whole fyftemt. 1216. Chalybeates * This caution againft the too free ufe of aromatics ought to be peculiarly attend- ed to by the young practitioner. The fpeedy relief which they procure tempts the patient to have frequent recourfe to them, which, as the Author juftly obferves, may materially hurt the tone of the ftomach, and confequently increafe the difeafe winch thev were intended to remove. + Forms of thefe tonics maybe feem in the preceding note* on Articles 981. D-2. 992. i2& PRACTICE 1216. Chalybeates may be employed as tonics in vari- ous formsf, and in confiderable quantities, with fafety. They have been often employed in the form of mineral waters, and feemingly with fuc- ceis: But, whether this is owing to the chalybeate in the composition of thefe waters, or to fome other circumdances attending their ufe, I dare not pofi- tively determine ; but the latter opinion feems to me the more probable. 1217. The remedies which drengthen the domach, by being applied to the whole body, are, exercife, and the application of cold. As exercife drengthens the whole body, it muft alfo drengthen the ftomach ; but it does this alfo in a particular manner, by promoting perfpiration, and exciting the a£tionof the veflels on the furface of the body, which have a particular content with the mufcular fibres of the domach. This particu- larly explains why the exerciies of gedation, though not the mod powerful in fireir^hening the whole fydem, are, however, very powerful in ftrength- cning the domach ; of which we have a remarka- ble proof in the effects of failing. In {lengthen- ing the general fydem, as fatigue mud be avoided, fo bodily exercife is of ambiguous ufe ; and per- haps it is thereby that riding on horfeback has been fo often found to be one of the mod powerful means of ftrengthening the ftomach, and thereby of curing dvfpcpfid. 1218. The + See the notes on Articles 9?!. 982. 092. In ttieie cilo, the Tincturi Martis, mentioned in the note on Article 1212. i» :».- proper a torm of chalybeates as any we can ufe. Its dofe is from ten to twenty •raps in any proper vehicle. A glafs of cold fpring water, acidulated with a t:-w drops ot this tincture, is agreeable and returning, and may be ufed as the patient'* common drink; its agreeablenefs may be confidently increafed bv -:dd::i; to each juit-pint j,iai» a uble-fpooiii'ui of limbic cinnamon Writer. OF PHYSIC. 127 I2l8. The other general remedy of dyfpepfia is the ap- plication of cold ; which may be in two ways ; that is, either by the application of cold air, or of cold water. It is probable, that, in the atmosphere con- dantly surrounding our bodies, a certain degree of cold, considerably lefs than the temperature ofoia bodies themfelves, is neceffary to the health ofthe human body. Such a degree of cold feems to drengthen the veffels on the furface of the body, and therefore the mufcular fibres of the domach. But, further, it is well known, that if the body is in exercife fufficient to support fuch a determinati- on to the furface, as to prevent the cold from pro- ducing an entire condriction of the pores; a cer- tain degree of cold in the atmosphere, with fuch exercife, will render the perforation more confi- derable. From the fharp appetite that in fuch cir- cumdances is commonly produced, we can have no doubt, that by the application of fuch cold, the tone of the domach is considerably drengthened. Cold air, therefore, applied with exercife, is a mod powerful tonic with refpect to the domach; and this explains why, for that purpofe, no exer- cifes within doors, or in clofe carriages, arc i® ufeful as thofe in the open air. 1219. From the fame reafonino;, we can perceive, that the application of cold water, or cold bathing, while it is a tonic with refpect to the fydem in ge- neral, and efpecially as exciting the action of the extreme veffels, mud in both refpecls be a power- ful means of drengthening the toi»e of the ftomach. 1220. Thefe *2S PRACTICE 1220. Thefe are the remedies to be employed towards a radical cure of idiopathic dyfpepfia ; and it might be, perhaps, expected here, that I fhould treat al- fo of the various cafes of the fympathic difeafe. But it will be obvious that this cannot be properly done without treating of all the difeafes of which dyfpepfia is a fymptom, which cannot be proper in this place. It has been partly done already, and will be further treated of in the courfe of this work. In the mean time, it may be proper to ob- ferve, that there is not fo much occafion for diflin- guifhing between the idiopathic and fympathic dyf- pepfia, as there is in many other cafes of idiopathic and fympathic difeafes. For, as the. fympathic cafes of dyfpepfia are owing to a lofs of tone in fome other part of the fydem, which is from thence communicated to the domach ; fo the tone of the domach redored, may be communicated to the part primarily affected; and therefore the reme- dies of the idiopathic may be often ufefully employ- ed, and are often the remedies chiefly employed, in fympathic dyfpepfia. 1221. Another part of our bufinefs here might be to fay, how fome other of the urgent fymptoms, be- sides thofe above mentioned, are to be palliated. On this fubject, I think it is enough to fay, that the fymptoms chiefly requiring to be immediately relieved, are flatulency, heartburn, other kinds of pain in the region of the domach, and vomiting. The dyfpeptic are ready to fuppofe that the whole of their difeafe confids in a flatulency. In this it will be obvious that they are miftaken; but, al- though the flatulency is not to be entirely cured, but by mending the imbecility of the iloiiuch by the OF PHYSIC. 129 the means above mentioned; yet the flatulent dis- tention of the ftomach may be relieved by carmin- atives, as they are called, or medicines that pro- duce a difcharge of wind from the domach; fuch are the various antispasmodics, of which the mod effectual is the vitriolic aether. The heartburn may be relieved by abforbents*, antifpafmodicst, or demulcents^. The other pains of the domach may be fome- times relieved by carminatives^, but mod certain- ly by opiates. Vomiting is to be cured mod effectually by opi- ates thrown by injection into the anus. CHAP. III. Of HYPOCHONDRIASIS, or the HYPO- CHONDRIAC AFFECTION, commonly called VAPOURS or LOW SPIRITS. 1222. IN certain perfons there is a date of mind didin- guifhed by a concurrence of the following cir- cumdances : A languor, lidleflhefs, or want of reso- lution and activity with refpect to all undertakings; a difpofition to ferioufnefs, fadnefs, and timidity; Vol. II. R as * The abforbents have been defcribed above, fee note on Article 1206. + It may be doubtful whether antifpafmodics are effectual in removing heart- burn. Opium undoubtedly often give» relief in dofes of twenty or thirty drops of laudanum. | Extract bf liquorice is as good a demulcent in thefe cafes as any in the lift of the Materia Medica. Sucking a little piece of it, and drinking a cup or two of weak lintfeed tea after it, feldom fail of giving relief. lj Carminatives fuitable in thefe cafes are the effential oils of the feeds of fome aromatic umbiliferous plants, as Gl. Anifi, the dofe of which is fifteen or twenty drops on a piece of fugar, though common practice feldom goes half that length. The Oleum Carvi is another excellent carminative, but it is very hot, and its dofe mult never exceed five drops ; two drops are a moderate dofe. The Oleum Men- thas is another good carminative; its dofe is two or three drops on a piece of fugar. Two grains ofthe Extract of Opium, or forty drops ofthe Laudanum, are ufual- ly given in half a cupful of lintfeed tea. The dofe may be increafed to 100 dropa of laudanum, in the fame quantity of vshickj efpecially if the pain of the ftonweb %e accompanied with vpaiilings, '130 'PkACTICE as to all future events an apprehenfion of the word or mod unhappy date of them ; and therefore, oft- en upon flight grounds, an apprehenfion of great evil. Such perfons are particularly attentive to the date of their own health, to every the fmalled change of feeling in their bodies; and from any unufuai feeling, perhaps ofthe dighted kind, they apprehend great danger, and even death itfelf. In refpect to all thefe feelings and apprehensions, there is commonly the mod obflinate belief and perfuafion. 1223. This date of mind is the Jtypochondriafis of me- dical writers. See Linnaei (Genera Morborum, Gen. 76. et Segari Syftema Symptomaticum, Clafs XIII. Gen. 5. The fame date of mind is what has been commonly called Vapours and Low Spi- rits. Though the term Vapours may be founded on a falfe theory, and therefore improper, I beg leave, for a purpofe that will immediately appear, to employ it for a little here. 1224. Vapours, then, or the date of mind defcribed above, is, like every other date of mind, connect- ed with a certain date of the body, which mud be inquired into in order to its being treated as a dif- eafe by the art of phyfic. 1225. This date ofthe body, however, is not very ca- fily afcertained: For we can perceive, that on dif- ferent occafions it is very different; vapours being combined fometimes with dyfpepfia, fometimes with hyderia, and fometimes with melancholia, which are difeafes feemingly depending on very different dates of the body. ' „ „,, 1 o of. Tn^ OF PH Y.S I C. 131 1226. The combination of vapours with dyfpepfia is very frequent, and in feemingly very different cir- cumdances. It is, efpecially, thefe different cir- cumdances that I would wifh to afcertain ; and I remark, that they are manifedly of two different kinds. Fird, as the difeafe occurs in young per- fons of both fexes, in perfons of a fanguine tem- perament, and of a lax and flaccid habit. Second- ly, as it occurs in elderly perfons of both fexes, of a melancholic temperament, and of a firm and rigid habit. 1227. Thefe two different cafes of the 'combination of vapours and dyfpepfia, I confider as two diftinct difeafes, to be drftinguifhed chiefly by the temper- ament prevailing in the perfons affected. As the dyfpepfia of fanguine temperaments is oft- en without vapours; and as the vapours, when joined with dyfpepfia in fuch temperaments, may be confidered as, perhaps, always a fymptom of the affection of the domach ; fo to this combina- tion of dyfpepfia and vapours, I would dill apply the appellation ot Dyfpepfia, and confider it as drict- ly the difeafe treated of in the preceding chapter. But the combination of dyfpepfia and vapours in melancholic temperaments, as the vapours or the turn of mind peculiar to the temperament, nearly that defcribed above in (1222.), are effential circumdan- ces of the difeafe ; and as this turn of mind is often with few, or only flight fymptoms of dyfpepfia; and even though the latter be attending, as they feem to be rather the effects of the general temper- ament, than of any primary or topical affection of the domach; I confider this Combination as a ve- ry different difeafe from the former, and would ap- ply to it itrictly the appellation of Ilypochcndyiajis. 1228. Having *33 PRACTICE 1228. Having thus pointed out a didinction between Dyfpepfia and Hypochondriafis, I fhall now, ufing thefe terms in the Arid fenfe above mentioned, make fome obfervations which may, I think, illu- drate the fubje6t, and more clearly and fully efta- blifh the didinction propofed. 1229. The dyfpepfia often appears early in life, and is frequently much mended as life advances : But the hypochondriafis feldom appears early in life, and more ufually in more advanced years only ; and more certainly dill, when it has once taken place, it goes on increafing as life advances to old age. This feems to be particularly well illudrated, by our obferving the changes in the date of the mind which ufually take place in the courfe of life. In youth, the mind is chearful, active, rafh, and move- able : But, as life advances, the mind by degrees becomes more ferious, flow, cautious, and deady; till at length, in old age, the gloomy, timid, dif- trudful, and obftinate date of melancholic tempe- raments, is more exquifitely formed. In produc- ing thefe changes, it is true, that moral caufes have a fhare; but it is at the fame time obvious, that the temperament of the body determines the ope- ration of thefe moral caufes, fooner or later, and in a greater or leffer degree, to have their effects. The fanguine temperament retains longer the cha- racter of youth, while the melancholic tempera- ment brings on more early the manners of old age, 123O. Upon the whole, it appears, that the date of the mind which attends^ and efpecially diltinguifhes hypochondriafis, OF PHYSIC. 133 hypochondriafis, is the effect of that fame rigidity of the folids, torpor of the nervous power, and pe- culiar balance between the arterial and venous lyf- tems which occur in advanced life, and which at all times take place more or lefs in melancholic temperaments. If therefore there be alfo fome- what of a like date of mind attending the dyfpepfia which occurs early in life in fanguine tempera- ments and lax habits, it mud depend upon a dif- ferent date of the body, and probably upon a weak and moveable date of the nervous power. 1231. Agreeable to all this in dyfpepfia, there is more of fpafmodic affection, and the affection of the mind (1222.) is often abfent, and, when prefent, is perhaps always of a flighter kind ; while in hypochondriafis the affection of the mind is more condant, and the fymptoms of dyfpepfia, or the af- fections of the domach, are often abfent, or, when prefent, are in a flighter degree. I believe the affection of the mind is commonly different in the two difeafes. In dyfpepfia, it is often languor and timidity only, eafily dispelled ; while, in hypochondriafis, it is generally the gloo- my and rivetted apprehenfion of evil. The two difeafes are alfo didinguifhed by fome other circumdances. Dyfpepfia, as I have faid, is often a fymptomatic affection ; while hypochondri- afis is, perhaps, always a primary and idiopathic difeafe. As debility may be induced by many different caufes, dyfpepfia is a frequent difeafe ; while hy- pochondriafis, depending upon a peculiar tempera-, ment, is more rare. Having thus endeavoured to didinguifh the two difeafes, I fuppofe the peculiar nature and proxi- mate ,34 PRACTICE mate caufe of hypochondriafis will be underdood; and I proceed, therefore, to treat of its cure. So far as the affections of the body, and parti- cularly of the ftomach, are the fame here as in the cafe of dyfpepfia, the method of cure might be fup- pofed to be alfo the fame ; and accordingly the practice has been carried on with little didinction: But I am perfuaded that a didinction is often ne- ceffary. 1*33- There may be a foundation here for the fame prefervative indication as fird laid down in the cure ot dyfpepfia (1202.); but I cannot treat this fubject fo clearly or fully as I could wifli, becaufe I have not yet had fo much opportunity of obfervatio'n as I think neceffary to afcertain the remote caufes; and I can hardly make ufe of the obfervations of others, who have feldom or never didinguifhed be- tween the two difeafes. What, indeed, has been faid with refpect to the remote caufes of melancho- lia, will often apply to the hypochondriafis, which I now treat of; but the fubject of the former has been fo much involved in a doubtful theory, that I find it difficult to felect the facts that might pro- perly and drictly apply to the latter. I delay this fubject, therefore, till another occafion ; but, in the mean time, trud that what I have faid regard- ing the nature of the difeafe, and fome remarks I fhall have occafion to offer in considering the me- thod of cure, may in fome meafure fupply my de- ficiency on this fubject of the remote caufes. 1234. The fecond indication laid down in the cure of dyfpepfia (1201.) has properly a place here ; but it is dill to be executed with fome didinction. 1235. An OF PHYSIC. 135 '235- An anorexia, and accumulation of crudities in the domach, does not fo commonly occur in the hypochondriafis as in dyfpepfia ; and therefore vo- miting (1204.) is not fo often neceffary in the for- mer as in the latter'. I236. The fymptom of excefs of acidity, from the flow evacuation of the domach in melancholic tempera- ments, often arifes to a very high degree in hypo- condriafis; and therefore, for the fame reafon as in (1205.), it is to be obviated and corrected with the utmolt care. It is upon this account that the feveral antacids, and the other means of obviating acidity, are to be employed in hypochondriafis, and with the fame attentions and confiderations as in (1206.), and following; with this reflection, however, that the exciting the action of the do- mach there mentioned, is to be a little differently underdood, as fhall be hereafter explained. 1237. As codivenefs, and that commonly to a confi- derable degree, is a very condant attendant of hy- pochondriafis, fo it is equally hurtful as in dyfpep- fia. It may be remedied by the fame means in the former as in the latter, and they are to be employ- ed with the fame redrictions as in (1210.). I238. It is efpecially with refpect to the third indica- tion laid down in the cure of dyfpepfia (1201.), that there is a difference of practice to be obferved in the cure of hypochondriafis; and that often one $ire6lly 136 P R A C T I C t: directly oppofite to that in the cafe of dyfpepfia, is to be followed. 1239. In dyfpepfia, the chief remedies are the tonic medicines, which to me feem neither neceffary nor fafe in hypochondriafis ; for in this there is not a lofs of tone, but a want of activity that is to be re- medied. Chalybeate mineral waters have commonly been employed in hypochondriafis, and feemingly with fuccefs. But this is probably to be imputed to the amufemcnt and exercife ufually accompanying the ufe of thefe waters, rather than to the tonic power of the fmall quantity of iron which they contain. Perhaps the elementary water, by favouring the excretions, may have a fhare in relieving the dif- eafe. 124O. Cold bathing is often highly ufeful to the dyfpcp- tic, and, as a general dimulant, may fometimes feem ufeful to the hypochondriac; but it is not commonly fo to the latter; while, on the other hand, warm bathing, hurtful to the dyfpeptic, is often extremely ufeful to the hypochondriac. 1241. Another indance of a contrary practice neceffa- ry in the two difeafes, and illudrating their re- spective natures, is, that the drinking tea and cof- fee is always hurtful to the dyfpeptic, but is com- monly extremely ufeful to the' hypochondriac. 1242. Exercife, as it drengthens the fydem, and there- by the ftomach, and more efpecially, as, by in- creasing OF PHYSIC. 137 creafing the perfpiration, it excites the action of the domach, it proves one of the mod ufeful reme- dies in dyfpepfia; and further, as, by increasing the perfpiration, it excites the activity of the do- mach, it likewife proves an ufeful remedy in the hypochondriafis. However, in the latter cafe, as I fhall explain prefently, it is dill a more ufeful re- medy by its operation upon the mind than by that upon the body. 1243. It is now proper that we proceed to confider the mod important article of our practice in this dif- eafe, and which is, to confider the treatment of the mind ; an affection of "which fometimes attends dyf- pepfia, but is always the chief circumdance in hy- pochondriafis. What I am to fugged here will ap- ply to both difeafes ; but it is the hypochondriafis that I am to keep mod condantly in view. 1244. The management of the mind in hypochondri- acs is often nice and difficult. The firm perfuafi- on that generally prevails in fuch patients, does not allow their feelings to be treated as imaginary, nor their apprehenfion of danger to be confidered as groundlefs, though the phyfician may be per- fuaded that it is the cafe in both refpecls. Such patients, therefore, are not to be treated either by raillery or by reafoning. It is faid to be the manner of hypochondriacs to change often their phyfician; and indeed they oft- en do it confidently : For a phyfician who does not admit the reality ofthe difeafe, cannot be fup- pofed to take much pains to cure it, or to avert the danger of which he entertains no apprehenfion. If, in any cafe, the pious fraud of a placebo be allowable, it feems to be in treating hypochondri- Vol. II. S acs; 138 PRACTICE acs ; who, anxious for relief, are fond of medi- cines, and, though often difappointed, will dill take every new drug that can be propofed to them. 1245. As it is the nature of man to indulge every pre- fent emotion, fo the hypochondriac cherifhes his fears; and, attentive to every feeling, finds in tri- fles light as air a ftrong confirmation of his appre- hensions. His cure, therefore, depends efpecially upon the interruption of his attention, or upon its being diverted to other objects than his own feelings. 1246. Whatever aversion to application of any kind may appear in hypochondriacs, there is nothing more pernicious to them than abfolute idlenefs, or a vacancy from all earned purfuit. It is owing to wealth admitting of indolence, and leading to the purfuit of tranfitory and unfatisfying amufements, or.to that of exhauding pleafures only, that the prefent times exhibit to us fo many indances of hypochondriacifm. The occupations of bufinefs fuitable to their cir- cumftances and situation in life, if neither attended with emotion, anxiety, nor fatigue, are always to be admitted, and perfifted in by hypochondriacs. But occupations upon which a man's fortune de- pends, and which are always, therefore, objects of anxiety to melancholic men ; and more particular- ly where fuch occupations are expofed to accident- al interruptions, difappointments, and failures, it is from thefe that the hypochondriac is certainly to be withdrawn. 1247. The hypochondriac who is not neceffarily, by circumdance or habits, engaged in bufinefs, is to be OF PHYSIC. 139 be drawn from his attention to his own feelings by fome amufement. The various kinds of fport and hunting, as pur- fued with fome ardour, and attended with exercife, if not too violent, are amongd the mod ufeful. All thofe amufements which are in the open air, joined with moderate exercife, and requiring fome dexterity, are generally of ufe. Within doors, company which engages attenti- on, which is willingly yielded to, and is at the fame time of a chearful kind, will be always found of great fervice. Play, in which fome fkill is required, and where the dake is not an objeft of much anxiety, if not too long protracted, may often be admitted. In dyfpeptics, however, gaming, liable to hid- den and confiderable emotions, is dangerous; and the long continuance of it, with night watching, is violently debilitating. But in melancholies, who commonly excel in fkill, and are lefs fulceptible of violent emotions, it is more admiffible, and is oft- en the only amufement that can engage them. Mufic, to a nice ear, is a hazardous amufement, as long attention to it is very fatiguing. 1248. It frequently happens, that amufements of every kind are rejected by hypochondriacs; and in that cafe, mechanical means of interrupting thought are the remedies to be fought for. Such is to be found in brilk exercife, which re- quires fome attention in the conduct of it. Walking is feldom of this kind ; though, as gra- tifying to the wredleffnefs of hypochondriacs, it has fometimes been found ufeful. The required interruption of thought is bed ob- tained by riding on horfeback, or in driving a car- riage of any kind. Th« ,4o PRACTICE, &c The exercife of failing, except it be in an open boat, engaging fome attention, does very little fer- vice. Exercife in an eafy carriage, in the direction of which the traveller takes no part, unlefs it be upon rough roads, or driven pretty quickly, and with Jong continuance, is of little advantage. 1249. Whatever exercife may be employed, it will be mod effectual when employed in the purfuit of a journey; fird, becaufe it withdraws a perfon from many objects of uneafinefs and care which might prefent themfelves at home ; fecondly, as it engag- es in more condant exercife, and in a greater de- gree of it than is commonly taken in airings about home ; and ladly, as it is condantly prefenting new objects which call forth a perfon's attention. 1250. In our fydem of Nofology we have, next to Hy- pochondriasis, placed the Chlorofis, becaufe I once thought it might be confidered as a genus, comprehending, befides the Chlorofis of Amenor- jhcea, fome fpecies of Cachexy: But, as I cannot find this to be well founded, and cannot didinctly point out any fuch difeafe, I now omit confidering Chlorofis as a genus here; and, as a fymptom of Amenorrhoea, I have endeavoured before to ex- plain it under that title. BOOK t * C Ht'l BOOK III. Of SPASMODIC AFFECTIONS with- out FEVER. 1251. UNDER this title I am to comprehend all the difeafes which confid in motu abnormi; that is, in a preternatural date of the contraction and motion ofthe mufcular or moving fibres in any part of the body. 1252. It will hence appear, why, under this title, I have comprehended many more difeafes than Sau- vages and Sagar have comprehended under the ti- tle of Spafmi, or than Linnaeus has done under the title of Motorii. But I expect it will be obvious, that upon this occafion, it would not be proper to confine our view to the affections of voluntary mo- tion only; and if thofe Nofologids have introduc- ed into the clafs of Spafmi, Palpitatio and Hyfie- ria, it will be with equal propriety that Adhma, Colica, and many other difeafes, are admitted. 1253- It has been hitherto the method of our Nofolo- gids to divide the Spafmi into the two orders of Tonici and Clonici, Spadici and Agitatorii; or, as many at prefent ufe the terms, into Spafms drict- ly fo called, and Convulfions, I find, however, 142 PRACTICE that many, and indeed mod of the difeafes to be confidered under our title of Spafmodic Affections, in refpect to Tonic or Clonic contractions, are of a mixed kind: And, therefore, I cannot follow the ufual general divifion; but have attempted another, by arranging the feveral Spafmodic Dif- eafes according as they affect the feveral functions, Animal, Vital, or Natural. Sect. I. Of the SPASMODIC AFFECTIONS or the ANIMAL FUNCTIONS. 1254. AGREEABLE to the language of the ancients, the whole of the difeafes to be treated of in this feBion might be termed Spafmi; and many of the moderns continue to apply the term in the fame manner: But I think it convenient to didinguifh the terms of Spafm and Convulfion, by applying the former, ftriQly to what has been called the Tonic ; and the latter, to what has been called the Clonic Spafm. There is certainly a foundation for the ufe of thofe different terms, as there is a remarka- ble difference in the date of the contraaion of moving fibres upon different occafions. This I have indeed pointed out before in my treatife of Physiology, but mud alfo repeat it here. 1255. In the exercife of the feveral funftions of the animal economy, the contractions of the moving fibres are excited by the will, or by certain other CifUreS ^ciaUy appointed by nature for exciting thofe contraaions; and thefe other caufes I name the natural caufes. In a date of health, the mov- ing OF PHYSIC. M3 ing fibres are comraded by the power of the will and by the natural caufes only. At the fame time, the contraaions produced are, in force and veloci- ty, regulated by the will, or by thee ircumfiances of the natural caufes; and the contraaions, whe- ther produced by the one or the other, are always loon fucceeded by a date of relaxation, and are not repeated but when the power of the will or of the natural caufes is again applied. 1256. Such are the conditions of the a&ion of the mov- ing fibres in a date of health; but, in a morbid date, the contraaions of the mufcles and moving fibres ordinarily depending upon the will are excit- ed without the concurrence of the will, or contra- ry to what the will intends; and in the other func- tions they are excited by the aaion of unufuai and unnatural caufes. In both cafes, the contraaions produced may be in two different dates. The one is, when the contraaions are to a more violent degree than is ufual in health, and are nei- ther fucceeded by a fpontaneous relaxation, nor even readily yield to an extenfion either from the aaion of antagonid mufcles, or from other ex- tending powers applied. This date of contraaions is what has been called a Tonic Spafm, and is what I fhall name limply and driaiy a Spafm. The other morbid date of contraction is, when they are fucceeded by a relaxation, but are imme- diately again repeated without the concurrence of the will or of the repetition of natural caufes, and are at the fame time commonly, with refpea to ve- locity and force, more violent than in a healthy date. This date of morbid contraaion is what has been named a Clonic Spafm, and what I fhall name fimply and driaiy a Convuljion. In this feaion I fhall follow nearly the ufual di- vifion ofthe fpafmodic difeafes into thofe confiding in 244 PRACTICE in Spafm, and thofe confiding in Convulsion; but it may not perhaps be in my power to follow fucii divifion exaaiy. CHAP. I. Or TETANUS. 1257. BOTH Nofologids and Praaical Writers have didinguifhed Tetanic complaints into the fe- veral fpecies of Tetanus, Opidhotonos, and Em- profthotonos; and I have in my Nofology put the Trifmus, or Locked Jaw, as a genus didina from the Tetanus. All this, however, I now judge to be improper ; and am of opinion that all the feve- ral terms mentioned denote, and are applicable only to, different degrees of one and the fame dif- eafe ; the hidory and cure of which I fhall endea- vour to deliver in this chapter. 1258. Tetanic complaints may, from certain caufes, occur in every climate that we are acquainted with ; but they occur mod frequently in the warmed cli- mates, and mod commonly in the warmed feafons of fuch climates. Thefe complaints affea all ages, fexes, temperaments, and complexions. The cau- fes from whence they commonly proceed, are cold and moidure applied to the body while it is very warm, and efpecially the fudden viciffitudes of heat and cold. Or, the difeafe is produced by punc- tures, lacerations, or other lefions of nerves in any part of the body. There are, probably, fome other caufes of this difeafe; but they are neither diftinft- ly known, nor well afcertained. Though the cau- fes mentioned do, upon occafion, affect all forts; OF PHYSIC. *45 of perfons, they feem however to attack perfons of middle age more frequently than the older or younger, the male fex more frequently than the fe- male, and the robuft and vigorous more frequently than the weaker. 1259. If the difeafe proceed from cold, it commonly comes on in a few days after the application of fuch cold; but, if it arife from a puncture or other le- fion of a nerve, the difeafe does not commonly come on for many days after the lefion has happen- ed, very often when there is neither pain nor un- eafinefs remaining in the wounded or hurt part, and very frequently when the wound has been en- tirely healed up. I260. The difeafe fometimes comes on fuddenly to a Violent degree, but more generally it approaches by flow degrees to its violent date. In this cafe it comes on with a fenfe of diffnefs in the back pare of the neck, which, gradually increasing, renders the motion of the head difficult and painful. As the rigidity of the neck comes on and increafes, there is commonly at the fame time a fenfe of un- eafinefs felt about the root of the tongue ; which, by degrees, becomes a difficulty of fwallowing, and at length an entire interruption of it. While the ri- gidity of the neck goes on increasing, there arifes a pain, often violent at the lower end of the der- num, and from thence fhooting into the back. When this pain arifes, all the mufcles of the neck, and particularly thofe of the back part of it, are immediately affeaed with fpafm, pulling the head drongly backwards. At the fame time, the muf- cles that pull up the lower jaw, which upon the fird approaches of the difeafe were affeaed with fomei Vol. II, T fpadi* HG PRACTICE fpadic rigidity, are now generally affected with more violent fpafm, and fet the teeth fo clofely to- gether that they do not admit of the fmalled opening. This is what has been named the Locked Jaw, and is often the principal part of the difeafe. When the difeafe has advanced thus far, the pain at the bottom of the dcrnum returns very frequently, and with it the fpafms of the hind neck and lower jaw are renewed with violence and much pain. As the difeafe thus proceeds, a greater number of mufcles come to be affeaed with fpafms. After thofe of the neck, thofe along the whole of the fpine become affeaed, bending the trunk of the body drongly backwards; and this is what has been named the Cpiflhotonos. In the lower extremities, both the flexor and extenfor mufcles are commonly at the fame time affeaed, and keep the limbs rigidly extended. Though the extenfors of the head and back are ufually the mod drongly affeaed, yet the flexors, or thofe mufcles of the neck that pull the head for- ward, and the mufcles that fhould pull down the lower jaw, are often at the fame time drongly af- feBed with fpafm. During the whole of the dif- eafe, the abdominal mufcles are violently affected with fpafm, fo that the belly is drongly retracted, and feels hard as a piece of board. " At length the flexors of the head and trunk be- come fo ftror.cjy affeaed as to balance the exten- fors, and to keep the head and trunk draight, and rigidly extended, incapable of being moved in any way ; and it is to this date the term of Tetanus has been driaiy applied. At the fame time, the arms, little affeaed before, are now rigidly extended ; the whole of the mufcles belonging to them being affeaed with fpafms, except thofe that move the fingers, which often to the laft retain fome mobility. The tongue alfo long retains its mobility ; but at length it alfo becomes affected with fpafms, which, attacking certain of its mufcles only, often thrufts it violently out between the teeth. A OF PHYSIC. 147 At the height of the difeafe, every organ of vo- luntary motion feems to be affeaed ; and amongd the red, the mufcles of the face. The forehead is drawn up into furrows, the eyes, fometimes didort- cd, are commonly rigid, and immoveable in their fockets; the nofe is drawn up, and the cheeks are drawn backwards towards the ears, fo that the whole countenance exprefles the mod violent grinning. Under thefe univerfal fpafms, a violent convulsion commonly comes on, and puts an end to life. I26l. Thefe fpafms are every where attended with mod violent pains. The utmod violence of fpafm is, however, not condant; but, after fubfiding for a minute or two, the mufcles admit of fome remifii- on of their contraaion, although of no fuch relax- ation as can allow the aBion of their antagonids. This remiffion of contraaion gives alfo fome re- miflion of pain ; but neither is of long duration. From time to time, the violent contractions and pains are renewed fometimes every ten or fifteen minutes, and that often without any evident excit- ing caufe. But fuch exciting caufes frequently ocr cur; for almod every attempt to motion, as attempt- ing a change of poiture, endeavouring to fwallow, and even to fpeak, fometimes gives occafion to a renewal of the fpafms over the whole body. 1262. .The attacks of this difeafe are feldom attended with any fever. When the fpafms are general and violent, the pulfe is contraBed, hurried, and irre- gular ; and the refpiration is affeaed in like man- ner : But, during the remiffion, both the pulfe and refpiration ufually return to their natural date. The heat of the body is commonly not increafed; frequently the face is pale, with a cold fweat upon ^ it; H8 PRACTICE it; and very often the extremities are cold, with a cold fweat over the whole body. When, how- ever, the fpafms are frequent and violent, the pulfe is fometimes more full and frequent than na- tural ; the face is flufhed, and a warm fweat is forc- ed out over the whole body. 1263. Although fever be not a condant attendant of this difeafe, efpecially when arifing from a lefion of nerves ; yet in thofe cafes proceeding from cold, a fever fometimes has fupervened, and is faid to have been attended with inflammatory fymptoms. Blood has been often drawn in this difeafe, but it never exhibits any inflammatory crufi; and all accounts feem to agree, that the blood drawn feems to be of a Ioofer texture than ordinary, and that it does not coagulate in the ufual manner. 1264. In this difeafe the head is feldom affeaed with delirium, or even confufion of thought, till the laft ftage of it; when, by the repeated fliocks of a vio- lent diftemper, every funBion of the fydem is greatly difordered. 1265. It is no lefs extraordinary, that, in this violent difeafe, the natural functions are not either imme- diately or considerably affeaed. Vomitings fome- times appear early in the difeafe, but commonly they are not continued; and it is ufual enough for the appetite of hunger to remain through the whole courfe of the difeafe ; and what food happens to be taken down, feems to be regularly enough diged- ed. The excretions are fometimes affeaed, but not always. The urine is fometimes fuppreffed, or is OF PHYSIC. M9 is voided with difficulty and pain. The belly is codive: But, as we have hardly any accounts ex- cepting of thofe cafes in which opiates have been largely employed, it is uncertain whether the cof- tivenefs has been the effea ofthe opiates or ofthe difeafe. In feveral indances of this difeafe, a mi- liary eruption has appeared upon the fkin ; but whe- ther this be a fymptom of the difeafe, or the effea of a certain treatment of it, is undetermined. In the mean while, it has not been obferved to denote either fafety or danger, or to have any effea in changing the courfe of the didemper. 1266. This difeafe has generally proved fatal; and this indeed may be juitly fuppofed to be the con- fequence of its nature: But, as we know, that, till very lately, phyficians were not well acquainted with a proper method of cure ; and that, since a more proper method has been known and praaif- ed, many have recovered from this difeafe; it may be therefore concluded, that the fatal tendency of it is not fo unavoidable as has been imagined. In judging of the tendency of this difeafe, in particular cafes, we may remark, that, when arif- ing from lefions of the nerves, it is commonly more violent, and of more difficult cure, than when proceeding from cold ; that the difeafe which comes on fuddenly, and advances quickly to a vi- olent degree, is always more dangerous than that which is flower in its progrefs. Accordingly, the difeafe often proves fatal before the fourth day; and, when a patient has paffed this period, he may be fuppofed to be in greater fafety, and in general the difeafe is the fafer the longer it has continued. It is, however, to be particularly obferved, that, even for many days after the fourth, the difeafe continues to be dangerous; and even after fome con fidcrablc abatement of its force, it is ready to recur j5o PRACTICE recur again with its former violence and danger. It never admits of any hidden, or what may be called a critical folution; but always recedes by degrees only, and it is often very long before the whole of the fymptoms difappcar. 1267. From the hiftory of the difeafe now defcribed, it will be evident, that there is no room for diflin- guifliing the tctc?:ns, opijlholonos, and tri/mus or locked jaw, as different fpecies of this difeafe, fince they all arife from the fame caufes, and are almod condantly conjoined in the fame perfon. I have no doubt that the emproflhotonos belongs alfo to the fame genus; and as the ancients have frequently mentioned it, we can have no doubt of its having occurred: But, at the fame time, it is certainly in thefe days a rare occurrence; and, as I have ne- ver feen it, nor find any hidories in which this par- ticular date of the fpafms is faid to have prevailed, I cannot mention the other circumftances which particularly attend it, and may didinguifh it from the other varieties of tetanic complaints. 1268. This difeafe has put on dill a different form from iany of thofe above mentioned. The fpafms have been fometimes confined to one fide of the body only, and which bend it drongly to that fide. This is what has been named by Sauvages the Te- tanus Lateralis, and by fome late writers the Pleu- ■rojlhotoiios. This form ofthe difeafe has certainly appeared very feldom ; and, in any of the accounts given of it, I cannot find any circumdances that would lead me to confider it as any other than a variety of the fpecies already mentioned, or to take further notice of it here.' 1269. The OF PHYSIC. *S* 1269. The pathology of this difeafe I cannot in any meafure attempt; as the druaure of moving fibres, the date of them under different degrees of con- traaion, and particularly the date of the fenfori- um, as variously determining the motion of the nervous power, arc all matters very imperfeaiy, or not at all, known to me. In fuch a situation, therefore, the endeavouring to give any rules of practice, upon a fcientific plan, appears to me vain and fruitlefs ; arid towards directing the cure of this difeafe, we muft be fatisfied with having learn- ed fomething ufeful from analogy, confirmed by experience. 127O. When the difeafe is known to arife from the lesi- on of a nerve in any part ofthe body, the fird, and, as I judge, the mod important dcp to be taken to- wards the cure, is, by every poffible means, to cut off that part from all communication with the fen- forium, either by cutting through the nerves in their courfe, or perhaps by dedroying, to a cer- tain length, their affeaed part or extremity. 1271. When the cure ofthe difeafe is to be attempted by medicine, experience has taught us that opium has often proved an effeaual remedy; but that, to render it fuch, it mud be given in much larger quantities than have been employed in any other cafe; and in thefe larger quantities,it may, in this difeafe, be given more fafely than the body has been known to bear in any other condition. The pradice has been, to give the opium either in a fo- lid or liquid form, not in any very large dofe at once, 152 PRACTICE once, but in moderate dofes, frequently repeated, at the interval of one, two, three, or more hours, as the violence of the fymptoms feem to require*. Even when large quantities have been given in this way, it appears that the opium does not operate here in the fame manner as in mod other cafes ; for, though it procure fome remiffion of the fpafms and pains, it hardly induces any fleep, or occafions that ftupor, intoxication, or delirium, which it oft- en does in other circumdances, when much fmall- er quantities only have been given. It is there- fore very properly oblerved, that, in tetanic affec- tions, as the opium fhows none of thofe efleas by which it may endanger life, there is little or no rea- fon for being fparing in the exhibition of it; and it may be given, probably fhould be given, as largely and as fall as the fymptoms ofthe difeafe may feem to demand. It is particularly to be obferved, that though the fird exhibition of the opium may have produced fome remiffion of the fymptoms, yet the effects of opium do not long continue in the fydem; and this difeafe being for fome time ready to recur, it is commonly very neceffary, by the time that the ef- feas of the opium given may be fuppofed to be wearing off, and efpecially upon the lead appear- ance * Though the exhibition of opium in Tetanus has been the moft univerfal prac- tice, it muft neverthelefs be acknowledged, that, in many, if not in moft cafes, it has been ineffectual. The difeafe, indeed, is in general fatal ; but, as in moft of the cafes that terminated happily, opium has been given, as the Author defcribes, either in large dofes, or frequently repeated fmall dofes, we muft neceiTarily con- clude that the practice ought to be followed. I have feen only one cafe of Tetanus; it proceeded from a wound which a carpen- ter received in the wrift of his left arm with a faw. Ths inflammation was violent : The diffnefs of the neck at firft appeared on the third day, when the inflammation began to abate after bleeding, and the application of emollient poultices : The pulfe was weak and fmall; thirty drops of laudanum were given ; the fymptoms increaf- ed ; and, on the day following, the jaw became fixed. Thirty drops of laudanum were repeated ; and the fymptoms abating within two hours cfter its exhibition, in- dicated a repetition ofthe dofe, which, from its good effects, was a fourth ti'.r.e re- peated that fame day. The wound fuppurated ; and the day following, with two dofes of forty drops of laudanum, the fymptoms of Tetanus wholly difappeared, but left the patieiu in a moft debilitated ftate. A coftivenefs fupervened, that was re- moved with the ufe of manna and Glauber's falts occafionally : 1 he patient was nourifhed with rich broths and wine ; but he did not recover his fcrr.ic.r fc; :r^ t; t'l? after fix we;ks, although the wound healed in half that time, OF PHYSIC. ance of the return of the fpafms, to repeat the exhi- bition of the opium in the fame quantities as before. This praaice is to be continued while the difeafe continues to fliow any disposition to return ; and it is only after the difeafe has already fubfiftcd for fome time, and when confiderable and long-conti- nued remiffions haye taken place, that the dofes of the opium may be diminifhed, and the intervals of exhibiting them be more confiderable. 1272. The adminidering of opium in this manner, has: in many cafes been fuccefsful; and probably would have been equally fo in many others, if the opiurri had not been too fparingly employed, either from the timidity of practitioners, or from its exhibition being prevented by that interruption of deglutition which fo often attends this difeafe. This latter circumdance dire6ts, that the medicine fliould be immediately and largely employed upon the firft approach of the difeafe, before the deglutition be- comes difficult; or that, if this opportunity be lod, the medicine, in fufficient quantity, and with due frequency, fhould be thrown into the body by gly- der ; which, however, docs not feem to have been hitherto often praaifed. 1273. It is highly probable, that, in this difeafe, the inteftines are affeaed with the fpafm that prevails fo much in other parts of the fydem ; and there- fore, that coftivenefs occurs here as a fymptom of the difeafe*. It is probably alfo increafed by the opium, which is here fo largely employed; and, from whichever of thefe caufes it arifes, it certain- ly mud be held to aggravate the difeafe, and that a' relaxation of the intedinal canal will contribute Vol. II. U to * This fymptom occurred in the cafe rnentiojied in the preceding note. 154 PRACTICE to a relaxation ofthe fpafms elfewhere. This con- sideration direas the frequent exhibition of laxa- tives while the power of deglutition remains, or the frequent exhibition of glyfters when it does not ; and the good effeas of both have been frequently obferved. 1274. It has been with fome probability fuppofed, that the operation of opium in this difeafe may be much aififted by joining with it fome other of the mod powerful antifpafmodics. The mod promising are muff; and camphor ; and fome practitioners have been of opinion, that the former has proved very ufeful in tetanic complaints. But, whether it be from its not having been employed of a genuine kind, or in sufficient quantity, the great advantage and propriety of its ufe are not yet clearly afcer- tained. It appears to me probable, that analogous to what happens with refpett to opium, both mufk and camphor might be employed in this difeafe, in much larger quantities than they commonly have been in other cafes. 1275. Warm bathing has been commonly employed as a remedy in this difeafe, and often with advantage; but, fo far as I know, it has not alone proved a cure ; and, in fome cafes, whether it be from the motion of the body here required, exciting the fpafms, or from the fear of the bath, which fome perfons were feized with, I cannot determine ; but it is allowed, that the warm bath hath in fome cafes done harm, and even occafioned death. Partial fomentations have been much commended, and, I believe, upon good grounds. And I have no doubt hut that fomentations of the feet and legs, as we now ufually apply them in fevers, might, without much O F P H Y S I C. 155 much dirring of the patient, be very affiduoudy employed with advantage. 1276. Unauous applications were very frequently em- ployed in this difeafe by the ancients : And fome modern praaitioners have confidered them as very ufeful. Their effeas, however, have not appear- ed to be confiderable ; and, as a weak auxiliary only, attended with fome inconvenience, they have been very much negteaed by the Britifh praaiti- oners. 1277. Bleeding has been formerly employed in this dif- eafe ; but of late it has been found prejudicial, ex- cepting in a few cafes, where, in plethoric habits, a fever has fupervened. In general, the date of men's bodies in warm climates is unfavourable to bloodletting ; and, if we may form indications from the date of the blood drawn out of the veins, the date of this in tetanic difeafes would forbid bleed- ing in them. 1278. Blidering alfo has been formerly employed in this difeafe; but feveral praaitioners aflert, that blilters are condantly hurtful, and they are now generally omitted. 1279. Thefe are the praaices that hitherto have been generally employed; but of late we are informed by feveral Wed India praaitioners, that in many indances they have employed mercury with great advantage. 'We are told, that it muft be employ- 156 PRACTICE ed early in the difeafe; that it is mod convenient- ly adminidered by unaion, and fliould be applied in that way in large quantities, fo that the body may be foon filled with it, and a falivation raifed, which is to be continued till the fymptoms yield. "Whether this method alone be generally fufficient for the cure of the difeafe, or if it may be affided by the ufe of opium, and require this in a certain meafure to be joined with it, I have not yet cer- tainly learned. I28o. I have been further informed, that the tetanus, In all its different degrees, has been cured by giv- ing internally the Piffelaeum Barbadenfe, or, as it is vulgarly called, the Barbadoes Tar. I think it proper to take notice of this here, although I am not exaaiy informed what quantities of this medi- cine are to be given, or in what circumdances of the difeafe it is moft properly to be employed. I38l, In the former edition of this work, among the remedies of tetanus I did not mention the ufe of cold bathing; becaufe, though I heard of this, J was not informed of fuch frequent employment of it as might confirm my opinion of its general ef- ficacy; nor was I fufficiently informed ofthe ordi- nary and proper adminidrarion of it. But now, from the information of many judicious praaition- ers who have frequently employed it, I can fay, that it is a remedy which in numerous trials has fccen found to be of great fervice in this difeafe ; and that, while the ufe of the ambiguous remedy of warm bathing is entirely laid afide, the ufe of cold bathing is over the whole of the Wed Indies commonly employed. The adminidration of it is fometimes- by bathing the pcrfon in the fea, or more OF PHYSIC. 157 more frequently by throwing cold water from a ba- ton or bucket upon the patient's body, and over the whole of it: When this is done, the body is carefully wiped dry, wrapped in blankets, and laid abed, and at the fame time a large dofe of an opiate is given. By thefe means a confiderable re- miffion of the fymptoms is obtained; but this re- miffion, at fird, docs not commonly remain long, but returning again in a few hours, the repetition both of the bathing and the opiate becomes necef- fary. By thefe repetitions, however, longer inter- vals of eafe are obtained, and at length the difeafe is entirely cured; and this even happens fometimes very quickly. I have only to add, that it does not appear to me, from any accounts I have yet had, that the cold bathing has been fo frequently em- ployed, or has been found fo commonly fuccefsful in the cafes of tetanus in confequence of wounds, as in thofe from the application of cold. 1282. Before concluding this chapter, it is proper for me to take fome notice of that peculiar cafe of the tetanus, or trifmus, which attacks certain infants foon after their birth, and has been properly enough named the Trifmus Nafcentium. From the fub- je6ts it affeas, it feems to be a peculiar difeafe : For thefe are infants not above two weeks, and commonly before they are nine days old ; info- much that, in countries where the difeafe is fre- quent, if children pafs the period now mentioned, they are confidered as fecure againd its attacks. The fymptom of it chiefly taken notice of, is the trifmus, or locked jaw, which is by the vulgar im- properly named the Falling of the Jaw. But this is not the only fymptom, as, for the mod part, it has all the fame fymptoms as the Opidhotonos and Tetanus driaiy fo called, and which occur in the other varieties of tetanic complaints above defcrib- 150 PRACTICE ed. Like the other varieties of tetanus, this is mod frequent in warm climates; but it is not, like thofe arifing from the application of cold, entirely confined to fuch warm climates, as indances of it have occurred in mod ofthe northern countries of Europe. In thefe latter it feems to be more fre- quent in certain diftrias than in others; but in what manner limited, I cannot determine. It feems to be more frequent in Switzerland than in France. I am informed of its frequently occurring in the Highlands of Scotland ; but I have never met with any indance of it in the low country. The particular caufes of it are not well known; and various conjeaures have been offered; but none of them are {satisfying. It is a difeafe that has been almod condantly fatal; and this, alfo, commonly in the courfe of a few days. The wo- men are fo much perfuaded of its inevitable fatali- ty, that they feldom or never.call for the aflidance of our art. This has occafioned our being little acquainted with the hidory of the difeafe, or with the effe6ts of remedies in it. Analogy, however, would lead us to employ the fame remedies that have proved ufeful in the other cafes of tetanus; and the few experiments that are yet recorded, feem to approve of fuch a praaice. C H A P. II. Or EPILEPSY. I283. IN what fenfe I ufe the term Convulfion, I have explained above in (1256.). The convulfions that affea the human body are in feveral refpeas various ; but I am to confider here only the chief and mod frequent form in which they appear, and which is in the difeafe named Epilepfy. OF PHYSIC. *59 Fpilepfy. This may be defined, as confiding in convulsions of the greater part of the mufcles of voluntary motion, attended with a lofs of fenfe, and ending in a date of infenfibility and teeming deep. 1284. The general form or principal circumdances of this difeafe, are much the fame in all the different perfons whom it affeas. It comes by fits, which often attack perfons feemingly in perfea health ; and, after lading for fome time, pafs off, and leave the perfons again in their ufual date. Thefe fits are fometimes preceded by certain fymptoms, which, to perfons who have before experienced fuch a fit, may give notice of its approach, as we fhall hereaf- ter explain; but even thefe preludes do not com- monly occur long before the formal attack, which in mod cafes comes on fuddenly without any fuch warning. The perfon attacked lofes fuddenly all fenfe and power of motion ; fo that, if danding, he falls im- mediately, or perhaps, with convulsions, is thrown to the ground. In that situation he'is agitated with violent convulsions, varioudy moving his limbs and the trunk of his body. Commonly the limbs on one fide of the body, are more violently or more considerably agitated than thofe upon the other. In all cafes the mufcles of the face and eyes are much affeaed, exhibiting various and violent dif- tonions of the countenance. The tongue is often affeaed, and thrud out of the mouth; while the mufcles of the lower jaw are alfo affeaed ; and, fliutting the mouth with violence while the tongue is thruft out between the teeth, that is often griev- oufly wounded. While thefe convulfions continue, there is com- monly at the fame time a frothy moidure iIdling from the mouth. Thefe convulfions have for fome moments fome remiffions, but are fuddenly again renewed iGo PRACTICE renewed with great violence. Generally, after no long time, the com ulfions ceafe altogether; and the perfon for fome time remains without motion, but in a date of abfolute infenfibility, and under the appearance of a profound fleep. After fome continuance of this feeming fleep, the perfon fome- times fuddenly, but for the mod part by degrees only, recovers his fenfes and power of motion ; but without any memory of what had paffed from his being fird feized with the fit. During the con- vulfions, the pulfe and respiration are hurried and irregular ; but, when the convulfions ceafe, they. return to their ufual regularity and healthy date. This is the general form of the difeafe ; and it varies only in different perfons, or on different oc- cafions in the fame perfon, by the phenomena men- tioned being more or lefs violent, or by their be- ing of longer or fliorter duration. 1285. With refpca to the proximate caufe of this dif- eafe, I might fay, that it is an afleaion of the ener- gy of the brain, which, ordinarily under the direc- tion of the will, is here without any concurrence of it, impelled by preternatural caufes. But I could go no farther: For, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no didina knowledge ; and there- fore mud be alfo ignorant of the preternatural date of the fame energy of the brain under the irregular motions here produced. To form, therefore, the indications of a cure, from a knowledge of the proximate caufe of this difeafe, I mud not attempt; bur, from diligent attention to the remote caufes which fird induce and occafionally excite the dif- eafe, I think we may often obtain fome ufeful di- reaions for its cure. It fhall therefore be my bufinefs now to point out and enumerate thefe re- mote caufes as well as I can, 1286. The OF PHYSIC. i6\ 1286. The remote caufes of epilepsy may be confider- ed as occafional or predifponent. There are, in- deed, certain remote caufes which aa independent- ly of anV predifpofition ; but, as we cannot always didinguifh thefe from the others, I fhall confider the whole under the ulual titles of Occafional or Predifponent. 1287. The occafional caufes may, I think, be proper- ly referred to two general heads; the firft being ot thofe which feem to a£t by direaiy flimulating and exciting the energy of the brain ; and the fecond^ of thofe which feem to aa by weakening the fame. With refpe6t to both, for the brevity of expreffing a faa, without meaning to explain the manner in which it is brought about, I fhall ufe the terms of Excitement and Collapfe. And though it be true, that with refpea to fome ofthe caufes I am to men- tion, it may be a little uncertain whether they aa in the one way or the other, that does not render it improper for us to mark, with refpea to others, the mode of their operating, wherever we can do it clearly, as the doing fo may often be of ufe in direaing our praaice. 1288. Fird, then, of the occafional caufes aaing by excitement: They are either fuch as aa immedi- ately and direaiy upon the brain itfelf; or thofe which are firit applied to the other parts of the bo- dy, and are from thence communicated to the brain. Vol. II, X 1289. The i$2 PRACTICE 1289. The caufes of excitement immediately and di- reaiy applied to the brain, may be referred to the four heads of, 1. Mechanical Stimulants; 2. Che- mical Stimulants; 3. Mental Stimulants; and, 4. The peculiar Stimulus of Over Didention. 129O. The mechanical ttimulants may be, wounding indruments penetrating the cranium, and entering the fubdance of the brain ; or splinters of a fraaur- ed cranium, operating in the fame manner; or fliarp pointed offifications, either arifing from the internal furface of the cranium, or formed in the membranes of the brain. 1291. The chemical dimulants (1289.) may be fluids- from various caufes lodged in certain parts of the brain, and become acrid by dagnation or other- wife. 1292. The mental irritations aaing by excitement, are, all violent emotions of the aaive kind, fuch as jov and anger. The fird of thefe is manifedly an ex- citing power, aaing drongly, and immediately, on the energy of the brain. The fecond is manifedly, alfo, a power aaing in the fame manner. But it muft be remarked, that it is not in this manner alone anger produces its effeas: For it aas, alfo, drongly on the sanguiferous fydem, and may be a means of giving the dimulus of over didention ; as, under a fit of anger, the blood is impelled into the veflels of the head with violence, and in a larg- er quantity. 1293. Under e F Pff Y S I C. 163 1293. Under the head of Mental Irritations, is to be mentioned, the fight of perfons in a fit of epilepfy, which has often produced a fit of the like kind in the fpeaator. It may, indeed, be a quedion, Whether this effea be imputable to the horror pro- duced by a fight of the feemingly painful agitations of the limbs, and of the didortions in the counte- nance of the epileptic perfon; or if it may be af- cribed to the force of imitation merely ? It is pof- fible, that horror may fometimes produce the effea: But certainly much may be imputed to that pro- penfity to imitation, at all times fo powerful and prevalent in human nature ; and fo often operating in other cafes of convulfive diforders, which do not prefent any fpectacle of horror. 1294. Under the fame head of Mental Irritation, I think proper to mention as an indance of it, the Epilepfia Simulata, or the Feigned Epilepfy, fa often taken notice of. Although this, at fird, may be entirely feigned, I have no doubt but that the repetition renders it at length real. The hidory of Quietifm and of Exorcifms leads me to this opi- nion ; and which receives a confirmation from what we know ofthe power of imagination, in re- newing epileptic and hyderic fits* 1295. I come now to the fourth head of the irritations applied immediately to the brain, and which I ap- prehend to be that of the Over Didention of the blood-veffels in that organ. That fuch a caufe ope- rates in producing epilepfy, is probable from this, that the difl'eaions of perfons dca.d of epilepfy, has commonly i64 PRACTICE commonly difcovered the marks of a previous con- geilion in the blood-veffels of the brain. This, per- haps, may be fuppofed the effea of the fit which proved fatal t But that the congedion was previous thereto, is probable from the epilepfy being fo oft- en joined with headach, mania, palfy, and apo- plexy ; all of them difeafes depending upon a con- gedion in the veffels of the brain. The general ©pinion receives alfo confirmation from this cir- cumdance, that, in the brain of perfons dead of epilepfy, there have been often found tumours and effusions, which, though feemingly not fufficient to produce thofe difeafes which depend on the com- preffion of a confiderable portion of the brain, may, however, have been fufficient to comprefs fo many veffels as to render the others upon any occafion of a more than ufual turgefcence, or impulfe of the blood into the veffels ofthe brain more liable to an over didention. 1296. Thefe considerations alone might afford founda- tion for a probable conjeaure with refpea to the effects of over didention. But the opinion does not red upon conjecture alone. That it is alfo found- ed in faa, appears from hence, that a plethoric date is favourable to epilepfy; and that every oc- cafional turgefcence, or unufuai impulfe of the blood into the veflels of the brain, fuch as a fit of ai-.^er, the heat of the fun, or of a warm chamber, violent exercife, a furfeit, or a fit of intoxication, are frequently the immediate exciting caufes of epileptic fits. I297. I venture to remark further, that a piece of the- ory may be admitted as a confirmation of this doc- trine. As I have formerly maintained, that a cer- tain OF PHYSIC. , 165 tain fulnefs and tenfion of the veflels of the brain is neceffary to the fupport of its ordinary and con- dant energy, in the didribution of the nervous pow- er; fo it mud be fufficiently probable, that an over didention of thefe blood-veffels may be a caufe of violent excitement. 1298. We have now enumerated the feveral remote or occafional caufes of epilepfy, aaing by excitement, and aaing immediately upon the brain itfelf. Of the caufes aaing by excitement, but aaing upon other parts of the body, and from thence commu- nicated to the brain, they are all of them impreffi- ons producing an exquifite or high degree either of pleafure or pain. Impreffions which produce neither the one nor the other, have hardly any fuch effeas ; unlefs when fuch impreffions are in a violent degree, and then their operations may be confidered as a mode of pain. It is, however, to be remarked, that all drong impreffions which are fudden and furprifing, or, in other words, unforefeen and unexpeaed, have frequently the effea of bringing on epileptic fits. 1299. There are certain impreffions made upon differ- ent parts of the body, which as they often operate without producing any fenfation, fo it is uncertain to what head they belong: But it is probable that the greater part of them aa by excitement, and therefore fall to be mentioned here. The chief in- dances are, The teething of infants; worms; aci- dity or other acrimony in the alimentary canal; calculi in the kidneys ; acrid matter in abfceffes or ulcers; or acrimony diffufed in the mafs of blood, as in the cafe of fome contagions. 1300. Phyficians t66 PRACTICE 1300. Phyficians have found no difficulty in compre- hending how direa dimulants, of a certain force, may excite the action of the brain, and occafion epilepfy ; but they have hitherto taken little notice of certain caufes which manifedly weaken the ener- gy of the brain, and aa, as I fpeak, by collapfe. Thefe, however, have the effea of exciting the ac- tion of the brain in fuch a manner as to occafion epilepfy. I might, upon this fubjea, fpeak of the vis medicatrix natures; and there is a foundation for the term : But, as I do not admit the Stahlian doctrine of a-^ adminidering foul, I make ufe of the term only as expreffing a faa, and would not employ it with the view of conveying an explana- tion of the manner in which the powers of collapfe mechanically produce their effects. In the mean ti,me, however, I maintain, that there are certain powers of collapfe, which in effea prove dimu- lants, and produce epilepfy. 13OI. That there are fuch powers, which may be term- ed Indirea Stimulants, I conclude from hence, that feveral of the caufes of epilepfy are fuch as fre- quently produce fyncope, which we fuppofe always to depend upon caufes weakening the energy of the brain (1176.). It may give fome difficulty to ex- plain, why the fame caufes fometimes occafion fyn- cope, and fometimes occafion the readion that ap- pears in epilepfy; and I ffiall not attempt to explain it : But this, 1 think, does not prevent my fuppof- iug that the operation of thefe caufes is by collapfe. 1 hat there are fuch caufes producing epilepfy, will, I think, appear very clearly from the particular ex- amples of them I am now to mention. 1302. The OF PHYSIC. 167 1302. The fird to be mentioned, which I fuppofe to be of this kind, is hemorrhagy, whether fpontaneous or artificial. That the fame hemorrhagy which produces fyncope, often at the fame time produces epilepfy, is well known ; and from many experi- ments and obfervations it appears, that hemorrha- gies occuring to fuch a degree as to prove mortal, feldom do fo without fird producing epilepfy. *3°3- Another caufe aaing, as I fuppofe, by collapfe, and therefore fometimes producing fyncope and fometimes epilepfy, is terror; that is, the fear of fome great evil fuddenly prefented. As this pro- duces at the fame time a hidden and confiderable emotion (1180.), fo it more frequently produces epilepfy than fyncope. 1304. A third caufe aaing by collapfe, and producing epilepfy, is horror ; or a drong averfion fuddenly raifed by a very difagreeable fenfation, and fre- quently arifing from a sympathy with the pain or danger of another perfon. As horror is often a caufe of fyncope, there can be no doubt of its man- ner, of operating in producing epilepfy; and it may perhaps be explained upon this general prin- ciple, That, as defire excites aaion and gives ac- tivity, fo averfion redrains from aaion, that is, weakens the energy of the brain ; and, therefore, that the higher degrees of averfion may have the effeas of producing fyncope or epilepfy. 1305. A »68 PRACTICE !3°5- A fourth fet of the caufes of epilepfy, which I fuppofe alfo to aa by collapfe, are certain odours, which occafion either fyncope or epilepfy ; and, with refpect to the former, I have given my rea- fons (1182.) for fuppofing odours in that cafe toaa rather as difagreeable than as fedative. Thefe rea- lons will, I think, alfo apply here ; and perhaps the whole affair of odours might be confidered as indances of the effea of horror, and therefore be- longing to the lad head. 1306. A fifth head of the caufes producing epilepfy by collapfe, is the operation of many fubdances con- fidered, and for the mod part properly confidered, as poifons. Many of thefe, before they prove mor- tal, occafion epilepfy. This effea, indeed, may in fome cafes be referred to the inflammatory ope- ration which they fometimes difcover in the do- mach and other parts of the alimentary canal; but, as the greater part of the vegetable poifons fhow chiefly a narcotic, or drongly fedative power, it is probably by this power that they produce epilepfy, and therefore belong to this head of the caufes a6t- ing by collapfe. 1307. Under the head of the remote caufes producing epilepfy, we mud now mention that peculiar one whofe operation is accompanied with what is cal- led the Aura Epileptica. This is a fenfation of fomething moving in fome part of the limbs or trunk ofthe body, and from thence creeping up- wards to the head ; and when it arrives there, the perfgn is immediately deprived of fenfe, and falls OF PHYSIC, i6cj into an epileptic fit. This motion is defcribed by the perfon's feeling it fometimes as a cold vapour* fometimes as a fluid gliding, and fometimes as the fenfe of a fmall inied creeping along their body ; and very often they can give no didind idea of their fenfation, otherwife than as in general of fome- thing moving along. This fenfation might be fup- pofed to arife from fome affeaion of the extremity or other part of a nerve aaed upon by fome irri- tating matter; and that the fenfation, therefore, followed the courfe of fuch a nerve: But I have never found it following didinaiy the courfe o£ any nerve ; and it generally feems to pafs along the teguments. It has been found in foine indances to arife from fomething prefling upon or irritating a particular nerve, and that fometimes in confe- quence of contufion or wound: But indances of thefe are more rare : and the more common con- fequence of contufions and Wounds is a tetanus. This latter effea wounds produce, without giving any fenfation of an aura or other kind of motion proceeding from the wounded part to the head ; while, on the other hand, the aura producing epi- lepfy often arifes from a part which had never be- fore been affeaed with wound or contufion, and in which part the nature of the irritation can fel- dom be difcovered. It is natural to imagine that this aura epileptica is an evidence of fome irritation or direa ftimulus aaing in the part, and from thence communicated to the brain, and fhould therefore have been men- tioned among the caufes aaing by excitement; but the remarkable difference that occurs in feemingly like caufes producing tetanus, gives fome doubt on this fubjea. I308. Having now enumerated the occafional caufes of epilepfy, I proceed to confider the predifponent. As fo many of the above mentioned caufes aa up- Vou II. Y *>u i7o PRACTICE on certain perfons, and not at all upon others, there mud be fuppofed in thofe perfons aprcdifpo- fifidn to this difeafe: But in what this predifpofi- tion confids, is not to be eafily afcertained. 1309. As many of the occafional caufes are weak im- pre'flions, and are applied to moft perfons with lit- tle or no effea, I conclude, that the perfons affeaed by thofe caufes are more eafily moved than others; and therefore, that, in this cafe, a certain mobili- ty gives the predifpofition. It will, perhaps, make this matter clearer, to fhow, in the fird place, that there is a greater mobility of conditution in fome perfons than in others. 13IO. This mobility appears mod clearly in the date of the mind. If a perfon is readily elated by hope, and as readily dejyrefTed by fear, and paffes eafily and quickly from the one date to the other ; if he is eafily pleafed, and prone to gaiety, and as eafily provoked to anger, and rendered peevifh; if liable, from flight impreffions, to drong emotions, but te- nacious of none ; this is the boyifh temperament, qui colligit ac ponit iram temere, et mutatur in ho- ras; this is the varinm et mutabile fazmina; and, both in the boy and woman, every one perceives and acknowledges a mobility of mind. But this is neceffarily conneaed with an analogous date of the brain ; that is, with a mobility, in refpea of every impreffion, and therefore liable to a rea- dy alternation of excitement and collapfe, and of both to a confiderable degree. 13H. There is, therefore, in certain perfons, a mobi- lity of conditution, generally derived from the date of OF PHYSIC. 171 of original damina, and more exquifite at a certain period of life than at others ; but fometimes arifing from, and particularly modified by, occurrences in the courfe of life. 1312. This mobility confids in a greater, degree of ei- ther fenfibility or irritability. Thefe conditions, indeed, phyficians confider as fo neceffarily con- ne&ed, that the conditution with refpea to them, may be confidered as one and the fame : But I am of opinion that they are different ; and that mobi- lity may fometimes depend upon an increafe of the one, and fometimes on that of the other. If an aaion excited, is, by repetition, rendered more ea- fily excited, and more vigoroufly -performed, .1 confider this as an increafe of irritability only. *I go no farther on this fubjea here, as it was only neceffary to take.notice of the cafe jud now menu-., oned, for the purpofe of explaining why epilepf ^ and convulfions of all kinds, by being repeatr :$. are more eafily excited, readily become habit' aal, and are therefore of more difficult cure. *3*3- However we may apply the didinaionof f edibi- lity and irritability, it appears that the m obility, which is the predifponent caufe of epilepfy, ( iepends more particularly upon debility, or upon a pletho- ric date of the body. i3x4- What fhare debility, perhaps by indu ci'ng fenfi- bility, has in this matter, appears cl ^arly from ' hence, that children, women, and othe rperfons of manifed debility, are the mod frequen t fubjeas of this difeafe. ^315. The 173 PRACTICE 13lS- The effeas of a plethoric date in difpofing to this difeafe appears from hence, that plethoric per- fons are frequently the fubjects of it : That it is . commonly excited, as I have faid above, by the caufes of any unufuai turgefcence of the blood ; and that it has been frequently cured by diminifh- ing the plethoric date ofthe body. That a plethoric date of the body fliould difpofe to this difeafe, we may underdand from feveral considerations. \Jl, Becaufe a plethoric date im- plies, for the mod part, a laxity of the folids, and therefore fome debility in the moving fibres, zdly, Becaufe, in a plethoric date, the tone of the mov- ing fibres depends more upon their tenfion, than upon their inherent power : And as their tenfion depends upon the quantity and impetus of the flu- ids in the blood-veffels, which are very changeable, and by many caufes frequently changed, fo thefe frequent changes mud give a mobility to the fydem. ^dly, Becaufe a plethoric date is favourable to a congedion of blood in the veflels of the brain, it mult render thefe more readily affeaed by every general turgefcence of the blood in the fydem, and therefore more efpecially difpofe to this difeafe. 1316, There is another circumdance of the body d.ifi. pofing to epilepfy, which I cannot fo well account for; and that is, the date of fleep: But whether I can account for it or not, it appears, in faft, that this date gives the difpofition I fpeak of; for, in many perfons liable to this difeafe, the fits happen only in the time of deep, or immediately upon the nerfon's coming out of it. In a cafe related by De 4^aen, it appeared clearly, that the difpofition to epilepfv OF P H YSI C. 173 epilepfy depended entirely upon the date of the body in fleep*. 1317- Having thus confidered the whole ofthe remote caufes of epilepfy, I proceed to treat of its cure, as I have faid it is from the consideration of thofe remote caufes only that we can obtain any direai- ons for our praaice in this difeafet. I begin with obferving, that as the difeafe may be confidered as fympathic or idiopathic, I muft treat of thefe feparately, and judge it proper to be- gin with the former. 1318. When this difeafe is truly fympathic, and de- pending upon a primary afieaion in fome other part * This was a very fingular cafe. The chief circumftances in it were, that the boy was more liable to the paroxyfms when lying and afleep, than when fitting up and awake. This peculiarity was not obferved till the difeafe had been of fome (landing ; and, on a more minute attention, the paroxyfms were found to be more frequent when the patient was in a peculiar ftate of deeping, namely, when he was drowfy, or when he fiiored in his fleep, the paroxyfms were more frequent than when he enjoyed an eafy and quiet fleep. A natural, quiet, and eafy fleep, was pro- cured by the ufe of opium ; and, in a fhort time, the difeafe was perfectly cured ; but the boy died afterwards, in confequence of a tumour in the groin. + Other caufes of Epilepfy are enumerated by medical writers, which the author! for the fake of brevity, left unnoticed. Cafes have occurred in which the epilepfy feems to have proceeded from an here- ditary taint. Qutckfilver, either accidentally or intentionally applied, has been frequently found to produce epilepfy. Perfons employed in gilding of metals are often feized with tremblings of the hands, with palfy, and with epilepfy, which can be attri- buted to nothing elfe than the abforption of the vapours of mercury ufed in the opera- tion, which is as follows: The piece of metal to be gilt is firft well cleaned and po- lilhed ; fome mercury fhaken with aquafortis fpread upon it, till the furface appears all over as white as filver; being then heated and retouched in thofe parts that have pfcaped the mixture, an amalgama of mercury and gold is laid on it; the heat foft- rning the amalgama, m ikes it fpread more uniformly ; and the intervention of the mercury and aquafortis makes it adhere more firmly. The piece thus covered with the amalgama is placed on a convenient fupport, over a charcoal fire ; and examined, from time to time, as the mercury evaporates, that, if any deficiencies appear, they may be fupplied with a little more ofthe amalgama before the operation is complet- td. This procefs neceffarily expofes the artift to the fumes of the mercury. Van Swieten fays that he has feen fkulls, in the dipploe of which globule? of mercury manifeftly appeared ; and he thinks it probable that the mercury may pof- Jibly be thrown out into the cavities of the brain itfelf, and produce much mifchief. Venery, when exceifive, has been enumerated among the caufes of epilepfy by goerhaav'c, but on what authority feems uncertain. *74 PRACTICE part of the body, fuch as acidity or worms in the alimentary canal, teething, or other similar caufes, it is obvious, that fuch primary affeaions mud be removed for the cure ofthe epilepfy ; but it is not our bufinefs here to fay how thefe primary difeafes -are to be treated. *3*9- There is, however, a peculiar cafe of fympathic epilepfy ; that is, the cafe accompanied with the aura epileptica, as defcribed in (1307.), in which, though we can perceive by the aura epileptica arif- ing from a particular part, that there is forne af- fection in that part; yet, as in many fuch cafes we cannot perceive of what nature the affeaion is, I can only offer the following general directions. ift, When the part can with fafety be entirely deftroyed, we should endeavour to do fo by cut- ting it out, or by dedroying it by the application of an aaual or potential cautery. idly, When the part cannot be properly dedroy- ed, that we fliould endeavour to correa the mor- bid affeaion in it by blidering, or by edablifliing an iffuesipon the part. %-dly, When thefe meafures cannot be executed, or do not fucceed, if the difeafe feems to proceed from the extremity of a particular nerve which we can eafily come at in its courfe, it will be proper to cut through that nerve, as before propofed on the fubject of tetanus. 4thly, WThen it cannot be perceived that the aura arifes from any precife place or point, fo as to di- rea to the above mentioned operations; but, at the fame time, we can perceive its progrefs along the limb ; it frequently happens that the epilepfy can be prevented by a ligature applied upon the limb, above the part from which the aura arifes: And this is always proper to be done, both becaufe the preventing a fit breaks the habit of the difeafe, and O F PHYSIC. 175 and becaufe the frequent compreffion renders the nerves lefs fit to propagate the aura. 1320. The cure of idiopathic epilepfy, as I have faid above, is to be directed by our knowledge of the remote caufes. There are therefore two general. indications to he formed : The fird is, to avoid the occafional caufes ; and the fecond is, to remove or correa the predifponent. This method, however, is not always purely pal- liative ; as in many cafes the predifponent may be confidered as the only proximate caufe, fo our fe- cond indication may be often confidered as proper* ly curative. 1321. From the enumeration given above, it will he manifed, that for the mod part the occafional cauf- es, fo far as they are in our power, need only to be known, in order to be avoided; and the means of doing this will be fufficiently obvious. I fhall here, therefore, offer only a few remarks. 1322. One ofthe mod frequent ofthe occafional cauf. es is that of over didention (1314.), v.hich, fo far as it depends upon a plethoric date of the fydem, I fhall fay hereafter how it is to be avoided. But as, not only in the plethoric, but in every moveable -conditution, occafional turgefcence is a frequent means of exciting epilepfy, the avoiding therefore of fuch turgefcence is what ought to be mod con- dantly the objeft of attention to perfons liable to epilepfy. J323. Another 176 PRACTICE *323- Another of the mod frequent exciting caufes of this difeafe are, all drong impreffions fuddenly made upon the fenfes; for as fuch impreffions, in moveable conditutions, break in upon the ufual force, velocity, and order of the motions of the nervous fydem, they thereby readily produce epi- lepfy. Such impreffions therefore, and efpecially thofe which are fuited to excite any emotion or paflion of the mind, are to be mod carefully guard- ed againd by perfons liable to epilepfy. 1324. In many cafes of epilepfy, where the predifpo- nent caufe cannot be correaed or removed, the recurrence of the difeafe can only be prevented, bv the driaed attention to avoid the occafional; and as the difeafe is often confirmed by repetition and habit, fo the avoiding the frequent recurrence of it is ofthe utmod importance towards its cure. Thefe are the few remarks I have to offer with refpea to the occafional caufes; and muft now ob- ferve, that, for the mod pait, the complete, or, as it is called, the Radical Cure, is only to be obtained by removing or correaing the predifponent caufe. 1325- I have faid above, that the predifponent caufe of epilepfy is a certain mobility of the ienforium; and that this depends upon a plethoric date of the fydem, or upon a certain date of the debility in it. How the plethoric date of the fydem is to be correaed, I have treated of fully above in (782. OF PHYSIC. i77 tt feq.) and I need not repeat it here. It will be enough to lay, that it is chiefly to be done by a proper management of exercife and diet ; and, with refpea to the latter, it is particularly to be obferved here, that an abdemious couric has been frequently found to be the moft certain means of curing epilepfy. 1327. Considering the nature of the matter poured out by iffues, thefe may be fuppofed to be a condant means of obviating the plethoric date of the fyf- tem ; and it is, perhaps, therefore, that they have been fo often found ufeful in epilepfy. Poflibly* alfo, as an open iffue may be a means of determin- ing occafional turgefcences to fuch places, and therefore of diverting them in,fome meafure from their aaion upon the brain ; fo alfo, in this man- ner, iffues may be ufeful in epilepfy. I328. It might be fuppofed that bloodletting would be the mod effeaual means of correaing the pletho- ric date of the fydem ; and fuch it certainly proves when the plethoric date has become confiderable, and immediately threatens morbid effeas. It is therefore, in fuch circumdances, proper and ne- ceffary : But as we have faid above, that bloodlet- ting is not the proper means of obviating a recur- rence of the plethoric date, and, on the contrary, is often the means of favouring it; fo it is not a remedy advifable in every circumdance of epilepfy. There is, however, a cafe of epilepfy in which there is a periodical or occafional recurrence of the fulnefs and turgefcence ofthe fanguiferous fydem, giving occafion to a recurrence of the difeafe. In fuch cafes, when the means of preventing plethora have been negleaed, or may haye proved ineffec- Vol. II. Z tual, i78 PRACTICE lual, it is abfolutely neceffary for the practitioner to watch the returns of thefe turgelcences, and to obviate their effeas by the only certain means of doing it, that is, by a large bloodletting. I329. The fecond caufe of mobility which we have af- figned, is a date of debility. If this is owing, as it frequently is, to original conformation, it is per- haps not poffible to cure it; but -when it has been brought on in the courfe of life, it poflibly may ad- mit of being mended; and; in either cafe, much may be done to obviate and prevent its effeas. 133°- The means of correaing debility, fo far as it can be done, are, The perfon's being much in cool air; the frequent ufe of cold bathing; the ufe of exercife, adapted to the drength and habits of the perfon; and, perhaps, the ufe of aflringent and tonic medicines. Thefe remedies are fuited to drengthen the1 in- herent power of the folids or moving fibres: But as the ftrength of thefe depends alio upon their tenfion, fo when debility has proceeded from in- anition, the drength may be reffored, by redor-!j ing the fulnefs and tenfion ofthe veffels by nourifh- ing diet; and we have had indances ofthe propri- ety and fuccefs of fuch a praaice. l33*- The means of obviating the effeas of debility, and ofthe mobility depending upon it, are the ufe of tonic and antifpafmodic remedies. The tonics are, Fear, or fome degree of terror; adringents; certain vegetable and metallic tonics; and cold bathing. j 332. That OF PHYSIC. l1d l332- ■ That fear, or fome degree of terror, may be of ufe in preventing epilepfy, we have a remarka- ble proof in Boerhaave's cure of the epilepfy, which happened in the Orphan-houfe at Haerlem. See Kauu Boerhaave's treatife, entitled Impetum Fa- ttens, § 406. And we have met with feveral other indances of the fame. As the operation of horror is in many refpeas analogous to that of terror, feveral feemingly fu- perditious remedies have been employed for the cure of epilepfv; and, if they have ever been fuc- cefsful, I think it mud be imputed to the horror they had infpired*. l333- Of the adringent medicines ufed for the cure of epilepfy, the mod celebrated is the vijcus quercinus, which, when given in large quantities, may poffi- bly be ufeful; but I believe it was more efpecially fo in ancient times, when it was an objea of fuper- ltition. In the few indances in which I have feen it employed, it did not prove of any effeat. *334- Among the vegetable tonics, the bitters are to be reckoned; and it is by this quality that I fup- pofe the orange tree leaves to have been ufeful: But they are not always fo. 1335- The » Drinking a draught ofthe blood of a gladiator juft killed ; drinking a draught of water with a toad at the bottom of the jug; eating a piece of human liver, or the marrow of the bones of the leg of a malefactor ; powder of the human flcull; or the mofs that tows on it; with a variety of fuch abominaole remedies, were formerly in great repute, and indeed fome of them are Hill r.u.ned in feveral foreign Phar- macopeias. + The dofe of it was from half a dram to a dram in powuer, or about an ounce. in infulion. i Bo PRACTICE l33S- The vegetable tonic, which from its ufe in ana- logous cafes is the mod promifing, is the Peruvian bark; this, upon occafion, has been ufeful, but has alfo often failed. It is efpecially adapted to thofe epilepsies which recur at certain periods, and which are at the lame time without the recurrence of any plethoric date, or turgefcence of the blood ; and in fuch periodical cafes, if the bark is employ- ed fome time before the expeaed recurrence, it may be ufeful: But it mud be given in large quan- tity, and as near to the time of the expefted return as poffible. l336- The metallic tonics feem to be more powerful than the vegetable, and a great variety of the form- er have been employed. Even arfenic has been employed in the cure of epilepfy; and its ufe in intermittent fevers gives an analogy in its favour. Preparations of tin have been formerly recom- mended in the cure of epilepfy, and in the cure of the analogous difeafe of hyderia; and feveral con- fiderations render the virtues of tin, with refpea to thefe difeafes, probable: But I have had no ex- perience of its ufe in fuch cafes. A much fafer metallic tonic is to be found in the preparations of iron ; and we have feen fome of them employed in the cure of epilepfy, but have never found them to be effeaual. This, however, I think, may be imputed to their not having been always emploved in the circumdances of the dif- eafe, and in the quantities of the medicine, that were proper and neceffary*. 1337- Of * The method of ufing iron was defcribed in a aoi: c:i article "'I. OF PHYSIC. ,8t »337- Ofthe metallic tonics, the mod celebrated and the mod frequently employed is copper, under va- rious preparation. What preparation of it may be the mod effeaual, I dare not determine; but of late the cuprum ammoniacum has been frequently found fuccefsful*. 1 1338- Lately the flowers of zinc have been recommend- ed by a great authority as ufeful in all convul- sive diforders; but in cafes of epilepfy, I have not hitherto found that medicine ufefult. J339- There have been of late, fome indances of the cure of epilepfy by the accidental ufe of mercury; and if the late accounts of the cure of tetanus by this remedy are confirmed, it will allow us to think that the fame may be adapted alfo to the cure of certain cafes of epilepfy. 1340. With refpea to the employment of any of the above mentioned tonics in this difeafe, it muft be obferved, that in all cafes where the difeafe de- pends upon a condant or occafional plethoric date ofthe fydem, thefe remedies are likely to be incf- feaual; and if fufficient evacuations are not made at * This was a favourite remedy of the Author's. He firft introduced it into prac- tice in this country, and the preparation of it was inferted in the Edinburgh Phar- macopoeia. It is employed by beginning with fmall dofes of half a grain, and>increafing them gradually to as much as the ftomach will bear. It is, however, like all preparations •f copper, a very dangerous medicine, and ought to be ufed with caution. t The great authority by which the flowers of zinc were recommended was Gau- bius. It is as dancerous a medicine as the cuprum ammoniacurn, sr.J muft be ufed W'lh the ft;ne caution. itt PRACTI.CE at the fame time, thefe medicines are likely to be very hurtful. I34I- The other fet of medicines which we have men- tioned as fuited to obviate the effeas of the too great mobility of the fydem, are the medicines named antifpafmodics. Of thefe there is a long lift in the writers on the Materia Medica, and by theie authors recommended for the cure of epilepfy. The greater part, however, of thofe taken from the vegetable kingdom, are manifedly.inert and infig- nificant*. Even the root of the wild valerian hardly fupports its credit. 1342. Certain fubdances taken from the animal king- dom feem to be much more powerful : And of thefe the chief, and feemingly the mod powerful, is muff; ; which, employed in its genuine date, and in due quantity, has often been an effeaual remedyt. It is probable alfo, that the oleum animale, as it has been named, when in its pured date, and exhi- bited at a proper time, may be an effeaual remedy J. 1343. In * This is certainly true ; but it muft be acknowledged that fome of them are ma. nifeftly aftive and ufeful, as the afafcrtid:, fagapenum, and other fetid gums. The pilulae gummoue of the Pharmacopoeias are good formulae for thefe naufeous medi- cines ; and their being reputed inefficacious and infignificant feems to have anl'cn from their not having been given in fufficiently large dofes. They may be given witS fafety to the quantity of two drams in a day, in repeated dofes of twenty or thiity grains each ; and, if they lhould happen to pure,;, this inconvenience may be pre- vented, by adding a qu.'iter or half.: grain of opium to each dofe ofthe pil!?, or tik- i::i', ten drips of laudanum after each dofe, as occafion may requi.r. t Mufk i» more efTetttal when piv:n in fubftance than in any preparation that i. isheen attempted ; it is given in dbfes of from v.n to thirty grains, and frequently repe..t;J. It •nay be m ide into a bolus, as in the following formula : R. blokb. gr. :;v. Terr !'i p'.orf'r. marmnr. cr.ai * Sa.TP. alb. i)i.; et a.lth Confeft. cardiac. ${$. M. f. Et, bolus may be repatrd three or four time; a-d.i". £ TIil' dofe of '.his oil ii from twenty to thirty drops; /. is, however, feldom uf-i. O F PH Y S I C. 183 '343- In many difeafes, the mod powerful amifpaf- modic is certainly opium; but the propriety of its ufe in epilepfy has-been disputed among phyficians. When the difeafe depends upon a plethoric date in which bleeding may be neceffary, the employment of opium is likely to be very hurtful; but, when there is no plethoric or inflammatory date prefent; and the difeafe feems to depend upon irritation or upon increafed irritability, opium is likely to prove the mod certain remedy*. Whatever effects in this and other convulsive diforders have been attri- buted to the hyofcyamus, mud probably be attri- buted to its pofieffing a narcotic power similar to that of opium. '344- With refpea to the ufe of antifpafmodics, it is to be obferved, that they are always mod ufeful, and perhaps only ufeful, when employed at a time when epileptic fits are frequently recurring, or near to the times of the acceffion of fits which recur after confiderable intervals. *345- On the fubjea of the cure of epilepfy, I have only to add, that as the difeafe in many cafes is continued by the power of habit only, and that in all cafes habit has a great fhare in increasing mobi- lity, and therefore in continuing this difeafe; fo the breaking in upon fuch habit, and changing the whole habits of the fydem, is likely to be a power- ful remedy in epilepfy. Accordingly, a confidera- ble * In thofe cafes, in which fome peculiar fyn-pvms ir'.icate the approach of the fir, opium taken in a large dofe has fometr.ne^; prevented it a'.:oj,cther; but moll commonly, however, fuch a dofe greatly leflens its violence. Two grain; of opium in l»bilaiice, or ii*ty or fevnty -iw-j yf laudanum, are luwe dofe;. 184 PRACTICE ble change of climate, diet, and other circumdances in the manner of life, has often proved a cure of this difeafe*. 1346. After treating of epilepfy, I might here treat of particular convulfions, which are to be didinguifh- ed from epilepfy by their being more partial : That is, affeaing certain parts of the body only, and by their not being attended with a lofs of fenfe, nor ending in fuch a comatofe date as epilepfy always docs. 1347- Of fuch convulsive affeaions many different in- dances have been obferved and recorded by phyfi- cians. But many of thefe have been manifedly fympathic affeaions, to be cured only by curing the primary difeafe upon which they depend, and therefore not to be treated of here : Or, though they are fuch as cannot be referred to another dif- eafe, as many of them however have not any fpe- cific charaaer with which they occur in different perfons, I mud therefore leave them to be treated upon the general principles I have laid down with refpea to epilepfy, or fhall lay down with refpea to the following convulsive diforder; which, as hav- ing very condantly in different perfons a peculi- ar charaaer, I think neceffary to treat of more particularly. C H A P. * After all that has been faid on this difeafe, we muft acknowledge that we know but little of its true nature, and, confequently, no certain method of cure can be given. It has baffled the fkill of phyficians from the earlieft ages of phyfic, and itill remains to be one of thofe many difeafes which we cannot certainly cure. Some fpecies of it, indeed, are certainly curable; but thefe are fe>v, and fuch only as are fymptomatic, or arife from peculiar mechanical irritations. Experience has moreover fhown us, that the difeafe often exifts without any appa- rent irritation, and without any caufe obfervable on diffe&ion : Much room is there- fore left for future inveftigations on this dark fubject; and we muft at prefent con- lent ourfelves with the hopes thai X'.r.v •vi'.l miioli what !nm*;i 'r^ouuity haj noj yet beyj capable of effsitir.-, OF PHYSIC. 185 Chap. III. Of the Chorea or Dance of St. Vitus. 1348. THIS difeafe affeas both fexes, and almod only young perfons. It generally happens from the age of ten to that of fourteen years*. It comes on al- ways before the age of puberty, and rarely con- tinues beyond that period. *349- It is chiefly marked by convulfive motions, fomewhat varied in different perfons, but nearly of one kind in all; affeaing the leg and arm on the fame fide, and generally on one fide only. *35°- Thefe convulfive motions commonly fird affea the leg and foot. Though the limb be at red, the foot is often agitated by convulfive motions, turn- ing it alternately outwards and inwards. When walking is attempted, the affeaed leg is feldom lifted as ufual in walking, but is dragged along as if the whole limb were paralytic ; and, when it is attempted to be lifted, this motion is undeadily performed, the limb becoming agitated by irregu- lar convulfive motions. The arm of the fame fide is generally affeaed at the fame time; and, even when no voluntary mo- Vol. II. A a tion * 1 have feen lt irt a rolmft man of *>rty-two. This patient, after various in- rffeftual remedies had been ufed, was cured by ftrong elcflricaj flwfo direfted il&rough the whole body, i86 PRACTICE tion is attempted, the arm is frequently agitated with various convulfive motioqs. But efpecially when voluntary motions are attempted, thefe are not properly executed, but are varioufly hurried 'or interrupted by convulfive motions in a direaion con- trary to that intended. The mod common indance of this is in the perfon's attempting to carry a cup of liquor to his mcuth, when it is only after repeat- ed efforts, interrupted by frequent convulfive re- traaions and deviations, that the cup can be carriv ed to the mouth. 13^2- It appears to me, that the will often yields to thefe convulfive motions, as to a propensity, and thereby they are often increafed, while the perfon affe6ted feems to be pleafed with increasing the furprife and amufement which his motions occafion in the bydanders. 1353- In this difeafe the mind is often affeaed: with' fome degree of fatuity ; and often fhows the fame varied, defultory, and caufelefs emotions which oc- cur in hyderia. 1354- Thefe are the mod common circumdances of this" difeafe ; but at times, and in different perfons, it is varied by fome difference in the convulfive motions, particularly by thefe affeaing the head and trunk of the body. As in this dileafe there feem to be propenfities to motion, fo various fits of leaping and running occur in the perlons affect- ed ; and there have been indances of this difeafe, confiding of fuch convulfive motions, appearing as an epidemic in a certain corner of the country. In fuck' OF P II YSIC. 187 fuch indances, perfons of different ages are affea- ed, and may feem to make an exception to the ge- neral rule above laid down ; but dill the perfons are, for the mod part, the young of both fexes, and of the more manifedly moveable conditutions. *355- The method of curing this difeafe has been vari- ouffy propofed. Dr. Sydenham propofed to cure it by alternate bleeding and purging. In fome ple- thoric habits I have found fome bleeding ufeful; but in many cafes I have found repeated evacuati- ons, efpecially by bleeding, very hurtful. In many cafes, I have found the difeafe, in fpite of remedies of all kinds, continue for many months; but I have alfo found it often readily yield to tonic remedies, fuch as the Peruvian bark, and chalybeates. The late Dr. De Haen found feveral perfons la- bouring under this difeafe cured by the application of elearicity. SECT. II. Of the SPASMODIC AFFECTIONS of the VITAL FUNCTIONS. C 11 a p. IV. * Ofthe Palpitation of the Heart. *356- TH E motion thus named is a contraaion or fydole of the heart, that is performed with more rapidity, and generally alfo with more force than * Though I have thought it proper to divide this book into fedtions, I think it necedary, for the conveniens of reference:, to number the chapters from, the be. firming. Autbu. i88 PRACTICE than ufual; and when at the fame time the hearf ftrikes with more than ufual violence againd the infide of the ribs, producing oftep a confiderable found. "357- This motion, or palpitation, is occafioned by a great variety of caufes, which have been recited with great pains by Mr. Senac and others; whom, however, I cannot follow in all the particulars with fufficient difcernment, and therefore fhall here on- ly attempt to refer all the feveral cafes of this dif- eafe to a few general heads. 1358- The fird is of thofe arifing from the application of the ufual dimulus to the heart's contraction; that is, the influx of the venous blood into its cavities, being made with more velocity, and therefore, in the fame time, in greater quantity than ufual. It feems to be in this manner that violent exercife oc- cafions palpitation. '359- A fecond head of the cafes of palpitation, is of thofe arifing from any refidance given to the free and entire evacuation of the ventricles of the heart. Thus a ligature made upon the aorta occafions pal- pitations of the mod violent kind. Similar refin- ances, either in the aorta or pulmonary artery, may be readily imagined; and fuch have been often found in the dead bodies of perfons who, during life, had been much affeaed with palpitations. To this head are to be referred all thofe cafes of palpitation arifing from caufes producing an accu- mulation of blood in the great veffels near to the heart. 1360. A O F P H Y S I C. !% 1360. A third head of the cafes of palpitation, is of thofe arifrng from a more violent and rapid influx of the nervous power into the mufcular fibres of the heart. It is in this manner that I fuppofe various caufes a&ing in the brain, and particularly certain emoti- ons of the mind, occafion palpitation. 1361. A fourth head of the cafes of palpitation, is of thofe arifing from caufes producing a weaknefs in the aaion of the heart, by diminifhing the energy of the brain with refpea to it. That fuch caufes operate in producing palpitation, I prefume from hence, that all the feveral caufes mentioned above (1177. etfeq.), as in this manner producing fyncope, do often produce palpitation. It is on this ground that thefe two difeafes are affeaions frequently oc- curring in the fame perfon, as the fame caufes may occafion the one or the other, according to the force of the caufe and mobility of the perfon aaed upon. It feems to be a law of the human economy, that a degree of debility occurring in any funaion, often produces a more vigorous exertion of the fame, or at lead an effort towards it, and that commonly in a convulfive manner. I apprehend it to be the convulfive aaion, fre- quently ending in fome degree of a fpafm, that gives occafion to the intermittent pulfe fo frequent- ly accompanying palpitation. 1362. A fifth head of the cafes of palpitation may per- haps be of thofe arifing from a peculiar irritability or mobility of the heart. This, indeed, may be confidered as a predifponent caufe only, giving oc- cafion igO PRACTICE cafion to the aaion of the greater part of the cau- fes recited above. But it is proper to obferve, that this predifpofition is often the chief part of the re- mote caufe ; infomuch that many ofthe caufes pro- ducing palpitation would not have this effea but in perfons peculiarly predifpofed. This head, therefore, of the cafes of palpitation, often requires to be didinguifhed from all the red. l363- After thus marking the feveral cafes and caufes of palpitation, I think it neceffary, with a view to the cure of this difeafe, to obferve, that the feve- ral caufes of it may be again reduced to two heads. The fird is, of thofe confiding in, or depending up- on, certain organic affeaions ofthe heart itfelf, or of the great veffels immediately conneaed with it. The fecond is, of thofe confiding in, or depending upon, certain affeaions fubfiding and aaing in other parts of the body, and aaing either by the force of the caufe, or in confequence of the mobi- lity ofthe heart. 1364. With refpea to the cafes depending upon the fird fet of caufes, I mud repeat here what I laid with refpea to the like cafes of fyncope, that I do not know any means of curing them. They, in- deed, admit of fome palliation, firft, by avoiding every circumdance that may hurry the circulation of the blood; and, Jecondly, by every means of avoiding a plethoric date ofthe fydem, or any oc- cafional turgefcence of the blood. In many of thefe cafes, bloodletting may give a temporary re- lief: But in fo far as debility and mobility are con- cerned, in fuch cafes this remedy is likely to do harm. •1365. With OF PHYSIC. j-gt »365- r With refpea to the cafes depending upon the other fet of caufes, they may be various, and re- quire very different meafures: But I can here fay in general, that thefe cafes may be confidered ^as of two kinds; one depending upon primary affec- tions in other parts ofthe body, and aaing by the force ofthe particular caufes ; and another depend- ing upon a date.of mobility in the heart itfelf In the fird of theie, it is obyious, that the cure of palpitation mud be obtained by curing the primary affeaion ; Which is not to be treated of here. In the fecond, the cure mud be obtained, partly by diligently avoiding the occafional caufes, partly and chiefly by correaing-the mobility ofthe fyf- tem, and of the heart in particular; for doing which we have treated of the proper means elfe- where. C H A P. V. Of Dyspnoea, or Difficult Breathing. 1366. THE exercife of refpiration, and the organs of it, have fo condant and confiderable a conneaion with almod the whole of the other functions and parts of the human body, that upon almod every occafion of difeafe, refpiration mud be affeaed. Accordingly, fome difficulty and diforder in this fiinaion, are in faa fymptoms very generally ac- companying difeafe. 1367- Upon this account, the fymptom of difficult breathing deferves a chief place and an ample con- v fideration 192 PRACTICE fideration in the general fydem of Pathology ; but what fhare of consideration it ought to have in a treatife of Praaice, I find it difficult to deter- mine. I368. , On this fubje&, it is, in the fird place, neceffary to didinguifh between the fymptomatic and idio- pathic affeaions; that is, between thofe difficul- ties of breathing which are fymptoms only of a more general affeaion, or of a difeafe fubfiding primarily in other parts than the organs of refpira- tion, and that difficulty of breathing which depends upon a primary affeaion of the lungs themfelves. The various cafes of fymptomatic dyfpncea I have taken pains to enumerate in my Methodical Nofo- logy, and it will be oovious they are fuch as can- not be taken notice of here. 1369. In my Nofology I have alfo taken pains to point out and enumerate the proper, or at lead the greater part of the proper, idiopathic cafes of the dyfpncea; but from that enumeration it will, I think, readily appear, that few, and indeed hardly any, of thefe cafes, will admit or require much of our notice in this place. 1370. The Dyfpncea Sicca*, fpecies 2d, the Dyfpncea Aereaf,fp. 3d, the Dyfpncea Terrea\,fp. 4th, and Dyfpncea * The definition, which the Author gives of this fpecies in his Nofology, is "Dyfpnoea cum tujft plerumque ficca. It arifes from various caufes, fome of which are extremely difficult, if not impoffible, to be difcovered. + The definition of this fpecies is, Dyfpncea a minima quavis temptftatttm titula- thne auila. | It is defined Dyfpncea cum tvfji matericm tcntam vcl cakulofim tjichntt. This is foruetimes the expulfion of a gouty matter. O F P H Y S I C. 193 £)yfpncea Thoracica*,fp. jth, are fome of them with difficulty known, and are all of them difeafes which in my opinion do not admit of cure. All, there- fore, that can be faid concerning them here is, that they may admit of fome palliation; and this, I think, is to be obtained chiefly by avoiding a plethoric date of the lungst, and every circumdance that may hurry refpiration* Of the Dyfpncea Extrinfeca%,fp. 8M, 1 can fay1 ho more, but that thefe external caufes marked in the Nofology, and perhaps fome others that might have like effeas, are to be carefully avoided; or, When they have been applied, and their effeas have; taken place, the difeafe is to be palliated by thd means mentioned in the lad paragraph. 1372. The other fpecies, though enumerated as idiopa- thic, can hardly be confidered as fuch, or as re- quiring to be treated of here. The Dyfpncea Catarrhalis ||, fp. lfi, may be con- fidered as a fpecies of catarrh, and is pretty cer- tainly to be cured by the fame remedies as that fpecies of catarrh which depends rather upon the; increafed afflux of mucus to the bronchiae, than up- on any inflammatory date in them§. The Dyfpncea Aquofal, fp. $th, is certainly to be confidered as a fpecies of dropfy, and is to be treat- Vol. II. B b ed • The definition of this fpecies is, Dyfpncea apartiius tboraccm clngentibus laefis, •uel male conformatis. + This intention is moft fpeedily obtained by occafional bleeding. % It is defined Dyfpncea a caufis externis manifefih. Thefe caufes are various, as expofure to dufts of different kinds, to metallic fumes, to vitiated air, to vapours of different kinds, &c. || It is defined, Dyfpncea cum tajftfrequente mucum vifcidum copiofum ejicientr. \ The remedies for this purpofe are, emetics, fudorifics, and expectorants; for- mulae of which may be feen in the notes on Article 1065. 1 It is defined, Dyfpncea cum urtnaparca, et cedetnafepedum, fwflu3uatknt i.t ptclere, vel aliii cha'ratferiflisis hydrvthoracis fgnis, 194 PRACTICE cd by the fame remedies as the other fpecies of that difeafe; The Dyfpncea Pinguedinofa*, fp. 6th, is fn like manner to be confidered as a fymptom or local ef- fea of the Polyfarcia, and is -only to be cured by correaing the general fault of the fydemt. *373- From this view of thofe idiopathic cafes of dy- fpncea, which are perhaps all I could properly ar- range under this title, it will readily appear that there is little room for treating of them here: But there is dill one cafe of difficult breathing, which has been properly diftinguifhed from every other under the title of Afihma; and as it deferves our particular attention, I fhall here feparately confi- der it. Chap. VI. Of Asthma. »374- THE term of Afthma has been commonly appli- ed by the vulgar, and even by many writers on the Practice of Phyfic, to every cafe of difficult breath- ing, that is, to every fpecies of Dyfpncea. The Methodical Nofologids, alfo, have didinguiffied Affhma from Dyfpncea chiefly, and almod folely, by the former being the fame affeaion writh the lat- ter, but in a higher degree. Neither of thefe ap- plications of the term feems to have been correa or proper. I am of opinion, that the term Afthma may be moft properly applied, and fhould be confined, to * It is defined, Dyfpncea in hom'mibus valde obefit. + A low diet, fufficient exercife, fweating, and brilk purges, wilHooft have the Isfired effeft j and the difestfe may be prevented by abhemious living. OF PHYSIC. *95 to a cafe of difficult breathing that has peculiar fymptoms, and depends upon a peculiar proximate caufe, which I hope to aflign with fufficient cer- tainty. It is this difeafe I am now to treat of, and it is nearly what Praaical Writers have generally diflinguifhed from the other cafes of difficult breath- ing, by the title of Spasmodic Adhma, or of Afih- ma convulfivum; although, by not didinguifliing it with fufficient accuracy from the other cafes of Dy- fpncea, they have introduced a great deal of con- fufion into their treatifes on this fubjea. '375- The difeafe I am to treat of, or the Adhma to be driaiy fo called, is often a hereditary difeafe. It* feldom appears very early in life, and hardly till the time of puberty, or after it. It affeas both fexes, but mod frequently the male. I have not obferved it to be more frequent in one kind of tem- perament than in another ; and it does not feem to depend upon any general temperament of the whole body, but upon a particular conditution of the lungs alone. It frequently attacks perfons of a full ha- bit; but it hardly ever continues to be repeated for fome length of time without occasioning an emaci- ation of the whole body. I376. The attacks of this difeafe are generally in the night time, or towards the approach of night; but there are alfo fome indances of their coming on in the courfe of the day. At whatever time they come on, it is for the mod part fuddenly, with a fenfe of tightnefs and driaure acrofs the bread, and a fenfe of draitnefs in the lungs impeding infpiration. The perfon thus attacked, if in a horizontal fituation, is immediately obliged to get into fomewhar of an ere-a • This defcription ofthe difeafe under confileration is excellent, *96 PRACTICE erea podure, and requires a free and cool air. The difficulty of breathing goes on for fome time increaf- ing; and both infpiration and exfpiration are per- formed flowly, and with a wheezing noife. In vi- olent fits, fpeaking is difficult and uneafy. There is often fome propensity to coughing, but it can hardly be executed. 1377- Thefe fymptoms often continue for many hours together, and particularly from midnight till the morning is far advanced- Then commonly a re- miffion takes place by degrees; the breathing be- comes lefs laborious and more full, fo that the perfon can fpeak and cough with more eafe; and, if the cough brings up fome mucus, the remiffion becomes immediately more confiderable, and the perfon falls into a much wifhed for fleep. I378. During thefe fits the pulfe often continues in its natural date; but in fome perfons the fits are at- tended with a frequency of pulfe, and with fome heat and third, as marks of fome degree of fever. If urine be voided at the beginning of a fit, it is commonly in confiderable quantity, and with little colour or odour; but, after the fit is over, the urine voided is in the ordinary quantity, qf a high colour, and fometimes depofites a fediment. In fome perfons, during the fit, the face is a little flufh- ed and turgid; but more commonly it is fc-mewhat pale and ihrunk. 1379- After fome fleep in the morning, the patient, for the red of the day, continues to have more free and eafy breathingi but it is feldom entirely fuch. OF PHYSIC. 197 fuch. He dill feels fome tightnefs acrofs his bread, cannot breathe eafily in a horizontial podure, and can hardly bear any motion of his body, without havin^ his breathing rendered more difficult and uneafv. In the afternoon he has an unufuai flatu- lency'of his domach, and an unufuai drowfinefs; and, very frequently, thefe fymptoms precede the fird attacks of the difeafe. But, whether thefe fymptoms appear or not, the difficulty of breathing returns towards the evening; and then fometimes gradually increafes, till it becomes as violent as in the night before: Or if, during the day, the diffi- culty of breathing has been moderate, and the per- fon got fome fieep in the fird part of the night, he is, however, waked about midnight, or at fome time between midnight and two o'clock in the morning; and is then fuddenly feized with a fit of difficult breathing, which runs the fame courfe as the night before. 138Q. In this manner fits return for feveral nights fuc- ceflively; but generally, after fome nights pafied in this way, the fits differ more confiderable re- miffions. This efpecially happens when the remif- fions are attended with a more copious expeaora- tion in the mornings, and that this continues from time to time throughout the day. In thefe circum- ftances, adhmatics, for a long time after, have not only more eafy days, but enjoy alfo nights of en- tire deep, without the recurrence ofthe difeafe. 1381. When this difeafe, however, has once taken place in the manner above defcribed, it is ready to return at times for the whole of life after. Thefe returns, however, happen with different circum- stances in different perfons. 1382. In. <9* PRACTICE 1382. In fome perfons the fits are readily excited by external heat, whether of the weather or of a warm chamber, and particularly by warm bathing. In fuch perfons fits are more frequent in fummer, and particularly during the dog days, than at other cold- er feafons. The fame perfons are alfo readily af- feBed by changes of the weather; efpecially by fudden changes made from a colder to a warmer, or, what is commonly the fame thing, from a hea- vier to a lighter atmofphere. The fame perfons are alfo affeaed by every circumftance draitening the capacity ofthe thorax, as by any ligature made, or even by a plader laid, upon it; and a like effea happens from any increafed bulk of the domach, either by a full meal, or by air collected in it. They are likewife much affeaed by exercife, or whatever elfe can hurry the circulation of the blood. ^383- As adhmatic fits feem thus to depend upon fome fulnefs of the veflels of the lungs, it is probable that an obflruaion of perfpiration, and the blood being lefs determined to the furface of the body, may favour an accumulation in the lungs, and thereby be a means* of exciting adhma. This feems to be the cafe of thofe aflhmatics who have fits jnoft frequently in the winter feafon, and who have commonly more of a catarrhal affeaion accompa- nying the adhma; which therefore. occurs more frequently in winter, and more manifedly from the application of cold. * 1384. Befide thefe cafes of adhma excited by heat or cold, there are others, in which the fits are efpeci- ally OF PHYSIC. *99 ally excited by powers applied to the nervous fyf- tern ; as, by paffions of the mind, by particular odours, and by irritations of smoke and dud. That this difeafe is an affeaion of the nervous fydem, and depending upon a mobility of the mov- ing fibres of the lungs, appears pretty clearly from its being frequently conneaed with other fpafmo- dic affeaions depending upon mobility ; fuch as hy- deria, hypochondriafis, dyfpepfia, and atonic gout. '1385- From the whole of the hidory of adhma now de- livered, I think it will readily appear, that the prox- imate caufe of this difeafe is a preternatural, and in fome meafure a fpafmodic, condriaion of the muf- cular fibres of the bronchiae; which not only pre- sents the dilatation of the bronchiae neceffary to a free and full infpiration, but gives alfo a rigidity which prevents a full and free exfpiration. This preternatural condriaion, like many other convul-, five and fpafmodic affeaions, is readily excited by a turgefcence of the blood, or other caufe of any unufuai fulnefs and didention of the veffels of the lungs. 1386. This difeafe, as coming by fits, may be generally didinguiffied from mod other fpecies of dyfpncea, whole caufes being more condantly applied, pro- duce therefore .a more condant difficulty of breath- ing. There may, however, be fome fallacy in this matter, as fome of thefe caufes may be liable to have abatements and intenfities, whereby the dy- fpncea produced by them may feem to come by fits; but I believe it is feldom that fuch fits put on the appearance of the genuine adhmatic fits defcrib- ed above. Perhaps, however, there is dill another eafe that may give more difficulty; and that is, when feveral 200 PRACTICE feveral of the caufes, which we have affigned a3 caufes of feveral of the fpecies of difficult breath- ing referred to the genus of Dyfpncea, may have the effea of exciting a genuine althmatic fit. Whe- ther this can happen to any but the .peculiarly pre^ difpofed to adhma, I am uncertain; and therefore, whether, in any fuch cafes, the adhma may be con- fidered as fymptomatic; or if, in all fuch cafes, the adhma may not dill be confidered and treated as an idiopathic difeafe. 1387. The adhma, though often threatening immedi* ate death, feldom occafions it; and many perfons have lived long under this difeafe. In many cafes, however, it does prove fatal; fometimes very quick- ly, and perhaps always at length. In fome young perfons it has ended foon, by occasioning a phthi- fis pulmonalis. After a long continuance, it often ends in a hydrothorax; and commonly, by occasi- oning fome aneurifm of the heart or great veffels, it thereby proves fatal. 1388. As it is feldom that an adhma has been entirely cured ; I therefore cannot propofe any method of cure which experience has approved as generally fuccefsful. But the difeafe admits of alleviation in feveral refpeBs from the ufe. of remedies ; and my bufinefs now fhall be chiefly to offer fome re- marks upon the choice and ufe of the remedies which have been commonly employed in cafes of adhma. 1389. As the danger of an adhmatic fit arifes chiefly from the difficult tranfmiffion of the blood through the OF PHYSIC. 20* the veffels ofthe lungs, threatening fuffocation ; fo the moft probable means of obviating this feems to be bloodletting ; and therefore, in all violent fits, praaitioners have had recourfe to this remedy. In fird attacks, and efpecially in young and plethoric perfons, bloodletting may be very neceffary, and is commonly allowable. But it is alfo evident, that, under the frequent recurrence of fits, blood- letting cannot be frequently repeated without ex- hauding and weakening the patient too much. It is further to be obferved, that bloodletting is not fo neceffary as might be imagined, as the paffage of the blood through the lungs is not fo much in- terrupted as has been commonly fuppofed. This I particularly conclude from hence, that, indead of the diffusion of face, which is the ufual effea of fuch interruption, the face, in adhmatic fits, is oft- en fhrunk and pale. I conclude the fame alfo from this, that, in adhmatic fits, bloodletting does not commonly give fo much relief as, upon the contra- ry fuppofition, might be expeaed. 1390. As I have alleged above, that a turgefcence of the blood is frequently the exciting caufe of adh- matic fits, fo it might be fuppofed, that a plethoric date of the fydem might have a great fhare in pro- ducing a turgefcence ofthe blood in the lungs; and efpecially, therefore, that bloodletting might be a proper remedy in adhma. I allow it to be fo in the fird attacks ofthe difeafe : But as the "difeafe, by continuing, generally takes off the plethoric date ofthe fydem ; fo, after the difeafe has continued for fome time, I allege that bloodletting becomes lefs and lefs neceffary. !39i- Upon the fuppofition of adhmatics being in a plethoric date, purging might be. fuppofed to prove Vol, II. C c a™*- 202 PRACTICE a remedy in this difeafe : But, both becaufe the fuppofition is not commonly well founded, and be- caufe purging is feldom found to relieve the vef- fels of the thorax, this remedy has not appeared to be well fuited to adhmatics ; and large purging has always been found to do much harm. But as adh- matics are always hurt by the dagnation and accu- mulation of matters in the alimentary canal, fo codivenefs mud be avoided, and an open belly proves ufeful. In the time of fits, the employ- ment of emollient and moderately laxative glyders* has been found to give confiderable relief. 1392. As a flatulency of the ftomach, and other fymp- toms of indigestion, are frequent attendants of afthma, and very troublefome to adhmatics ; fo, both for removing thefe fymptoms, and for taking off all determination to the lungs, the frequent ufe of gentle vomitst is proper in this difeafe. In cer- tain cafes, where' a fit was expeBed to come on in the courfe ofthe night, a vomit given in the even- ing has frequently feemed to prevent it. >393- Blidering between the fhoulders, or upon the bread, has been frequently employed to relieve adhmatics; but in the pure fpafmodic adhma we treat of here, I have rarely found bliders ufeful, either in preventing or relieving fits. 1394. Iffues * A jtlvfterof milk, with a little fait, is generally fufncient. The coftivenefs may be removed by mucilaginous laxatives ofthe milder kind, as manna, caffia, &c. or by a proper attention to diet, efpecially by ufing the pulps of particular fruits, as prunes or raifuis boiled in barky-water; roafted apples eaten with brown fugar, &c. f Vomits ought, in thefe c if--, ta be mild. Some formula of them are given in •ne of the notes- on article i8n« OF PHYSIC. lo3 *394- Iffues are certainly ufeful in obviating plethora; but as fuch indications feldom arife in cafes of adhma, to iffues have been feldom found ufeful in this difeafe. 1395- As adhmatic fits are fo frequently excited by a turgefcence .of the blood, fo the obviating and al- laying of this by acids and neutral falts, feems to have been at all times the objea of praaitioners. See Floyer on the Afthma. 1396. Although a plethoric date of the fydem may feem to difpofe to adhma, and the occafional tur- gefcence of the blood may feem to be frequently the exciting caufe ofthe fits; yet it is evident, that the difeafe mud have arifen chiefly from a peculiar conditution in the moving fibres of the bronchiae, disposing them upon various occafions to fall into a fpafmodic condriaion; and therefore, that the entire cure of the difeafe can only be expeBed from the correaing of that predifpofition, or from cor- reBing the preternatural mobility or irritability of the lungs in that refpea. '397- In cafes wherein this predifpofition depends up- on original conformation, the cure muft be diffi- cult, and perhaps impoflible ; but it may perhaps be moderated by the ufe of antifpafmodics. Upon this footing, various remedies of that kind have been commonly employed, and particularly the fe- tid gums; but v/e have not found them of any con- fiderable 204 PR ACT ICE fiderable efficacy, and have obferved them to be fometimes hurtful by their heating too much. Some other antispasmodics which might be fuppofed pow- erful, fuch as musk, have not been properly tried. The vitriolic ether has been found to give relief, but its effeas are not lading. 1398. As in other fpafmodic affeaions, fo in this, the mod certain and powerful antifpafmodic is opium*. I have often found it effeaual, and generally fafe; and if there have arifen doubts with refpect to its fafety, I believe they have arifen from not didin- guifhing between,, certain plethoric and inflamma- tory cafes of dyfpncea, improperly named Adhma, and the genuine fpafmodic adhma we treat of here, >399- As in many cafes this difeafe depends upon a predifpofition which cannot be corrected by our art, £0 in fuch cafes the patient can only efcape the difeafe by avoiding the occafional or exciting cau- fes, which I have endeavoured to point out above. It is, however, difficult to give any general rules here, as differejit adhmatics have their different idiofyncrafies with refpea to externals. Thus, one adhmatic finds himfelf eafied living in the midd of a great city, while another cannot breathe but in the free air of the country. In the latter cafe, how- ever, mod adhmatics bear the air of alow ground, if tolerable free and dry, better than that of the mountain. 1400. In * The great efficacy of opium, in cafes of fpafmodic afthma, is fully confirmed fcy experience. It ought to be given in la»ge dofes, but not often repeated in the day. It feems to be moft ufeful when given occafionally to allay the violence ofthe fit, or to prevent its accefllon. Thus, forty drops of laudanum have been frequent- ly found to relieve the fymptoms when the fit is violent; or, when taken at the ap. yroach of the fit, to have wholly fuppreffed it, or at leaft to have confiderablj blunted its violence, OF PHYSIC. 805 1400. In diet, alfo, there is fome difference to be made with refpea to different adhmatics. None of them bear a large or full meal, or any food that is of flow and difficult folution in the domach ; but ma- ny of them bear animal food of the lighter kinds, and in moderate quantity. The ufe of vegetables which readily prove flatulent, are always very hurtful. In recent adhma, and efpecially in the young and plethoric, a fpare, light, and cool diet is proper, and commonly neceffary ; but, after the difeafe has continued for years, adhmatics com- monly bear, and even require,,a tolerable full diet, though in all cafes a very full diet is very hurtful. 14OI. In drinking, water, or cool watery liquors, are the only fafe and fit drinks for adhmatics; and all liquors ready to ferment, and become flatulent, are hurtful to them. Few adhmatics can bear any kind of drong drink ; and any excefs in fuch is always very hurtful to them. As adhmatics are commonly hurt by taking warm or tepid drink; fo, both upon that account and upon account of the liquors weakening the nerves of the domach, neither tea nor coffee is proper in this difeafe. 1402. Adhmatics commonly bear no bodily motion ea- fily but that of the mod gentle kind. Riding, however, on horfeback, or going in a carriage, and efpecially failing, are very often ufeful to adh- matics. Chap. ;. ao6 PRACTICE Chap. VII. Of the Chincough, or Hoopingcough. 1403. THIS difeafe is commonly epidemic, and mani- fedly contagious. It feems to proceed from a con- tagion of a fpecific nature, and of a fingular qua- lity. It does not, like mod other contagions, ne- ceffarily produce a fever; nor does it, like moft others, occafion any eruption, or produce other- wife any evident change in the ftate of the human fluids. It has, in common with the catarrhal con- tagion, and with that of the meafles, a peculiar de- termination to the lungs; but with particular effeas there, very different from thofe of the other two; as will appear from the hidory of this difeafe now 10 be delivered. 1404. This contagion, like feveral others, affeas per- fons but once in the courfe of their lives; and therefore, neceffarily, children are mod common- ly the fubjeas of this difeafe: But there are many ^indances of it occurring in perfons considerably ad- vanced in life; though it is probable, that the fur- ther that perfons are advanced in life, they are the lefs liable to be affeaed with this contagion. 1405. The difeafe commonly comes on with the ordi- nary fymptoms of a catarrh arifing from cold; and often, for many days, keeps entirely to that appearance; and I have had instances of a difeafe which, though evidently arifing from the chincough contagion, never put on any other form than that of a common catarrh. This OF PHYSIC. 207 This, however, feldom happens; for, generally in the fecond, and at farthed in the third week af- ter the attack, the difeafe puts on its peculiar and charaacridic fymptom, a convulfive cough. This is a cough in which the exfpiratory motions pecu- liar to coughing are made with more frequency, rapidity, and violence, than ufual. As thefe cir- cumdances, however, in different indances of coughing, are in very different degrees; fo no cx- aa limits can be put to determine when the cough can be driaiy laid to be convulfive ; and it is therefore efpecially by another circumdance that the chincough is didinguiffied from every other form of cough. This circumdance is, when many exfpiratory motions have been convulfively made,. and thereby the air is in great quantity thrown out of the lungs, a full infpiration is neceffarily and fuddenly made; which, by the air ruffling in through the glottis with unufuai velocity, gives a peculiar found. This found is fomewhat different in different cafes, but is in general called a Hoop; and from it the whole of the difeafe is called thev Hoopingcough. When this fonorous infpiration has happened, the convulfive coughing is again re- newed, and continues in the fame manner as be- fore, till a quantity of mucus is thrown up from the lungs, or the contents of the domach arc. thrown up by vomiting. Either of thefe evacua- tions commonly puts an end to the coughing, and the patient remains free from it for fome time af- ter. Sometimes it is only after feveral alternate fits of coughing and hooping that expeaoration or vomiting takes place; but it is commonly after the fecond coughing that thefe happen, and put an end to the fiu 1406. When the difeafe, in this manner, has taken its proper form, it generally continues for a long time aft-r, 208 PRACTICE after, and generally from one month to three; but fometimes much longer, and that with very vari- ous circumdances. I4O7.; The fits of coughing return at Various intervals, rarely obferving any exaa period. They happen frequently in the courfe of the day, and more fre- quently dill in the courfe of the night. The pati- ent has commonly fome warning of their coming on ; and, to avoid that violent and painful concuf- fion which the coughing gives to the whole body, he clings fad to any thing that is near to him, or demands to be held fad by any perfon that he can come at. When the fit is over, the patient fometimes • breathes fad, and feems fatigued for a little after But in many this appears very little; and children are commonly fo entirely relieved, that they im- mediately return to their play, or what elfe they were occupied in before. 1408. If it happens that the fit of coughing ends in vo- miting up the contents of the domach, the patient is commonly immediately after feized with a drong craving and demand for food, and takes it in very greedily. 1409. At the fird coming on of this difeafe, the expec- toration is fometimes none at all, or of a thin mu- cus only ; and while this continues to be the cafe, the fits of coughing are more violent, and conti- nue longer: But commonly the expcaoration foon becomes confiderable, and a very thick mucus often in great quantity, is thrown up; and as this is OF PHYSIC. 209 is more readily brought up, the fits of coughing are of fhorter duration. I4IO. The violent fits of coughing frequently interrupt the free tranfmiffion of the blood through the lungs, and thereby the free return of blood from the vef- fels of the head. This occafions that turgefcence and suffusion of face which commonly attends the fits of coughing, and feems to occafion alfo thofe eruptions of blood from the nofe, and even from the eyes and ears, which fometimes happen in thid difeafe. I41 I. This difeafe often takes place in the manner we have now defcribed, without any pyrexia attending it; but, though Sydenham had feldom obferved it, we have found the difeafe very frequently accom- panied with pyrexia, fometimes from the very be- ginning, but more frequently only after the difeafe had continued for fome time. When it does ac- company the difeafe, we have not found it appear- ing under any regular intermittent form. It is con- dantly in fome degree prefent; but with evident exacerbations towards evening, continuing till next morning. 1412. Another fymptom very frequently attending the chincough, is a difficulty of breathing ; and that not only immediately before and after fits of cough- ing, but as condantly prefent, though in different degrees in different perfons. I have hardly ever feen an indance of a fatal chincough, in which a confiderable degree of pyrexia and dyfpncea had not been for fome time condantly prefent. Vol. II. D d 1413. When 21(3 PRACTICE *4*3- When by the power ofthe contagion this difeafe has once taken place, the fits of coughing are oft- en repeated, without any evident exciting caufe : But, in many cafes, the contagion may be confix dered as giving a predifpofition only ; and the fre- quency of fits depends in fome meafure upon vari- ous exciting caufes ; fuch as, violent exercife ; a full meal ; the having taken in food of difficult fo- lution ; irritation of the lungs by dud, fmoke, or difagreeable odours of a drong kind; and efpeci- ally any confiderable emotion of the mind. I414. Such are the chief circumdances of this difeafe, and it is of various event ; which, however, may be commonly forefeen by attending to the follow- ing considerations. The younger that children are, they are in the greater danger from this difeafe ; and of thofe to whom it proves fatal, there are many more under two years old than above it. The older that children are, they are the more fecure againd an unhappy event ; and this I hold to be a very general rule, though I own there are many exceptions to it. Children born of phthisical'and adhmatic pa- rents are in the greated danger from this difeafe. When the difeafe, beginning in the form of a catarrh, is attended with fever and difficult breath- ing, and with little expeaoration, it often proves fatal, without taking on the form of the hooping- cough; but, in mod of fuch cafes, the coming on of the convulfive cough and hooping, bringing on at the fame time a more free expeaoration, gene- rally removes the danger. When the difeafe is fully formed, if the fits are neither frequent nor violent, with moderate expec- toration, OF PHYSIC. 211 toration, and the patient, during the intervals of t the fits, is eafy, keeps his appetite, gets deep, and is without fever or difficult breathing, the difeafe is attended with no danger ; and thefe circum- dances becoming daily more favourable, the dif- eafe very foon fpontaneoufly terminates. An expeaoration, either very fcanty or very co- pious, is attended with danger ; efpecially if the latter circumdance is attended with great difficulty of breathing. Thofe cafes in which the fits terminate by a vo- miting, and are immediately followed by a craving of food, are generally without danger. A moderate hemorrhagy from the nofe often proves falutary ; but very large hemorrhagies are generally very hurtful. This difeafe coming upon perfons under a date of much debility, has very generally an unhappy event. The danger of this difeafe fometimes arifes from the violence of the fits of coughing, occasioning apoplexy, epilepfy, or immediate fuffocation : But thefe accidents are very rare; and the danger of the difeafe feems generally to be in proportion to the fever and dyfpncea attending it. I415. The cure of this difeafe has been always confi- dered as difficult, whether the purpofe be to obvi- ate its fatal tendency when it is violent, or merely to fhorten the courfe of it when it is mild. When the contagion is recent, and continues to aa, we neither know how to correa, nor how to expel it; and therefore the difeafe neceffarily continues for fome time : But it is probable, that the contagion in this as in other indances ceafes at length to aa; and that then the difeafe continues, as in other convulfive afie&ions, by the power of habit alone. 1416, From 2i2 PRACTICE 1416. From this view of the matter I maintain, that the praaice mud be different, and adapted to two different indications, according to the period of the difeafe. At the beginning of the difeafe, and for fome time after, the remedies to be employed muff be fuch as may obviate the violent effe6ls of the difeafe, and the fatal tendency of it; but, af- ter the difeafe has continued for fome time, and is without any violent fymptoms, the only remedies which can be required are thofe which may inter- rupt its courfe, and put an entire dop to it fooner than it would have fpontaneoufly ceafed. 1417. For answering the fird indication. In plethoric fubjeas, or in others, when from the circumdances ofthe cough and fits it appears that the blood is difficultly transmitted through the lungs, bloodlet- ting* is a neceffary remedy ; and it may be even neceffary to repeat it, efpecially in the beginning of the diieafe : But, as fpafmodic affeaions do not commonly admit of much bleeding, fo it is feldom proper in the chincough to repeat this remedy often. 1418. As codivenefs frequently attends this difeafe, fo it is neceffary to obviate or remove it by lax- atives employed; and keeping an open belly is generally ufeful: But large evacuations in this way are commonly hurtfult, 1419. To * Bleeding, in thefe cafes, is beft performed by leeches; and they feem to give greater relief when applied about the neck than on any other part. + In general, the belly may be kept open by a proper attention to diet: Roaftei-1 apples, eaten with brown fugar, ftewed prunes, and other limilar food, which chil- dren generally devour with avidity, fufhcicntly anfwer the puroofe of runevirj£ cr. j'rcvc::t,ir^ coitiYcaifs, OF PHYSIC, 213 1419. To obviate or remove the inflammatory deter- mination to the lungs that fometimes occurs in this difeafe, bliflering is often ufeful, and even repeat- ed bliftering has been of fervice; but iffues have not fo much effea, and fhould by no means fuper- fede the repeated blidering that may be indicated. When bliders are proper, they are more effeaual when applied to the thorax, than when applied to any didant parts. 142O. Of all other remedies, emetics are the mod ufe- ful in this difeafe; both in general by interrupting the return of fpafmodic affeaions, and in particu- lar by determining very powerfully to the furface ofthe body, and thereby taking off determinations to the lungs. For thefe purpofes, I think, full vo- miting is frequently to be employed; and, in the intervals neceffary to be left between the times of full vomiting, naufeating dofes of the antimonial emetics may be ufeful*. I have never found the fulphur auratum, fo much praifed by Cloffius, to be a convenient medicine, on account of the un- certainty of its dofe; and the tarter emetic em- ployed in the manner dircacd by the late Dr. Fo- thergill, has appeared to be more ufeful. 1421. Thefe ■ * The method of giving cut.-.r emetic in naufeating dofes has been frequently mentioned in preceding notes ; but, in cafes of chincough, where children are ge- nerally our patients, 'we are under the neceffity of varying the doles to the age and conftitution. When the child is under a year old, we ought to ufe the weak, foluti- on of tartar emetic fpecified in the end ofthe laft note on article 185. in repeated dofes of a table-fpoonful every ten or fifteen minutes, till it operates. Large dofes, efpecially to young children, are frequently attended with dangerous confequence;., of which the following cafe is a fufficient proof. To a child often months old, that laboured under the chincough, half a grain of tartar emetic was given in a little cinnamon water. A violent vomiting was re- duced, and the child died fuddenly, during the action of the medicine. On in. fpefting the body aftei death, we found the llomach burlt, there being in it a tace- ratipn that admitted two fingers. The infpeftion of this body has mad: ir.e always extremely cautious :a .iumij:iilering emetics to young ch^:-.?., H4 PRACTICE ^ 1421. Thefe are the remedies to be employed in the fird dage of the difeafe for obviating its fatal ten- dency, and putting it into a fafe train. But in the fecond dage, when I fuppofe the contagion has ceafed to acf, and that the difeafe continues merely by the power of ha.bit, a different indication arifes, and different remedies are to be employed. 1422. This difeafe, which often continues for a long time, does not, in my opinion, continue during the whole of that time in confequence of the con- tagion's remaining in the body, and continuing to ^a in it. That the difeafe does often continue long after the contagion has ceafed to a6t, and that too by the power of habit alone, appears to me probable from hence, that terror has frequently cured the difeafe; that any confiderable change in the date of the fydem, fuch as the coming on of the fmall pox, has alfo cured it; and, ladly, that it has been cured by antifpafmodic and tonic me- dicines ; whild none of all thefe means of cure can be fuppofed either to correa or to expel a mor- bific matter, though they are evidently fuited tQ change the date and habits ofthe nervous fyltem. 1423. From this view we are direaed to the indication that may be formed, and in a great meafure to the remedies which may be employed in what we fuppofe to be the fecond dage of the difeafe. It may perhaps be alleged, that this indication of (hortening the courfe of the difeafe is not very im- portant or neceffary, as it fuppofes that the vio- lence or danger is over, and in confequence, that the OF PHYSIC. *«5 the difeafe will foon fpontaneoufly ceafe. The lad fuppofition, however, is not well founded • as the difeafe, like many other convulfive and fpaf- modic affec\ions, may continue for a long time by the pv.-ver of habit alone, and by the repetition of paroxyfms may have hurtful effeas; more efpeci- ally as the violence of paroxyfms, and therefore their hurtful effeas, may be much aggravated by various external caufes that may be accidentally applied. Our indication, therefore, is proper; and we proceed to confider the feveral remedies which may be employed to anfwer it. 1424. Terror may poffibly be a powerful remedy, but it is difficult to meafure the degree of it that fhall be produced ; and, as a flight degree of it may be ineffeaual, and a high degree of it dangerous, I cannot propofe to employ it. 1425. The other remedies which we fuppofe fuited to our fecond indication, and which indeed have been frequently employed in this difeafe, are antifpafmd- dics or tonics. Of the antifpafmodics, cador has been particu- larly recommended by Dr. Morris; but in many trials we have not found it effeaual. With more probability mufk has been employed: But whether it be from our not having it of a genu- ine kind, or not employing; it in fufficiently large dofes, I cannot determine; but we have not found it commonly fuccefsful. Of antifpafmodics, the mod certainly powerful is opium : And when there is no confiderable fever or difficulty of breathing prefent, opium has often proved ufeful in mode- rating the violence of the chincough ; but I have not known it employed fo as entirely to cure the difeafe. If si6 PRACTICE If hemlock has proved a remedy in this difeafe, as we mud believe from Dr. Butter's accounts, I agree with that author, that it is to be confidered as an antifpafmodic. Upon this fuppofition, it is a probable remedy ; and from the accounts of Dr. Butter and fome others, it feems to have been oft- e,i ufeful : but, in our trials, it has often difap- pointed us, perhaps from the preparation of it not having been always proper*. 1426. Of the tonics, I confider the cupmofs, formerly celebrated, as of this kind ; as alfo the bark of the mifletoe : But I have had no experience of either, as I have always trudcd to the Peruvian bark.. I confider the ufe of this medicine as the mod certain means of curing the difeafe in its fecond dage ; and when there has been little fever prefent, and a fuf- ficient quantity of the bark has been given, it has feldom failed of foon putting an end to the difeafe. 1427. When convulfive diforders may be fuppofed to continue by the force of habit alone, it has been found that a confiderable change in the whole of the circumdances and manner of life has proved a cure of fuch difeafes ; and analogy has applied this in the cafe ofthe ehincough fo far, that a change of air has been employed, and fuppofed to be ufeful. In feveral indances I have obferved it to be fo ; but I have never found the effeas of it durable, or fuf- ficient to put an entire dop to the difeafe. SECT. * Experience ha« not found that any ofthe nntifpafmodics have ever been em- ployed with much advantage in this diieafe. All otthem are extremely naufeousj and confequently difficultly given to chikken who cannot well fwallow pills. OF PHYSIC. 217 SECT. III. Of the SPASMODIC AFFECTIONS in the NATURAL FUNCTIONS. C H A I*. VIII. Of the Pyrosis, or what is named in Scotland the Water Brash. 1428. THE painful fenfations referred to the ftorrtachj and which are probably occafioned by real affeaions of this organ, are of different kinds. Probably they proceed from affeaions of different, natures, and fhould therefore be didinguifhed by different appellations; but I mud own that the utmod precision in this matter will be difficult. In my essay towards a methodical Nofology, I have> however, attempted it. For thofe pains that are either acute and pungent, or accompanied with a fenfe of didention, or with a fenfe of condriaion, if they are at the fame time not attended with any fenfe of acrimony or heat, I employ the appella- tion of Gadrodynia. To exprefs thofe painful or uneafy fenfations which feem to arife from a fenfe of acrimony irritating the part, or from fuch a fenfe of heat as the application ofacrids, whether externally or internally applied, often gives, I em- ploy the term of Cardialgia ; and by this I parti- cularly mean to denote thofe feelings which are expreffed by the term Heartburn in the Englifli language. I think the term Soda has been com- monly employed by praaical writers to exprefs art affeaion attended with feelings of the latter kind. Vol. II. E e 1429. Befide 8ifc ♦ P P. A C T I C E 1429. Befide the pains denoted by the terms Gaftro- dynia, Periadynia, Cardialgia, and Soda, there is, I think, another painful fenfation different from all of thefe, which is named by Mr. Sauvages Py- rosis Suecica ; and his account of it is taken from Linnaeus, who names it Cardialgia Sputatoria. Under the title of Pyrosis Mr. Sauvages has form- ed a genus, -of which the whole of the fpecies, ex- cept the eighth, which he gives under the title of Pyrofis Suecica, are all of them fpecies ofthe Gaf- trodynia or ofthe Cardialgia ; and if there is a ge- nus to be formed under the title of Pyrofis, it can in my opinion comprehend only the fpecies I have mentioned. In this cafe, indeed, I own that the term is not very proper ; but my averfion to intro- duce new names has made me continue to employ the term of Mr. Sauvages. 1430. The Gadrodynia and Cardialgia I judge to be for the mod part fymptomatic affeaions; and there- fore have given them no place in this work : But the Pyrofis, as an idiopathic difeafe, and never be- fore treated of in any fyftem, I propofe to treat of here. I431- It is a difeafe frequent among people in lower life ; but occurs alfo, though more rarely, in peo- ple of better condition. Though frequent in Scot- land, it is by no means fo frequent as Linnaeus re- ports it to be in Lapland. It.appears mod com- monly in perfons under middle age, but feldom in any perfons before the^ age of puberty. When it has once taken place, it is ready to recur occasion- ally OF PHYSIC. 21$ ally for a long time after; but it feldom appears in perfons considerably advanced in life. It affeas both fexes, but more frequently the female. It fometimes attacks pregnant women, and ibrae wo- men only when they are in that condition. Of other women, it more frequently affe&s the unmar- ried ; and of the married, mod frequently the bar- ren. I have had many indances of its occurring in women labouring under a fluor albus. 1432. The fits of this difeafe ufually come on in the morning and forenoon, when the domach is empty. The fird fymptom of it is a pain at the pit of ;the domach, with a fenfe of condriaion, as if the fto- mach was drawn towards the back ; the pain is in- creafed by raifing the body into an erea podure, and therefore the body is bended forward. This pain is often very fevere ; and, after continuing for fome time, it brings on an eruaafiion of a thin wa- tery fluid in confiderable quantity. This fluid 'has fometimes an acidtade, but is very often abfolute- Jy infipid. The eruaation is ifor fome time fre- quently repeated; and does not immediately give relief to the pain .which-preceded it, but does^'o^at length, and puts an .-end to the fit. '433- The fits of this difeafe commonly come on with- out any evident exciting caufe ; and I have not found it deadilyconne&ed with any particular di- et. It attacks perfons ufing animal food, but I think more frequently :thoie living on milk and fa- rinacea. It feems often to be excited by cold ap- plied to the lower extvemHies; and is readily ex- cited by any confiderable emotion of mind. It is often wuhaut any fymptoms of dyfpepfia. 1434. The 220 PRACTICE 1434- The nature of this affeaion is not very obvious j but I think it may be explained in this manner: It feems to begin by a fpafm of the mufcular fibres of the domach; which is afterwards, in a certain man- ner, communicated to the blood-ve.flels and exha- lants, fo as to increafe the impetus of the fluids in thefe veffels, while a condriaion takes place on their extremities. While therefore the increafed impeftis determines a greater quantity than ufual of fluids into thefe veffels, the condriaion upon their extremities allows only the pure watery parts to be poured out, analogous, as I judge, in every refpea, ^o what happens in the diabetes hydericus. '435- The praaice in this difeafe is as difficult as the theory. The paroxyfin is only to be certainly re- lieved by opium. Other antifpafmodics, as vitrio- lic ether and volatile alkali, are fometimes of fer- vice, but not condar\tly fo. Although opium and other antifpafmodics relieve the fits, they have no effea in preventing their recurrence. For this purpofe, the whole of the remedies of dyfpepfia have been employed without fuccefs. Of the ufe pf the nux vomica, mentioned as a remedy by Lin- naeus, I have had no experience. Chap. IX. Of the Colic. *436- THE principal fymptom of this difeafe, is a pain felt in the lower belly. It is feldom fixed and pun- gent OF PHYSIC. 221 gent in one part, but is a painful didention in fome meafure spreading over the whole of the belly ; and particularly with a fenfe of twiding or wring- ing round the navel. At the fame time, with this pain, the navel and teguments of the belly are fre- quently drawn inwards, and often the mufcles of the belly are fpafmodically contraaed, and this in feparatc portions, giving the appearance of a bag full of round balls. *437- Such pains, in a certain degree, fometimes oc- cur in cafes of diarrhoea and cholera ; but thefe are lefs violent and more tranfitory, and are named Gripings. It is only when more violent and per- manent, and attended with codivenefs, that they conditute colic. This is alfo commonly attend- ed with vomiting, which in many cafes is frequent- ly repeated, efpecially when any thing is taken down into the domach ; and in fuch vomitings, not only the contents of the domach are thrown up, but alfo the contents ofthe duodenum, and therefore frequently a quantity of bile. H38< In fome cafes of colic, the peridaltic motion is inverted through the whole length of the aliment- ary canal, in fuch a manner that the contents of the great guts, and therefore dercoraceous matter, is thrown up by vomiting ; and the fame inversion appears dill more clearly from this, that what is thrown into the reaum by glyder is again thrown out by the mouth. In thefe circumdances of in- version the difeafe has been named Ileus, or the Iliac Paffion ; and this has been fuppofed to be a peculiar difeafe didina from colic ; but to me it appears that the two difeafes are owing to the fame proximate 222 PRACTICE proximate caufe, and have the fame fymptoms, on- ly in a different degree. r439- The colic is often without'any pyrexia attending it. Sometimes, however, an inflammation comes upon the part of the intedine efpecially affeaed ; and this inflammation aggravates all the fymptoms ofthe difeafe, being probably what brings on the moft confiderable inversion of the peridaltic mo- tion; and, as the dercoraceous vomiting is what ef- pecially didinguifhes the ileus, this has heen confi- dered as always depending on an inflammation of the intedines. However, I can affirm, that as there are inflammations of the intedines without dercoraceous vomiting, fo I have feen indances of dercoraceous vomiting without inflammation ; and there is therefore no ground for didinguifhing ile- us from colic, but as a higher degree of the fame affeaion. 1440. The fymptoms of the colic, and the diffeaions of bodies dead of this difeafe, fhow very clearly that it depends upon a fpafmodic condriaion of a part of the intedines ; and that this therefore is to be confidered as the proximate caufe of the difeafe. In fome of the diffeaions of perfons dead of this difeafe, an intus-fufception has been remarked to have happened; but whether this be condantly the cafe in all the appearances of ileus, is not cer- tainly determined. 1441. The colic has commonly been confidered as be- ing of different fpecies, but I cannot follow the writers on this fubjea in the didinaions they have edablifhed. OF PHYSIC. 223 edablifhed. So far, however, as a difference of the remote caufe conditutes a difference of fpecies, a djdinaion may perhaps be admitted ; and accord- ingly in my Nofology 1 have marked feven differ- ent fpecies : But I am well perfuaded, that in all thefe different fpecies the proximate caufe is the fame, that is, a fpafmodic condriclion of a part of the intedines ; and confequently, that in all thefe cafes the indication of cure is the fame, that is, to remove the condriaion mentioned. Even in the feveral fpecies named Stercorea, Callofa, and Calcu- lofa, in which the difeafe depends upon an obdruc- tion of the intedine, I am perfuaded that thefe ob- druaions do not produce the fymptoms of colic, excepting in fo far as they produce fpafmodic con- ftriaions of the intedines; and therefore, that the means of cure in thefe cafes, fo far as they admit of cure, mud be obtained by the fame means which the general indication above mentioned fuggeds. 1442. The cure, then, of the colic univerfally, is to be obtained by removing the fpafmodic conduc- tions ofthe intedines; and the remedies fuited to this purpofe may be referred to three general heads: 1. The taking off the fpafm by various antifpaf- modic powers. 2. The exciting the aaion of the intedines by purgatives. 3. The employing mechanical dilatation. »443- Before entering upon a particular account of thefe remedies, it will be proper to obferve, that in all cafes of violent colic, it is advifable to praaife bloodletting ; both as it may be ufeful in ohviating the inflammation which is commonly to he apprehended, and even as it may be a means of relaxing £24 P R A C T 1 C E relaxing the fpafm of the intedinc. This remedy may perhaps be improper in perfons of a weak and lax habit, but in all perfons of tolerable vigour it will be a fafe remedy ; and in all cafes where there is the lead fufpicion of an inflammation aaually coming on, it will be absolutely neceffary. Nay, it will be even proper to repeat it perhaps feveral times, if, with a full and hard pulfe, the appear- ance of the blood drawn, and the relief obtained bv the fird bleeding, fhall authorife fuch repeti- tion. 1444. The antifpafmodic powers that may be employ- ed, are, the application of heat in a dry or humid form, the application of bliders, the ufe of opium, and the ufe of mild oils. The application of heat, in a dry form, has been employed by applying to the belly of the patient a living animal, or bladders filled with warm water, or bags of fubdances which long retain their heat; and all thefe have fometimes been applied with fuccefs ; but none of them feem to me fo powerful as the application of heat in a humid form. This may be employed either by the immersion of a great part of the body in warm water, or by fomenting the belly with cloths wrung out of hot water. The immersion has advantages from the application of it to a greater part of the body, and particularly to the lower extremities: But immer- sion cannot always be conveniently praaifed, and fomentation may have the advantage of being long- er continued; and it may have nearly all the be- nefit of immersion, if it be at the fame time appli- ed both to the belly and to the lower extremities. 1445. From considering that the teguments ofthe lower belly have fuch a conneaion with the inteftines, as OF PHYSIC. C2j as at the fame time to be affeaed with fpafmodic contraaion, we perceive that bliders applied to the belly may have the effea of taking off the fpafms both from the mufcles of the belly and from the intedines; and accordingly, blidering has oft- en vbeen employed in the colic with advantage. Analogous to this, rubefacients_applied to the bel- ly have been frequently found ufefuh 1446. The ufe of opium in colic may feem to be art , ambiguous remedy. Very certainly it may for fome time relieve the pain, which is often fo vio- lent and urgent, that it is difficult to abdain from the ufe of fuch a remedy. At the fame time, the Ufe of opium retards or fufpends the-peridaltic mo- tion fo much, as to allow the intedines to fall into condriaions; and may therefore, while it relieves the pain, render the caufe of the difeafe more ob- dinate. On this account, and further as opium prevents the operation of purgatives fo often necef- fary in this difeafe, many praaitioners are averfe to the ufe of it, and fome entirely rejea the ufe of it as hurtful. There are, however," others who think they can employ opium in this difeafe with much advantage. In all cafes where the colic comes on without any previous codivenefs, and arifes from cold, from paffions of the mind, or other caufes which operate efpecially on the nervous fydem, opium proves a fafe and certain remedy; but in cafes which have been preceded by long codivenefs, or where the colic, though not preceded by codive- nefs, has however continued for fome days without ;■ flool, fo that a ftagnation of faeces in the colon is to be fufpeaed, the ufe of opium is of doubtful ef- fea. In fuch cafes, unlefs a dool has been firft procured by medicine, opium cannot be employed but with fome hazard of aggravating the difeafe. \\u.. II. F f However, *a6 PRACTICE However, even in thofe circumftances of coftive- nefs, when, without inflammation, the violence of the fpafm is to be fulpeaed, when vomiting pre- vents the exhibition of purgatives, and when with all this the pain is extremely urgent, opium is to be employed, not only as an anodyne, but alfo as an antifpafmodic, neceffary to favour the operation of purgatives; and may be fo employed, when, ei- ther at the fame time with the opiate, or not long after it, a purgative can be exhibited. Is the hyofcyamus, as often fhowing, along with its narcotic, a purgative quality, better fuited to this difeafe than opium ? 1447. It is feemingly on good grounds that feveral praaitioners have recommended the large ufe of mild oils in this difeafe, both as antifpafmodics and as laxatives; and, where the palate and domach could admit them, I have found them very ufeful. But as there are few Scottifh domachs that can ad- mit a large ufe of oils, I have had few opportuni- ties of employing them. 1448. The fecond fet of remedies adapted to the cure of colic, are purgatives ; which, by exciting the aaion of the intedines, either above or below the obdruaed place, may remove the condriaion; and therefore thefe purgatives may be given either by the mouth, or thrown by glyders into the anus. As the difeafe is often feated in the great guts ; as glyders, by having a more fudden operation, may give more immediate relief; and as purgatives giv- en by the mouth are ready to be rejected by vo- miting ; fo it is common, and indeed proper, to attempt curing the colic in the fird place by glyf- ters. Thefe may at firft be of the mildeft kind, confiding OF PHYSIC. t2f confiding of a large bulk of water, with fome quantity of mild oil; and fuch are fometimes fuffi- ciently efficacious: However, they are not always fo; and it is commonly neceffary to render them more powerfully dimulant by the addition of neu- tral falts, of which the mod powerful is the com- mon or marine fait. If thefe faline glyders, as fometimes happens, are rendered again too quick- ly, and on this account or otherwife are found in- effeaual, it may be proper, indead of thefe falts, to add to the glyders an infufion of fenna, or of fome other purgative that can be extraaed by wa- ter. The antimonial wine* maybe fometimes em- ployed in glyders with advantage. Hardly any glyders are more effeaual than thofe made of tur- pentine properlyt prepared. When all other in- jeaions are found ineffeaual, recourfe is to be had to the injeaion of tobacco imoke; and, when even this fails, recourfe is to be had to the mechanical dilatation to be mentioned hereafter. 1449. As glyders often fail altogether in relieving this difeafe, and as even when they give fome relief they are often imperfea in producing a complete cure ; fo it is generally proper, and often neceffa- ry, to attempt a more entire and certain cure by purgatives given by the mouth. The more power- ful * Tartar emetic is furer than the antimonial wine ; but it is a very violent i:nw- dy, and ought to be ufed with caution even in glyfters. Five or fix grains is the 'jiiul quantify given in glyfters. t The proper manner of preparing turpentine glyfters is as follows ; R. Tereb. Vena. 5vi. Vitd. Ov. No. ii. Tere in mortario marmoreo donee penitus folvetur Terebinthina; dein add? gradJtim, Aq. Tint, frigida, §ii. Jrluic affunde Aq. font, tepid, ft i. M. f. Enema, (tutim injiciend. If the turp*nti;ie doss not ihiblvt i'jiH.^ntly with the yallzc of (w a th.ri ■lay be added. 228 PRACTICE ful of thefe, or, as they are called, the Dradic Pur- gatives, may be fometimes neceffary; but their ufe is to be avoided, both becaufe they are apt to be rejected by vomiting, and becaufe when they do not fucceed in removing the obdruaion they are ready to induce an inflammation. Upon this ac- count it is ufual, and indeed proper, at lead in the fird place, to employ the milder and lefs inflamma- tory purgatives. None have fucceeded with me better than the crydals of tartar*, becaufe this medicine may be given in fmall but repeated dofes to a confiderable quantity ; and under this management it is the purgative lead ready to be rejeaed by vomiting, and much lefs fo than the other neutral falts. If a dronger purgative be required, jalapt, properly prepared, is lefs offen- five to the palate, and fits better upon the domach, than mod other powerful purgatives. On many occafions of colic, nothing is more effeaually pur- gative than a large dofe of calomel^. Some prac- titioners have attempted to remove the obflruaion of the intedines by antimonial emetics |j exhibited in fmall dofes, repeated at proper intervals; and when thefe dofes are not entirely rejeaed by vo- miting, they often prove effeaual purgatives. When * Cryftals of tartar may be |iven in dofes of two drams each, repeated every two hours or oftener. The chief objection againft the ufe of this fait is its difficult folu- tion in water, and therefore many practitioners prefer the foluble tartar, or the Ro- chel fait. + The Pulvis Jilap. comp. of the Edinburgh Pharmacopoeia anfwers in general very well ;v but, the following formula is lefs liable to be rejected by the vomiting which fo frequently accompanies this difeafe. R. Refin. Jalnp. gr. xii. Amygdal. dulc. decorticat. No. vi. Sacch. alb. 5i« Tere in mortario marmoreo, et adde gradatim, Aq. Cinnamom. fimpl. §i. M. f. hauft. Half of this portion may be given at once, and the other half an hour afterward. X This is French practice, but it is dangerous. It has however been ferviceable in many cafes, when given in dofes of 12 or 15 grains, or even a fcruple when other, purgatives have failed. || As the ftomach, as was before obferved, is very irritable in this difeafe, the practitioner will find confiderable difficulty in managing antimonials. It is batter |o avoid yicm altogether, for they may do much mifchief. Of PHYSIC. 229 When evrry purgative has failed, the aaion of the intedines has been effectually excited by throw- ing cold water on the lower extremities. 145O. The third means of overcoming the fpafm of the intedines in this difeafe, is by employing a mecha- nical dilatation ; and it has been frequently fuppof- ed that quickfilver, given in large quantity, might operate in this manner. I have not, however, found it fuccefsful; and the theory of it is with me very doubtful. Some authors have mentioned the ufe of gold and silver pills, or balls, swallowed down ; but I have no experience of fuch praaices, and I cannot fuppofe them a probable means of relief. 1451. Another means of mechanical dilatation and a more probable meafure, is by injeaing a large quan- tity of warm water by a proper fyringe, which may throw it with fome force, and in a continued dream, into the reaum. Both from the experiments re- ported by the late Mr. De Haen, and from thofe I myfelf have had occafion to make, I judge this re- medy to be one of the mod powerful and effeaual*. 1452. I have now mentioned all the feveral means that may be employed for the cure of the colic, confi- dered as a genus ; but before I quit this fubjea, it may be expeaed that I fliould take notice of fome of * It is to be thrown up, by means of a large fyringe, in fuch quantities, that die patient begins to feel a fenfe of uneaiinefs from the grwat diftention which itoccafi- ens. Some patients have borne two gallons to be injeded, and the cafes were at- tended with the defired fuccefs. I'he cafes, in which thefe large injections are mod ufefulj are thofe in which hard- ened faeces are accumulated in the colon. The warm vrctcr anfwer* two int.r.iioas, *u. dilating the paffage, and foftening the feces. £3 From this lad circumdance I conclude, that the difeafe depends upon an increafed fecretion of bile, and its copious effufion into the alimentary canal ; and, as in this it irritates and excites the motion* above mentioned, I infer, that the bile thus effuf- ed in larger quantity is at the fame time alfo of a more acrid quality. This appears likewife from the violent and very painful gripings that attend the difeafe, and which we can impute only to the violent fpafmodic contraaions of the intedines that take place here. Thefe fpafms are commonly communicated to the abdominal mufcles, and very frequently to thofe of the extremities. 1456. In the manner now defcribed, the difeafe fre- quentlyproceedswith great violence, till the drength of the patient is greatly, and often fuddenly, weak- ened ; while a coldnefs of the extremities, cold fweats, and faintings, coming on, an end is put to the patient's life, fometimes in the courfe of one day. In other cafes the difeafe is lefs violent, con- tinues for a day or two, and then ceales by degrees ; though fuch recoveries feldom happen without the aflidancc of remedies. , r_ T, 232 PRACTICE. H57- The attacks of this difeafe are feldom accompa- nied with any fymptoms of pyrexia; and though, during the courfe of it, both the pulfe and refpira- ration are hurried and irregular, yet thefe fymp- toms arc generally fo entirely removed by the re- medies that quiet the fpafmodic affeaion peculiar to the difeafe, as to leave no ground for fuppof- ing that it had been accompanied by any proper pyrexia. 1458. This is a difeafe attending a very warm date of the air; and, in very warm climates, it may per- haps appear at any time of the year : But even in fuch climates it is mod frequent during their warm- ed feafons ; and in temperate climates, it appears only in the warm feafons. Dr. Sydenham confi- dered the appearances of this difeafe in England to be confined to the month of Augud; but he him- felf obferved it to appear fometimes towards the end of dimmer, when the feafon was unufually warm ; and that, in proportion to the heat, the vi- olence ofthe difeafe wasgreater. Others have ob- ferved that it appeared more eaily in dimmer, and always fooner or later, according as the great beats fooner or later let in. 1459. From all thefe circumdances, it is, I think, ve- ry evident, that this diieafe is the effea of a warm atmofphere, producing fome change in the date of the bile in the human body : And the change may confiit, either in the matter of the bile being ren- dered more acrid, and there.by fitted to excite a more copious iecrctk-n •> or, in the fame matter, its OF PHYSIC. 233 Us being prepared to pafs off in larger quantity than ufual. 1460. It has been remarked, that in warm climates and feafons, after extremely hot and dry weather, a fall of rain cooling the atmosphere feems efpeci- ally to bring on this difeafe ; and it is very proba- ble that an obdruaed perfpiration may have alfo a fhare in this, though it is alfo certain that the difeafe does appear when no change in the tempe- rature of the air, nor any application of cold has been obferved. 1461. It is poffible, that, in fome cafes, the heat of the feafon may give only a predifpofition, and that the difeafe may be excited by certain ingeda or other caufes ; but it is equally certain, that the difeafe has occurred without any previous change or error, either in diet, or in the manner of life, that could be obferved. 1462. The Nofologids have condituted a Genus under the title of Cholera, and under this have arranged as a fpecies every affeaion in which a vomiting and purging of any kind happened to concur. In ma- ny of thefe fpecies, however, the matter evacuated is not bilious; nor does the evacuation proceed from any caufe in the date of the atmofphere. Further, in many of thefe fpecies alfo, the vomit- ing which occurs is not an effential, but merely an accidental fymptom from the particular violence of the difeafe. The appellation of Cholera therefore fhould, in my opinion, be confined to the difeafe I have defcribed above ; which by its peculiar Vol, II. C g caufe, 234 PRACTICE caufe, and perhaps alfo by its fymptoms, is very different from all the other fpecies that have been affociated with it. I believe that all the other fpe- cies arranged under the title of Cholera by Sau- vages or Sagar, may be properly enough referred to the genus of Diarrhcea; which we are to treat of in the next chapter. The didinction I have endeavoured to edablifh between the proper Cholera, and the other difeafes that have fometimes got the fame appellation, will, as I judge, fuperfede the quedion, Whether the Cholera, in temperate climates, happens at any other feafon than that above adigned ? '463- In the cafe of a genuine cholera, the cure of it lias been long edablifhed by experience. In the beginning of the difeafe, the evacuation of the redundant bile is to be favoured by the plentiful exhibition ofmiid diluents*, both given by the mouth, and injected by the anus ; and all eva- cuant medicines, employed in either way, are not only superfluous, but commonly hurtful. 1464. When the redundant bile appears to be fufficient- ly wafhed out, and even before that, if the fpaf- modic affeaions of the alimentary canal become ve- ry violent, and are communicated in a confiderable degree to other parts of the body, or when a dan- gerous debility feems to be induced, the irritation is to be immediately obviated by opiates, in suffici- ently large dofes, but in fmall bulk, and given ei- ther by the mouih or by glyderf. ^^ Though * Thin rice gruel is as proper a mild diluent as any we can ufe; as is alfo water in wl.iJi a cruilof bread is boiled. A veryfma.l quantity of port wine may be add- ed to thtfi diluents if die pulfe be fmall or weak. + A pill confifting of a grain of opium may be given every two hours, and if it does not relieve the fv mptoms after the third or fourth repetition, we may injedt the following glyfter; 11. Decodt, OF PHYSIC. >35 1465. Though the patient be in this manner relieved, it frequently happens, that when the operation of the opium is over, the difeafe fiiows a tendency to return ; and, for at lead fome days after the fird attack, the irritability of the intedines, and their difpofition to fall into painful fpafmodic contraai- ons, feem to continue. In this fituation, the re- petition of the opiates, for perhaps feveral days, may come to be neceffary ; and as the debility commonly induced by tfie difeafe favours the dif- pofition to fpafmodic affections, it is often ufeful and neceffary, together with the opiates, to em- ploy the tonic powers of the Peruvian bark*. Chap. XI. Of Diarrhoea or Looseness. 1466. THIS difeafe confids in evacuations by dool, more frequent and of more liquid matter than ufual. This leading and charaaeridic fymptom is fo diver- sified in its degree, in its caufes, and in the variety of matter evacuated, that it is almod impofiible to give any general hidory of the difeafe. 1467. It R. Docoa. Hord. §x. Tinft. Thebaic. 5ii- M. f. Enema. This glyfter may be repeated twice, or thrice if there mould be occafion. * The bark in thefe cafes is often fuccefsfully given aliAig with rhubarb, as in the following formula: R. Pulv. Cort. Peruv. § ft. Rad. Rhei, 3i. M. f. Pulv. in part, xqual. xii. dividend. # One of thefe powders may be given three times a day with a glafs of port wine. «3® PRACTICE 1467. It is to be didinguifhed from dyfentery, by not being contagious; by being generally without fever; and by being with the evacuation of the natural ex- crements, which are, at lead for fome time, retain- ed in dyfentery. The two difeafes have been com* monly didinguiffied by the gripings being more vi- olent in the dyfentery; and they are commonly lefs violent and lefs frequent in diarrhcea: But as they frequently do occur in this alfo, and fometimes to a confiderable degree, fo they do not afford any proper didinction*, 1468. A diarrhcea is to be didinguifhed from cholera chiefly by the difference of their caufes; which, in cholera, is of one peculiar kind ; but in diarrhcea is prodigioufly diversified, as we fhall fee prefently, It has been common to didinguifh cholera by the evacuation downwards being of bilious matter, and by this being always accompanied with a vomiting of the fame kind; but it does not univerfally apply, as a diarrhcea is fometimes attended with vomiting, and even of bilious matter. 1469. The difeafe of diarrhcea, thus didinguifhed, is very greatly diversified; but in all cafes, the fre- quency of dools is to be imputed to a preternatural increafe of the peridaltic motion in the whole, or at lead in a confiderable portion, of the intedinal canal. This increafed aaion is in different de- grees, is often convulfive and fpafmodic, and at any * Tenefmus is a diftinguifhing fymptom of dyfentery, but it is fometim?* prefent in diarrhoea alfo; efpecially thofe diarrhoeas which proceed from acrid or putrid i"c»- (lances in the inteftines, OF PHYSIC. 237 any rate is a motus abnormis: For which reafon, in the Methodical Nofology, I have referred it to the order of Spafmi, and accordingly treat of it in this place. 147O. Upon the fame ground, as I confider the difeafe named Lientery to be an increafed peridaltic mo- tion over the whole of the intedinal canal, arifing from a peculiar irritability, I have confidered it as merely a fpecies of diarrhcea. The idea of a laxity of the intedinal canal being the caufe either of lientery, or other fpecies of diarrhcea, appears to me to be without foundation, except in the tingle cafe of frequent liquid dools from a palfy of the Jphintler ani, 1471. The increafed aaion ofthe peridaltic motion, I confider as always the chief part of the proximate caufe of diarrhcea: But the difeafe is further, and indeed chiefly, diversified by the different caufes of this increafed action; which we arc now to inquire into, 1472. The feveral caufes of the increafed aBion cf the intedines may be referred, I think, in the fird place, to two general heads. The firfi is, of the difeafes of certain parts of the body which, either from a confent ofthe intedines with thefe parts, or from the relation which the in- tedines have to the whole fydem, occafion an in- creafed aaion in the intedines, without the trans- ference of any dimulant matter from the primary difeafed part to them. The fecond head of the caufes of the increafed aaion of the intedines is of the dimuli of various kinds, which are applied direaiy to the intedines themfelves. 1473. Tbw 238 PRACTICE *473- That affeaions of other parts of the fydem may affea the inteftines without transference or ap- plication of any dimulant matter, we learn from hence, that the paffions of the mind do in fome perfons excite diarrhcea. 1474. That difeafes in other parts may in like manner affea the intedines, appears from the dentition of infants frequently exciting diarrhcea. I believe that the gout often affords another inftance of the fame kind ; and probably there are others alfo, though not well afcertained. H75- The dimuli (1472.) which may be applied to the intedines are of very various kinds ; and are either, 1. Matters introduced by the mouth. 2. Matters poured into the intedines by the fe- veral excretories opening into them. 3. Matters poured from certain preternatural openings made into them in certain difeafes. 1476. Of thofe (1475. 1.) introduced by the mouth, the fird to be mentioned are the aliments common- ly taken in. Too great a quantity of thefe taken in, often prevents their due digedion in the do- mach ; and by being thus fent in their crude, and probably acrid, date to the intedines, they frequent- ly excite diarrhcea. The fame aliments, though in proper quantity, yet having too great a proportion, as frequently happens, of faline or faccharine matter along with thema OF PHYSIC. 239 them, prove dimulant to the intedines, and excite diarrhcea. But our aliments prove efpecially the caufes of diarrhcea, according as they, from their own na- ture, or from the weaknefs of the ftomach, are dif- pofed to undergo an undue degree of fermentation there, and thereby become dimulant to the intef- tines. Thus acefcent aliments are ready to pro- duce diarrhcea ; but whether from their having any direaiy purgative quality, or only as mixed in an over proportion with the bile, is not well determined. 1477. Not only the acefcent, but alfo the putrefcent difpofition of the aliments, feems to occafion a di- arrhoea ; and it appears that even the effluvia of putrid bodies, taken in any way in large quantity, have the fame effea. Are oils or fats, taken in as part of our ali- ments, ever the caufe of diarrhcea ? and if fo, in what manner do they operate* ? 1478. The other matters introduced by the mouth, which may be caufes of diarrhcea, are thofe thrown in either as medicines, or poifons that have the fa- culty of dimulating the alimentary canal. Thus, in the lid of the Materia Medica, we have a long catalogue of thofe named purgatives ; and in the lift of poifons, we have many poffeffbd of the fame quality. The former, given in a certain quantity, occafion a temporary diarrhcea; and given in very large dofes, may occafion it in excels, and conti- nue it longer than ufual, producing that fpecies of diarrhcea named a Hypercatharfis. 1179. The * Rancid oils and fats certainly irritate, the inteftines, .*,rj m\v th:i■.i>.<■ pro- Juce diarrhea. 24° PRACTICE 1479. The matters (1475. 2-) poured into the cavity of the intedines from the excretories opening into them, and which may occafion diarrhcea, are ei- tier thoi'e from the pancreatic or biliary dua, or thofe from the excretories in the coats ofthe intef- tines themfelves. 1480. What changes may happen in the pancreatic juice, I do not cxaaiy know ; but I fuppofe that an acrid fluid may iffue from the pancreas, even while dill entire in its druaure ; but more efpeci- ally, when it is in a fuppurated, fcirrhous, or can- cerous date, that a very acrid matter may be poured out by the pancreatic dutt, and occafion diarrhcea. 1481. We know well, that from the biliary dua the l-iie may be poured out in greater quantity than ufual; and there is little doubt of its being alfo fometimes poured out of a more than ordinary acrid quality. It is very probable, that in both ways the bile is frequently a caufe of diarrhcea. Though I have faid above that diarrhcea may be commonly didinguifhed from cholera, I mud ad- mit here, that as the caufes producing that date of 1 lie bile which occafions cholera, may occur in all the different poffible degrees of force, fo as, on one occafion, to produce the mod violent and dif- tinajy marked cholera ; but, upon another, to pro- duce only the gentled diarrhcea ; which, however, will be the fame difeafe, only varying in degree : So I think it probable, that in warm climates, and in warm feafons, a diarrhcea lilioja of this kind may frequently occur, not to be always certainly dil- tinguifhed from cholera. However OF PHYSIC. 241 However this may be, it is fufficiently probable, that, in fome cafes, the bile, without having been aaed upon by the heat of the climate or feafon, may be redundant and acrid, and prove therefore a particular caufe of diarrhcea. 1482. Befide bile from the feveral caufes and in the conditions mentioned, the biliary dua may pour out pus, or other matter, from abfeeffes in the li- ver, which may be the caufe of diarrhcea. Praaical writers take notice of a diarrhcea where- in a thin and bloody liquid is difcharged ; which they fuppofe to have proceeded from the liver, and have therefore given the difeafe the name of rie- patirrhoea: But we have not met with any indance of this kind ; and therefore cannot properly fay any thing concerning it. 1483. A fecond fet of excretories, from which matter is poured into the cavity of the intedines, are thofe from the coats of the intedines themfelves; and are either the exhalants proceeding direaiy from the extremities of arteries, or the excretories from the mucous follicles: And both thefe fources occur in prodigious number over the internal furface of the whole intedinal canal. It is probable that it is chiefly the effufion from thefe fources which, in mod indances, gives the matter of the liquid dools occurring in diarrhcea. 1484. The matter from both fources may be poured out in larger quantity than ufual, merely by the increafed aaion of the intedines, whether that be excited by the paffions of the mind (1473.), by dif- Vol. II. Hh eafes *42 PRACTICE eafes in other parts ofthe lydem (1472. 1.), or by the various dimulants mentioned (1476.), and fol- lowing ; or the quantity of matter poured out may be increafed, not fo much by the increafed aaion ofthe intedines, as by an increafed afflux of fluids from other parts ofthe fydem. Thus cold, applied to the furface ofthe body, and fupprefling perfpiration, may determine a greater quantity of fluids to the intedines. Thus, in the ifchuria renalis, the urine taken in- to the blood-veffels is fometimes determined to pafs off again by the intedines. In like manner, pus or ferum may be abforbed from the cavities in which they have been dagnant, and be again poured out into the intedines, as fre- quently happens, in particular with refpea to the water of dropfies. I485. It is to be obferved here, that a diarrhcea may be excited not only by a copious afflux of fluids from other parts ofthe fydem, but likewife by the mere determination of various acrid matters from the mafs of blood into the cavity ofthe intedines. Thus it is fuppofed that the morbific matter of fe- vers is fometimes thrown out into the cavity of the intedines, and gives a critical diarrhcea : And whe- ther I do or do not admit the doarine of critical evacuations, I think it is probable that the morbi- fic matter ofthe exanthemata is frequently thrown upon the intedines, and occafions diarrhcea. i486. It is to me fuTther probable, that the putrefcent matter diffufed over the mafs of blood in putrid difeafes, is frequently poured out by the exhalants into the intedines, and proves there the caufe, at lead in part, of the diarrhcea fo commonly attend- ing thefe difeafes. T487. Upon OF PHYSIC. *43 1487. Upon this fubjea of the matters poured into the cavity of the inteftines, I have chiefly confidered them as poured out in unufuai quantity : But it is probable that, for the mod part, they are alfo changed in their quality, and become of a .more acrid and dimulant nature; -upon which account efpecially it is, that they excite, or at lead incTeafe, a diarrhcea. 1488. How fax, and in what manner, the exhalant fluid may be changed in its nature and quality, we do not certainly know: But with refpea to the fluid from the mucous excretories, we know, that, when poured out in unufuai quantity, it is commonly, at the fame time, in a more liquid and acrid form ; and may prove, therefore, considerably irritating. I489- Though the copious effufion of a more liquid and acrid matter from the mucous excretories, be probably owing to the matter being poured out im- mediately as it is fecreted from the blood into the mucous follicles, without being allowed to dagnate in the latter, fo as to acquire that milder quality and thicker confidence we commonly find in the mucus in its natural date ; and although we might fuppofe the excretions of a thin and acrid fluid mould always be the effea of every determination to the mucous follicles, and of every dimulant applied to them ; yet it is certain, that the reverfe is fometimes the cafe ; and that, from the mucous follicles, there is frequently an increafed excretion of a mucus, which appears in its proper form of a mild, vifcid, and thickifh matter. This common- 244 PRACTJCE ly occurs in the cafe of dyfentery ; and it has been obferved to give a fpecies of diarrhcea, which has been properly named the Diarrhoea Mucofa. 1490. A third fource of matter poured into the cavity of the intedines, and occasioning diarrhoea (1475. 3.), is from thofe preternatural openings produced by difeafes in the intedines or neighbouring parts. Thus the blood-veffels on the internal furface of the inteftines may be opened by erofion, rupture, or anaflomofis, and pour into the cavity their blood, which, either by its quantity or by its acrimony, whether inherent, or acquired by stagnation, may fometimes give a diarrhcea evacuating bloody mat- ter. This is what I think happens in that difeafe which has been called the Melcena or Morbus Niger. 1491. Another preternatural fource of matter poured into the cavity ofthe inteftines, is the rupture of abfceffes feated either in the coats of the intedines themfelves, or in any of the contiguous vifcera, which, during an indamed date, had formed an ad- hefion with fome part ofthe intedines. The mat- ter thus poured into their cavity may be various ; purulent, or fanious, or both together, mixed at the fame time with more or lefs of blood; and in each of thefe dates may be a caufe of diarrhcea. 1492. Amongd the dimuli that may be direaiy applied to the inteftines, and which, by increafing their peridaltic motion, may occafion diarrhcea, I muft not omit to mention worms, as having frequently that effea. 1493. I mud OF PHYSIC. 245 H93- I mud alfo mention here a date of the inteftines, wherein their peridaltic motion is preternaturally increafed, and a diarrhcea produced ; and that is, when they are affeaed with an erythematic inflam- mation. With refpea to the evidence of fuch a date, and its occasioning diarrhcea, fee what is faid above in (398.) and following. Whether it is to be confidered as a particular and diftina cafe of diarrhcea, or is always the fame with fome of thofe produced by one or other of the caufes above men- tioned, I have not been able to determine. 1494. Ladly, by an accumulation of alimentary or of other matter poured into the cavity of the intef- tines from feveral of the fources above mentioned, a diarrhoea may be efpecially occafioned when the abforption of the laaeals, or of other abforbents, is prevented, either by an obdruaion of their ori- fices, or by an obdruction of the mesenteric glands, through which alone the abforbed fluids can be tranfmitted. In one indance of this kind, when the chyle pre- pared in the ftomach and duodenum is not abforb- ed in the courfe of the inteftines, but paffes off in confiderable quantity by the anus, the difeafe has been named Morbus Coeliacus, or simply and more properly Cceliaca ; which accordingly 1 have con- fidered as a fpecies of diarrhcea, *495- I have thus endeavoured to point out the vari- ous fpecies of difeafe that may come under the ge- neral appellation of Diarrhcea; and from that enu- meration it will appear, that many, and indeed the greater £4« PRACTICE greater part of the cafes of diarrhcea, are to be Confidered as fympathetic affeaions, and to be cur- ed only by curing the primary difeafe upon which they depend ; of which, however, I cannot pro- perly treat here. From our enumeration it will al- io appear, that many of the cafes of diarrhcea which may be confidered as idiopathic, will not require my faying much of them here. In many indances, the difeafe is afcertained, and alfo the caufe aflign- ed, by the condition of the matter evacuated; fo that what is neceffary to correa or remove it will be fufficiently obvious to praaitioners of any know- ledge. In fhoft, I do not find that I can offer any general plan for the cure of diarrhcea; and all that I can pretend to do on this fubjea, is to give fome general remarks on the praaice that has been com- monly followed in the cure of this difeafe. 1496. The praaice in this difeafe has chiefly proceed- ed upon the fuppofition of an acrimony in the flu- ids, or of a laxity in the simple and moving fibres ofthe intedines; and the remedies employed have accordingly been, Correaors of particular acrimo- ny, general demulcents, evacuants by vomiting or purging, adringents, or opiates. Upon each of thefe kinds of remedies I fhall now offer fome remarks. 1497. An acid acrimony is, upon feveral occafions, the caufe of diarrhcea, particularly in children ; and in fuch cafes the abforbent earths have been very pro- perly employed. The common, however, and pro- rnifcuous ufe of thefe, hath been very injudicious ; and where there is any puirefcency, they mud be hurtful, 1498. The O F P H Y S I C. 217 1498. The cafes in which there is a putrid or putrefcent acrimony prevailing, have been, I think, too fel- dom taken notice of; and, therefore, the ufe of acids too feldom admitted. The acrimony to be fuf- peaed in bilious cafes, is probably of the putref- cent kind. 1499. The general correaors of acrimony are the mild diluents and demulcents. The former have no; been fo much employed in diarrhcea as they ought; for, joined with demulcents, they very much in- creafe the effeas of the latter : And although'the demulcents, both mucilaginous and oily, may by themfelves be ufeful, yet without the affidance of diluents they can hardly be introduced in fuch quan- tity as to anfwer the purpofe*. 15OO. As indigedion and crudities prefent in the do- mach are fo often the caufe of diarrhcea, vomit- ing mud therefore be frequently very ufeful in this difeafe. In * Lintfeed tea is both diluent and demulcent; but as the patient fometimes loaths it, we may in its place ufe a decoction of marfli-mallow root, or of quince feed. Thefe infufions and decodtions ought to be extremely thin. An wince of bruifed quince feed will make three pints of water as thick and ropy as the white of an egg : hence a dram is fufficient for a pint of the decoc"Uon. We have another ioftance of a diluent and demulcent in the almond emulfion, which is an exceedingly elegant medicine. The formulae in both the London and Sdinburgh Pharmacopoeias are not well adapted to cafes of diarrhcea: for the former contains fugar, and the latter bitter almonds; both of which ingredient* increafe tr..- irritation. In thefe cafes, therefore, an emulfion made with Ivree' almond* «r,' jum arable, is preferable to either or the others; as, R. Amygdal. dulc. decorticat. 31". Gum Arabic. Si- Tyre i» mortario marmoreo, et adde gradatim, Aq. font, ft i. M. f. Emulf. S4» PRACTICE In like manner, when the difeafe proceeds, as it often does, from obdruaed perfpiration, and in- creafed afflux of fluids to the inteftines, vomiting is perhaps the mod effeaual means of redoring the determination ofthe fluids to the furface of the body. It is poffihle alfo, that vomiting may give fome inversion ofthe peridaltic motion, which is deter- mined too much downwards in diarrhoea; fo that upon the whole it is a remedy which may be very generally ufeful in this difeafe*. I5OI. Purging has been fuppofed to be more univerfal- ly neceffary, and has been more generally praaif- ed. This, however, in my opinion, proceeds up- on very miftaken notions with refpea to the difeafe; and fuch a praaice feems to me for the moft part fuperfluous, and in many cafes very hurtful. It goes upon the fuppofition of an acrimony prefent in the intedines, s.at ought to be carried out by purg- ing: but, if that acrimony has either been intro- duced by the mouth, or brought into the inteftines from other parts of the body, purging can neither be a means of correaing nor of exhaultingit; and mult rather have ihe effea of increafing its afflux, and of aggravating its effeas. From whatever fource the acrimony which can excite a diarrhcea pro- ceeds, it may be fuppofed fufficient to evacuate it- ir:lf, fo far as that can be done by purging ; and as in cholera, fo in the fame kind of diarrhoea, it will be more proper to affift the evacuation by diluents and demulcents, than to increafe the irritation by purgatives. I5O2. If, then, the ufe of purgatives in diarrhcea may be * The methods of pv':-,", th- tartar emetic, for produces cither vomiting or fw eating, may be feen in iiiS nUe; on article 1S5. O F P H Y S I C. 243 be confidered, even when an acrimony is prefent, as fuperfluous, there are many other cafes in which it may be extremely hurtful. If the irritability of the intedines fhall, from affeaions in other parts of* the fydem, or other caufes, have been already ve- ry much increafed, purgatives mud neceffarily ag- gravate the difeafe. In the cafe of lientery, nobo- dy thinks of giving a purgative; and in many cafes of diarrhcea approaching to that, they mud be equally improper. I have already obferved, that when diarrhoea proceeds from an afflux of fluids to the intedines, whether in too great quantity, or of an acrid quality, purgatives may be hurtful; and whoever, therefore, considers the numerous and va- rious'fources from which acrid matter may be pour- ed into the cavity of the intedines, will readily perceive, that in many cafes of diarrhcea, purga- tives may be extremely pernicious. There is one cafe in particular to be taken no- tice of. When, from a general and acrid diffolu- tion ofthe blood, the ferous fluids run off too co- pioufly in the cavity of the intedines, and excitb that diarrhcea which attends the advanced date of heaic fever, and is properly called a Colliquative Diarrhcea; I have, in fuch cafes, often feen pur- gatives given with the mod baneful effeas. There is dill another cafe of diarrhcea in which purgatives are pernicious; and that is, when the difeafe depends, as we have alleged it fometimes may, upon an erythematic inflammation ofthe in- teftines. I need hardly add, that if there be a cafe of di- arrhoea depending upon a laxity of the folids, pur- gatives cannot there be of any fervice, and may do much harm. , Upon the whole, it will, I think, appear, that the ufe of purgatives in diarrhcea is very much limited; and that the promifcuous ufe of them, which has been fo common, is injudici- ous, and often pernicious. I believe the praaice has been chiefly owing to the ufe of purgatives in Vol. II. I i dyfenteris 250 PRACTICE dyfenteric cafes, in which they are truly ufeful; becaufe, contrary to the cafe of diarrhcea, there is in dyfentery a confiderable condriaion of the in- tedines*. l5°3- Another fct of remedies employed in diarrhcea are adringents. There has been fome hefitation about the employment of thefe in recent cafes, up- on the fuppofition that they might occafion the re- tention of an acrid matter that fhould be thrown out. I cannot, however, well underdand or af- fign the cafes in which fuch caution is neceffary ; and I think that the power of aftringents is feldom fo great as to render their ufe very dangerous. The only difficulty which has occurred to me, with refpect. to their ufe, has been to judge of the circumdances to which they are efpecially adapted. It appears to me to be only in thofe where the ir- ritability of the intedines depends upon a lofs of tone: And this, I think, may occur from the debi- lity of the whole fyftem, or from caufes aaing on the intedines alone. All violent or long continu- ed spasmodic and convulfive affections of the intef- tinal canal neceffarily induce a debility there; and fuch caufes often take place, from violent irrita- tion, in colic, dyfentery, cholera, and diarrhceat. 1504. The * Notwithstanding all the author advances concerning the danger of purgatives in a diarrhoea, there are fome cafes in which they are of fingular utility. Mis argu- ments in this article are doubtlefs juft; and, in the fpecies of diarrhoea which he here enuinerates, purgatives are certainly hurtful : but many inftances of diarrhoea occiip, which proceed from an acrimony that is extremely tenacious, and that ad- heres, clofely to the internal furface of the interims, or is retained in their folds. In fuch cafes, purgatives are the only remedies for removing the difeafe, and ought therefore to he ufed. In all other cafes, as the author juftly obferves, they are cer- tainly pernicious. Having afcertained tvh'n purgatives are proper, the next confederation is, tuhat purgatives ought to he ufed? The anfwer is obvious;—Neutral falts, particularly Soda jhofphorata, Rochel fait, Glauber's falts, and Epfom fait, which are enu- merated in the order of their being agreeable, but in a contrary order to their degree ofeWwy; the Epfom fait being the leaft agreeable, but the moft efficacious. + The aftringents to be ufed, when they are proper, are various : as Alum, Log- wood, Catechu, Ki^barb, &c. The author juftly remarks, that aftringents are onlj OF PHYSIC. *5* 1504. The lad of the remedies of diarrhoea that remain to be mentioned are opiates. The fame objeaions have been made to the ufe of thefe, in recent cafes of diarrhoea, as to that of adringents; but on no good grounds: For the effea of opiates, as aitrin- gent, is never very permanent; and an evacuation depending upon irritation, though it may be for fome time fufpended by opiates, yet always returns very foon. It is only by taking off irritability that opiates aie ufeful in diarrhcea; and therefore, when the difeafe depends upon an increafe of irritability alone, or when, though proceeding from irritation, that irritation is correaed or exhauded, opiates are the mod ufeful and certain remedy. And though opiates are not fuited to correa or remove an ir- ritation applied, they are often of great benefit in fufpending the effects of that irritation whenever thefe are violent: And, upon the whole, it will ap- pear, that opiates may be very frequently, and with great propriety, employed in the cure of diarrhcea. Chap. •nly ufeful in cafes of debility, and therefore the tonic aftringents are undoubtedly preferable to any other. Rhubarb and Peruvian bark, each pofleflmg both thefe qualities, may therefore be advantigejufly ufrd conjointly, as in the following for- mula : R. Pulv. Cort. P>ruv. I'x. Rad. Rhei, I ft. M. f. Pulv. The dofe of this powder may be varied according to circumftances, from a fcruple to a dram, twice a day, with a glafs of Port wine after it. It may not be improper to obferve, that in diarrhoeas in general, peeuliar attenti- «n muft be paid to diet. The oleraceous and acefcent vegetables muft be carefully avoided; as muft alfo all fermented lienors except Port wine: of the farinaceous vegetables, rice is the beft; and rice-water, with a little cinnamon and Port wine, is the .-ioft proper drink for patients in thefe cafes. Roafted meats are preferable to boiled; and vca!, hmb, or chickens, preferable to beef or mutton. Pork is very improper; as are alfo all kinds of film Paddings of all kinds without fruit are very proper food for fuch patient'., efpecially r:ce-puddings made without eggs, but with rji.'fc and cinnamon , and alio ike-milk, fago with Port wine, blanc mange, &c. «5* PRACTICE Chap. XII. Of the Diabetes. THIS difeafe confids in the voiding of an unufu- ally large quantity of urine. As hardly any fecretion can be increafed with- out an increafed aaion ofthe veffels concerned in it, and as fome indances of this difeafe are attend- ed with affeaions manifedly fpafmodic, I have had no doubt of arranging the diabetes under the order of Spafmi, 1506. This difeafe is always accompanied with a great degree of third, and therefore with the taking in of a great quantity of drink. This in fome meafure accounts for the very extraordinary quantities of urine voided : But dill, independent of this, a pe- culiar difeafe certainly takes place ; as the quanti- ty of urine voided does almod always exceed the whole ofthe liquids, and fometimes the whole of both folids and liquids, taken in. 1507. The urine voided in this difeafe is always very clear, and at fird fight appears entirely without a- ny colour ; but viewed in a certain light, it gene- rally appears to be dightly tinged with a yellowifh green, and in this refpea has been very properly compared taa folution of honey in a large propor- tion of water. Examined by the tade, it is very generally found to be more or lefs fweet; and many experiments that have now been made in different indances of the difeafe fhow clearly that fuch Urine contains, in confiderable O F P H Y S I C. 253 confiderable quantity, a faccharine matter which appears to be very exa£tly ofthe nature of common fugar. 1508. Doaor Willis feems to me to have been the fird who took notice ofthe fweetnefs of the urine in diabetes, and almod every phyfician of England has fince taken notice of the fame. It is to be doubted, indeed, if there is any cafe of idiopathic diabetes in which the urine is of a different kind. Though neither the ancients, nor, in the other countries of Europe, the moderns, till the latter were direaed to it by the Englifh, have taken no- tice ofthe fweetnefs ofthe urine, it does not per- fuade me, that either in ancient or in modern times the urine in diabetes was of another kind. I my- felf, indceH, think I have met with one indance of diabetes in which the urine was perfeaiy infipid ; and it would feem that a like obfervation had oc- curred to Dr. Martin Lifter. I am perfuaded, ' however, that fuch indances are very rare; and that the other is by much the more common, and perhaps the almod univerfal occurrence. I judge, therefore, that the prefence of fuch a faccharine matter may be confidered as the principal circum- dance in idiopathic diabetes; and it gives at lead the only cafe of that difeafe that I can properly treat of here, for I am only certain that what I am further to mention relates to fuch a cafe. 1509. The antecedents of this difeafe, and confequenN ly the remote caufes of it, have not been well af- certained. It may be true that it frequently hap- pens to men who, for a long time before, had been intemperate in drinking; that it happens to perfons of a broken conditution, or who, as we often ex- prefs 251 PRACTICE prefs it, are in a cacheaic date ; that it fometimes follows intermittent fevers ; and that it has often occurred from excefs in drinking of mineral waters. But none of thefe caufes apply very gene- rally to the cafes that occur: Such cafes are not always, nor even frequently, followed by a diabe- tes ; and there are many indances of diabetes which could not be referred to any of them. In mod of the cafes of this difeafe which I have met with, I could not refer it to any particular caufe. I5IO. This difeafe commonly comes on ffowly, and al- mod imperceptibly, without any previous diforder. It often arifes to a confiderable degree, and fub- fids long without being accompanied with evident diforder in any particular part ofthe fydem. The great third which always, and the voracious appe- tite which frequently, occur in it, are often the only remarkable fymptoms. Under the continu- ance ofthe difeafe, the body is often greatly ema- ciated ; and a great wcaknefs alfo prevails. The pulfe is commonly frequent; and an obfeure fever is for the mod part prefent. When the difeafe proves fatal, it generally ends with a fever, in ma- ny circumftances, particularly thofe of emaciation and debility, refembling a heaic. H5I. The proximate caufe ofthis difeafe is not certain- ly or clearly known. It feems to have been fome- times conneaed with calculous affeaions of the kidneys; and it is poffible, that an irritation ap- plied there may increafe the fecretion- of urine. It perhaps often does fo; but how it fliould prol duce the fingular change that takes place in the date ofthe urine, is not to be eafily explained. It certainly often happens, that calculous matters aie © F PHYSIC. *55 are long prefent in the urinary paffages, without having any fuch effea as that of producing diabe- tes in any fhape. Some have fuppofed that the difeafe occurs from a relaxed date of the fecretory veffels of the kid- neys; and indeed the diffeaions of perfons who had died of this difeafe have fhown the kidneys in a very flaccid date. This, however, is probably to be confidered as rather the effea than the caufe of the difeafe. That no topical affeaion of the kidneys has a fhare in producing this difeafe, and that a fault in the aflimilation ofthe fluids is rather to be blamed, I conclude from hence, that even the folid food taken in, incrcafes the quantity ofthe urine void- ed, at the fame time with an increafe ofthe faccha- rine matter above mentioned. 1512. The diabetes has been fuppofed to be owing to a certain date of the bile : and it is true, that this difeafe has fometimes occurred in perfons who were at the fame time affeaed with difeafes ofthe liver: But this occurrence does not often take place ; and the diabetes frequently occurs feparately from any affeaion of the liver. In twenty indances of diabetes which I have feen, there was not in any one of them any evident affeaion ofthe liver. The explanation that has been offered of the na- ture and operation ofthe bile, in producing diabe- tes, is very hypothetical, and no wife fatisfying. As I have already faid, I think it probable, that in mod cafes the proximate caufe of this diieafe is lome fault in the affimilatory powers, or in tl.ofe employed in converting alimentary matters inio the proper animal fluids. This I formerly hinted to z56 PRACTICE to Dr. Dobfon, and it has been profecuted and publifhed by him ; but I muft own, that it is a the- ory embarraffed with fome difficulties which I can- not at prefent very well remove. 1514. The proximate caufe of diabetes being fo little known or afcertained, I cannot propofe any rati- onal method of cure in the difeafe*. From the te- dimony of feveral authors, I believe that the dif- eafe has been cured: But I believe alfo, that this has feldom happened ; and when the difeafe has been cured, I doubt much if it was effected by the feveral remedies to which thefe cures have been afcribed. In all the indances of this difeafe which I myfelf have feen, and in feveral others of which I have been informed, no cure of it has ever been made in Scotland, though many indances of it have occurred, and in mod of them the remedies recom- mended by authors have been diligently employed. I cannot, therefore, with any advantage, enter in- to a detail of thefe remedies; and as the difeafe, together with its feveral circumdances, when they fhall hereafter occur, is likely to become the fub- ject of diligent invedigation, I avoid going farther at prefent, and judge it prudent to fufpend my opi- nion till I fhall have more obfervations and expe- riments upon which I can form it more clearly. C H A p. ' 'I'he difeafe is happily not very common : but, when a phyfician is called, he % is under the neceflity 01 doing fomething, and not remaining inactive. Some gene. rul directions may therefore be acceptable to the young practitioner. The cure will principally conlift in avoiding whatever may relax the renal veffels, cljecially l»y avoiding ftrong drink. As the quantity ot urine is always lefs in pro- portion as the perfpiration is increafed, it feems adviliable to keep the furface of the ikin lax and perfpirablc; and, if the patient's ftrength allows him, he ought fre- quently to ufe bojilv exercife to promote fweat. For a fimilar reafon, external cold mult be avoided, bJcaufc by diminiftiing perfpiration, a larger quantity of fluids is derived to the kidneys. In fome cafes the difeafe may be probably owing to a lax or weak ftate ofthe kid- mji: hc:icc the indication of Ionics, as Peruvian bark, and other tonic bitters. OF PHYSIC. £57 Chap. XIII. Of the Hysteria, or the Hysteric Disease. 1515. THE many and various fymptoms which have been fuppofed to belong to a difeafe under this ap-* pellation, render it extremely difficult to give a ge- neral charaaer or definition of it. It is, however, proper in all cafes to attempt fome general idea ; and therefore, by taking the mod common form, and that concurrence of fymptoms by which it is principally didinguiffied, I have formed a charac- ter in my fydem of Methodical Nofology, and fhall here endeavour to illudrate it by giving a more full hidory of the phenomena. I516. The difeafe attacks in paroxyfms or fits. Thefe commonly begin by fome pain and fulnefs felt in the left fide of the belly. From this a ball* feems to move with a grumbling noife into the other parts ofthe belly; and, making as it were various con- volutions there, feems to move into the ftomach ; and more didinaiy dill riles up to the top of the gullet, where it remains for fome time, and by its preflure upon the larynx gives a fenfe of fuffocati- on. By the time that the difeafe has proceeded thus far, the patient is affected with a ftupor and infenfibility, while at the fame time the body is agi- tated with various convulfions. The trunk of the body is wreathed to and fro, and the limbs are va- rioufly agitated ; commonly the convulfive motion of one arm and hand, is that of beating, with the clofed fid, upon the bread very violently and re- peatedly. This date continues for fome time, and Vol. II. K k has * Commonly called G.'»but hyfitrictu by authors, *5$ PRACTICE \ has during that time fome remiffions and renewals of the convulfive motions ; but they at length ceafe, leaving the patient in a dupid and feemingly deep- ing date. More or lefs fuddenly, and frequently with repeated sighing and fobbing, together with a murmuring noife in the belly, the patient returns to the exercife of fenfe and motion, but generally without any recolleaion ofthe feveral circumdances that had taken place during the fit. 1517. This is the form of what is called an hyfteric pa-* roxyfm, and is the mod common form; but its pa- roxyfms are considerably varied in different per- fons, and even in the fame perfon at different times. It differs, by having more or fewer of the circum- dances above mentioned; by thefe circumdances' being more or lefs violent; and by the different duration ofthe whole fit. Before the fit, there is fometimes a fudden and unufually large flow of limpid urine. At the com- ing on of the fit the domach is fometimes affeaed with vomiting, the lungs with confiderable difficul- ty of breathing, and the heart with palpitations. During the fit, the whole of the belly, and parti- cularly the navel, is drawn drongly inwards; the fphinaer ani is fometimes fo firmly confhiaed as not to admit a fmall glyder pipe, and there is at the fame time an entire fuppreffion of urine. Such fits are, from time to time, ready to recur; and during the intervals, the patients are liable to in- voluntary motions, to fits of laughing and crying, with fudden transition from the one to the other; while fometimes falfe imaginations, and fome de- gree of delirium, alfo occur. I518. Thefe affeaions have been fuppofed peculiar to the female fcx ; and indeed they mod commonly appear OF PHYSIC. 259 appear in females : But they fometimes, though rarely, attack alfo the male fex ; never, however, that I have obferved, in the fame exquifite degree. In the female fex, the difeafe occurs efpecially from the age of puberty to that of thirty five years; and though it does fometimes, yet it very feldom appears before the former or after the latter of thefe periods. At all ages, the time at which it mod readily oc- curs is that of the mendrual period. The difeafe more efpecially affects the females of tfie mod exquisitely fanguine and plethoric habits, and frequently affeas thofe of the mod robuft and mafculine conditutions. It affeas the barren more than the breeding wo- men, and therefore frequently young widows. It occurs efpecially in thofe females who are li- able to the Nymphomania ; and the Nofologids have properly enough marked one of the varieties of this difeafe by the title of Hyfteria Libidinofa. In the perfons liable to the fits of this difeafe, it is readily excited by the paffions of the mind, and by every confiderable emotion, efpecially thofe brought on by furprife. The perfons liable to this difeafe acquire often fuch a degree of fenfibility, as to be drongly af- feaed by every impreflion that comes upon them by furprife. 1519. In this hidory, there appears to be a concur- rence of fymptoms and circumdances properly marking a very particular difeafe, which I think may be didinguifhed from all others. It feems to me to have been improperly confidered by phyfi- cians as the fame with fome other difeafes, and particularly with hypochondriafis. The two dif- eafes may have fome fymptoms in common, but for the mod part are confiderably different. Spafmodic 3So PRACTICE Spafmodic affeaions occur in both difeafes; but neither fo frequently, nor to fo great a degree, in hypochondriafis as in hyderia. Perfons liable to hyderia are fometimes affeaed at the fame time with dyfpepfia. They are often, however, entirely free from it; but I believe this never happens to perfons affected with hypochon- driafis. Thefe different circumdances mark fome differ- ence in the two difeafes; but they are fti 11 more certainly didinguifhed by the temperament* they attack, and by the timet of life at which they ap- pear to be mod exquisitely formed. It has been generally fuppofed, that the two dif- eafes differ only in refpea of their appearing in dif- ferent fexes. But this is not well founded: For although the hyderia appears moft commonly in females, the male fex is not abfolutely free from it, as 1 have obferved above ; and although the hy- pochondriafis may be moft frequent in men, the in- stances of it in the female fex are very common^, I520. From all thefe considerations, it mud, I think, appear, that the hyderia may be very well, and properly, didinguifhed from hypochondriafis. Further, it feems to me to have been with great impropriety, that almod every degree of the irre- gular motions of the nervous fydem has been re- ferred to the one or other of thefe two difeafes. Both are marked by a peculiarity of temperament, as well as by certain fymptoms commonly accompa- nying that; but fome of thefe, and many others ulually marked by the name of nervous fymptoms may, from various caufes, arife in temperaments different Hyfteria attacks the fanguine and plethoric, but Hypochondriafis the melan- cholic. t Hypochondriafis fcarcely ever appears early in life, nor Hyfteria late : and Ilypochonurufis becomes i^ravated, hut Hyfterii relieved by advancing age. | She H; |)^.h;:r.,r:aiis in women has been frequently m:ftaken for Hyfteria. O F P H Y S I C. *6x different from that which is peculiar to either hy- deria or hypochondriafis, and without being joined with the peculiar fymptoms of either the one or the other difeafe: So that the appellations of Hyderic and Hypochondriac are very inaccurately applied to them. Under what view thefe fymptoms arc otherwife to be confidered, I am not ready to de- termine ; but mud remark, that the appellation of Nervous Difeafes is too vague and undefined to be of any ufeful application. 1521. Having thus endeavoured to didinguifh hyderia from every other difeafe, I fhall now attempt it* peculiar pathology. With refpea to this, I think it will, in the firlt place, be obvious, that its pa- roxyfms begin by a convulfive and fpafmodic affec- tion of the alimentary canal, which is afterwards communicated to the brain, and to a great part of the nervous fydem. Although the difeafe appears to begin in the alimentary canal, yet the connec- tion which the paroxyfms fo often have with the mendrual flux, and with the difeafes that depend on the date of the genitals, fliows, that the phyfi- cians have at all times judged rightly in confider-' ing this difeafe as an affection of the uterus and other parts of the genital fydem, 1522. With regard to this, however, I can go no far- ther. In what manner the uterus, and in particu- lar the ovaria, are affeaed in this difeafe ; how the affeaion of thefe is communicated, with parti- cular circumdances, to the alimentary canal ; or how the affeaion of this, rising upwards, affeas the brain, fo as to occafion the particular convul- fions which occur in this difeafe, I cannot pretend to explain. But 462 PRACTICE . But although I cannot trace this difeafe to its firft caufes, or explain the whole of the pheno* mena, I hope, that with refpea to the general na- ture ofthe difeafe, I may form fome general con- clusions, which may ferve to direft our condua in the cure of it. 1523. Thus, from a consideration of the predifponent and occafional caufes, it will, I think, appear, that the chief part ofthe proximate caufe is a mo- bility of the fyftem, depending generally upon its plethoric date. I524. Whether this difeafe ever arifes from a mobility of the fydem, independent of any plethoric date of it, I cannot positively determine; but in many cafes that have fubfided for fome time, it is evi- dent, that a fenfibility, and eonfequently a mobili- ty, are acquired, which often appear when neither a general plethora can be fuppofed to fubfid, nor an occafional turgefcence to have happened. However, as we have fhown above, that a diden- tion of the veffels of the brain feems to occafion epilepfy, and that a turgefcence of the blood in the veffels of the lungs feems to produce adhma; fo analogy leads me to fuppofe, that a turgefcence of blood in the uterus, or in other parts of the gen- ital fydem, may occafion the fpafmodic and con- vulfive motions which appear in hyderia. It will, at the fame time, be evident, that this affeaion of the genitals mud efpecially occur in plethoric ha- bits ; and every circumdance mentioned in the hif- tory of the difeafe ferves to confirm this opinion with relpea to its proximate caufe. 1525. From OF PHYSIC. *6j 1525. From this view of the fubjeS, the analogy of hyderia and epilepfy will readily appear ; and why, therefore, I am to fay that the indications of cure are the fame in both*. As the indications, fo the feveral means of an- fwering them, are fo much the fame in both difeaf- es, that the fame obfervations and directions, with regard to the choice and employment of thefe re- medies, that have been delivered above on the fub- jea of epilepfy, will apply pretty exactly to hyde- ria; and therefore need not to be repeated here. Chap. * Although the indications of cure may he the fame in both difeafes, yet in hy- fteria we are more frequently under the neceftity pf relieving the violence of thefymp- loms than in epilepfy; and for this purpofe we muft have recourfe to a variitj of •ntifpafmodics. Afifcetida, in various forms, is ufually employed; as are alfo volatile fpirits- but boih thefe joined prove more efficacious than either of them fingly. There ;n itus Ammoniae foetidus. Its dofe is twenty or thirty drops, icpe.iitei kecording to .Ik- uit'ency ofthe cafe, feveral times a d iy. The Tin^turi Caftprei compofita of the Edinburgh Pharmacopoeia is anoilwr ex. client formula ot the fame kind : it is a remedy of real efficacy. The dofe of it it tii.rty or forty drops rep.ztt-'d occasionally. The SincJura Vil.riarje volatilis of both the Pharmacopeias ic alfo freque.it'j ufed. Its dofe is a tea-fpoonhii or tvo. F.-w of the cornp .fir'uvns ol the (bops are fo^i to be more efficacious antifpafmo- elicsthan the Spiritus /Etherjs VitrioLicus comppfitus ofthe Loudon Pharrrui;opirj4. Its dofe is from thirty to fifty drops in two or three ipoopfuls of cold water; &ud it mull be r.vallowed immediately on pouring outo! the vial. Thefe and other antnpaur.odics -i.ay be ufed promifxuoufly; for, in different cife* and constitutions, they prove differently efficacious, bon.etimes thry hk y be v.n-.- culh' combined with one another, and with opium. Opium, however, on>.ht iu? fymptoms; but the fetid gums, in fubftance, muft be ufed, when we wilh to pro. duce permanent effects. The formulae of them are in both our Pi 11 macoposias, un- der the title of Gum-piUs{ but they will be found much more efficacious ky adding loihem a little caltor, as in the following formula : R. Pflul. Gummof. Edinb. g jb- Caftor. Ruffic. 3i. Syr. fimpl. q. s. M. f. maff. in pilulas lxxv. equales dividend. Five of thefe pills maybe taken twice a day, wafhing ihem down with a tea-rup- " fill of cold water with a tea-fpoonful of volatile tincture of valerian in it. The Pilulie tdtida? ofthe Swedifti Pharmacopeia, in which caftor is one cf the. ingredients, ispreferable to either of our gum-pil'.,. 1C4 PRACTICE Chap. IX. Of Canine Madness and Hydrophobia. 1526. THIS difeafe has been fo exaaiy and fully de- fcribed in books that are in every body's hands, that it is on no account neceffary for me to give any hidory of it here ; and with refpea to the pa- thology of it, I find that I can fay nothing fatisfy- ing to myfelf, or that I can expea to prove fo to others. I find alfo, with refpea to the cure of this difeafe, that there is no fubje£t in which the fallacy of experience appears more drongly than in this. From the mod ancient to the prefent times, many remedies for preventing and curing this dif- eafe have been recommended under the fanaion of pretended experience, and have perhaps alfo kept their credit for fome time : But fucceeding times have generally, upon the fame ground of ex- perience, dedroyed that credit entirely ; and mod ofthe remedies formerly employed are now fallen into abfolute neglea. In the prefent age, fome new remedies have been propofed, and have expe- rience alleged to vouch for their efficacy ; but many doubts dill remain with refpea to this : and though I cannot determine in this matter from my own experience, I think it incumbent on me to \ give the bed judgment I can form with refpea to the choice of the remedies at prefent recommended. 1527. I am, in the fird place, firmly perfuaded, that the mod certain means of preventing the confe- quences of the bite, is to cut out, or otherwife de- flroy, the part in which the bite has been made. In this every body agrees ; but with this difference, that OF PHYSIC 265 that fome are of opinion that it can only be effec- tual when it is done very foon after the wound has been made, and they therefore neglea it when this opportunity is miffed. There* have been, how- ever, no experiments made proper to determine this matter : And there are many condderations which lead me to think, that the poifon is not im- mediately communicated to the fydem ; and there- fore, that this meafure of dedroying the part may be praaifed with advantage, even many days after1 the bite has been given. 1528. Whild the date of our experience, with refpea: to feveral remedies now in ufe is uncertain, I can- not venture to affert that any of thefe is abfolutely ineffeaual ; but I can give it as my opinion, that the efficacy of mercury, given very largely, and perfided in for a longtime, both as a means of pre- venting the difeafe, and of curing it when it has ac- tually come on, is better fupported by experience than that of any other remedy now propofed, of, commonly employed. Voi. II. LI BOOK. [ 266^ ] BOOK IV. Of VESANI/E, or of the DISORDERS of the INTELLECTUAL FUNCTIONS. CHAP. I. Of VESANI^E in general. 1529. THE Nofologids, Sauvages and Sagar, in a clafs of difeafes utider the title qf Vesani/e, have corryprehended the two oilers,, of Hallucina- tiones or Falfe Perceptions, and of Morofitates or Erroneous Appetites and Paffions; and in like manner, Linnaeus in his clafs of Mentales, cor- refponding to the Vefaniae of Sauvages, has com- prehended the two orders of Imaginarii and Pa- thetici, nearly the fame with the Hallucinationes and Morofitates of that author. This, however, from fe- veral condderations, appears to me improper; and I have therefore formed a clafs of Vefaniae nearly the fame with the Paranoia of Vogel, excluding from it the Hallucinationes and Morofitates, which I have referred to the Morbi Locales. Mr. Vogel has done the like, in feparating from the Paranoias the falfe perceptions and erroneous appetites; and has thrown thefe into another clafs, to which he has given the title of Hyperaedheies. 1530. It is indeed true, that certain hallucinationes and morofitates are frequently combined with what I propofe PRACTICE, &c. 267 I propofe to confider as driaiy a vefania or an er- roneous judgment; and fometimes the hallucina- tiones feem to lay the foundation of, and to form almod entifely, the vefania. But as mod part of the hallucinationes enumerated by the Nofologids are affeaions purely topical, and induce no other error of judgment befide that which relates to the fingle objea. of the fenfe or particular organ affea- ed; fo thefe are certainly to be feparated from the difeafes which confid in a more general affeaion of the judgment. Even when the hallucinationes con- dantly accompany or feem to induce the vefania, yet being fuch as arife from internal caufes, and may be prefumed to arife from the fame caufe as the more general affeaion of the judgment, they are therefore to be confidered as fymptoms of this only. In like manner I judge with refpea to the mo- rofitates, or erroneous paffions, that accompany vefania; which, as confequcnces of a falfe judg- ment, mud be confidered as arifing from the fame caufes, and as fymptoms only, of the more gene- ral affeaion. There is, indeed, one cafe of a morofitas which feems to induce a vefania, or more general affec- tion of the judgment; and this may lead us to con- fider the vefania, in this cafe, as a fymptom of an erroneous appetite, but will not afford any good reafon for comprehending the morofitates in gene- ral under the vefaniae, confidered as primary dif- eafes. / The limitation, therefore, of the clafs of Vefa- niae to the lefions of our judging faculty, feems from every consideration to be proper. The particular difeafes to be comprehended un- der this clafs, may be didinguifhed according as they affea perfons in the time of waking or deep- ing. Thofe which affea men awake, may again be confidered, as they confid in an erroneous judgment, to which I fhall give the appellation of Delirium ; 268 PRACTICE Delirium ; or as they confid in a weaknefs or 1m- perfeaion of j'1 gment, which I fhall name Fatuity. I begin with the consideration of Delirium. 1531- As men differ greatly in the foundnefs and force of their judgment, fo it may be proper here to af- certain more precifely what error or imperfeaion of our judging faculty is to be confidered as mor- bid, and to admit of the appellations of Delirium and Fatuity. In doing this, I fhall fird confider the morbid errors of judgment under the general appellation of Delirium, which has been common- ly employed to denote every mode of fuch error. '532- As our judgment is chiefiy exercifed in difcern- jng and judging ofthe feveral relations of things, I apprehend that delirium may be defined to be,— In a perfon awake, a falfe or midaken judgment of thofe relations of things, which, as occurring mod frequently in life, are thofe about which the generality of men form the fame judgment; and particularly when the judgment is very different from what the perfon himfelf had before ufually formed. •533- With this midaken judgment of relations there \s frequently joined fome falfe perception of exter-! nal objeas, without any evident fault in the or- gans of fenfe, and which feems therefore to de- pend upon an internal caufe; that is, upon the imagination arifing from a condition in the brain preienting objeas which are not aaually prefent. Such falfe perceptions mud neceffarily occafion a delirium, or an erroneous judgment, which is to J>c confidered as the difeafe. 1534. Another OF PHYSIC. 269 '534- Another circumdance, commonly attending de- lirium, is a very unufuai affociation of ideas. As, with refpea to mod of the affairs of common life, the ideas laid up in the memory are, in mod men, affociated in the fame manner; 10 a very unufuai affociation, in any individual, mud prevent his forming the ordinary judgment of thofe relations which are the mod common foundation of affocia- tion in the memory : And therefore this unufuai and commonly hurried affociation of ideas, ufually is, and may be confidered as, a part of delirium. In particular it may be confidered as a certain mark of a general morbid affeaion ofthe intellec- tual organs, it being an interruption or perversion of the ordinary operations of memory, the com- mon and neceffary foundation of the exercife of judgment. *535- A third circumdance attending delirium, is an emotion or paffion, fometimes of the angry, fome- times of the timid kind; and from whate\er caufe in the perception or judgment, it is not propor- tioned to fuch caufe, either in the manner former- ly cultomary to the perfon himfelf, or in the man- ner ufual with the generality of oilier men. Delirium, then, may be more fhortly defined,— J n a perfon awake, a falfe judgment arifing from perceptions of imagination, or from falfe recollec- tion, and commonly producing difproportionate emotions. Such delirium is of two kinds ; as it is combined with pyrexia and cornatofe affc&ion?; or, as it is entirely 270 PRACTICE entirely without any fuch combination. It is the latter cafe that we name Infanity; and it is this kind of delirium only that I am to treat of here. J537- Insanity may perhaps be properly confidered as a genus comprehending many different fpecies, each of which may deferve our attention; but be- fore proceeding to the consideration of particular fpeGies, I think it proper to attempt an invediga- tion of the caufe of infanity in general. 1538. In doing this, I fhall take it for granted, as de- mondrated elfewhere, that although this difeafe feems to be chiefly, and fometimes folely, an affec- tion of the mind; yet the conneaion between the mind and body in this cafe is fuch, that thefe affec- tions ofthe mind mud be confidered as depending upon a certain date of our corporeal part. See Halleri Prim. Lin. Phyfiolog. § 570. See Boer- haavii Ind. Med. \ 581. 696. '539- Admitting this proposition, I mud in the next place aflume another, which I likewife fuppofe t© be demondrated elfewhere. This is, that the part of our body more immediately conneaed with the mind, and therefore more efpecially concerned in every affeaion of the intellectual funaions, is the common origin of the nerves; which I fhall, in what follows, fpeak of under the appellation of the Brain. 1540. Here, however, in affuming this lad proposition, a very great difficulty immediately prefents itfelf. Although OF PHYSIC. *7i Although we cannot doubt that the operations of our intellect always depend upon certain motions taking place in the brain (fee Gaub. Path. Med. \ 523.); yet thefe motions have never been the objeas of our fenfes, nor have we been able to perceive that any particular part of the brain has more concern in the operations of our intellea than any other. Neither have we attained any knowledge of what fhare the feveral parts of the brain have in that operation; and therefore, in this fituation of our fcience, it mud be a very difficult matter to difco- ver thofe dates of the brain that may give occafion to the various date of our intelleaual funaions. 1541. It may be obferved, that the different date ofthe motion ofthe blood in the veffels ofthe brain has fome diare in affeaing the operations of the intel- lea ; and phyficians, in feeking for the caufes of the different dates of our intelleaual funaions, have hardly looked further than into the date of the motion ofthe blood, or into the condition of the blood itfelf: But it is evident that the opera- tions of the intelleaual functions ordinarily go on, and are often considerably varied, without our be- ing able to perceive any difference either in the motions or in the conditions of the blood. 1542. Upon the other hand, it is very probable that the date of the intelleaual funaions depends chief- ly upon the date and condition of what is termed the Nervous Power, or, as we fuppofe, of a fub- tile very moveable fluid, included or inherent, in a manner we do not clearly underfland, in every part of the medullary fubftance of the brain and nerves, and which in a living and healthy man is capable of being moved from every one part to tvcry other of the nervous fydem. 1543. With 272 PRACTICE *543- With refpea to this power, we have pretty clear proof that it frequently has a motion from the fen- tient extremities of the nerves towards the brain, and thereby produces fenfation ; and we have the fame proof, that in confequence of volition the nervous power has a motion from the brain into the mufcles or organs of motion. Accordingly, as fenfation excites our intelleaual operations, and volition is the effea of thefe, and as the conneai- on between fenfation and volition is always by the intervention of the brain and of intelleaual opera- tions; fo we can hardly doubt, that thefe latter de- pend upon certain motions, and the various modi- fication of thefe motions, in the brain. 1544. To afccrtain the different dates of thefe motions may be very difficult; and phyficians have com- monly confidered it to be fo very myderious, that they have generally despaired of attaining any knowledge with regard to it: But I confider fuch abfolute despair, and the negligence it inspires, to be always very blameable; and I diall now venture to go fome length in the inquiry, hoping that fome deps made with tolerable firmnefs may enable us to go dill further. '545- To this purpofe, I think it evident, that the ner- vous power, in the whole as well as in the feveral parts of the nervous fydem, and particularly in the brain, is at different times in different degrees of mobility and force. To thefe .different dates, I beg leave to apply the terms of Excitement and Col- lapfe. To that date in which the mobility and force are O F P H Y S I C. 27 j are fufficient for the exercife of the funaions, or when thefe dates are any way preternaturally in- creafed, 1 give the name of Excitement; and to that date in which the mobility a.d force are not fuffi- cient for the ordinary exercife of the funaions, or when they are diminifhed from the date in which they had been before, I give the name of Collapje. I beg, however, it may be obferved, that by thefe terms I mean to exprefs matters of facf only ; and without intending, by thefe terms, to explain the circumdance or condition, mechanical or physical, of the nervous power or fluid in thefe different dates* 1546. That thefe different dates of excitement and col- lapfe take place on different occafions, mud, I think, be manifed from numberlefs phenomena of the animal economy : But it is efpecially to our prefent purpofe to obferve, that the different dates of excitement and collapfe, are in no inflance more remarkable, than in the different dates of waking and deeping. In the latter, when quite complete,, the motion and mobility of the nervous power, with refpea to the whole of what are called the Animal Funaions, entirely ceafe, or, as I would exprefs it, are in a date of collaple ; and are very different from the date of waking, which in healthy perfons I would call a date of general and entire excitement, I547- This difference in the dates of the nervous pow- er in deeping and waking being admitted, I mud in the next place obferve, that when thefe dates are changed from the one into the other, as common- ly happens every day, the change is hardly ever made indantaneoufly, but almod always by degrees, and in fome length of time only : And this may be obferved with refpea to both fenfe and motion. Vol. II, M m Thus £74 PRACTICE Thus when a perfon is falling afleep, the fenfibility is gradually diminiflied: So that, although fome degree of fleep has come on, flight impreffions will excite fenfation, and bring back excitement; which the fame, or even dronger impreffions, will be in- fufficient to produce when the date of fleep has con- tinued longer, and is, as we may fay, more com- plete. In like manner, the power of voluntary motion is gradually diminiflied. In fome members it fails fooner than in others; and it is fome time before it becomes general and confiderable over the whole. The fame gradual progrefs may be remarked in a perfon's coming out,of fleep: The ears in this cafe are often awake before the eyes are opened or fee clearly, and the fenfes are often awake before the power of voluntary motion is recovered ; and it is curious to obferve, that, in fome cafes, fenfati- ons may be excited without producing the ordinary affociation of ideas. See Mem. de Berlin, 1752. 154?- From all this, I think it will clearly appear, that not only the different dates of excitement and col- lapfe can take place in different degrees, but that they can take place in different parts of the brain, or at lead, with refpea to the different funaions, in different degrees. As I prefume that almod every perfon has per- ceived the gradual approach of deeping and wak- ing, I likewife fuppofe every perfon has obferved, that, in fuch intermediate date of unequal excite- ment, there almod always occurs more or lefs of delirium, or dreaming, if any body choofes to call it fo. There are in this date falfe perceptions, falfe associations, falfe judgments, and difproportionate emotions; in fliort, all the circumdances by which I have above defined delirium. This clearly fliows that delirium may depend, 'and I fliall hereafter endeavour to prove that it commonly OF PHYSIC. a 75 commonly does depend, upon fome inequality in the excitement of the brain ; and that both thefe affertions are founded on this, that, in order to the proper exercife of our intelleaual funaions, the excitement mud be complete, and equal in every part ofthe brain. For though we cannot fay that the vediges of ideas are laid up in different parts of the brain, or that they are in fome meafure diffuf- ed over the whole, it will follow upon either fup- pofition, that as our reafoning and our intelleaual operations always require the orderly and exaa re- colleaion or memory of affociated ideas ; fo, if any part of the brain is not excited, or not excitable, that recolleaion cannot properly take place, while at the fame time other parts of the brain, more ex- cited and excitable, may give falfe perceptions, af- fociations, and judgments. 1549. It will ferve to illudrate this, that the collapfe in fleep is more or lefs complete; or that the fleep, ?s we commonly fpeak, is more or lefs profound: And therefore, that in many cafes, though deep takes place to a confiderable degree, yet certain impreffions do dill take effea, and excite motions, or, if you will, fenfations in the brain ; but which fenfations, upon account of the collapfed date of fo great apart of the brain, are generally ofthe deliri- ous kind, or dreams, confiding of falfe perceptions, affbeiations, and judgments, that would have been correaed if the brain had been entirely excited. Every one, I believe, has obferved, that the mod imperfea deeps are thofe chiefly attended with dreaming ; that dreams, therefore, mod common- iv occur towards morning, when the complete date of fleep is paffing away; and further, that dreams are mod commonly excited by drong and uneafy impreffions made upon the body. I apprehend it may alfo be an illuftration ofthe fame thing, that, even in waking hours, we have an 276 PRACTICE an indance of an unequal date of excitement in the brain producing delirium. Such, I think, occurs in the cafe of fever. In this it is manifed, that the energy ofthe brain, or its excitement, is consider- ably diminifhed with refpea to the animal funai- ons: And it is accordingly upon this ground that I have explained above, in (45.), the delirium which fo commonly attends fever. To what I have there faid I fhall here only add, that it may ferve to con- firm my doarine, that the delirium in fever comes on at a certain period of the difeafe only, and that we can commonly difcern its approach by a more than ufual degree of it appearing in the time ofthe patient's falling into or coming out of fleep. It ap- pears, therefore, that delirium, when it fird comes on in fever, depends upon an inequality of excite- ment ; and it can hardly be doubted, that the de- lirium which comes at length to prevail in the en- tirely weakened date of fevers, depends upon the fame caufe prevailing in a more confiderable degree. 1550. From what has been now delivered, I hope it will be fufficiently evident, that delirium may be, and frequently is, occafioned by an inequality in the excitement of the brain. How the different portions of the brain may at the fame time be excited or collapfed in different degrees, or how the energy of the brain may be in different degrees of force, with refpect. to the feve- ral animal, vital, and natural functions, I cannot pretend to explain; but it is fufficiently evident in faa, that the brain may be at one and the fame time in different conditions with refpea to thefe funaions. Thus in inflammatory difeafes, when by a dimulus applied to the brain the force of the vital funaions is preternaturally increafed, that of the animal is either little changed, or considerably diminifhed. On the contrary, in many cafes of mania, OF PHYSIC. 277 mania, the force of the animal funaions depending always on the brain, is prodigioufly increafed, while the date of the vital funaion in the heart is very little or not at all changed. I mud therefore fay again, that how difficult foever it may be to explain the mechanical or phyfical condition of the brain in fuch cafes, the faas are fufficient to fhow that there is fuch an inequality as may didurb our intelleaual operations. I551- I have thus endeavoured to explain the general caufe of Delirium ; which is of two kinds, accord- ing as it is with, or without, pyrexia. Of the fird I take no further notice here, having explained it as well as I could above, in (45.). I proceed now to confider that delirium which properly belongs to the clafs of Vefaniae, and which I fhall treat of under the general title of In- r J • Janity. 1552. In entering upon this fubjea, it immediately occurs, that in many indances of infanity, we find, upon diffeaion after death, that peculiar circum^ dances had taken place in the general condition of the brain. In many cafes, it has been found of a drier, harder, and firmer confidence, than what it is ufually of in perfons who had not been affeaed with that difeafe. In other cafes, it has been found in a more humid, foft, and flaccid date; and in the obfervations of the late Mr. Meckel*, it has been found considerably changed in its den- lity or fpecific gravity. Whether thefe different dates have been obferved to be uniformly the fame over * Memoir, de Berlin pour l'annce 1764. It appeared in many inftances of in- fane perfons, that the medullary fubftance of tt:c cerebrum was drier, and of a lefs !j":ork-gravity, than in perfons who had been always ol a found judgment A#tht)t, c78 PRACTICE over the whole of the brain, I ctnnot certainly learn ; and I fufpea the diffeftors have not always accurately inquired into this circumdance : But in feveral indances, it appears that thefe dates had been different in different parts of the brain ; and indances of this inequality will afford a confirmation of our general doarine. The accurate Morgagni has obferved, that in maniacal perfons the medullary portion of the brain is ufually dry, hard, and firm : And this he had fo frequently obferved, that he was difpofed to confi- der it as generally the cafe. But in mod of the particular indances which he has given, it appears, that, for the mod part, while the cerebrum was of an unufually hard and firm confidence, the cere- bellum was of its ufual foftnefs, and in many of the cafes ft was unufually foft and flaccid. In fome other cafes, Morgagni obferves, that while a part of the cerebrum was harder and firmer than ordinary, other parts of it were preternaturally foft. I553- Thefe obfervations tend to confirm our general doarine : And there are others which I think will apply to the fame purpofe. Upon the difleaion of the bodies of perfons who had laboured under infanity, various organic af- ftaions have been difcovered in particular parts of the brain ; and it is fufficiently probable, that fuch organic affeaions might have produced a different degree of excitement in the free and affeaed parts, and mud have interrupted in fome meafure the free communication between the feveral parts of the brain, and in either way have occafioned infanity. There have occurred fo many indances of this. kind, that I believe phyficians are generally difr pofed to fulpeft organic lefions of the brain to ex- id in almod every cafe of infanity. 1554. This, OF PHYSIC. *79 '554- This, however, is probably a midake : For we know that there have been many indances of infan- ity, from which the perfons have entirely recover- ed ; and it is difficult to fuppofe that any organic lefions of the brain had in fuch cafe taken place.* Such tranfitory cafes, indeed, render it probable, that a date of excitement, changeable by various caufes, had been the caufe of fuch indances of in- fanity. *5S5- It is indeed further afferted, that in many indan- ces of infane perfons, their brain had been exa- mined after death, without fhowing that any or- ganic lefions had before fubfided in the brain, of finding that any morbid date of the brain then appeared. This, no doubt, may ferve to fhow, that organic lefions had not been the caufe of the difeafe; but it does not affure us that no morbid change had taken place in the brain: For it is pro- bable, that the difleaors were not always aware of its being the general condition of hardnefs and density, as different in different parts of the brain, that was to be attended to, in order to difcover the caufe of the preceding difeafe; and therefore many of them had not with this view examined the date of the brain, as Morgagni feems carefully to have done. 1556. Having thus endeavoured toinvedigate the caufe of infanity in general, it were to be widied that I could apply the doarine to the didinguifhing the feveral fpecies of it, according as they depend up- on the different date and circumdances of the brain, 280 PRACTICE brain, and thereby to the edablifhing of a fcien- tific and accurately adapted method of cure. Thefe purpofes, however, appear to me to be extremely difficult to be attained ; and I cannot hope to ex- ecute them here. All I can do is to make fome attempts, and offer fome refleaions, which further obfervation, and greater 'fagacity, may hereafter render more ufeful. '557- The ingenious Dr. Arnold has been commend- ably employed in didinguifhing the different fpecies of infanity as they appear with refpea to the mind: and his labours may hereafter prove ufeful, when we fhall come to know fomething more of the dif- ferent dates of the brain correfponding to thefe different dates ofthe mind ; but at prefent I can make little application of his numerous didinclions. It appears to me that he has chiefly pointed out and enumerated dift.in6t.ions, that are merely vari- eties, which can lead to little or no variety of prac- tice : And I am efpecially led to form the latter conclufion, becaufe thefe varieties appear to me to be often combined together, and to be often changed into one another, in the fame perfon ; in whom we mud therefore fuppofe a general caufe of the difeafe, which, fo far as it can be known, mud edablifh the pathology, and efpecially direa the pra6tice. i558. In my limited views of the different dates of in- fanity, I mud go on fo confider them under the two heads of Mania and Melancholia : And though I am fenfible that thefe two genera do not com- prehend the whole of the fpecies of infanity, I am not clear in affigning the other fpecies which may not be comprehended under thofe titles. I 'fhall, however, OF PHYSIC. a8i however, endeavour, on proper occafions as I gtf along, to point them out as well as I can. CHAP. II. Of MANIA, or MADNESS. *559* THE circumdances which I have mentioned above in (1536.), as condituting delirium in general, do more efpecially belong to that kind of it which I fliall treat of here under the title of Mani a. There is fometimes a falfe perception or imagi- nation of things prefent that are not; but this is not a condant, nor even a frequent, attendant of the difeafe. The falfe judgment, is of relations long before laid up in the memory. It very often turns upon one single fubjecl: But more common- ly the mind rambles from one fubjea to another, with an equally falle judgment concerning the moft part ot them ; and as at the fame time there is com- monly a falfe affociation, this increafes the condi- tion of ideas, and therefore the falfe judgments. What for the mod part more efpecially didinguifh- es the difeafe, is a hurry of mind, in purfuing any thing like a train of thought, and in running from one train of thought to another. "Maniacal perfons are in general very irafcible ; but what more par- ticularly produces their angry emotions is, that their falfe judgments lead to fome action which is always pufhed with impetuosity and violence; when this is interrupted or redrained, they break out in- to violent anger and furious violence againd every perfon near them, and upon every thing that dands in the way of their impetuous will. The falfe judgment often turns upon a midaken opinion of fome injury fuppofed to haye been formerly re- Vol. II. N n e-eivedj 282 PRACTICE ceived, or now fuppofed to be intended: And it is remarkable, that fuch an opinion is often with refpea to their former deared friends and relations i and therefore their refentment and anger are par- ticularly direaed towards thefe. And although this fhould not be the cafe, they commonly, foon lofe that refpea and regard which they formerly had for their friends and relations. With all thefe circumdances, it will be readily perceived, that the difeafe mud be attended very condantly with that incoherent and abfurd fpeech we call raving. Further, with the circumdances mentioned, there is commonly joined an unufuai force in all the vo- luntary motion* ; and an infenfibility or refidance ofthe force of all impreffions, and particularly a refidance of the powers of fleep, of cold, and even of hunger; though indeed in many indances a vo- racious appetite takes place. 1560. It appears to me, that the whole of thefe circum- ftances and fymptoms point out a confiderable and unufuai excefs in the excitement of the brain, efpe- cially with refpea to the animal funaions; and it appears at the fame time to be manifedly in fome meafure unequal, as it very often takes place with refpea to thefe funaions alone, while at the fame time the vital and natural are commonly very little changed from their ordinary healthy date. 1561. How this excefs of excitement is produced, it may be difficult to explain. In the various indances of what Sauvages has named the Mania Metafiatica, and in all the indances I have mentioned in my Nofology under the title ofthe Mania Corporea, it may be fuppofed that a morbid organic affeaion is produced in fome part of the brain; and how that may OF PHYSIC. t$3 may produce an increafed or unequal excitement in certain parts of it, I have endeavoured to ex- plain above in (1553.)- ^ut * mud at the fame time acknowledge, that fuch remote caufes of mania have very rarely occurred; and that therefore fome other caufes of the difeafe mud be fought for. The effe6ts of violent emotions or paffions of the mind have more frequently occurred as the remote caufes of mania; and it is fufficiently probable, that fuch violent emotions, as they do often immediate- ly produce a temporary increafe of excitement, fo they may, upon fome occafions of their permanent inherence or frequent repetition, produce a more confiderable and more permanent excitement, that is, a mania. With refpea to thofe caufes of mania which arife in confequence of a melancholia which had previ- ously long fubfided ; whether we confider that me- lancholia as a partial infanity, or as a long perfid- ing attachment to one train of thinking, it will be readily perceived, that in either cafe fuch an in- creafe of excitement may take place in fo confider- able a degree, and in fo large a portion of the brain, as may give occafion to a complete mania. I562. Thefe condderations with regard to the remote caufes appear to me to confirm sufficiently our ge- neral do£trine of increafed and unequal excitement in the mania which I have defcribed above ; but I muft own, that I have not* exhaufted the fubjea, and that there are cafes of mania of which I can- not affign the remote caufes: But although I can- not in all cafes explain in what manner the mania is produced, I prefume, from the explanation giv- en, and efpecially from the fymptoms enumerated above, to conclude, that the difeafe defcribed above depends upon an increafed excitement of the brain ; an opinion in which I am the more confirmed, as I think 284 PRACTICE I think it will point out the proper method of cure. At lead I think it will mod clearly explain the ope- ration of thofe remedies, which, fo far as I can learn from my own experience and that of others, have proved the mod fuccefsful in this difeaie ; and, to illudrate this, I now enter upon the consi- deration of thefe remedies, and to make fome re- marks upon the proper manner of employing them. J563- Redraining the anger and violence of madmen is always neceffary for preventing their hurting themfelves or others : But this redraint is alfo to be confidered as a remedy. Angry paffions are always rendered more violent by the indulgence of the impetuous motions they produce; and even in madmen the feeling of redraint will fometimes pre- vent the efforts which their paffion would otherwife occafion. Redraint, therefore, is ufeful, and ought to be complete; but it fhould be executed in the eafied manner poffible for the patient, and the drait waidcoat anfwers every purpofe better than any other that has yet been thought of. The rellrainr ing madmen by the force of other men, as occasi- oning a condant druggie and violent agitation, is often hurtful. Although, on many occafions, it may not be fafe to allow maniacs to be upon their legs or to walk about, it is never desirable to con- fine them to a horizontal fituation ; and whenever it can be admitted, they fhould be more or lefs in an erea podure. Although there may be no fymp- toms of any preternatural fulnefs or increafed im- petus of blood in the veffels of the brain, a hori- zontal podure always increafes the fulnefs and ten- don of thefe veffels, and may thereby increafe the excitement of the brain. *564- The OF PHYSIC. 285 1564. The redraint mentioned requires confinement within doors, and it fhould be in a place which prefents as few objeas of fight and hearing as poffi- ble ; and particularly, it fhould be removed from the objeas that the patient was formerly acquaint- ed with, as thefe would more readily call up ideas and their various affociations. It is for this reafon that the confinement of madmen d)ould hardly ever be in their ufual habitation ; or if they are, that their apartment fhould be dripped of all its former furniture. It is alfo for the mod part proper, that maniacs fhould be without the company of any of their former acquaintance ; the appearance of whom commonly excites emotions that increafe the dif- eafe. Strangers may at fird be offenfive; but in a little time they come to be objeas either of indif- ference or of fear, and they fhould not be fre- quently changed. 1565. Fear being a paffion that diminifhes excitement, may therefore be oppofed to the excefs of it; and particularly to the angry and irafcible excitement of maniacs. Thefe being more fufceptible of fear than might be expeaed, it appears to me to have been commonly ufeful. In mod cafes it has ap- peared to be neceffary to employ a very condant impreffion of fear ; and therefore to infpire them with the awe and dread of fome particular perfons, efpecially of thofe who are to be condantly near them. This awe and dread is therefore, by one means or other, to be acquired ; in the fird place, by their being the authors of all the redraints that may be occafionally proper; but fometimes it may be neceffary to acquire it even by dripes and blows. rf he former, although having the appearance of more 286 PRACTICE more feverity, are much fafer than drokes or blows about the head. Neither of them, however, fhould be employed further than feems very neceffary, And fhould be truded only to thofe whofe difcreti- on can be depended upon. There is one cafe in which they are fuperfluous; that is, when the ma- niacal rage is either not fufceptible of fear, or inca- pable of remembering the objeas of it; for in fuch indances, dripes and blows would be wanton bar- barity. In many cafes of a moderate difeafe, it is of advantage that the perfons who are the authors of redraint and puniffiment fhould be upon other occafions the beftowers of every indulgence and gratification that is admiffible; never, however, ne- gleaing to employ their awe when their indulgence fliall have led to any abufe. 1566. Although in mania, no particular irritation nor fulnefs of the fydem feem to be prefent, it is plain, that the avoiding all irritation and means of ful- nefs is proper ; and therefore, that a diet neither dimulatirrg nor nourifhing is commonly to be em- ployed. Ask may even be ufeful to diminifh the fulnefs ofthe fydem, fo both a1 low and a fpare di- et is likely in moft cafes to be of fervice. 1567. Upon the fame principle, although no unufuai fulnefs ofthe body be prefent, it may be of advan- tage to diminifh even its ordinary fulnefs by differ- ent evacuations1. B-loodletting, in particular, might be fuppofed ufeful; and in all recent cafes of mania it has been commonly praaifed, and I think with advantage ; but when the difeafe has fubfided for fome time, I have feldom found bloodletting of fervice. In thofe indances in which there is any frequency or fulnefs 0 F P H Y S I C. 287 fulnefs of pulfe, or any marks of an increafed im- petus ofthe blood in the veflels of the head, blood- letting is a proper and even a neceflary remedy. Some praaitioners, in fuch cafes, have preferred a particular manner of bloodletting, recommend- ing arteriotomy, fcarifying the hind head, or open- ing the jugular vein ; and where any fulnefs or in- flammatory difpofition in the veffels of the brain is to be fufpeaed, the opening ofthe veffels near- ed to them is likely to be ofthe greateft fervice. The opening, however, of either the temporal ar- tery or the jugular vein in maniacal perfons is very often inconvenient ; and it may generally be fuf- ficient to open a vein in the arm, while the body is kept in fomewhat of an ere& podure, and fuch a quantity of blood drawn as nearly brings on a deliquium animi, which is always a pretty certain mark of fome diminution of the fulnefs and tend- on of the veflels of the brain. 1568. For the fame purpofe of taking off the fulnefs and tenfion of thefe veffels ofthe brain, purging maybe employed ; and I can in no other view un- derdand the celebrated ufe of hellebore among the ancients. I cannot, however, fuppofe any fpeci- fic power in hellebore ; and can by no means find that, at lead the black hellebore, is fo efficacious with us as it is faid to have been at Anticyra. As codivenefs, however, is commonly a very condant and hurtful attendant of mania, purgatives come to be fometimes very neceflary; and I have known fome benefit obtained from the frequent ufe of pretty dradic purgatives. In this, however, I have been frequently difappointed ; and I have found more advantage from the frequent ufe of cooling purga- tives, particularly the foluble tartar, than from more dradic medicines. 1569. Vomiting 288 P R A C T I C E 1569. Vomiting has alfo been frequently employed in mania ; and by determining powerfully to the fur- face of the body, it may poffibly diminifh the ful- nefs and tenfion ofthe veflels, and thereby the ex- citement of the brain ; but I have never carried the ufe of this remedy fo far as might enable me to judge properly of its effeas. Whether it may do harm by impelling the blood too forcibly into the veffels of the brain, or whether by its general agi- tation ofthe whole fydem it may remove that ine- quality of excitement which prevails in mania, I have not had experience enough to determine. 157O. Frequent fhaying of the head has been found of fervice in mania, and by prorrioting perfpiration it probably takes off" from the excitement of the in- ternal parts. This, however, it is likely, may be more effeaually done by blidering, which more certainly takes off the excitement of fubjacent parts. In recent cafes it has been found ufeful by inducing fleep ; and when it has that effea, the re- petition of it may be proper: But in maniacal cafes that have laded for fome time, blidering has not appeared to me to be of any fervice; and in fuch cafes alfo I have not found perpetual bliders, or any other form of ifTue, prove ufeful. 1571. As heat is the principal means of fird exciting the nervous fydem, and edablifliing the nervous power and vital principle in animals; fo, in cafes of preternatural excitement, the application of cold might be fuppofed a proper remedy: But there are many inflates of maniacs who have been cxpofed OF PHYSIC. &8£ expofed for a great length of time to a confiderable degree of cold without having their fymptoms any- wile relieved. This may render in general the application of cold a doubtful remedy ; but it is at the fame time certain, that maniacs have often been relieved, and fometimes entirely cured, by the ufe of cold bathing, efpecially when admini- dered in a certain manner. This feems to confid, in throwing the madman into cold water by fur- prife ; by detaining him in it for fome length of time; and pouring water frequently upon the head, while the whole ofthe body except the head is inv merfed in the water; and thus managing the whole procefs, fo as that, with the affidance of fome fear^ a refrigerent effect may be produced. This, I can affirm, has been often ufeful; and that the exter- nal application of cold may be of fervice, we know further, from the benefit which has been received in fome maniacal cafes from the application of ice and fnow to the naked head, and from the appli-* cation ofthe noted Clay Cap. Warm bathing alfo has been recommended by fome praaical writers; and in rigid melancholic habits it may poffibly be ufeful, or as employed in the manner prefcribed by fome, of immersing the lower parts of the body in warm water, while cold water is poured upon the head and upper parts. Of this praaice, however, I have had do experi- ence ; and in the common manner of employing warm bathing I have found it rather hurtful to maniacs. 1572. According to my fuppofition that the difeafe de- pends upon an increafed excitement of the braini especially with refpea to the animal funaions, opium, fo commonly powerful in inducing deep, or a confiderable collapfe as to thefe funaions, fhould be a powerful remedy of mania. That it Vol. II. O o has *Q0 PRACTICE has truly proved fuch, I believe from the teftimo- ny of Bernard Huet, whofe practice is narrated at the end of Wepferi Hidoria Apopleaicorum. I leave to my readers to dudy this in the work I have referred to, where every part of the praaice is fully, and, as it appears to me, very judicioufly delivered. I have never indeed carried the trial fo far as feems to be requifite to an entire cure: But I have frequently employed in fome maniacal cafes, large doles of opium; and when they had the effea of inducing deep, it was manifedly with advantage. At the fame time, in fome cafes, from doubts, whether the difeafe might not depend up- on fome organic lefions of the brain,, when the opi- um would be fuperfluous ; and in other cafes, from doubts, whether there might not be tome inflamma- tory affeaion joined with the mania, when the opi- um would be hurtful, I have never pufhed this re- medy to the extent that might be neceflairy to make an entire cure. »573- Camphire has been recommended; as a remedy of mania, and there are indances alleged of its having performed an entire cure. As it appears from the experiments of Beecaria that this fubdance is poffeffed of a fedative and narcotic virtue, thefe cures are not altogether improbable: But in feve- ral trials, and even in large dofes, I have found no benefit from it; and excepting thofe in the Philofophical Tranfacf ions, No. 400, I have hard- ly met with any other tedimonies in its favour. *574- I have been informed that fome maniacs have been cured by being compelled to condant and even hard labour; and as a forced attention to the condua of any bodily exercife, i& a very certain means OF PHYSIC. CQ1 means of diverting the mind from purfuing any train of thought, it is highly probable that fuch ex- ercife may be ufeful in many cafes of mania. I mult conclude this fubjeft with obferving, that even in feveral cafes of complete mania, I have known a cure take place in the courfe of a journey carried on for fome length of time. x575- Thefe are the remedies which have been chiefly employed in the mania that has been above de- fcribed, and I believe that they have been employed promifcuoufly without fuppofi.ig that the mania was to be didinguifhed into different fpecies. In- deed I am not ready to fay how far it is to be fo didinguifhed, but I fhall offer one obfervation which may poffibly merit attention. It appears to me, that there are two different ca- fes of mania that are efpecially different according to the original temperament of the perfons whom the difeafe affeas. It perhaps occurs mod fre- quently in perfons of a melancholic or atrabilarian temperament; but it certainly does alfo often oc- cur in perfons of that very oppofite temperament which phyficians have named the Sanguine. Ac- cording as the difeafe happens to occur in perfons of the one or other of thefe temperaments, I ap- prehend it may be confidered as of a different na- ture ; and I believe, that accurate obfervation, employed upon a fufficient number of cafes, would difcern fome pretty condant difference, either of the fymptoms, or at lead of the date of the fymp- toms, in the two cafes. I imagine that falfe imagi- nations, particular aversions and rcfentments, are more fixed and deady in the melancholic than in the fanguine; and that fome what inflammatory is more commonly joined with mania in the fanguine than in the melancholic. If fuch difference, hew- ever, does truly take place, it will be obvious, that it may 292 PRACTICE may be proper to make fome difference alfo in the praaice. I am of opinion, that in the mania of fanguine perfons, bloodletting and other antiphlo- gidic meafures are more proper, and have been more ufeful, thin in the melancholic. I likewife apprehend that cold bathing is more ufeful in the fanguine than in the melancholic : But I have not had experience enough to afcertain thefe points with fufficient confidence. I have only to add to this other obfervation, that maniacs ofthe fanguine temperament recover more frequently and more entirely than thofe of the melancholic. CHAP. III. Of MELANCHOLY, and other forms of INSANITY. J576- MELANCHOLY has been commonly confl- dered as partial infanity; and as fuch it is denned in my Nofology: But I now entertain doubts if this be altogether proper. By a partial Infanity, I underdand a falfe and midaken judg- ment upon one particular fubjea, and what relates to it; whild, on every other fubjea, the perfon af- feaed judges as the generality of other men do. Such cafes have certainly occurred ; but, I believe, few in which the partial infanity is driaiy limited. In many cafes of general infanity, there is one tub* ject of anger or fear, upon which the falfe judg- ment more particularly turns, or which is at lead more frequently than any other the prevailing ob- jea of delirium : And though, from the inconfifl- ency which this principal obje6t of delirium mud produce, there is therefore alfo a great deal of in- fanity with regard to mod other objeas; yet this lad O F P II Y S I C. 293 lad is in very different degrees both in different perfons, and in the fame perfon at different times. Thus perfons confidered as generally infane, will, however, at times, and in fome cafes, prettv con- dantly judge properly enough of prefent circum- ftances and incidental occurrences; though, when thefe objeas engaging attention are not prefented, the operations of imagination may readily bring back a general confufion, or recal the particular objea ofthe delirium. From thefe confiderations, I am inclined to conclude, that the limits between general and partial infanity cannot always be fo ex- a6tly afligned, as to determine when the partial af- feaion is to be confidered as giving a peculiar fpe- cies of difeafe, different from a more general infanity. *577- When infanity, neither driaiy partial, nor en- tirely nor condantly general, occurs in perfons of a fanguine temperament, and is attended with agreeable, rather than with angry or gloomy emo- tions, I think fuch a difeafe mud be confidered as different from the Mania defcribed above; and al- fo, though partial, mult be held as different from the proper Melancholia to be mentioned hereafter. 1578. Such a difeafe, as difierent from thofe defcribed (1555.), requires, in my opinion, a different admi- niftration of remedies : and it will be proper for me to take particular notice of this here. Although it may be neceflary to redrain fuch in- fane perfons as we have mentioned (1577.), from purfuing the objeas of their falfe imagination or judgment, it will hardly be requisite to employ the fame force of redraint that is neceffary in the im- petuous and angry mania. It will be generally *94 PRACTICE fufficient to acquire fome awe over them, that may be employed, and fometimes even be neceflary, to cheek the rambling of their imagination, and inco- berenqy of judgment. 1579. The reftraint jud now mentioned as neceffary will generally require the patient's being confined to one place, for the fake of excluding the objeas, and more particularly the perfons, that might ex- cite ideas conneaed with the chief objeas of their delirium. At the fame time, however, if it can be perceived there are objeas or perfons that can call off their attention from the purfuit of their own difordered imagination, and can fix it a little upon fome others, thefe lad may be frequently prefented to them: And for this reafon, a journey, both by its having the effea of interrupting all train of thought, and by prefenting obje6ts engaging atten- tion, may often be ufeful. In fuch cafes alfo, when the infanity, though more efpecially fixed upon one midaken fubjea, is not confined to this alone, but is further apt to ramble over other fuhjeas with incoherent ideas, I apprehend the confining or forcing fuch perfons to fome condant uniform labour, may prove an ufeful remedy. I580. When fuch cafes as in (1577-) occur in fanguine temperaments, and may therefore approach more nearly to Phrenitic Delirium; fo, in proportion as the fymptoms of this tendency are more evident and confiderable, bloodletting and purging will be the mare proper and neceflary, I 58 I. To this fpecies of infanity, when occurring in {anguine temperaments, whether it be more or lefs partial, OF PHYSIC. 395 partial, I apprehend that, cold bathing is particu- larly adapted ; while, in the partial infanity of me- lancholic perfons, as I fhall fhow hereafter, it is hardly admiffible. 1582. Having thus treated of a fpecies of insanity, dif- ferent, in my apprehenfion, from both the Mania and Melancholia, I proceed to confider what feems more properly to belong to this lad. 15*3- The difeafe which I name Melancholia is very often a partial infanity only. But as in many in- dances, though the falfe imagination or judgment feems to be with refpea to one fubje6t only ; yet it feldom happens that this does not produce much inconfidency in the other intellectual operations: And as, between a very general and a very partial infanity, there are all the poffible intermediate de- grees ; fo it will be often difficult, or perhaps im- proper, to diftinguifh Melancholia by the charac- ter of Partial Infanity alone. If I midake not, it mud be chiefly didinguifhed by its occurring in perfons of a melancholic temperament, and by its being always attended with fome feemingly ground* lefi, but very anxious, fear. I584. To explain the caufe of this, I mud obferve, that perfons of a melancholic temperament are for the moft part of a ferious thoughtful difpofition, and difpofed to fear and caution, rather than to hope and temerity. Perfons of this caft are lefs movea- ble than others by any impreffions; and are there- fore capable of a clofer or more continued attend- on to one particular objea, or .train of thinking. They 2Qb PRACTICE They are even ready to be engaged in a conflant application to one fubjea ; and arc remarkably te- nacious of whatever emotions they happen to be affeaed with. '585- Thefe circumdances of the melancholic charac- ter, feem clearly to fhow, that perfons drongly af- fected with it may be readily feized with an anx- ious fear; and that this, when much indulged, as is natural to fuch perfons, may eafily grow into a partial infanity. 1586. Fear and dejeaion of mind, or a timid and de- fponding difpofition, may arife in certain dates, or upon certain occafions, of mere debility : And it is upon this footing, that I fuppofe it fometimes to attend- dyfpepfia. But in thefe cafes, I believe the defpondent difpofition hardly ever arifes to a confiderable degree, or proves fo obftinately fixed as when it occurs in perfons of a melancholic tem- perament. In thefe lad, although the fear pro- ceeds from the fame dyfpeptic feelings as in the other cafej yet it will be obvious, that the emotion may rife to a more confiderable degree ; that it may be more anxious, more fixed, and more ar- tentive ; and therefore mav exhibit all the various circumdances which I have mentioned in (1222.) to take place in the difeafe named Hypochondri- asis. 1587. In confidcring this fubjeef formerly in difiin- guifhing Dyfpepfia from Hypochondriafis, although the lymptoms allccting the body be verv much the fame in both^ and even thofe affeaing the mind be fome what O F P H Y S I C. ttf fomewhat similar, I found no difficulty in didin- guifhing the latter difeafe, merely from its occur- ring in perfons of a melancholic temperament. But I mud now acknowledge, that I am at a lofs to determine how in all cafes hypochondriafis and melancholia may be didinguifhed from one ano- ther, whild the fame temperament is common to both. 1588. I apprehend, however, that the didinaion may be generally afcertained in the following manner. The hypochondriafis I would confider as being always attended with dyfpeptic fymptoms: And though there may be, at the fame time, an anxious melancholic fear arifing from the feeling of thefe fymptoms; yet while this fear is only a midaken judgment with refpea to the date of the perfon's own health, and to the danger to be from thence apprehended, I would dill confider the difeafe as a hypochondriafis, and as didinct from the proper melancholia. But when an anxious fear and def- pondency arifes from a midaken judgment with re- fpea to other circumdances than thofe of health, and more efpecially when the perfon is at the fame time without any dyfpeptic fymptoms, every one will readily allow this to be a difeafe widely differ- ent from both dyfpepfia and hypochondriafis; and it is, what I would drictly name Melancholia. 1589. In this there feems little difficulty: But as an exquifitely melancholic temperament may induce a torpor and fiownefs in the acfion of the domachj fo it generally produces fome dyfpeptic fymptoms 5 and from thence there may be fome difficulty in diftinguifhing fuch a cafe from hypochondriafis. But I would maintain, however, that when the cha- Vol. II. P P ratters 2q3 PRACTICE raaers of the temperament are drongly marked; and more particularly when the falfe imagination turns upon other fubjeas than that of health, or when, though relative to the perfon's own body, it is of a groundlefs and abfurd kind; then not- withdanding the appearance of fome dyfpeptic fymptoms, the cafe is dill to be confidered as that of a melancholia, rather than a hypochondriafis. 159O. The difeafe of melancholia, therefore, manifed- ly depends upon the general temperament of the body : And although, in many perfons, this tem- perament is riot attended with any morbid affeaion either of mind or body; yet when it becomes ex- quifitely formed, and is in a high degree, it may become a difeafe affeaing both, and particularly the mind. It will therefore be proper to consider in what this melancholic temperament efpecially confids; and to this purpofe, it may be obferved, that in it there is a degree of torpor in the motion of the nervous power, both with refpea to fenfa- tion and volition ; that there is a general rigidity of the fimple folids; and that the balance of the fan- guiferous fydem is upon the fide of the veins. But all thefe circumdances are the direaiy oppofite of thofe of the fanguine temperament; and mult therefore alfo produce an oppofite date of mind. 1591. It is this date of mind, and the date of the brain correfponding to it, that is the chief objetk of our prefent consideration. But what that date of the brain is, will be fuppofed to be difficult to explain; and it may perhaps feem rafh in me to attempt it. I will, however, venture to fay, that it is proba- ble the melancholic temperament of mind depend* upon OF PHYSIC. *93 upon a drier and firmer texture in the medullary fubdance of the brain ; and that this perhaps pro- ceeds from a certain want of fluid in that fubdance, which appears from its being of a lefl'er fpecific gravity than ufual. That this date of the brain in melancholia does aaually exid, I conclude, firfi, from the general rigidity of the whole habit; and, Jecondly, from diffecfions, fliowing fuch a date of the brain to have taken place in mania, which is often no other than a higher degree of melancholia. It does not appear to me anywife difficult to fup- pofe, that the fame date of the brain may in a mo- derate degree give melancholia; and in a higher, that mania which melancholia fo often paffes into ; efpecially if I fhall be allowed further to fuppofe, that either a greater degree of firmnefs in the fub- dance of the brain may render it fulceptible of a higher degree of excitement, or that one portion of the brain may be liable to acquire a greater firmnefs than others, and confequently give occa- fion to that inequality of excitement upon which mania fo much depends. 1592. I have thus endeavoured to deliver what appears to me mod probable with refpea to the proximate caufe of melancholia; and although the matter fhould in fome refpeas remain doubtful, I am well perfuaded that thefe obfervations may often be em- ployed to direa our praaice in this difeafe, as I fhall now endeavour to fhow. *593- In mod ofthe indances of melancholia, the mind is to be managed very much in the fame manner as I have advifed above with regard to hypochondri- afis ; but as in the cafe of proper melancholia, there is commonly a falfe imagination or judgment ap- pearing goo PRACTICE pearing as a partial infanity, it may be further ne- ceffary in fuch cafes to employ fome artifices for correcfing fuch imagination or judgment. 1594. The various remedies for relieving the dyfpeptic fymptoms which always attend hypochondriafis, will feldom be either requifite or proper in melan-r cholia. There is only one of the dyfpeptic fymptoms, which, though there fhould be no other, is very condantly prefent in melancholia, and that is cof- tivenefs. This it is always proper and even necef- fary to remove; and I believe it is upon this ac- count that the ufe of purgatives has been found fo often ufeful in melancholia. Whether there be any purgatives peculiarly proper in this cafe, I dare not positively determine; but with refpea to the choice of purgatives in melancholia, I am of the fame opinion that I delivered above on this fame fubjea with refpea to mania. 1595. With refpea to other remedies, I judge that bloodletting will more feldom be proper in melanr pholia than in mania; but how far it may be in any cafe proper, mud be determined by the fame con- dderations as in the cafe of mania. 1596. The cold bathing that I judged to be fo very ufer ful in feveral cafes of infanity, is, I believe, in me- lancholia, hardly ever fit to be admitted; at lead while this is purely a partial affeaion, and without any marks of violent excitement. On the contra- ry, upon account ofthe general rigidity prevailing in melancholia, it is probable that warm bathing may be often ufeful. _Tr. , 7 1597. With OF PHYSIC, 301 '597- With refpea to opiates which I have fuppofed might often be ufeful in cafes of mania, I believe they can feldom be properly employed in the par- tial infanities of the melancholic, except in certain indances of violent excitement, when the melan- cholia approaches nearly to the date of mania. i598. In fuch cafes of melancholia approaching to a date of mania, a low diet may fometimes be necef- fary ; but as the employing a low diet almod una- voidably leads to the ufe of vegetable food, and as this in every torpid date of the domach is ready to produce fome dyfpeptic fymptoms, fuch vegetable food ought, in moderate cafes of melancholia, to be ufed with fome caution. Though exercife, as a tonic power, is not pro- per either in hypochondriafis or melancholia ; yet, with refpea to its effeas upon the mind, it may be extremely ufeful in both, and in melancholia is to be employed in the fame manner that I have advif- ed above in the qafe of hypochondriafis. ?599- Having now delivered my doarine with refpeft to the chief forms of infanity, I fhould in the next place proceed to confider the other genera of A- mentia and Oneirodynia, which in the Nofology I have arranged under the order of Vefaniae : But as I cannot pretend to throw much light upon thefe fubjeas, and as they are feldom the objects of prac- tice, I think it allowable for me to pafs them over at prefent; and the particular circumdances of this work in fome meafure requires that I fhould do fa. PART PART III. Of Cachexies. 1600. UNDER this title I propofe to eflablifh a clafs of difeafes, which confid in a depraved date ofthe whole, or of a confiderable part, of the ha- bit of the body, without any primary pyrexia or neurosis combined with that date. 1601. The term Cachexy has been employed by Linnae- us and Vogel, as it had been formerly by other au- thors, for the name of a particular difeafe : But the difeafe to which thefe authors have affixed it, comes more properly under another appellation ; and the term of Cachexy is more properly employ- ed by Sauvages and Sagar for the name of a clafs. In this I have followed the lad mentioned nofolo- gids, though I find it difficult to give fuch a cha- raaer of the clafs as will clearly apply to all the fpecies I have comprehended under it. This diffi- culty would be dill greater, if, in the clafs I have edablifhed under the title of Cachexies, I were to comprehend all the difeafes that thofe other nofo- logids have done ; but I am willing to be thought deficient rather than very incorre6t. Thofe diffi- culties, however, which dill remain in methodical nofology, mud not affea us much in a treatife of praaice. If I can here properly diftinguifh and defcribe the feveral fpecies that truly and mod commonly exid, I fhall be the lefs concerned about the accuracy of my general claffification : Though at the fame time this, I think, is always to be at- tempted ; and I fhall purfue it as well as I can. BOOK [ 3°3 ] BOOK I. Of EMACIATIONS. 1602. EMACIATION, or a confiderable diminu- tion of the bulk or plumpnefs of the whole body, is for the moft part only a fymptom of dif- eafe, and very feldom to be confidered as a prima- ry and idiopathic affeaion. Upon this account, according to my general plan, fuch a fymptom might perhaps have been omitted in the Methodi- cal Nofology : But both the uncertainty of con- cluding it to be always fymptomatic, and the con- fidency of fyftem, made me introduce into the No- fology, as others had done, an order under the ti- tle of Marcores; and this renders it requifite now to take fome notice of fuch difeafes. 1603. Upon this occafion, therefore, I hope it may be ufeful to invedigate the feveral caufes of emaciati- on in all the different cafes of difeafe in which it appears. And this I attempt, as the fured means of determining how far it is a primary, or a fymp- tomatic affeaion only ; and even in the latter view, the invedigation may be attended with fome advantage. 1604. The caufes of emaciation may, I apprehend, be referred to two general heads; that i-?, either to a general 304 PRACTICE general deficiency of fluid in the veffels of the bo- dy, or to the particular deficiency of the oil in the cellular texture of it*. Thefe caufes are frequent- ly combined together; but it will be proper, in the fird place, to confider them feparately. 1605. As a great part of the body of animals is made up of veffels filled with fluids, the bulk of the whole mud depend very much on the fize of thefe veffels, and the quantity of fluids prefent in them: And it will therefore be fufficiently obvious, that a defici- ency of the fluids in thefe veffels mud, according to its degree, occafion a proportionate diminution of the bulk of the whole body. This, however, will appear dill more clearly, from considering that in the living and found body the veffels every where feem to be preternaturally didended by the quantity of fluids prefent in them; but being at the fame time eladic, and condantly endeavouring to contraa themfelves, they mud on the withdraw- ing of the diftending force, or, in other words, upon a diminution of the quantity of fluids, be in proportion contraaed and diminifhed in their fize: And it may be further obferved, that as each part of the vafcular fydem communicates with every other part of it; fo every degree of diminution of the quantity of fluid, in any one part, muft in pro- portion diminifh the bulk of the vafcular fydem, and confequently of the whole body t. ^ 1606. The diminution and deficiency ofthe fluids may be occafioned by different caufes : Such as, fird, by * Might not a third oaufe be added, viz. a deficiency ofthe folid parts ? t There may, however, be a partial without a general emaciation, as is the cafe in a palfied limb; but this partial diminution of bulk in the difealed limb is not ow- ing to a leffened quantity of the general mafs of the circulating fluids, but to the lan- guid circulation in tfwt j»art, Jii artsrie* no; f r»?cliir.g the. blood through it wi.il: 1'jffident vi|our. OF PHYSIC. 305 by a due quantity of aliments not being taken in ; or by the aliment taken in not being of a fuffici- ently nutritious quality. Of the want of a due quantity of aliment not being taken into the body, there is an indance in the Atrophia latlantium Sau- vagefii, fpecies 3 ; and many other examples have occurred of emaciation from want of food, occafi- oned by poverty, and other accidental caufes. With refpe6t to the quality of food, I apprehend it arifes from the want of nutritious matter in the food employed, that perfons living entirely on ve- getables are feldom of a plump and lucculent habit*.; 1607. A fecond caufe of the deficiency of fluids may be, the aliments taken in not being conveyed to the blood-veffels. This may occur from a perfon's being affetted with a frequent vomiting ; which, rejecting the food foon after it had been taken in, mud prevent the neceffary fupply of fluids to the blood-veffelst. Another caufe, frequently interrupting the con- veyance of the alimentary matter into the blood- veffels, is an obflruaion of the conglobate or lym- phatic glands of the mefentery, through which the chyle muft neceffarily pafs to the thoracic dua. Many inftances of emaciation, feemingly depend- ing upon this caufe, have been obferved by phy- ficians, in perfons of all ages, but efpecially in the young. It has alfo been remarked, that fuch cafes have mod frequently occurred in fcrophulous per- V01.. II. Q q fons, * As the author fays at the conclufion of this chapter, " After having confidered " the various caufes of emaciations, I fhould perhaps treat of their cure : but it will " readily appear, that the greater part of the cafes'above mentioned are purely " fymptomatic, and confequently that the cure of them muft be that ofthe primary " difeafes upon which they depend. Of thofe cafes that can any wife be confidered " as idiopathic, it will appear that they are to be cured entirely by removing the " remote caufes;" it may not be improper to treat ofthe cure as we proceed. This fpecies of emaciation may be obvioufly cured by a rich and nutritious diet. + This fpecies may be cured by preventing the vomiting by antifpafmodics, efpe- cially opium, and by the ufe of gentle laxatives ocufionaily. A nutritious dwt \v'i\) *Mb be neceffary in thefe cafcs. 306 t PRACTICE fons, in whom the mefentcric glands are common- ly affeaed with tumour or obflruaion, and in whom, generally at the fame time, fcrophula ap- pears externally. Hence the Tabes jcrophuloja Sy- nop. Nofolog. vol. ii. p. 266: And under thefe I have put as fynonimes Tabes glandularis, fp. 10; Tabes mefenierica, fp. 9; Scrophula mefentenca, fp. 4; Atrophia infantilis, fp. 13; Atrophia rachitica, fp. 8 ; Tabes rachialgica, fp. 16. At the fame time, I have frequently found the cafe occurring in perfons who did not ffiow any external appearance of fcrophula, but in whom the mefenteric obdruc- tion was afterwards difcovered by diffe6tion. Such alfo I fuppofe to have been the cafe in the difeafe frequently mentioned by authors under the title of the Atrophia infantum. This has received its name from the time of life at which it generally appears; but I have met with indances of it at fourteen years of age afcertained by difleaion. In feveral fuch cafes which I have feen, the patients were without any fcrophulous appearances at the time, or at any period of their lives before*. In the cafe of phthisical perfons, I fhall hereaf- ter mention another caufe of their emaciation ; but it is probable that an obdruaion of the mefenteric rla;!:L, which fo frequently happens in fuch per- fon.i, concurs very powerfully in producing the emaciation that takes place. Although a fcrophulous taint may be the mod frequent caufe of mefenteric obdruaions, it is fuf- ficiently probable that other kinds of acrimony may produce the fame, and the emaciation that follows. It may perhaps be fuppofed, that the interrup- tion of the chyle's paffing into the blood-veffels may be * Thefe cafes are generally incurable ; if, however, there be no fufpicion of fcro- phula, we may attempt a cure by endeavouring to remove the obftruclion either by invigoratine; the habit, or by a£live aperients. Open and pure air, with exercife fuited to the ftrength ofthe patient, the ufe of chalybeate waters, have admirable eifecls in thefe cafes. Peruviai. bark, fo often ufed as a tonic, is improper in all cafti of obltru&ed gUmi*, M are alfo aftringents and ftyptics. OF PHYSIC. 3°7 be fometimes owing to a fault of the abforbents on the internal furface of the intedines. This, how- ever, cannot be readily afcertained : But the in- terruption of the chyle's palling into the blood-vef- fels may certainly be owing to a rupture of the tho- racic dua; which, when it does not prove foon fatal, by occasioning a hydrothorax, mud in a fhort time produce a general emaciation*. 1608. A third caufe of the deficiency of fluids may be a fault in the organs of digedion, as not duly converting the aliment into a chyle fit to form in the blood-veflels a proper nutritious matter. It is not, however, eafy to afcertain the cafes of emaciation which are to be attributed to this caufe; but I ap- prehend that the emaciation which attends long fubfiding cafes of dyfpepfia, or of hypochondriafis, is to be explained chiefly in this way. It is this which I have placed in the nofology under the ti- tle of the Atrophia debilium; and of which the Atrophia nervofa, Sauv. fp. 1, is a proper indance, and therefore put there as a fynonime. But the other titles of Atrophia lateralis, Sauv. fp. 15, and AtrophiaJenilis, Sauv. fp. 11, are not fo properly put there, as they mud oe explained in a different mannert. 1609. A fourth caufe of a deficiency of the fluids in the body, may be exceffive evacuations made from it by different outlets ; and Sauvages has properly enumerated the following fpecies^ which we have put as fynonimes under the title of Atrophia inani- torura ; as, Tabes nutricuvi, fp. 4; Atrophia nutri- cum, * TJms is an absolutely incurable cafe. + This fpecies of emaciation may be fuccefrfuMy cured by the means of thofe re- medies mentioned in the notes on thp articles 1204. iao6. 1210. 1213. 121J. 1.115. 1216. 1221. 308 PRACTICE cum, fp. 5 ; Atrophia d leucorrhcea, fp. 4 '> Atrophia ab alvifiuxu, fp. 6 ; Atrophia a ptyalifimo, fp. 7 ; and ladly, the Tabes a fanguifiuxu ; which, it is to be obferved, may arife not only from fpontaneous he- morrhagies or accidental wounds, but alfo from bloodletting in too large a quantity, and too fre- quently repeated. Upon this fubjea it feems proper to obferve, that a meagre habit of body frequently depends upon a full perfpiration being condantly kept up, though at the fame time a large quantity of nutritious ali- ment is regularly taken in*. l6lO. Befides this deficiency of fluids from evacuations by which they are carried entirely out of the body, there may be a deficiency of fluid and emaciation in a confiderable part of the body, by the fluids being drawn into one part, or colleaed into one cavity ; and of this we have an indance in the Ta- kes d hydrope, Sauv. fp. 5f. l6l I. In the Methodical Nofology, among the other fynonimes of the Atrophia inanitorum I have fet down the Tabes dorfalis; but whether properly or not, I at prefent very much doubt. In the evacu- ation confidered as the caufe of this tabes, as the quantity evacuated is never fo great'as to account for a general deficiency of fluids in the body, we muft leek for another explanation of it. And whe- ther the effeas of the evacuation may be account- ed for, either from the quality of the fluid evacu- ated, or from the Angularly enervating pleafure at- tending * In thefe cafes aftringents are the principal remedies on which we muft depend - and thofe aftringents muft be thofen which are adapted to fupprefs the peculiar eva- cuation that occafions the difeafe. + The emaciation from this caufe is merely fymptomatic, and can only be cured by curing the primary difeafe. OF PHYSIC. 309 tending the evacuation, or from the evacuation's taking off the tenfion of parts, the tenfion of which has a fingular power in fupportiug the tenfion and vigour ofthe whole body, I cannot pofitively de- termine; but I apprehend that upon one or other of thefe fuppofitions the emaciation attending the tabes dorfalis mud be accounted for; and therefore that it is to be confidered as an indance of the^ro- phia debilium, rather than ofthe Atrophia inanitorum*. l6l2. A fifth caufe of a deficiency of fluids and of ema- ciations in the whole or in a particular part of the body, may be the concretion of the fmall veflels, either not admitting of fluids, or of the fame pro- portion as before ; and this feems to me to be the cafe in the Atrophia jenilis, Sauv. fp. 2. Or it may be a palfy of the larger trunks of the arteries ren- dering them unfit to propel the blood into the small- er veffels; as is frequently the cafe of paralytic limbs, in which the arteries are affecfed as well as the mufcles. The Atrophia lateralis, Sauv. fp. 15, feems to be of this naturet. 1613. A fecond general head of the caufes of emaciati- on I have mentioned in (1603.) to be a deficiency of oil. The extent and quantity of the cellular texture in every part of the body, and therefore how confiderable a part it makes in the bulk of the whole is now well known. But this fubdance, in different circumdances, is more or lefs filled with an oily matter; and therefore the bulk of it, and in a great meafure that of the whole body, mud be greater or lefs according as this fubdance is more or * If a particular abominable practice be the caufe, it muft be abandoned before a cure can be attempted. t This is one of the incurable i^aclcs of emaciation, and it can only be relieved by a very nutritious and invigorating diet, ?>1° PRACTICE r;r lefs filled in that manner. The deficiency of fluids, for a reafon to be immediately explained, is :'^nerally accompanied with a deficiency of oil : Kut phyficians have commonly attended more to the latter caufe of emaciation than to the other, that being ufually the mod evident ; and I fhall now endeavour to affign the feveral caufes ofthe de- ficiency of oil as it occurs upon different occafions. 1614. The bufinefs of fecretion in the human body is in. general little underdood, and in no indance lefs fo than in that of the fecretion of oil from blood which does not appear previoufly to have contain- ed it. It is poffible, therefore, that our theory of the deficiency of oil may be in feveral refpeas im- perfea; but there are certain faHs that may in the mean time apply to the prefent purpofe. 1615. Fird, it is probable, that a deficiency of oil may be owing to a date of the blood in animal bodies lefs fitted to afford a fecretion of oil, and confe- quently to fupply the wade of it that is condantly made. This date of the blood mud efpecially de- pend upon the date of the aliments taken in, as containing lefs of oil or oily matter. From many obfervations made, both with refpea to the human body and to that of other animals, it appears pret- ty cleavlv, that the aliments taken in by men and domedic animals, according as they contain more of oil, are in general more nutritious, and in par- siculacarc belter fit-ted to fill the cellular texture of their bodies with oil. I might illudrate this, by a minute and particular consideration of the differ- errfe of alimentary matters employed ; but it will be enough to give two inftances. The one is, that the herbaceous part of vegetables does not fatten animals, OF PHYSIC. 3" animals, fo much as the feeds of vegetables, which manifedly contain in any given weight a greater proportion of oil; and a fecond indance is, that in general vegetable aliments do not fatten men fo much as animal food, which generally contains a larger proportion of oil. It will be obvious, that upon the fame principles a want of food, or a lefs nutritious food, may not only occafion a general deficiency of fluids (1605.), but mud alfo afford lefs oil, to be poured into the cellular texture. In fuch cafes, therefore, the ema- ciation produced, is to be attributed to both theie general caufes*. l6l6. A fecond cafe of the deficiency of oil may be explained in this manner, it is pretty manifed, that the oil of the blood is fecretetl and depofited in the cellular texture in greater or leffer quantity, according as the circulation of the blood is fader or flower; and therefore that exercife, which haf- tens the circulation of the blood, is a frequent caufe of emaciation. Exercife produces this effea in two ways, id, By increafing the perfpiration, and thereby carrying off a greater quantity of the nutritious matter, it leaves lefs of it to be depofited in the cellular texture ; thereby not only prevent- ing an accumulation of fluids, but, as I have fa.d above, causing a general deficiency of thefe, which muft alfo caufe a deficiency of oil in the cellular texture. 2dly, It is well known, that the oil de- pofited in the cellular texture is upon many occafi- ons, and for various purpoies of the economy, again abforbed, and mixed or diffufed in the mafs of blood, to be from thence perhaps carried entirely out of the body by the feveral excretions. Nov,, among other purpofes of the accumulation and re- abfoota u * The eure of this fpecies of emaciation will be feeft effected by a rich diet cf ;:..- mal food. 312 PRACTICE abforption of oil, this feems to be one, that the oil is requifite to the proper afcfion of the moving fibres in every part of the body ; and therefore that na- ture has provided for an abforption of oil to be made according as the aaion of the moving fibres may demand it. It will thus be obvious, that the exercife of the mufcular and moving fibres every where, mud occafion an abforption of oil ; and confequently that fuch exercife not only prevents the fecretion of oil, as has been already laid, but may alfo caufe a deficiency of it, by occasioning an abforption of what had been depofited ; and in this way perhaps efpecially, does it produce emaciation*. 1617. A third cafe of the deficiency of oil may occur from the following caufe. It is probable, that one purpofe of the accumulation of oil in the cellular texture of animals is, that it may, upon occafion, be again abforbed from thence, and carried into the mafs of blood, for the purpofe of enveloping and correcting any unufuai acrimony arifing and exiding in the date of the fluids. Thus, in mod indances in which we can difcern an acrid date of the fluids, as in fcurvy, cancer, syphilis, poifons, and feveral other difeafes, we find at the fame time a deficiency of oil and an emaciation take place ; which, in my apprehenfion, mud.be attributed to the abforption of oil, which the prefence of acri- mony in the body excites. It is not unlikely that certain poifons introduced into the body, may fubfid there; and, giving oc- cafion to an abforption of oil, may lay a foundati- on for the Tabes d veneno, Sauv. fp. 17+. 1618. A * Abftinence from tio fevere exsi rife is the only cure for this fpecies of the difeafe. + As this kind of emaciation proceeds from various caufes the practitioner muft, after having afcertained the true caufe, endeavour to remove it: and this muft be left entirely to his own fagacity. It may however be proper to obferve, that feveral ol thefe emaciations proceed from incurable difeafes; 2s from Cancer, Scrophula, •W. and confequently admit of no cure : And thofe emaciations which proceed liorci foirvy, fyphilis, or thofe difeafes which we can cure, are only to be cured by curing the neimar; difeafe. OF PHYSIC. 3*3 1618. A fourth cafe of emaciation, and which I would attribute to a fudden and confiderable abforption of oil from the cellular texture, is that of fever, which fo generally produces emaciation. This may perhaps be in part attributed to the increafed per- fpiration, and therefore to the general deficiency of fluids that may be fuppofed to take place : But whatever fhare that may have in producing the ef- fea, we can, from the evident fhrinking and dimi- nution of the cellular fubftance, wherever it falls under our obfervation, certainly conclude, that there has been a very confiderable abforption of the oil which had been before depofited in that fub- dance. This explanation is rendered the more probable from this, that I fuppofe the abforption mentioned is neceffarily made for the purpofe of enveloping or correaing an acrimony, which ma- nifedly does in many, and may be fufpeaed to arife in all, cafes of fever. The mod remarkable indance of emaciation occurring in fevers, is that which appears in the cafe of heaic fevers. Here the ema- ciation may be attributed to the profufe iweatings that commonly attend the difeafe : But there is much reafon to believe, that an acrimony alfo is prefent in the blood ; which, even in the beginning of the difeafe, prevents the fecretion and accumu- lation of oil; and in the more advanced dates of it, mud occafion a more confiderable abforption of it; which, from the fhrinking of the cellular fub- dance, feems to go farther than in almod any other inftance*. Upon the fubjea of emaciations from a deficiency of fluids, it may be observed, that every increafed evacuation excites an abforption from other parts. Vol. II. R r and * This emaciation is purely fymptomatic, and confequently cannot be cured but by removing the primary difeafe, and a fubfequent very nutritious dist, cunfirtin; «:hiefly of animal foe1. 3*4 PRACTICE, &c. and particularly from the cellular texlure; and it is therefore probable, that a deficiency of fluids, from increafed evacuations, produces an emaciati- on, not only by the wade of the fluids in the vaf- cular fydem, but alfo by occafioning a confiderable abforption from the cellular texture. 1619. I have thus endeavoured to explain the feveral cafes and caufes of emaciation ; but I could not profecute the consideration of thefe here in the or- der they are fet down in the Methodical Nofology. In that work I was engaged chiefly in arranging the Species of Sauvages; but it is my opinion now, that the arrangement there given is erroneous, in both combining and feparating fpecies improperly : And it feems to me more proper here to take notice of difeafes, and put them together, according to the affinity of their nature, rather than by that of their external appearances. I doubt, if even the didinc- tion of the Tabes and Atrophia, attempted in the Nofology, will properly apply ; as I think there are certain difeafes of the fame nature, which fome- times appear with, and fometimes without, fever. 162O. After having confidered the various cafes of emaciations, I fhould perhaps treat of their cure : But it will readily appear, that the greater part of the cafes above mentioned are purely fymptomatic, and confequently that the cure of them mud be that of the primary difeafes upon which they depend. Of thofe cafes that can anywife be confidered as idiopathic, it will appear that they are to be cured entirely by removing the remote caufes ; the means ,pf accomplifhing which mud be fufficiently obvious. BOOK C 315 ] BOOK II. Of INTUMESCENTI^E or GENERAL SWELLINGS. 1621. THE fwellings to be treated of in this place, are thofe which extend over the whole or a great part ofthe body ; or fuch at lead, as, though of fmall extent, are however of the fame nature with thofe that are more generally extended. The fwellings comprehended under this artifici- al order, are hardly to be didinguifhed from one another otherwife than by the matter they contain or confid of: And in this view I have divided the order into four feaions, as the fwelling happens to contain, ift, Oil; 2d, Air ; 3d, A watery fluid ; or, $th, As the increafed bulk depends upon the en- largement of the whole fubdance of certain parts, and particularly of one or more of the abdominal vifcera, CHAP. I. Of ADIPOSE SWELLINGS. 1622. THE only difeafe to be mentioned in this chap- ter, I have, with other Nofologids, named Polyfarcia ; and in Englifh it may be named Cor- pulency, or, more driaiy, Obefity ; as it is placed here upon the common fuppofition of its depend- 316 PRACTICE ing chiefly upon the increafe of oil in the cellular texture ofthe body. This corpulency, or obefity, is in very different degrees in different perfons, and is often confiderable without being confidered as a difeafe. There is, however, a certain degree of it, which will be generally allowed to be a dif- eafe ; as, for example, when it fenders perfons, from a difficult refpiration, uneafy in themfelves, and, from the inability of exercife, unfit for dif- charging the duties of life to others : And for that reafon I have given fuch a difeafe a place here. Many phyficians have confidered it as an objea of praaice, and as giving, even in a very high de- gree, a difpofition to many difeafes ; I am of opi- nion that it fhould be an objea of praaice more frequently than it has been, and therefore that it merits our consideration here. 1623. It may perhaps be alleged, that I have not been; fufficiently correa, in putting the difeafe of corpu- lency as art intumefcentia' pinguedinofa, and there- fore implying its being an increafe of the bulk of the body from an accumulation of oil in the cellu- lar texture only. I am aware of this objeaion: And as I have already faid, that emaciation (1604.) depends either upon a general deficiency of fluids in the valcular fydem, or upon a deficiency of oil in the cellular texture; fo I fliould perhaps have obferved farther, that the corpulency, or general fulnefs of the body, may depend upon the fulnefs of the vafcular fyftem as well as upon that of the cellular texture. This is true; and from the fame reafons I ought, perhaps, after Linnaeus and Sagar, to have fet down plethora as aV particular difeafe, and as an indance of morbid intumefcence. I have, however, avoided this, as Sauvages and Vogel have done ; becaufe I apprehended that plethora is to be (fonfidered as a date of temperament only, which may OF PHYSIC. 3^7 may indeed difpofe to difeafe; but not as a difeafe in itfelf, unlefs, in the language of the Stahlians, it be a plethora commota, when it produces a dif- eafe accompanied with particular fymptoms, which give occafion to its being didinguiffied by a differ- ent appellation. Further, it appears to me, that the fymptoms which Linnaeus, and more particular- ly thofe which Sagar employs in the character of plethora, never do occur but when the intumefcen- tia pihguedinofa has a great fhare in producing them. It is, however, very neceffary to obferve here, that plethora and obefity are generally com- bined together; and that in fome cafes of corpu- lency it may be difficult to determine which of the caufes has the greeted fhare in producing it. It is indeed very poffible that a plethora may occur without great obefity ; but I apprehend that obefi- ty never happens to a confiderable degree without producing a. plethora ad fpatium in a great part of the fydem of the aorta, and therefore a plethora ad molem in the lungs, and in the veffels of the brain. 1624. In attempting the cure of polyfarcia, I am of opinion, that the conjunaion of plethora and obe- fity, in the manner jud now mentioned, fhould be condantly attended to; and when the morbid ef- feas ofthe plethoric habit are threatened, either in the head or lungs, that bloodletting is to be prac- tifed: But at the fame time it is to be obferved, that perfons of much obefity do not bear bloodlet- ting well ; and when the circumdances I have mentioned do not immediately require it, the prac- tice upon account of obefity alone, is hardly ever to be employed. The fame remark is to be made with refpea to any other evacuations that may be propofed for the cure of corpulency : for without the other means I am to mention, they can give but a very imperfea relief; and, in fo far as they can 3»8 PRACTICE can either empty or weaken the fydem, they may favour the return of plethora, and the increafe of obeii'y. 1625. Pclyfarcia, or corpulency, whether it depend upon plethora or obefity, whenever it either can be confidered as a difeafe, or threatens to induce one, is to be cured, or the effeas of it are to be obviat- ed, by diet and exercife. The diet mud be fpar- ing; or rather, what is more admiffible, it mud be fuch as affords little nutritious matter. It mud therefore be chiefly, or almod only, of vegetable matter, and at the very utmod of milk. Such a diet fhould be employed, and generally ought to precede exercife; for obefity does not eafily admit of bodily exercife; which is, however, the only mode that can be very effeaual. Such, indeed, in many cafes, may feem difficult to be admitted ; but I am of opinion, that even the moft corpulent may be brought to bear it, by at fird attempting it very moderately, and increafing it by degrees very flowly, but at the fame time perfiding in fuch at- tempts with great condancy*. 1626. As thefe, though the only effeaual meafures, are often difficult to be admitted or carried into exe- cution,' fome other means have been thought of and employed for reducing corpulency. Thefe, if I midake not, have all been certain methods of in- ducing a faline date in the mafs of blood; for fuch I fuppofe to be the effecls of vinegar and of foap, which have been propofed. The latter, I believe, hardly paffes into the blood-veflels, without being refolved and formed into a neutral fait, with the acid * B?fides the mearrs mentioned by the author, evscmtions of different kioda ought Jo be o;cafionally made, efpecially by purging and fweating. OF PHYSIC. 3*9 acid which it meets with in the domach. Howwell acrid and faline fubdances are fitted to diminifti obefity, may appear from what has been faid above in (1616.). What effeas vinegar, foap, or other fubdances employed, have had in reducing corpu- lency, there have not proper opportunities of ob- ferving occurred to me : But I am well perfuaded, that the inducing a faline and acrid date of the blood, may have worfe confequences than the cor- pulency it was intended tp correa; and that no perfon fhould hazard thefe, while he may have re- courfe to the more fafe and certain means of abiu- nence and exercife. C II A P. II. Of FLATULENT SWELLINGS. 1627. THE cellular texture of the human body very readily admits of air, and allows the fame to pafs from any one to every other part of it. Hence Emphyfemata have often appeared from air colleaed in the cellular texture under the fkin, and in feveral other parts of the body. The flatu- lent fwellings under the fkin, have indeed mod com- monly appeared in confequence of air immediately introduced from without: But in fome indances ol flatulent fwellings, efpecially. thofe of the internal parts not communicating with the alimentary canal, fuch an introduaion cannot be perceived or fup- pofed; and therefore, in thefe cafes, fome other caufe of the produ6tion and colleaion of air mud be looked for, though it is often not to be clearly afcertained. In every folid as well as every fluid fubdance which makes a part of the human body, there is a confiderable quantity of air in a fixed date, which may g20 PRACTICE may be again redored to its eladic date, and fepa- rated from thofe fubdances, by the power of heat, putrefaaion, and perhaps other caufes : But which of thefe may have produced the feveral indances of pneumatofis and flatulent fwellings that have been recorded by authors, I cannot pretend to afcertain. Indeed, upon account of thefe difficulties, I can- not proceed with any clearnefs on the general fub- jea of pneumatofis ; and, therefore, with regard to flatulent fwellings, I find it neceffary to confine myfelf to the confederation of thofe of the abdomi- nal region alone; which I fhall now treat of under the general name of Tympanites. 1628. The tympanites is a fwelling of the abdomen ; in which the teguments appear to be much dretched by fome diftending power within, and equally dretched in every podure ofthe body. The fwell- ing does not readily yield to any preffure ; and in fo far as it does, very quickly recovers its former date upon the preffure being removed. Being flruck, it gives a found like a drum, or other dretched animal membranes. No fiuauation with- in is to be .perceived : And the whole feels lefs weighty than might be expeaed from its bulk. The uneafinefs of the didention is commonly relieved by the difcharge of air from the alimentary canal, either upwards or downwards. 1629. Thefe are the charaQers by which the tympanites may be didinguifhed from the afcites or phyfconia ; and many experiments fliow, that the tympanites always depends upon a preternatural colleaion of air, fomcwhere within the teguments of the abdo- men : But the feat of the air is in different cafes Somewhat different; and this produces the differ- , cut fpecies of the difeafe. . OF PHYSIC. 321 One fpecies is, when the air colleaed is entirely confined within the cavity ofthe alimentary canal, and chiefly in that of the intedines. This Aperies* therefore, is named the Tympanites intefiinalis, Sauv. fp. 1. It is, of all others, the mod common ; and to it efpecially belong the chapters given above. A fecond fpecies is, when the air colle6tedis not entirely confined to the cavity of the inteftines, but is alfo prefent between their coats; and fuch is that which is named by Sauvages Tympanites enterophy- fiodes, Sauv. fp. 3. This has certainly been a rare occurrence; and has probably occurred only in confequence of the tympanites intefiinalis, by the air efcaping from the cavity of the inteftines into the inteiitices of the coats. It is, however, poffi- ble that an erofion of the internal coat of the in- tedines may give occafion to the air, fo condantly prefent in their cavity, to efcape into the interdices of their coats, though in the whole of their cavity ihere has been no previous accumulation. A third fpecies is, when the air is colleaed iri the fac of the peritonaeum, or what is commonly called thecavity of the abdomen, that is, the fpace between the peritonaeum and vifcera ; and then the difeafe is named Tympanites abdominalis, Sauv. fp. 2. The exidence of fuch a tympanites, without any tympanites intefiinalis, has been disputed; and it certainly has been a rare occurrence: But from feveral diffeaions, it is unquedionable that fuch a difeafe has fometimes truly Occurred. A fourth fpecies of tympanites isi when the tym-* panites intejlinalis and abdominalis are joined toge- ther, Or take place at the fame time. With refpea to this, it is probable that the tympanites intefiina- lis is the primary difeafe ; and the other, only a confequence ofthe air efcaping, by an erofion or rupture of the coats of the inteftines, from the ca- vity of thefe into that of the abdomen. It is indeed poffible, that in confequence of erofion or rupture, the air which is fo condantly prefent in the intedinal Vol. II. S s * canal, 322 PRACTICE canal, may efcape from thence in fuch quantity in- to the cavity ofthe abdomen, as to give a tympani- tes abdominalis, whild there was no previous confi- derable accumulation of air in the intedinal cavity itfelf; but I have not faas to afcertain this matter properly. A fifth fpecies has alfo been enumerated. It is when a tympanites abdominalis happens to be joined with the hydrops afcites; and fuch a dif- eaie therefore is named by Sauvages Tympanites ajciticus, Sauv. fp. 4. In moft cafes of tympanites, iideed, fome quantity of ferum has, upon diffeai- on, been found in the fac of the peritonaeum ; but that is not enough to conditute the fpecies now mentioned; and when the colleaion of ferum is more confiderable, it is commonly where, both from the caufes which have preceded, and like- wife from the fymptoms which attend, the afcites may be confidered as the primary difeafe; and therefore that this combination does not exhibit a proper fpecies ofthe tympanites. 163O. As this lad is not a proper fpecies, and as fome of the others are not only extremely rare,, but even, when occurring, are neither primary, nor to be ea- fily didinguifhed, nor, as confidered in themfelves, admitting of any cure, I fhall here take no further notice of them ; confining myfelf, in what follows, to the confideration of the mod frequent cafe, and almod the only objea of praaice, the tympanites intefiinalis. 1631. With refpea to this, I cannot perceive that it arifes in any peculiar temperament, or depends up- on any predifpofition, which can be difcerned. It occurs in either fex, at every age, and frequently in young perfons. * 1632. Van- OF PHYSIC. 8*3 1632. Various remote caufes of it have been affigned: But many of thefe have not commonly the effea of producing this difeafe ; and although fome of them have been truly antecedents of it, I can in few in- dances difcover the manner in which they produce the difeafe, and therefore cannot certainly afcer- tain them to have been caufes of it. l633- The phenomena of this difeafe in its feveral dages are the following. The tumour of the belly fometimes grows very quickly to a confiderable degree, and feldom in the dow manner the afcites commonly comes on. In fome cafes, however, the tympanites comes on gradually, and is introduced by an unufuai flatu- lency of the domach and intedines, with frequent borborygmi, and an uncommonly frequent expul- sion of air upwards and downwards. This date is alfo frequently attended with colic pains, efpecial- ly felt about the navel, and upon the fides towards the back; but generally as the difeafe advances, thefe pains become lefs confiderable. As the dif- eafe advances, there is a pretty condant defire to difcharge air, but it isaccomplifhed with difficulty; and when obtained, although it give fome relief from the fenfe of didention, this relief is common- ly transient and of fhort duration. While the dif- eafe is coming on, fome inequality of tumour and tenfion may be perceived in different parts of the belly ; but the didention foon becomes'equal over the whole, and exhibits the phenomena mentioned in the character. Upon the fird coming on of the difeafe, as well as during its progrefs, the belly is bound, and the faeces difcharged are commonly hard and dry. The urine, at the beginning, is ufually 324 PRACTICE ufually very little changed in quantity or quality from its natural date : But as the difeafe continues, it is commonly changed in both refpeas ; and at length fometimes a dranguary, and even an ifchuria, comes on. The difeafe has feldom advanced far, before the appetite is much impaired, and digedion ill performed ; and the whole body, except the bel- ly, becomes confiderably emaciated. Together with thefe fymptoms, a third and uneafy fenfe of heat at length come on, and a confiderable fre- quency of pulfe occurs, which continues through- out the courfe of the difeafe. When the tumour ofthe belly arifes to a confiderable bulk, the breath- ing becomes very difficult, with a frequent dry cough. With all thefe fymptoms the drength of the patient declines ; and the febrile fymptoms daily increafing, death at length enfues, fometimes pro- bably in confequence of a gangrene coming upon the intedines.' 1634. The tympanites is commonly of fome duration, and to be reckoned a chronic difeafe. It is very feldom quickly fatal, except where fuch an affec- tion fuddenly arifes in fevers. To this Sauvages has properly given a different appellation, that of Meteorijmus; and I judge it may always be confi- dered as a fymptomatic affeaion, entirely diflincf from the tympanites we are now considering, l635- The tympanites is generally a fatal difeafe, fel- dom admitting of cure; but what may be attempt- ed in this way, I fhall try to point out, after I fhall have endeavoured to explain the proximate caufe, which alone can lay the foundation of what may Ipe rationally attempted towards its cure. 1636. To OF PHYSIC. 325 1636. To afcertain the proximate caufe of tympanites, is fomewhat difficult. It has been fuppofed in ma- ny cafes, to be merely an uncommon quantity of air prefent in the alimentary canal, owing to the extrication and detachment of a greater quantity of air than ufual from the alimentary matters taken in. Our vegetable aliments, I believe, always undergo fome degree of fermentation ; and in confequence, a quantity of air is extricated and detached from them in the domach and intedines: But it appears, that the mixture of the animal fluids which our aliments meet with in the alimen- tary canal, prevents the fame quantity of air from being detached from them that would have been in their fermentation without fuch mixture; and it is probable that the fame mixture contributes alfo to the reabforption ofthe air that had been before in fome meafure detached. The extrication, therefore, of an unufuai quantity of air from the aliments, may, in certain circumdances, be fuch, perhaps as to produce a tympanites ; fo that this dif- eafe may depend upon a fault of the digedive fluids, whereby they are unfit to prevent the too copious extrication of air, and unfit alfo to occa- fion that reabforption of air which in found perfons commonly happens. An unufuai quantity of air in the alimentary canal, whether owing to the nature ofthe aliments taken in, or to the fault of the di- gedive fluid, does certainly fometimes take place; and may poffibly have, and in fome meafure cer- tainly has, a ffiare in producing certain flatulent diforders of the alimentary canal; but cannot be fuppofed to produce the tympanites, which often occurs when no previous diforder had appeared in the fydem. Even in thofe cafes of tympanites which are attended at their beginning with flatu- lent diforders in the whole of the alimentary canal, as / 226 PRACTICE as we know that a firm tone ofthe intedines both moderates the extrication of air, and contributes to its reabforption or ready expulfion, fo the flatu- lent fymptoms which happen to appear at the com- intf on of a tympanites, are, in my opinion, to be re?erred to a lofs of tone in the mufcular fibres of the intedines, rather than to any fault in the digef- tive fluids. ^37- Thefe, and other considerations, lead me to con- clude, that the chief part ofthe proximate caufe of tympanites, is a lofs of tone in the mufcular fibres of the intedines. But further, as air of any kind accumulated in the f avity of the intedines fhould, even by its own eladicity, find its way either up- wards or downwards, and fhould alfo, by the af- iillauce of infpiration, be entirely thrown out of the body ; fo, when neither the reabforption nor the expulfion takes place, and the air is accumu- lated Jo as to produce tympanites, it is probable that the paffage of the air along the courfe of the intedines is in fome places of thefe interrupted. Thia interruption, however, can hardly be fuppof- ed to proceed from any other caufe than fpafmod- ic condriaions in certain parts ofthe canal; and I conclude, therefore, that fuch condriaions concur as part in the proximate caufe of tympanites. Whether thefe fpafmodic condriaions are to be at- tributed to the remote caufe of the difeafe, or may be confidered as the confequence of fome degree of atony fird arifing, I cannot with certainty, and do not find it neceffary, to determine, 1638. Having thus endeavoured to afcertain the prox- imate caufe of tympanites, I proceed to treat of its ^e; which indeed has feldom fucceeded, and al- mod O F P H Y S I C. 327 mod never but in a recent difeafe. I muft, howe- ver, endeavour to fay what may be reafonably at- tempted ; what has commonly been attempted ; and what attempts have fometimes fucceeded in the cure of this difeafe. 1639. It mud be a fird indication to evacuate the air accumulated in the intedines : And for this purpofe it is neceffary that thofe condriaions, which had efpecially occafioned its accumulation, and conti- nue to interrupt its paffage along the courfe ofthe intedines, fhould be removed. As thefe, however, can hardly be removed but by exciting the peridal- tic motion in the adjoining portions of the intef- tines, purgatives have been commonly employed; but it is at the fame time agreed, that the more gentle laxatives only ought to be employed, as the more dradic, in the over-ftretched and tenfe date of the inteftines, are in danger of bringing on in- flammation. It is for this reafon alfo, that glyders have been frequently employed ; and they are the more ne- ceffary, as the faeces colleaed are generally found to be in a hard and dry date. Not only upon ac- count of this date of the faeces, but, farther, when glyders produce a confiderable evacuation of air, and thus ffiow that they have fome effea in relax- ing the fpafms of the inteftines, they ought to be repeated very frequently. 164O. In order to take off the condriaions of the in- teftines, and with fome view alfo to the carmina- tive effeas of the medicines, various antifpafmo- dics have been propofed, and commonly employ- ed ; but their effeas are feldom confiderable, and it is alleged that their heating and inflammatory powers 328 PRACTICE powers have fometimes been hurtful. It is, how* ever, always proper to join fome ofthe milder kinds with both the purgatives and glyders that are em- ployed*; and it has been very properly advifed to give always the chief of antifpafmodics, that is, an opiate, after the operation of purgatives is finifhed. 1641. In consideration of the over-dretched, tenfe, and dry date of the inteftines, and efpecially of the fpaf- modic condriaions that prevail, fomentations and warm bathing have been propofed as a remedy; and are faid to have been employed with advan- tage : But it has been remarked, that very warm baths have not been found fo ufeful as tepid baths long continued. 1642. Upon the fuppofition that this difeafe depends ef- pecially upon an atony of the alimentary canal^ tonic remedies feem to be properly indicated. Ac- cordingly chalybeates, and various bitters, have been employed; and, if any tonic, the Peruvian bark might probably be ufeful. 1643. But as no tonic remedy is more powerful than cold applied to the furface ofthe body, and cold drink thrown into the ftomach ; fo fuch a remedy has been thought of in this difeafe. Cold drink has been condantly prefcribed, and cold bathing has been * The antifpafmodics that are to be joined with purgatives ought to be efTential oils, efpecially the effential oils of umbelliferous plants, as oil of anifeed, oilofca- rui, &c. and their dofe ought to be moderate. In many cafes they may be ufed in repeated fmall dofes by themfelves on a piece of fugar. The dole of the ol. anifi ought not to exceed ten or twelve drops, nor ofthe ol. carui five drops; larger dofes are too heating. It may be proper alfo to obferve, that the effential oils ofthe ver- ticeliated plants, as mint, marjoram, thyme, &c. are mudi too heating, and much more lb thofe of the aromatics, as cloves, '.:r.amon,*;c, OF PHYSIC. 329 been employed with advantage; and there have been feveral indances of the difeafe being fudden- ly and entirely cured by the repeated application of fnow to the lower belly. 1644. It is hardly neceffary to remark, that, in the diet of tympanitic perfons, all forts of food ready to be- come flatulent in the domach are to be avoided; and it is probable, that the foffil acids and neutral falts, as antizymics, may be ufeful*. 1645. In obdinate and defperate cafes of tympanites* the operation of the paracentesis has been propofed: But it is a very doubtful remedy, and there is hard- ly any tedimony of its having been praaifed with fuccefs. It mud be obvious, that this operation is a remedy fuited efpecially, and almod only, to the tympanites abdominalis; the exidence of which, fe- parately from the intefiinalis, is very doubtful, at lead not eafily afcertained. Even if its exidence could be afcertained, yet it is not very likely to be cured by this remedy : And how far the operation might be fafe in the tympanites intefiinalis, is not yet determined by any proper experience. CHAP. III. Or WATERY SWELLINGS, or DROPSIES. 1646. A PRETERNATURAL colleaion of ferous or watery fluids, is often formed in different Vol. II. Tt parts * The foffil acids are undoubtedly very powerful in refifting fermentation ; an J if the air in the inteftines is produced by fermentation, they ajre confequently high. ly ufeful, gSo PRACTICE parts of the human body ; and although the difeafe thence arifing be didinguifhed according to the dif- ferent parts which it occupies, yet the whole of fuch colleaions come under the general appellation of Dropsies. At the fame time, although the particu- lar indances of fuch colleaion are to be didinguifh- ed from each other according to the parts they oc- cupy, as well as by other circumdances attending them; yet all of them feem to depend upon fomfc general caufes, very much in common to the whole* Before proceeding, therefore, to confider the feve- ral fpecies, it may be proper to endeavour to affigtt the general caufes of dropfy.. 1647. In perfons in health,, a ferous or watery fluid feems to be condantly poured out, or exhaled in vapour, into every cavity afid interdice of the hu- tnan body capable of receiving it; and the fame flu- id, without remaining long or being accumulated in thefe space?, feems coridantly to be foon again abforbed from thence by veffels adapted to the pur- pofe. From this view of the animal economy, it will be obvious, that if the quantity poured out in- to any space, happens to be greater than the abforb- ents can at the fame time take up, an unufuai ac- cumulation of ferous fluid will be made in fuch parts; or though the quantity poured out be not more than ufual, yet if the abforption be anywife interrupted or diminifhed, from this caufe alfo an unufuai colleaion of fluids may be occafioned. Thus, in general, dropfy may be imputed to an increafed effufion, or to a diminifhed abforption ;. and I therefore proceed to inquire into the feveral caufes of thefe. 1648. An increafed effufion may happen, either from a- preternatural increafe of the ordinary exhalation,. or OF PHYSIC. 33* or from the rupture of veffels carrying, or of facs containing, ferous or watery fluids, 1649. The ordinary exhalation may be increafed by va- rious caufes, and particularly by an interruption given to the free return of the venous blood front the extreme veffels of the body to the right ventri- cle of the heart. This interruption feems to ope- rate by redding the free paffage of the blood from the arteries into the veins, thereby increafing the force ofthe arterial fluids in the exhalants, and con- fequently the quantity of fluid which they pour out, 1650. The interruption ofthe free return ofthe venous blood from the extreme veffels, may be owing to certain circumdances affeaing the courfe of the ve- nous blood; very frequently, to certain conditions in the right ventricle of the heart itfelf, preventing it from receiving the ufual quantity of blood from the vena cava; or to obdrucfions in the veffels of the lungs preventing the entire evacuation of the right ventricle, and thereby hindering its receiving the ufual quantity of blood from the cava. Thus, a polypus in the right ventricle ofthe heart, and the offification of its valves, as well as all confider- able and permanent obdruaions of the lungs, have been found to be caufes of dropfy. 1651. It may ferve as an illudration ofthe operation of thefe general caufes, to remark, that the return of the venous blood is in fome meafure redded when the podure of the body is fuch as gives occa- fion to the gravity ofthe blood to oppofe the moti- on of it in the veins, which takes effea when the * force 33* PRACTICE force ofthe circulation is weak; and from whence it is that an upright podure of the body produces or in- creafes ferous fwellings in the lower extremities. 1652. Not only thofe caufes interrupting the motion of the venous blood more generally, but, farther, the interruption of it in particular veins, may likewife have the effea of increafing exhalation, and pro- ducing dropfy. The mod remarkable indance of this is, when confiderable obdruaions of the liver prevent the blood from flowing freely into it from the vena portarum and its numerous branches ; and hence thefe obdruaions are a frequent caufe of dropfy. l653- Scirrhofities of the fpleen and other vifcera, as well as the fcirrhofity of the liver, have been con- fidered as caufes of dropfy; but the manner in which they can produce the difeafe, I do not per- ceive, except it may be where they happen to be near fome confiderable vein, by the compreffion of which they may occafion fome degree of afcites; or, by comprefling the vena cava, may produce an anafarca of the lower extremities. It is indeed true, that fcirrhofities of the fpleen and other vifce- ra, have been frequently difcovered in the bodies of hydropic perfons; But I believe that they have been feldom found unlefs when fcirrhofities of the liver were alfo prefent; and I am inclined to think, that the former have been the effeas of the latter, ra- ther than the caufe of the dropfy ; or that, if fcir- rhofities of the other vifcera have appeared in hy- dropic bodies when that of the liver was not pre- fent, they mud have been the effeas of fome of thofe caufes of dropfy to be hereafter mentioned ; and confequently to be the accidental attendant^ rather than the caufes, of fuch dropsies. 1654. Even OF PHYSIC. 333 1654. Even in smaller portions of the venous fydem, the interruption of the motion of the blood in par- ticular veins has had the fame effea. Thus, a po- lypus formed in the cavity of a vein, or tumours formed in its coats, preventing the free paffage of the blood through it, have had the effea of pro- ducing dropfy in parts towards the extremity of fuch veins. 1655. But the caufe mod frequently interrupting the motion of the blood through the veins is, the com- preffion of tumours exiding near to them ; fuch as aneurisms in the arteries, abfcefles, and fcirrhous or fleatomatous tumours in the adjoining parts. To this head may be referred the compreffion of the defcending cava by the bulk of the uterus in pregnant women, and the compreffion of the fame by the bulk of water in the afcites; both of which compreffions frequently produce ferous fwellings in the lower extremities. 1656. It may be fuppofed, that a general preternatural plethora of the venous fydem may have the effea of increafing exhalation ; and that this plethora may happen from the fuppreffion of duxes, or evacuations of blood, which had for fome time taken place in the body, fuch as the mendrual and hemorrhoidal duxes. A dropfy, however, from fuch a caufe, has been at lead a rare occurrence; and when it feems to have happened, I fhould fup- pofe it owing to the fame caufes as the fuppreffion itfelf, rather than to the plethora produced by it. 1657. One 534 PRACTICE 1657. One ofthe mod frequent caufes of an increafed exhalation, I apprehend to be the laxity of the ex- halant veflels. That fuch a caufe may operate, appears probable from this, that paralytic limbs, in which fuch a laxity is to be fufpeaed, are fre- quently affeaed with ferous, or, as they are call- ed, ©edematous fwellings. But" a much more remarkable and frequent ex- ample of its operation occurs in the cafe of a gene- ral debility of the fydem, which is fo often attend- ed with dropfy. That a general debility does in- duce dropfy, appears fufficiently from its being fo commonly the confequence of powerfully debilitat- ing caufes ; fuch as fevers, either of the continued or intermittent kind, which have laded long; long continued and fomewhat exceffive evacuations of any kinds; and, in ffiort, almod all difeafes that have been of long continuance, and have at the fame time induced the other fymptoms of a gene- ral debility. Among other caufes inducing a general debility <;f the fydem, and thereby dropfy, there is one to be mentioned as frequently occurring, and that is, intemperance in the ufe of intoxicating liquors; from whence it is that drunkards of all kinds, and efpecially dram drinkers, are fo affeaed with this difeafe. 1658. That a general debility may produce a laxity of ihe exhalants, will be readily allowed ; and that by this, efpecially it occafions dropfy, I judge from thence, that while mod of the caufes already men- tioned are fuited to produce dropfies of particular t juirts only, the date of .general debility gives rife £0 an increafed exhalation into every* cavity and interdice OF PHYSIC. 335 interfiice of the body, and therefore brings on a general difeafe. Thus, we have feen effufions of a ferous fluid made, at the fame time, into the ca- vity of the cranium, into that of the thorax and of the abdomen, and likewife into the cellular texture almod over the whole of the body. In fuch cafes, the operation of a general caufe difcovered itfelf, by thefe feveral dropfies increafing in one part as they diminifh in another, and this alternately in the different parts. This combination, therefore, of the different fpecies of dropfy, or rather, as it may be termed, this univerfal dropfy, mud, I think, be referred to a general caufe; and in moft indances, hardly any other can be thought of, but a general laxity ofthe exhalants. It is this, there- fore, that I call the hydropic diathefis; which fre- quently operates by itfelf; and frequently, in fome meafure, concurring,with other caufes, is efpecial- ly that which gives them their full effea. This date of the fydem, in its fird appearance, feems to be what has been confidered as a particu- lar difeafe under the name of Cachexy; but in eve- ry inftance of it that has occurred to me, I have always confidered, and have always found, it to be the beginning of general dropfy. 1659. The feveral caufes of dropfy already mentioned; may produce the difeafe, although there be no pre- ternatural abundance of ferous or watery fluid in the blood-veffels; but it is now to be remarked,, that a preternatural abundance of that kind may often give occafion to the difeafe, and more efpe- cially when fuch abundance concurs with the cau- fes above enumerated. One caufe of fuch preternatural abundance may be an unufuai quantity of water taken into the bo- dy. Thus an unufuai quantity of water taken in by drinking, has fometimes occafioned a dropfy. Large 336 PRACTICE Large quantities of water, it is true, are upon ma- ny occafions taken in; and being as readily thrown out again by dool, urine, or perfpiration, have not produced any difeafe. But it is alfo certain, that, upon fome occafions, an unufuai quantity of wate- ry liquors taken in has run off by the feveral inter- nal exhalants, and produced a dropfy. This feems to have happened, either from the excretories not being fitted to throw out the fluid fo fad as it had been taken in, or from the excretories having been obdruaed by accidentally concurring caufes. Ac- cordingly it is faid, that the fudden taking in of a large quantity of very cold water, has produced dropfy, probably from the cold producing a con- driaion ofthe excretories. The proportion of watery fluid in the blood may be increafed, not only by the taking in a large quantity of water by drinking, as now mentioned, but it is poffible that it may be increafed alfo by water taken in from the atmofphere by the fkin in an abforbing or imbibing date. It is well known that the dun may be, at lead, occasionally in fuch a date; and it is probable, that in many cafes of beginning dropfy, when the circulation ofthe blood on the furface of the body is very languid, that the fkin may be changed from a perfpiring to an im- bibing date ; and thus, at lead, the difeafe may be very much increafed. 1660. A fecond caufe of a preternatural abundance of watery fluids in the blood-veffels, may be, an in- terruption of the ordinary watery excretions ; and accordingly it is alleged, that perfons much ex- pofed to a cold and moid air are liable to dropfy. It is alfo faid, that an interruption, or confiderable diminution, of the urinary fecretion, has produc- ed the difeafe : and it is certain, that, in the cafe ot an ijchuria renalis, the ferofity retained in the blood- OF PHYSIC. 337 blood-vefiels has been poured out into fome inter- nal cavities, and has occafioned dropfy. l66l. A third caufe, of an over proportion of ferous fluid in the blood ready to run off by the exhalants* has been very large evacuations of blood, either fpontaneous or artificial. Thefe evacuations, by abdraaing a large proportion of red globules and gluten, which are the principal means of retaining fe- rum in the red veffels, allow the ferum to run off more readily by the exhalants: And hence dropfies have been frequently the confequence of fuch evacuations. It is poffible alfo, that large and long continued iffues, by abdraaing a large proportion of gluten, may have the fame effea. An over proportion of the ferous parts of the blood, may not only be owing to the jpoliationjuft now mentioned, but may, I apprehend, be like- wife owing to a fault in the digefting and affimilat- ing powers in the domach and other organs; where- by they do not prepare and convert the aliments taken in, in fuch a manner as to produce from them the due proportion of red globules and gluten ; but, ftill continuing to fupply the watery parts, occafion thefe to be in an over proportion, and confequent- ly ready to run off in too large quantity by the ex- halants. It is in this manner that we explain the dropfy, fo often attending chlorofis : which ap- pears always at fird by a pale colour of the whole body, fhowing a manifed deficiency of red blood ; which in that difeafe can only be attributed to an imperfea digedion and affimilation. Whether a like imperfeaion takes place in what has been called a Cachexy, 1 dare not determine. This difeafe indeed has been commonly and very evidently owing to the general caufes of debility above mentioned ; And it being probable that the Vol. II. U u general 338 PRACTICE general debility may affea the organs of digedion and affimilation ; fo the imperfecf date of thefe funaions, occasioning a deficiency of red globules and gluten, may often concur with the laxity ofthe exhalants in producing dropfy. 1662. Thefe are the feveral caufes of increafed exhala- tion, which I have mentioned as the chief caufe of the effufion producing dropfy ; but I have likewife obferved in (1648.), that with the fame effea, an effufion may alfo be made by the rupture of veflels carrying watery fluids. In this way, a rupture of the thoracic dua, has given occafion to an effufion of chyle and lymph into the cavity ofthe thorax; and a rupture ofthe laaeals has occafioned a like effufion into the cavi- ty of the abdomen ; and in either cafe, a dropfy has been produced. It is fufficiently probable, that a rupture of lym- phatics, in confequence of drains, or the violent compreffion of neighbouring mufcles, has occafion- ed an effufion; which, being diffufed in the cellu- lar texture, has produced dropfy. It belongs to this head of caufes, to remark, that there are many indances of a rupture or erofion of the kidneys, ureters, and bladder of urine ; where- by the urine has been poured into the cavity of the abdomen, and produced an afcites. 1663. Upon this fubjea, ofthe rupture of veffels car- rying, or of veficles containing, watery fluids, I mud obferve, that the diffeaion of dead bodies has often ffiown veficles formed upon the furface of many of the internal parts ; and it has been fup- pofed, that the rupture of fuch veficles, commonly named Hydatides, together with their continuing to OF PHYSIC. 339 to pour out a watery fluid, has been frequently the caufe of dropfy. I cannot deny the poffibility of fuch a caufe, but fufpea the matter mud be explain- ed in a different manrter. There have been frequently found, in almod eve- ry different part of animal bodies, colleaions of fpherical veficles, containing a watery fiuid ; and in many cafes of fuppofed dropfy, particularly in thofe called the preternatural encyded dropfies, the swell- ing has been entirely owing to a colleaion of fuch hydatides. Many conjeaures have been formed with regard to the nature and produaion of thefe veficles: but the matter at lad feems to be afcer- tained. It feems to be certain, that each of thefe veficles has within it, or annexed to it, a living animal of the worm kind; which feems to have the power of forming a vesicle for the purpofe of its own economy, and of filling it with a watery fiuid drawn from the neighbouring parts : And this ani- mal has therefore been properly named by late na- turalids, the Taenia hydatigena. The origin anfl economy of this animal, or an account of the fe- veral parts of the human body which it occupies, I cannot profecute further here ; but it was proper for me, in delivering the caufes of dropfy, to fay thus much of hydatides: And I mud conclude with obferving, I am well perfuaded, that mod of the indances of preternatural encyded dropfies which have appeared in many different parts of the human body, have been truly colleaions of fuch hydatides; but'how the fwellings occafioned by thefe are to be didinguifhed from other fpecies of dropfy, or how they are to be treated in praaice, I cannot at pre- fent determine. 1664. After having mentioned thefe, I return to confi- der the other general caufe of dropfy, which I have faid in (1647,) maybe, An interruption or dirainu- v tion 34° PRACTICE tion of the abforption that fhould take up the ex- haled fluids from the feveral cavities and interdices of the body ; the caufes of which interruption, however, are not eafily afcertained. 1665. It feems probable, that abforption may be dimi- nifhed, and even ceafe altogether, from a lofs of tone in the abforbent extremities of the lymphatics. I cannot indeed doubt that a certain degree of tone or active power is neceffary in thefe abforbent ex- tremities ; and it appears probable, that the fame general debility which produces that laxity of the exhalant'veflels, wherein 1 have fuppofed the hy- dropic diathesis to confid, will at the fame time oc- cafion a lofs of tone in the abforbents; and there- fore that a laxity of the exhalants will generally be accompanied with a lofs of tone in the abforbents; and that this wid have a diare in the produaion of dropfy. Indeed it is probable that the diminution of abforption has a confiderable fhare in the mat- ter ; as dropfies are often cured by medicines which feem to operate by exciting the aaion of the ab- sorbents. 1666. It has been fuppofed, that the abforption per- formed by the extremities of lymphatics may be in- terrupted by an obflruaion of thefe veflels, or at lead of the conglobate glands through which thefe veffels paf's. This, however, is very doubtful. Asthe lymphatics have branches frequently communicat- ing with one another, it is not probable that the obflruaion of any one, or even feveral of thefe, can have any confiderable effecl in interrupting the abforption of their extremities. And for the fame reafon, it is as little probable that the obflruaion of conglobate glands can have fuch OF PHYSIC. 34i fuch an effea : At lead it is only an obdruaion of the glands of the mefentery, through which fo con- fiderable a portion of the lymph paffes, that can poffibly have the effea of interrupting abforption. But even this we fhould not readily fuppofe, there being reafon to believe that thefe glands, even in a confiderably tumefied date, are not entirely ob- druaed : And accordingly I have known feveral indances of the mod part of the mefenteric glands being confiderably tumefied, without either inter- rupting the tranfmiffion of fluids to the blood-vef- fels, or occafioning any dropfy. An hydropic fwelling, indeed, feems often to affea the arm from a tumour of the axillary gland: But it feems to me doubtful, whether the tumour of the arm may not be owing to fome compreffion of the axillary vein, rather than to an obdruaion of the lymphatics. 1667. A particular interruption of abforption may be fupoofed to take place in the brain. As no lym- phatic veflels have, yet very certainly been difco- vered in that organ, it may be thought that the ab- forption, which certainly takes place there, is per- formed by the extremities of veins, or by veffels that carry the fluid direaiy into the veins ; fo that any impediment to the free motion of the blood in the veins ofthe brain, may interrupt the abforption there, and occafion that accumulation of ferous fluid which fo frequently occurs from a congedion of blood in thefe veins. But I give all this as a matter of conjeaure only. 1668. Having thus explained the general caufes of dropfy, I fliould proceed, in the next place, to mention the feveral parts of the body in which fe- rous 342 PRACTICE rous colleaions take place, and fo to mark the dif- ferent fpecies of dropfy: But I do not think it ne- ceffary for me to enter into any minute detail up- on this fubjea. In many cafes, thefe colleaions are not to be afcertained by any external fymptoms, and therefore cannot be the objeas of praaice; and many of them, though in fome meafure dif- cernible> do not feem to be curable by our art. I the more efpecially avoid mentioning very particu- larly the feveral fpecies, becaufe that has already been fufticiently done by Dr. D. Monro, and other writers, in every body's hands. I muft con- fine myfelf here to the confideration of thofe fpe- cies which are the mod frequently occurring and the mod common objeas of our praaice; whicfc are, the Anafarca, Hydrothorax, and Afcites; and each of thefe I fhall treat of in fo many fepa- rate feaions. Sect. I. Of Anasarca. 1669. THE Anafarca is a fwelling upon the furface of the body, at fird commonly appearing in particu- lar parts only, but at length frequently appearing over the whole. So far as it extends, it is an uni- form swelling over the whole member, at fird al- ways foft, and readily receiving the preffure ofthe finger, which forms a hollow that remains for fome little time after the preffure is removed, but at length rifes again to its former fulnefs. This fwell- ing generally appears, fird, upon the lower extre- mities; and there too only in the evening, difap- pearing again in the morning. It is ufually more confiderable as the perfon has been more in an erea podure during the day; but there are many indances OF PHYSIC. 343 indances ofthe exercife of walking preventing al- together its otherwife ufual coming on. Although this fwelling appears at fird only upon the feet and about the ankles ; yet if the caufes producing it con- tinue to aa, it gradually extends upwards, occu- pying the legs, thighs, and trunk of the body, and fometimes even the head. Commonly the fwell- ing of the lower extremities diminidies during the night; and in the morning, the fwelling of the face is mod confiderable, which again generally difappears almod entirely in the courfe of the day. 1670. The terms of Anafarca and Leucophlegmatia have been commonly confidered as synonymous; but fome authors have propofed to confider them as denoting didin6t difeafes. The authors who are of this lad opinion employ the name of Anafarca, for that difeafe which begins in the lower extremi- ties, and is from thence gradually extended up- wards in the manner I have juft now defcribed ; while they term Leucophlegmatia, that in which the fame kind of fwelling appears even at fird very ge- nerally over the whole body. They feem to think alfo, that the two difeafes proceed from different caufes; and that, while the anafarca may arife from the feveral caufes in (1649.—1660.), the leu- cophlegmatia proceeds efpecially from a deficien- cy of red blood, as we have mentioned in (1661. et fieq.) I cannot, however, find any proper foun- dation for this diitinaion. For although in drop- fies proceeding from the caufes mentioned in (1661. et Jeq.), the difeafe appears in fome cafes more immediately affeaing the whole body; yet that does not eftablifh a difference from the com- mon cafe of anafarca: for the difeafe, in all its circumdances, comes at length to be entirely the fame ; and in cafes occafioned by a deficiency ot red blood, I have frequently obferved it to come on 344 PRACTICE on exaaiy in the manner of an anafarca, as above defcribed. 1671. An anafarca is evidently a preternatural collec- tion of ferous fluid in the cellular texture immedi- ately under the fkin. Sometimes pervading the fkin itfelf, it oozes out through the pores of the cu- ticle; and fometimes, too grofs to pafs by thefe, it raifes the cuticle in bliders. Sometimes the fkin, not allowing the water to pervade it, is compreffed and hardened, and at the fame time fo much didend- ed, as to give anafarcous tumours an unufuai firm- nefs. It is in thefe laft circumdances alfo that an erythematic inflammation is ready to come upon anafarcous fwellings. 1672. An anafarca may immediately arife from any of the feveral caufes of dropfy which aa more gene- rally upon the fydem : And even when other fpecies of dropfy, from particular circumdances, appear fird ; yet whenever thefe proceed from any caufes more generally affeaing the fydem, an anafarca fooner or later comes always to be joined with them. 1673. The manner in which this difeafe commonly fird appears, will be readily explained by what I have faid in (1651.), refpc&ing the effeas ofthe podure of the body. Its gradual progrefs, and its affea- ing, after fome time, not only the cellular texture under the fkin, but probably alfo much ofthe fame texture in 'the internal parts, will be underdood partly from the communication that is readily made between the feveral parts of the cellular texture ; but efpecially from the fame general caufes of the difeafe OF PHYSIC. 345 difeafe producing their effeas in every part of the body. It appears to me, that the water of anafar- cous fwellings is more readily, communicated to the cavity of the thorax, and to the lungs, than to the cavity of the abdomen, or to the vifcera contained in it. 1674. An anafarca is almod always attended with a fcarcity of urine; and the urine voided, is, from its fcarcity, always of a high colour; and from the fame caufe, after cooling, readily lets fall a copi- ous reddiffi fediment. This fcarcity of urine may fometimes be owing to an obdruaion of the kid- neys ; but probably is generally occasioned by the watery parts of the blood running off into the cel- lular texture, and being thereby prevented from paffing in the ufual quantity to the kidneys. The difeafe is alfo generally attended with an unufuai degree of third; a circumdance I would attribute to a like abdraaion of fluid from the tongue and fauces, which are extremely fenfible to every diminution of the fluid in thefe parts. 1675. The cure of anafarca is to be attempted upon three general indications. 1. The removing the remote caufes of the dif- eafe. 2. The evacuation of the ferous fluid already colleaed in the cellular texture. 3. The redoring the tone ofthe fydem, the lofs of which may be confidered in many cafes as the proximate caufe of the difeafe. Vol. II. X x 1676. The 34$ PRACTICE 1676. The remote caufes are very often fuch as had not only been applied, but had alfo been removed* long before the difeafe came on. Although, there- fore, their effeas remain, the caufes themfelves cannot be the objeas of praaice; but if the caufes dill continue to be applied, fuch as intemperance, indolence, and fome others, they mud be remov- ed. For the moft part, the remote caufes are cer- tain difeafes previous to the dropfy, which arc to be cured by the remedies particularly adapted to them, and cannot be treated of here. The curing of thefe, indeed, may be often difficult; but it was proper to lay down the prefent indication, in order to ffiow, that when thefe remote caufes can- not be removed, the cure of the dropfy mud be difficult, or perhaps impofiible. In many cafes, therefore, the following indications will be to lit- tle purpofe; and particularly, that often the exe- cution of the fecond will not only give the patient a great deal of fruitlefs trouble, but commonly al- fo hurry on his fate. 1677. The fecond indication for evacuating the col- leaed ferum, may be fometimes executed with ad- vantage, and often, at lead, with temporary relief. It may be performed in two ways. Fird, by draw- ing off the water direaiy from the dropfical part, by openings made into it for that purpofe : Or, fecondly, by exciting certain ferous excretions; in confequence of which, an abforption may be ex- cited in the dropfical parts, and thereby the ferum abforbed and carried into the blood-veffels, may afterwards be direaed to run out, or may fponta- neoudy * Thefe are large evacuations of different kinds, but efpecially hxmorrljagies, which have ceafed before the dropfy came on. OF PHYSIC. 347 neoufly pafs out, by one or other of the common excretions. 1678. In an anafarca, the openings into the dropfical part are commonly to be made in fome part of the lowerextremities; and will be mod properly made by many fmall punaures reaching the cellular texture. Formerly, confiderable incifions were employed for this purpofe: But as any wound made in dropfical parts, which, in order to their healing, mud necef- farily inflame and fuppurate, are liable* to become gangrenous; fo it is found to be much fafer to make the openings by fmall punaures only, which may heal up by the fird intention. At the fame time, even with refpea to thefe punaures, it is proper to obferve, that they fhould be made at fome didahce from one another, and that care fliould be tdken to avoid making them in the mod depending parts. 1679. The water of anafarcous limbs may be fometimes drawn off by pea iffues, made by caudic a little be- low the knees: For as the great fwelling of the low- er extremities is chiefly occafioned by the ferous fluid exhaled into the upper parts condantly falling down to the lower; fo the iffues now mentioned, by evacuating the water from the upper parts, may very much relieve the whole of the diieafe. Unlefs, however, the iffues be put in before the difeafe is far advanced, and before the parts have very much lod their tone, the places ofthe iffues are ready to become affeaed with gangrene. Some praaical writers have advifed the employ- ment of fetons for the fame purpofe that I have propofed iffues; but I apprehend, that fetons will be * Peculiarly liable in this difeafe on account of the diminilhed tone and coafe- jueutly the dimiiifl»:l ftrength ofthe parts. 348 PRACTICE be more liable than iffues to the accident jud now mentioned. 1680. For the purpofe of drawing out ferum from ana- farcous limbs, bliders have been applied to them, and fometimes with great fuccefs ; but the bliffered parts are ready to have a gangrene come upon them. Blidering is therefore to be employed with great caution; and perhaps only in the circumdances that I have mentioned above to be fit for the employ- ment of iffues. l68l. Colewort leaves applied to the fkin, readily oc- cafion a watery exfudation from its furface; and ap- plied to the feet and legs affected with anafarca, have fometimes drawn off the water very copioufly, and with great advantage. Analogous, as I judge, to this, oiled filk hofe put upon the feet and legs, fo as to ffiut out all com- munication with the external air, have been found fometimes to draw a quantity of water from the pores of the {kin, and are faid in this way to have relieved anafarcous fwellings : But in feveral trials made, I have never found either the application of thefe hofe, or that of the colewort leaves, of much fervice*. 1682. The fecond means propofed in (1677.) for draw- ing off the water from dropfical places, may be the employment of emetics, purgatives, diuretics, or fudorifics. 1683. As f How does this laft agr«e wi,th the firft fentence of this article ? OF PHYSIC. 349 1683. As fpontaneous vomiting has fometimes excited an abforption in hydropic parts, and thereby drawn off the waters lodged in them, it is reafonable to fuppofe that vomiting excited by art may have the fame effea; and accordingly it has been often prac- tifed with advantage. The praaice, however, re- quires that the drong antimonial emetics be employ- ed, and that they be repeated frequently after fhort intervals. 1684. Patients fubmit more readily to the ufe of pur- gatives, than to that of emetics ; and indeed they commonly bear the former more eafily than the lat- ter. At the fame time, there are no means we can employ to procure a copious evacuation of a ferous fluid with greater certainty than the operation of purgatives ; and it is upon thefe accounts that purg- ing is the evacuation which has been mod frequent- ly, and perhaps with mod fuccefs, employed in dropfy. It has been generally found neceffary to employ purgatives of the more dradic kind ; which are commonly known, and need not be enumerat- ed here*. I believe indeed, that the more dradic purga- * Th» Draftic purgatives are Jalap, Colocynth, Gamboge, Scammony, &c. Their draftic quality however depends very much on the dofe in which they are give;:, fmall dofes being gently laxative, while large ones are very violent in their operation. They ought feldom to be given alone, but in conjunction with fome aromatic, which greatly increafes their action, and at the fame time prevents the uneafinefs of griping, with which their operation is frequently attended: moft of thefe draftics being re- finous fubftances, they are difficultly foluble in the alimentary canal, or if reduced to a powder they are liable to concrete; in either cafe their action is impeded. To re- medy thefe inconveniences, it is ufual to add to them fome fult, which both divides the refill and prevents its concretion; and confequently increafes its action. For thefe reafons, we find in the fhops many formulje, in which the draftic refins are mixed with either falts or aromatics, or both: As, the Pulvis Aloeticus, Pulvis e Scammonio compofitus, Pulvis e Scammonio cum Aloe, Pulvis e fenna compofitus, and Electuarium e Scammonio ofthe London Pharmacopoeia; and, the Pulvis e Ja- lappa compofitus, Pulvis e Scammonio compofitus, Pilulx Aloeticje, Pilulae ex co- locynthide*cHm Aloe, Pilula e Jalappa, and Pilul* Run of the Edinburgh Phar- macopeia. Any 350 PRACTICE purgatives are the mod effeaual for exciting abforp- tion, as their dimulus is mod readily communicat- ed to the other parts ofthe fydem; but of late an opinion has prevailed, that fome milder purgatives may be employed with advantage. This opinion has prevailed particularly with regard to the cryf- tals vulgarly called the Cream of Tartar, which in large dofes, frequently repeated, have fometimes anfwered the purpofe of exciting large evacuations both by dooi and urine, and has thereby cured dropfies. This medicine, however, has frequently failed, both in its operation and effeas, when the draftic purgatives have been more fuccefsful. Praaitioners have long ago obferved, that, in the employment of purgatives, it is requifite they be repeated after as fhort intervals as the patient can bear; probably for this reafon, that when the purging is not carried to the degree of foon excit- ing an abforption, the evacuation weakens the fyf- tem, and thereby increafes the afflux of fluids to the hydropic parts. 1685. The "kidneys afford a natural outlet for a great part of the watery fluids contained in the blood- veffels ; and the increafing the excretion by the kidneys to a confiderable degree, is a means as like- ly as any other of exciting an abforption in dropfi- cal parts. It is upon this account that diuretic me- dicines have been always properly employed in the cure Any of the foregoing compofitions, if given in fufficient dofe?, are very active and briflt purges. Many more might be contrived, and on fome occafirms may be ne- ceffary. For procuring a briflc difcharge of fluids, an addition of Calomel is re* rnarkably efficacious as in the following formula : ft, Scammon. Calomel. Crem. Tart^ Zinzib aa. p. x, M. f. Puh. The dofe of this powder is twofcruple9or a- dram,- it is eatremelj' active and ought to be ufed with care, the patients being kept moderately warm, and drinking fome" thia mucilaginous liquor (luring its operation. OF PHYSIC. 35 «■ cure of dropfy. The various diuretics that may be employed, are enumerated in every treatife of the Materia Medicaand ofthe Praaice of Phyfic, and therefore need not be repeated here. It hap- pens, however, unluckily, that none of them are of very certain operation; neither is it well known why they fometimes fucceed, and why they fo often fail; nor why one medicine fliould prove of fervice when another tioes not. It has been ge- nerally the fault of writers upon the Praaice of Phyfic, that they gjve us indances of cafes in which certain medicines have proved very efficacious, but neglea to tell us in how many other indances the fame have failed. 1686. It deferves to be particularly obferved here, that there is hardly any diuretic more certainly power- ful than a large quantity of common water taken in by drinking. I have indeed obferved above in (1659.), tnat a large quantity of water, or of wa- tery liquors, taken in by drinking, has fometimes proved a caufe of dropfy; and praaitioners have been formerly fo much afraid that watery liquors taken in by drinking might run off into dropfical places and increafe the difeafe, that they have ge- nerally enjoined the abdaining as much as poffible, from fuch liquors. Nay, it has been further alien- ed, that by avoiding this fupply of exhalation, and by a tptalr abdinence from drink, dropfies have been entirely cured. What conclufion is to be drawn from thefe faas is, however, very doubtful. A dropfy arifing from a large quantity of liquids taken into the body has been a very rare occur- rence ; and there are, on the other hand, innume- rable indances of very large quantities of water having been taken in and running off again very quickly by ftool and urine, without producing any degree of dropfy. With refpea to the total ahfli- 352 PRACTICE nence from drink, it is a praaice of the mod diffi- cult execution; and therefore has been fo feldom praaifed, that we cannot pofiibly know how far it might prove effeaual. The praaice of giving drink very sparingly has indeed been often employed : But in a hundred indances, I have feen it carried to a great length without any manifed advantage: While, on the contrary, the praaice of giving drink very largely has been found not only fafe, but very often effeaual in curing the difeafe. The ingenious and learned Dr. Millman has, in my opi- nion, been commendablv employed in redoring the praaice of giving large quantities of watery liquors for the cure of dropfy. Not only from the indan- ces he mentions from his own praaice, and from that of feveral eminent phyficians in other parts of Europe, but alfo from many indances in the re- cords of phyfic, of the good effeas of drinking large quantities of mineral waters in the cure of dropfy, I can have no doubt of the praaice recom- mended by Dr. Millman being very often extreme- ly proper. I apprehend it to be efpecially adapt- ed to thofe cafes in which the cure is chiefly at- tempted by diuretics. It is very probable, that thefe medicines can hardly be carried in any quan- " tity to the kidneys without being accompanied with a large portion of water; and the late frequent em- ployment of the crydals of tartar has often fhown, that the diuretic effeas of that medicine are almod only remarkable when accompanied with a large quantity of water; and that without this, the diu- retic effeas of the medicine feldom appear. I fhall conclude this fubjea with obferving, that as there are fo many cafes of dropfy abfolutely incurable, the praaice now under consideration may often fail, yet in mod cafes it may be fafely tried ; and if it appear that the water taken in pades readily by the urinary fecretion, and efpecially that it increa- fes the urine beyond the quantity of drink taken in, the praaice may probably be continued with great OF PHYSIC. 853 great advantage : but, on the contrary, if the urine be not increafed, or be not even in proportion to the drink taken in, it may be concluded, that the water thrown in runs off by the exhalants, and will augment the difeafe. 1687. Another fet of remedies which may be employed for exciting a ferous excretion, and thereby curing dropfy, is that of fudorifics. Such remedies, in- deed, have been fometimes employed : But how- ever ufeful they may have been thought, there are few accounts of their having effected a cure ; and although I have had fome examples of their fuccefs, in mod indances of their trial they have been ineffeaual. Upon this fubjea it is proper to take notice of the feveral means that have been propofed and em- ployed for diffipating the humidity of the body; and particularly that of heat externally applied to the furface of it. Of fuch applications I have had no experience ; and their propriety and utility mud red upon the credit of the authors who relate them. I fliall offer only this conjeaure upon the fubjea t That if fuch meafures have been truly ufeful, as it has feldom been by the drawing out of any fenfible humidity, it has probably been by their redoring the perfpiration, which is fo often greatly diminifh- ed in this difeafe; or, perhaps, by changing the date ofthe fkin, from the imbibing condition which is alleged to take place, into that of perfpiring. 1688. When, by the feveral means now mentioned, we fliall have fucceeded in evacuating the water of dropfies, there will then efpecially be occafion for our third indication ; which is, to reflore the tone of the fydem, the lofs of which is fo often the Vol. II, Yv caufe *54 PRACTICE caufe ofthe difeafe. This indication, indeed, may properly have place from the very fird appearance of the difeafe; and certain rneafures adapted to this purpofe may, upon fuch fird appearance, be employed with advantage. In many cafes of a mo- derate difeafe, I am perfuaded that they may obvi- ate any future increafe of it. 1689. Thus, upon what is commonly the fird fymptom of anafarca, that is, upon the appearance of what are called Oedematous Swellings of the feet and legs, the three remedies of bandaging, friaion, and exercife, have often been ufed with advantage. 1690. That fome degree of external compreffion is fuit- ed to fupport the tone ofthe veffels, and particu- larly to prevent the effeas of the weight of the blood in dilating thofe of the lower extremities, mud be fufficiently evident; and the giving that compreffion by a bandage properly applied, has been often ufeful. In applying fuch a bandage, care is to be taken that the compreffion may never be greater on the upper than on the lower part of the limb ; and this, I think, can hardly ever be fo certainly avoided, as by employing a properly con- druaed laced docking. 1691. Friaion is another means by which the aaion of the blood-veffels may be promoted, and thereby the dagnation of fluids in their extremities prevented. Accordingly, the ufe of the fleffi-brufh has often contributed to difcufs cedematous fwellings. It ap- pears to me, that friaion, for the purpofes now mentioned, is more properly employed in the morn- ing* OF PHYSIC. 355 ing, when the fwelling is very much gone off, than in the evening, when any confiderable degree of it has already come on. I apprehend alfo, that friaion being made from below upwards only, is more ufe- ful than when made alternately upwards and down- wards. It has been common, indead of employing the flefh-brufh, to make friaion by warm and dry flannels; and this may in fome cafes be the moft convenient: But I cannot perceive that the im- pregnation of thefe flannels with certain dry fumes is of any benefit. 1692. With refpea to exercife, I muft obferve, that although perfons being much in an erea podure during the day, may feem to increafe the fwelling which comes on at night; yet as the aaion of the mufcles has a great fhare in promoting the motion of the venous blood, fo I am certain, that as much exercife in walking as the patient can eafily bear, will often prevent that cedematous fwelling which much danding, and even fitting, would have brought on. 1693. Thefe meafures, however, although they may be ufeful at the coming on of a dropfy, whole caules are not very powerful, will be often infufficient in a more violent difeafe; and fuch therefore will re- quire more powerful remedies. Thefe are, exer- cife and tonic medicines; which may be employed both during the courfe of the difeafe, and efpeci- ally after the water has been evacuated. 1694. Exercife is fuited to aflid in every funaion of the animal economv, particularly to promote per- fpiration, 356 PRACTICE fpiration, and thereby prevent the accumulation of watery fluids in the body. I apprehend alfo, that it may be the mod effeaual means for prevent- ing the dun from being in an imbibing date; and, as it has been hinted above on the fubjea of Ema- ciation (1608.), I am perfuaded, that a full and large perfpiration will always be a means of exciting ab- forption in every part of the fydem. Exercife, therefore, promifes to be highly ufeful in dropfy; and any mode of it may be employed that the pa- tient can mod conveniently admit of. It fhould, however, always be as much as he can eafily bear; and in anafarca, the fhare which the exercife of mufcles has in promoting the motion of the venous blood, induces me to think that bodily exercife, to whatever degree the patient can bear it, will al- ways be the mod ufeful. From fome experience alfo, I am perfuaded, that by exercife alone, em- ployed early in the difeafe, many dropfies may be Cured. 1695. Besides exercife, various tonic remedies are pro- perly employed to redore the tone of the fydem. The chief of thefe are, chalybeates, the Peruvian bark, and various bitters. Thefe are not only fuited to redore the tone of the fydem in general, but are particularly ufeful in drengthening the or- gans of digedion, which in dropfies are frequently very much weakened : and for the fame purpofe alfo aromatics may be frequently joined with the tonics. 1696. Cold bathing is upon many occafions the moft powerful tonic we can employ; but at the begin- ning of dropfy, when the debility of the fydem is confiderable, it can hardly be attempted with fafe- ty- After, however, the water of dropfies has been OF PHYSIC. 357 been very fully evacuated, and the indication is to drengthen the fydem for preventing a relapfe, cold bathing may perhaps have a place. It is, at the fame time, to be admitted with caution; and can fcarcely be employed till the fydem has otherwife recovered a good deal of vigour. When that in- deed has happened, cold bathing may be very ufe- ful in confirming and completing it. 1697. In perfons recovering from dropfy, while the fe- veral means now mentioned for strengthening the fydem are employed, it will be proper at the fame time to keep condantly in view the fupport of the watery excretions; and confequently the keeping up the perfpiration by a great deal of exercife, and continuing the full dow of the urinary excre- tions by the frequent ufe of diuretics. Sect. II. Of the Hydrothorax, or Dropsy of the Breast, 1698. THE preternatural colleaion of ferous duid in the thorax, to which we give the appellation of Hydrothorax, occurs more frequently than has been imagined. Its prefence, however, is not always to be very certainly known ; and it often takes place to a confiderable degree before it be difco- vered. 1699. Thefe colleaions of watery fiuids in the thorax, are found in different fituations. Very often the water is found at the fame time in both facs of the pleura. 358 PRACTICE pleura, but frequently in one of them only. Sometimes it is found in the pericardium alone; but for the moft part it only appears there when at the fame time a colleaion is prefent in one or both cavities of the thorax. In fome indances, the colleaion is found to be only in that cellular texture of the lungs which furrounds the bronchiae, without there being at the fame time any effufion into the cavity of the thorax. Pretty frequently the water coileaed confids chiefly of a great number of hydatides in different situations; fometimes feemingly floating in the ca- vity, but frequently conneaed with and attached to particular parts of the internal furface of the pleura. 17OO. From the colleaion of water being thus in vari- ous situations and circumdances, fymptoms arife which are different in different cafes; and from thence it becomes often difficult to afcertain the prefence and nature ofthe affeaion. I fhall, how- ever, endeavour here to point out the mod com- £ mon fymptoms, and efpecially thofe of that prin- i cipal and mod frequent form of the difeafe, when the ferous fluid is prefent in both facs of the pleura, or, as we ufually fpeak, in both cavities of the thorax. I7OI. The difeafe frequently comes on with a fenfe of anxiety about the lower part of the fternum. This, before it has fubfided long, comes to be joined with fome difficulty of breathing; which at fird ap- pears only upon the perfon's moving a little fader than ufual, upon his walking up an acclivity, or upon his afcending a flakcafe : But after fome time, this difficulty of breathing becomes more condant and ccw*ikler*bie,, -especially during the night, when the O F P H Y S I C. 359 the body is in a horizontal fituation. Commonly, at the fame time, King upon one tide is more eaiy than upon the otjier, or perhaps lying upon the back more e?fy than upon either fide. Thefe cir- cumdances are ulually attended with a frequent cough, that is at firft dry ; but which, after fome time, is accompanied with an expeaoration of thin mucus. With all thefe fymptoms, the hydrothorax is not certainly difcovered, as the fame fymptoms often attend other difeafes of the bread. When, howe- ver, along with thefe fymptoms, there is at the iame time an cedematous fwelling ofthe feet and legs, a leucophlegmatic palenefs ofthe face, and a fcarci- ty of urine, the exidence of a hydrothorax can be no longer doubtful. Some writers have told ur., that fometimes in this difeafe, before the fwelling of the feet comes on, a watery fwelling of the icro- tum appears ; but I have never met with any in- dance of this. 1702. Whild the prefence of the difeafe is fomewhat uncertain/ there is a fymptom which fometimes takes place, and has been thought to he a certain characleriftic of it; and that is, when, foon after the patient has fallen afleep, he is fuddenly awaked with a fenfe of anxiety and difficult breathing, and with a violent palpitation of the heart. Thefe feelings immediately require an erea podure; and very often the difficulty of breathing continues to require and to prevent fleep for a great part ofthe night. This fymptom I have frequently found at- tending the difeafe ; but I have alfo met with feve- ral inftances in which this fymptom did not appear. I mud remark further, that I have not found this fymptom attending the empyema, or any other dii- eafe of the thorax ; and therefore, when it attends a -difficulty of breathing, accompanied with anv the ' "~ r ' 11 _ Of tonic remedies, one of the mod promising feems to have been cold bathing; and I have found it the mod powerful in preventing the difeafe. For a long time pad, it has been the praaice in this country, with people of all ranks, to wafh their children from the time of their birth with cold wa- ter; and from the time that children are a month old, it has been the praaice with people of better rank to have them dipped entirely in cold water every morning : And wherever this praaice has been purfued, I have not met with any indance of rickets. Amongd our common people, although they wafh their children with cold water only, yet they do not fo commonly praaife immersion : And when amongd thefe I meet with indances of rickets, I prefcribe cold bathing ; which accordingly has often checked the progrefs ofthe difeafe, and fome- times feems to have cured it entirely. 1732. The remedy of Ens Veneris* recommended by- Mr. Boyle; and fince his time very univerfally em- ployed, is to be confidered as entirely a tonic reme- dy. That or fome other preparation of iron I have almod condantly employed, though not indeed al- ways with fuccefs. I have been perfuaded, that the ens veneris of Mr. Boyle, notwithdanding his giving it this appellation, was truly a preparation of iron, and no other than what we now name the Vol. II. 3B Flore:- 378 P&ACT ICE Fibres Mdrtiales*: But it appears, that botli Behe- voli and Buchher have employed a preparation of copper; and I am ready to believe it to be a more powerful toiiic than the preparations of irorit. '733- Upon the fuppofitidn of tonic remedies being proper in this difeafe, I have endeavoured to em- ploy the Peruvian bark: But frorri the difficulty of adminidering it to infants iii any ufeful quantity, I have not been able to difcover its efficacy ; but I ani very ready to believe the tedimony or Dc Haen upon this fubjeaj. ": T734. Exercife, which is one of the mod powerful to- nics, has been properly recommended for the cure of rickets ; and as the exercife of gedation only can be employed, it fliould always be> with the child laid in a horizontal fituation; as the carrying them, or moving them in any degree of an erea pofitafe, is very apt to occafion fome diflortiori. It is ex- tremely probable, that, in this difeafe, friction with dry flannel's may be found an ufeful remedy. 1735- li * The dofe of this medicine is from four to twenty grains, it muft be given in the form of a bolus. The young practitioner ought to beware of prefcribing Flores mar- tiales in pills, which will fwell and crumble to pieces if they are not compofed of * confiderable quantity of fome gummi refin. The Flores martiales may be very conveniently given in a tincture of proof fpirit. There is a formula of it in the laft London Pharmacopoeia, under the name of Timc- tura ferri Ammoniacalis. The dofe of it is a tea.fpoonful in a wine gfefsof cold water, and it is a very elegant form of adminiftenrig the chalybeates. + Copper is a very dangerous remedy, as was mentioned above in the notes on article 1337. The Author had a very high opinion of copper as a tonic. t It is doubtlefs difficult to make children "Swallow a fufrkient quantity of bark (0 produce any good effects, yet it is not impoffible. The formula beft adapted for children, is the powder,of the extract; but as it fometimes occafions conftipation,. this effect muft be guarded againft by fome proper laxative, efpecially by Rhubarb given either with the bark or feparat*ly. The following formula is a proper ddfe for a child of two years old, to be/epeated twice a day : R. Extf. Cort. Pcruv. dm-, gr. viiu Pulv. Rad. Rbej. gr. x. Sacch. Alb. pr.. xv. M. f. Pulv. " of » p y 6 i e. m }t is alfo fijfpciently prpbable, that the avoiding of moif)ure i^ not only advifpable, hut may likewife be of fervice in the cure .of this difeafe. There is no doubt that a certain diet may cqn- trifyut? to tjie fame end ; but what may be the mod eligible, J dare riot determine. I have no dpu|K that leavened ^rea4 niay be more proper than un- fermented farinacea; b,ut I cannot fjnd any reafon tp believe that ftrong l?eer can ever be a proper remedy. practitioners fiave been divided in opinion con- cerning the ufe of milk in tl)is difeafe. £eviani, perhaps from theory, condemns the ufe of it; but Benevoli employed it without its impeding the cure of the difeafe. This lad I have often remarked in the courfe of my own praaice. As it is difficult to feed cfijjcjren entirely wjtjiont milk ; fo I have common- ly admitted )t as a part of the xj'iet of rickety chil- pren j %f)4 in many indances I can affirm, .that it difl not prevent the cure ofthe difeafe. In cafes, hpyfpver, of any appearance of rickets, and parti- cularly of a flow jGlentition, I have diffuaded the continuance of a child upon the frreaft; becaufe the milk of women is a mpre watery nourifriment than that of cows: And I have efpecially 4'ffuaded tne continuing a c^3Ld upon t)ie bread, when I thought the nurfe gave rather too much of fuch a watery nou- rifhment ; for, as has been above mentioned, I have had frequent occafion to fufpea, that the milk of fuch nurfes has a tendency to favour the coming on of the rickets*. »736- Besides the remedies and regimen now mention- ed, praaitioners have commonly employed in this difeafe j * How does this accord with the laft fentence of article 1723 * 380 P R A C T I C E, &c. difeafe, both emetics and purgatives. When the appetite and digedion are confiderably impaired, vo- miting, if neither violent, nor frequently repeated, feems to be of fervice ; and by a moderate agitati- on ofthe abdominal vifcera, may in fome meafure obviate the dagnation and confequent fwelling that ufually occur in them. As the tumid date of the abdomen, fo condantly to be met with in this difeafe, feems to depend ve- ry much upon a tympanitic affeaion of the inted- ines ; fo, both by obviating this, and by deriving from the abdominal vifcera, frequent gentle purg- atives may be of fervice. Zeviani, perhaps pro- perly, recommends in particular rhubarb ; which, besides its purgative quality, has thofe alfo of bit- ter and adringent. J737- I have now mentioned mod ofthe remedies com- monly employed by the praaitioners of former times; but I mud not omit mentioning fome others that have been lately fuggeded. The late Mr. De Haen recommends the tedacea; and affures us of their having been employed with fuccefs -. But in the few trials which I have had occafion to make, their good effeas did not appear. The late Baron Van Swieten gives us one indance of rickets cured by the ufe of hemlock : but I do ppt know that the praaice has been repeated. BOOK C 38i ] BOOK III. Of the IMPETIGINES; or DEPRAVED HABIT, with AFFECTIONS of the SKIN. IF I N D it difficult to give any fufficiently cor- rea and proper charaaer of this order. The difeafes comprehended under it, depend, for the mod part, upon a depraved date of the whole of the fluids, producing tumours, eruptions, or other preternatural affeaions of the fkin. Although it be extremely difficult to find a general charaaer of the order that will apply to each of the genera and fpecies, I fliall here treat of the principal genera which have been commonly comprehended under this order, and which I have enumerated in my Nofology. CHAP. I. Of SCROPHULA, or the KING's EVIL. I739- THE charaaer of this difeafe I have attempted in my Nofology: But it will be more proper- ly taken from the whole of its hiflory, now to be delivered. 1740. It 382 PRACTICE 1740. It is commonly, and very generally, a heredita- ry difeafe; and although it fometimes may, yet it Farsly appear^ but in children whole parents had at fome period of their lives been affeaed with it. Whether it may net fail to appear in the children ©f fcrophulous parents, and difcover itfelf after- wards in their offspring in the fucceeding genera- tion, J cannot certainly deterniine ; but believe that this has frequently happened. It appears to me to be derived mpre commonly from fathers than from mothers; but whether this happens from there being more fcrophulous men than fcrophulous women married, I am not certain. With refpea to the influence of parents in pro- ducing this difeafe, it deferves to be remarked, that in a family of many-children, when pne of the parents has been affeaed with fcrpphula, and the other not; as it is ufual for fome of the chil- dren to be in conditution pretty exaaiy like the on« parent, and others of them like the other; it commonly happens that thofe children who mod refembie the fcrophulous pa-rent become affe&ed with fcrophula, while thofe refembling the other parent entirely efcape. J74i- The fcrophula generally appears at a particular period of life. It feldom appears in the fird, or even in the fecond year of a child's life ; and molt commonly it occurs from tjie fecond, or, as fome allege, and perhaps more properly, from the third •to the feventh year. Frequently, however, it (Jif- covers itfelf at a later period; and there are in- itanccs of its firft appearance, at every period till the age of puberty; after which, however, the fird appearance of it is very rare. 1742. When OF PHYSIC. zH 1742. When it does not occur very early, we can ge- nerally didihguifh the habit of body peculiarly dif- pofed to it. it mod commonly afreas children of foft a*nd flaccid habits, of fair hair and blue eyes; or at le'Sd affeas thofe much more frequently than thofe of ah oppofite complexion. It affects especi- ally children of frhooth fkins and fosy cheeks; and fuch children have frequently a tumid upper lip, with a. chop in the middle of it; and this tumour is often considerable, and extended to the cohimha nafi arid lower part of the rioftrils. The difeafe is fometimes joined with, or follows rickets; and al- though it frequently appears in children who have not had rickets in any great degree, yet it often at- tacks thofe who, by a protuberant forehead, by tu- mid joints, and a tumid abdomen, fhow that they hid fofrie rachitic difpofition. In parents who, without having had the difeafe themfelves, feem to produce fcropnulous children, we can commonly perceive much of the farrie habit and conditution that lias been jud now defcribed. Some authors have fuppofed that the fmall pox has a tendency to produce this difeafe ; and Mr. t)e Haen aflerts its following the inoculated, more frequently than the natural, fmall pox. This laft ^bfition, however, we can confidently affirm to be a midake ; although it miifi be allowed, that in faa the fcrophula does often come on immediately after the fmall pox. It is, however, difficult to find any c'onneaion between the two difeafes. According to my obfervation, the accident only happens in children who have pretty manifedly the fcrophulous difpofition ; and I have had feveral indances ofthe natural fmall pox coming upon children affeaed at the fame time with fcrophula, not only without this difeafe being any ways aggravated by the fmall pox, but even of its being for fome time after much re- lieved. 1743. The 384 PRACTICE 1743- The fcrophula generally fhows itfelf fird at a par- ticular feafon of the year; and at fome time be- tween the winter and dimmer foldice; but com- monly long before the latter period. It is to be obferved further, that the courfe of the difeafe is ufually conneacd with the courfe of the feafons. Whild the tumours and ulcerations peculiar to this difeafe, appear fird in the fpring, the ulcers are frequently healed up in the courfe of the fucceed- ing fummer, and do not break out again till the en- fuing fpring, to follow again with the feafon the fame courfe as before. 1744. Frequently the fird appearance of the difeafe is the tumid and chopped lip above mentioned. Up- on other occafions the fird appearance is that of fmall fpherical or oval tumours, moveable under the d;in. They are foft, but with fome eladicity. They are without pain ; and without any change in the colour of the fkin. In this date they often continue for a long time; even for a year or two, and fometimes longer. Mod commonly they fird appear upon the fides of the neck below the ears; but fometimes alfo under the chin. In either cafe, they are fuppofed to affea in thefe places the con- globate or lymphatic glands only ; and not at all the falivary glands, till the difeafe is very greatly ad- vanced. The difeafe frequently affeas, and even at fird appears in, other parts of the body. In par- ticular, it affeas the joints of the elbows and an- kles, or thofe of the fingers and toes. The appear- ances about the joints are not commonly, as elfe- where, fmall moveable fwellings ; but a tumour al- mod uniformly furrounding the joint, and inter- rupting its motion. 1745. Thefe OF PHYSIC. 3«5 *745- Thefe tumours, as I have faid, remain for fome time little changed; and, from the time they firft. appeared in the fpring, they often continue in this way till the return of the fame feafon in the next, or perhaps the fecond year after. About that time, however, or perhaps in the courfe of the feafon in which they firft appear, the tumour becomes larger and more fixed; the fkin upon it acquires a purple, feldom a clear rednefs: But growing redder by de- grees, the tumour becomes fofter, and allows the fluauation of a liquid within to be perceived. All this procefs, however, takes place with very little pain attending it. At length fome part of the fkin becomes paler; and by one or more fmall aper- tures a liquid is poured out. 1746. The matter poured out has at firft the appear- ance of pus, but it is ufually of a thinner kind than that from phlegmonic abfceffes ; and the matter as it continues to be difcharged, becomes daily lefs purulent, and appears more and more a vifcid fe- rum, intermixed with fmall pieces of a white fub- ftance refembling the curd of milk. By degrees the tumour almod entirely fubfides, while the ul- cer opens more, and fpreads broader; unequally, however, in different direaions, and therefore is without any regular circumfcription. The edges of the ulcer are commonly flat and fmooth, both on their outfide and their inner edge, which fel- dom puts on a callous appearance. The ulcers, however, do not generally fpread much, or become deeper; but at the fame time their edges do not advance, or put on any appearance of forming a cicatrix. Vol. II. gC 1747. In |8'6 PRACTICE I747- In this condition the ulcers often continue for a long time ; while new tumours, with ulcers fuc- ceeding them in the manner above defcribed, make their appearance in different parts of the body. Of the firft ulcers, however, fome heal up, while other tumours and ulcers appear in their vicinity, or in other parts of the body : And in this manner the difeafe proceeds, fome of the ulcers healing up, at lead to a certain degree, in the courfe of fummer, and breaking out in the fucceeding fpring: Or it continues, by new tumours and ulcers fucceeding them, in the fpring feafon, making their appear- ance fucceffiveiy for feveral years. 1748. In this way the difeafe goes on for feveral years; but very commonly in four or five years it is fpon- taneoufly cured, the former ulcers being healed up, and no new tumours appearing : And thus at length the difeafe ceafes entirely, leaving only fome inde- lible efchars, pale and smooth, but in fome parts fhrivelled ; or, where it had occupied the joints, leaving the motion of thefe impaired, or entirely dedroyed. '749- Such is the moft favourable courfe of this difeafe; and with us, it is more frequently fuch, than other- wife : But it is often a more violent, and fometimes a fatal malady. In thefe cafes, more parts of the body are at the fame time affeaed ; the ulcers al- fo feeming to be imbued with a peculiarly fliarp ' acrimony, and therefore becoming more deep, erod- ing, fpreading, as well as feldomer healing up. In fuch cafes, the eyes are often particularly affeaed. The O F P H Y S I C. g87 The edges of the eyelids are affeaed with tumour and fuperficial ulcerations; and thefe commonly •excite obdinate inflammation in the adnata, which frequently produces an opacity of the cornea. When the fcrophula efpecially affeas the joints, it fometimes produces there confiderable tumours ; in the abfceffes following which, the ligaments and cartilages are eroded, and the adjoining bones are affeaed with a caries of a peculiar kind. In thefe cafes, alfo, of more violent fcrophula, while every year produces a number of new tumours and ulcers, their acrimony feems at length'to taint the whole fluids of the body, occafioning various diforders ; and particularly a heaic fever, with all its fymp- toms, which at length proves fatal, with fometimes the fymptoms of a phthifis pulmonalis. 1750. The bodies of perfons who have died of this dif- eafe fhow many of the vifcera in a very morbid ftate; and particularly mod of the glands of the mefentery very much tumefied, and frequently in an ulcerated date. Commonly alio a great number of tubercles or cyds, containing matter of various kinds, appear in the lungs. '751- Such is the hidory ofthe difeafe; and from thence it may appear, that the nature of it is not eafily to be afcertained. It feems to be a peculiar affeaion of the lymphatic fydem ; and this in fome meafure accounts for its connection with a particular period of life. Probably, however, there is a peculiar acri- mony of the fluids that is the proximate caufe ofthe difeafe; although of what nature this is, has not yet been difcovered. It may perhaps be generally aiffufed in the fydem, and exhaled into the feveral cavities and cellular texture ofthe body ; and there- 888 PRACTICE fore, being taken up by the abforbents, may difco- ver itfelf efpecially in the lymphatic fydem. This, however, will hardly account for its being more confined to that fydem, than happens in the cafe of many other acrimonies which may be fuppofed to be as generally diffufed. In fhort, its appear- ance in particular conflitutions, and at a particular period of life, and even its being a hereditary dif- eafe, which fo frequently depends upon the tranf- miffion of a peculiar conditution, are all of them circumdances which lead me to conclude, upon tfie whole, that this difeafe depends upon a peculiar confiitution of the lymphatic fyftem. 1752. It feems proper to obferve here, that the fcro- phula does not appear to be a contagious difeafe ; at lead I have known many indances of found chil- dren having had frequent and clofe intercourfe with fcrophulous children without being infea.ed with the difeafe. This certainly fhows, that in this dif- eafe the peculiar acrimony of it is not exhaled from the furface of the body, but that it depends especi- ally upon a peculiar conditution ofthe fydem. J753- Several authors have fuppofed the fcrophula to have been derived from the venereal difeafe; but upon no jud grounds that I can perceive. In ve- ry many indances, there can hardly be any fufpici- on of the parents producing this difeafe having been imbued with fiphylis, or with any fiphylitic taint; and I have known feveral examples of pa- rents conveying fiphylis to their offspring, in whom, however, no fcrophulous fymptoms at any time af- terwards appeared. Further, the fymptoms ofthe two difeafes are very different; and the difference pf their natures appears particularly from hence, OF PHYSIC. 3«9 that while mercury commonly and readily cures the fiphylis, it does no fervice in fcrophula, and very often rather aggravates the difeafe. '754- For the cure of fcrophula, we have not yet learn- ed any praaice that is certainly or even generally fuccefsful. The remedy which feems to be the mod fucceff- ful, and which our praaitioners efpecially trud to and employ, is the ufe of mineral waters; and in- deed the wafhing out, by means of thefe, the lym- phatic fydem, would feem to be a meafure promif- ing fuccefs: but in very many indances of the ufe of thefe waters, I have not been well fatisfied that they had fhortened the duration of the difeafe more than had often happened when no fuch re- medy had been employed. '755- With regard to the choice of the mineral waters mod fit for the purpofe, I cannot with any confi- dence give an opinion. Almod all kinds of mine- ral waters, whether chalybeate, fulphureousor fa- line, have been employed for the cure of fcrophu- la, and feemingly with equal fuccefs and reputa- tion : A circumdance which leads me to think, that, if they are ever fuccefsful, it is the elemen- tary water that is the chief part of the remedy. Of late, fea water has been efpecially recom- mended and employed; but after numerous trials, I cannot yet difcover its fuperior efficacy. i756. The other remedies propofed by praaical writ- ers are very numerous; but, upon that very ac- count, I apprehend they are little to be trulted: and 39° PRACTICE and as I cannot perceive any jud reafon for expect- ing fuccefs from them, I have very feldom em- ployed them. Of late, the Peruvian bark has been much re- commended: And as in fcrophulous perfons there are generally fome marks of laxity and flaccidity, this tonic may poffibly be of fervice ; but in a great variety of trials, I have never feen it pro- duce any immediate cure of the diieafe. In feveral indances, the leaves of coltsfoot have appeared to me to be fuccefsful. I have ufed it frequently in drong decoaion, and even then with advantage ; but have found more benefit from the expreffed juice, when., the plant could be had in fomewhat of a fucculent date, foon after its fird appearance in the fpring. '757- I have alfo frequently employed the hemlock, and have fometimes found it ufeful in difcufling obflinate fwellings: But in this, it has alfo often difappointed me ; and I have not at any time ob- ferved that it dilpofed fcrophulous ulcers to heal. I cannot conclude the fubjea of-internal medi- cines without remarking, that I have never found, either mercury or antimony, in any fhape, of ufe in this difeafe ; and when any degree of a feverifh date had come on, the ufe of mercury proved ma- nifedly hurtful. i758. In the progrefs of fcrophula, feveral external medicines are requifite. Several applications have been ufed for difcufling the tumours upon their fird coming on; but hithero my own praaice, in thefe refpeas, has been attended with very little fuccefs. The folution of faccharum faturni has feemed to be ufeful; but it has more frequently failed: OF PHYSIC. 39» failed: And I have had no better fuccefs with the fpiritus Mindereri. Fomentations of every kind have been frequently found to do harm; and poul- tices feem only to hurry on a fuppuration. I am doubtful if this lad be ever praaifed with advan- tage ; for fcrophulous tumours fometimes fponta- neoufly difappear, but never after any degree of in- flammation has come upon them; and therefore poultices, which commonly induce inflammation, prevent that difcuffion of tumours, which might otherwife have happened. Even when fcrophulous tumours have advanced towards fuppuration, I am unwilling to haden the fpontaneous opening, or to make it by the lancet; becaufe I apprehend the fcrophulous matter is lia- ble to be rendered more acrid by communication with the air, and to become more eroding and fpreading than when in its inclofed date. *759- The management of fcrophulous ulcers has, fo far as I know, been as little fuccefsful as that ofthe tumours. Efcharotic preparations, of either mer- cury or copper, have been fometimes ufeful in bring- ing on a proper fuppuration, and thereby difpofing the ulcer to heal; but they have feldom fucceeded, and more commonly they have caufed the ulcer to fpread more. The efcharotic from which I have received mod benefit is burnt alum, and a portion of that mixed with a mild ointment, has been as ufeful an application as any I have tried. The ap- plication, however, that I have found mod fervice- able and very univerfally admiffible, is that of linen cloths wetted with cold water, and frequently chang- ed when they are becoming dry, it being inconve- nient to let them be glued to the fore. They are therefore to be changed frequently during the day ; and a cloth fpread with a mild ointment or plader may be applied for the night. In this practice i have 392 PRACTICE have fometimes employed fea water; but generally it proved too irritating ; and neither that nor any mineral water has appeared to be of more fervice than common water. 1760. To conclude what I have to offer upon the cure of fcrophula, I mud obferve, that cold bathing feems to have been of more benefit than any other remedy that I have had occafion to fee employed. CHAP. II. Of SIPHYLIS, or the VENEREAL DISEASE. 1761. AFTER praaitioners have had fo much expe- rience in treating this difeafe, and after fo many books have been publifhed upon the fubjea, it does not feem neceflary, or even proper, for me to attempt any full treatife concerning it; and I fliall therefore confine myfelf to fuch general re- marks, as may ferve to illudrate fome parts of the pathology or of the praaice. I762. It is fufficiently probable, that, anciently, in cer- tain parts of Alia, where the leprofy prevailed, and in Europe after that difeafe had been introduced into it, a difeafe of the genitals, refembling that which now commonly arifes from fiphylis, had fre- quently appeared : But it is equally probable, that a new difeafe, and what we at prefent term Siphylis, was fird brought into Europe about the end of the iifteenth century; and that the didemper now fo frequently OF PHYSIC. 393 frequently occurring, has been very entirely deriv- ed from that which was imported from America at the period mentioned*. 1763. This difeafe, at lead in its principal circumftan- ces, never arifes in any perfon but from fome com- munication with a perfon already affeaed with it. It is moft commonly contraaed in confequence of coition with an infeaed perfon; but in what man- ner the infeaion is communicated, is not clearly explained. I am perfuaded, that in coition, it is communicated without there being any open ulcer either in the perfon communicating or in the per- fon receiving the infeaion ; but in all other cafes, I believe it is never communicated in any other way than by a contaa of ulcer, either in the per- fon communicating, or in the perfon receiving the infeaion. I764. As it thus arifes from the contaa of particular parts, fo it always appears firft in the neighbour- hood of the parts to which the infeaing matter had been immediataly applied; and therefore, as moft commonly contraaed by coition, it generally ap- pears firft in the genitals. 1765. After its firft appearance in particular parts, more efpecially when thefe are the genitals of either fex, Vol. II. 3 D its * Various opinions have beeh held by different phyficians about the origin of this difeafe; fome fuppofing it to have exifted in the old world, while others think it was imported from the new world, difcovered by Columbus. The difpute produced many controverfial trads, from (he perufal of which, the young practitioner can gain. little advantageous knowledge. All that we certainly know about the origin of the difeafe is, that it was firft obferved among the French, when they were at Naples in the year 1493, and that it was brought into France by die French who returned thi- ther with Charles. Columbus landed at Palos on the 15th of March in the fame year, on his return from his firft voyage. The difeafe therefore, if IftpttWd by Columbus'i crew, muft haYC fpread rapidly through Ew^i g94 PRACTICE its effeas for fome time feem to be confined to* thefe parts ; and indeed, in many cafes, never ex- tends further. In other cafes, however, the infec- ting matter paffes from the parts fird affeaed, and from the genitals, therefore, into the blood-veffels ;, and being there diffufed, produces diforders in ma- ny other parts of the body. From this view ofthe circumdances, phyficians- have very properly didinguidied the different dates of the difeafe, according as they are local or are more univerfal. To the former, they have adapt- ed appellations fuited to the manner in which the difeafe appears; and to the other the general af- feaion, they have almod totally confined the ap- pellations of Siphylis, Lues Venerea, or Pox. In the remarks I am now to offer, I fliall begin with confidering the local affeaion. 1766. This local affeaion appears chiefly in the form of gonorrhoea or chancre. The phenomena of gonorrhoea either upon its fird coming on or in its after progrefs, or the fymp- toms of ardor urinae, chordee, or others attending it, it is not neceffary for me to defcribe. I fliall only here obferve, that the chief circumdance to be taken notice of, is the inflamed date of the ure- thra, which I take to be infeparable from the difeafe 1767. In thefe well known circumdances, the gonor- rhoea continues for a time longer or fliorter, accord- ing to the conditution of the patient; it ufually re- maining longed in the mod vigorous and robud, or according to the patient's regimen, and the care taken to relieve or cure the difeafe. In many ca- fes, if by a proper regimen the irritation ofthe in- flamed date is carefully avoided, the gonorrhoea fpontaneoufly OF PHYSIC. 395 fpontaneoufly ceafes, the fymptoms of inflamma- tion gradually abating, the matter difcharged be- coming of a thicker and more vifcid confidence, as well as of a whiter colour; till at length, the flow of it ceafes altogether; and whether it be thus eured fpontaneoufly, or by art, the difeafe often exids without communicating any infeaion to the •other parts ofthe body. 1768. In other cafes, however, the difeafe having been negfeaed, or by an improper regimen aggravated, it continues with all its fymptoms for a long time; and produces various other diforders, in the geni- tal parts, which, as commonly taken notice of by authors, need not be defcribed here. I fhall only obferve, that the inflammation ofthe urethra, which at fird feems to be feated chiefly, or only, in its anterior parts, is in fuch negfeaed and aggravated cafes fpread upwards along the urethra, even to the neck of the bladder. In thefe circumdances, a more confiderable inflammation is occafioned in •certain parts of the urethra; and confequently, fuppuration and ulcer are produced, by which the venereal poifon is fometimes communicated to the fydem, and gives rife to a general fiphylis. I769, It was fome time ago a pretty general fuppofi- lion, that the gonorrhoea depended always upon ulcers of the urethra, producing a difcharge of purulent matter ; and fuch ulcers do indeed fome- times occur in the manner that has been jud now mentioned. We are now allured, however, from many diffeaions of perfons who had died when la- bouring under a gonorrhoea, that the a'ifeafe may exid, and from many considerations it is probable that it commonly does exid, without any ulcera- tion 396 PRACTICE tion of the urethra : fo that the difcharge which ap- pears, is entirely that of a vitiated mucus from the mucous follicles of the urethra. I770. Although moft of the fymptoms of gonorrhoea fhould be removed, yet it often happens that a mucous fluid continues to be difcharged from the urethra for a long time after, and fometimes for a great part of a perfon's life. This difcharge is what is commonly called a Gleet. With refpea to this, it is proper to obferve, that in fome cafes, when it is certain the matter difcharged contains no veneral poifon, the matter may, and often does put on that puriform appear- ance, and that yellow and greenifh colour, which appears in the difcharge at the beginning and dur- ing the courfe of a virulent gonorrhoea. Thefe appearances in the matter of a gleet which before had been of a lefs coloured kind, have frequently given occafion to fuppofe that a frefh infeaion had been received: But I am certain that fuch appear- ances may be brought on by, perhaps, various other caufes; and particularly, by intemperance in venery and drinking concurring together. I be- lieve, indeed, that this feldom happens to any but thofe who had before frequently laboured under a virulent gonorrhoea, and have more or lefs of gleet remaining with them: But I muft alfo ob- ferve, that in perfons who at no period of their life had ever laboured under a virulent gonorrhoea, or any other fymptom of fiphylitic affeaion, I have met with inftances of difcharges from the urethra refembling thofe of a virulent gonorrhoea. The purpofe of thefe obfervations is, to fugged. to praaitioners what I have not found them al- ways aware of, that in perfons labouring under a gleet, fuch a return of the appearances of a viru- lent gonorrhoea may happen without any new infec- tion OF PHYSIC. 397 tion having been received, and confequently not requiring the treatment which a new infeaion might perhaps demand. When in the cure of go- norrhoea it was the praaice to employ purgatives very frequently, and fometimes thofe of the draf- tic kind, I have known the gleet, or spurious go- norrhoea, by fuch a praaice much increafed, and long continued, and the patient's conditution ve- ry much hurt. Nay, in order, more certainly fur- ther to prevent midakes, it is to be obferved, that the fpurious gonorrhoea is fometimes attended with heat of urine, and fome degree of inflammation ; but thefe fymptoms are feldom confiderable, and, merely by the affidance of a cool regimen, com- monly difappear in a few days. 1771. With refpea to the cure of a virulent gonor- rhoea, I have only to remark, that if it be true, as I have mentioned above, that the difeafe will often, under a proper regimen, be fpontaneoudy cured; and that the whole of the virulent matter may be thus entirely difcharged without the affidance of art; it would feem that there is nothing required of praaitioners, but to moderate and remove that inflammation which continues the difeafe, and oc- cafions all the troublefome fymptoms that ever at- tend it. The fole bufinefs therefore of our art in the cure of gonorrhoea, is to take off the inflam- mation accompanying it : And this I think may commonly be done, by avoiding exercife, by ufing a low and cool diet, by abdaining entirely from fermented and fpirituous liquors, and by taking plentifully of mild diluent drinks*. 1772. The * This fimple method of curing a gonorrhoea is, in many cafes, fufficient; but it can only be depended on when the difeafe is flight and the patient of a healthy con- ditution. As every virulent gonorrhoea is evidently produced by the aclion ofthe venereal poifon, the judicious practitioner will feldom truft to this method without the ufe of mercurials after the inflammatory fymptoms have been fomewhat fubdued. They ought to be given irvfuch cafes in very fmall quantities, fo as to produce only a flight effect00 ths mouth; a»d tlieir ufe ouglit to fce continued till every fymptom disappears. Mercury 39* PRACTICE I772. The heat of urine, which is fo troublefome in this difeafe, as it arifes from the increafed fenfibi- lity of the urethra in its inflamed date; fo, on the other hand, the irritation of the urine has the effea of increafing the inflammation, and is therefore to be removed as foon as poffible. This can be done mod effeaually by taking in a large quantity of mild watery liquors. Demulcents may be employ- ed ; but unlefs they be accompanied with a large quantity of water, they will have little effea*. Ni- tre has been commonly employed as a fuppofed re- frigerant: But, from much obfervation, I am con- vinced, that in a fmall quantity it is ufelefs, and in a large quantity certainly hurtfulf; and, for this reafon, that every faline matter paffing with the urine generally gives fome irritation to the urethra. To prevent the irritation of the urethra arifing from its increafed fenfibility, the injeaion of mucilage or of mild oil into it has been praaifed ; but I have feldom found this of much fervice. 1773. In _ Mercury miy be uf;J either internally or externally, as occafion may require ; if « does not arh-it the bowels nor purge, the common mercurial pill ofthe Edinburgh Pharmacopoeia is as goad a formula a3jany we have in the (hops, its dofe muft be vegukted by the effefts it produces. In general, we begin with a four grain pill every ni^ht, and continue that quantity till the gums be flightly affefted or a cop- pery tafte be perceived in the mouth. When either of thefe fymptoms appea- we are certain that the mercury is received, in a fufficient quantity, into the sen-ral maft of the blood, for deftroying the venereal virus, and then a pill may be given ence in two or three days, fo as to keep up the fame flight affection of the mouth, but without increafing it. If the pill purges, we then are to have recourfe to the ftrong mercurial ointment, half a dram of which muft be rubbed into the hams ni^ht and morning, till the mouth be alerted in the manner above defcribed The paVi eat OMght to wear flannel drawers during the whole time of the continuing the rub- ting which ought to be regulated1 by'the degree of affedion perceived in the mouth. 1 he ufe either ol the pill orof fnft.on muft be continued eight or ten days after every fymptom of the difeafe has difappeared. ' ' * Lintfeed tea, a very thin decoction of rmrfh-mallow root, or thin barley water, l„Wn T I' " i6 'nte"tV0R Efficiently well. The common almond emul. on has been recommended in thefe cales, and when taken in large quantities •s certainly very efficacious It may be ufed as the patient's common drink. t She ufe of nitre has been ftrongly recommended by many practical writers, in cales of fimple gonorrhoea unaccompanied with this fymptom; but it muft be ac- knowledged, as the author juftly obferves, to be hurtful by its irritating quality It » certainly a refrigerant, and as fuch is ufeful in allayfcig the inflammatory lyrnp- :-aw i but it is nuJmiifiblc in cafes where th« ardor wine is yiolint, ^ OF PHYSIC. 399 »773- In gonorrhoea, as coftivenefs may be hurtful, both by an irritation of the fyftem in general, and N of the urethra in particular, as this is occafioned always by the voiding of hardened faeces ; fo cof- tivenefs is to be carefully avoided or removed ; and the frequent ufe of large glyfters of water and oil, I have found of remarkable benefit in this difeafe. If glyfters, however, do not entirely obviate cof- tivenefs, it will be neceffary to give laxatives by the mouth : which, however, fhould be of the mildeft kind, and fhould do no more than keep the belly regular and a little loofe, without much purging*. The practice of frequent purging, which was for- merly fo much in ufe, and is not yet entirely laid aside, has always appeared to me to be generally fuperfluous, and often very hurtful. Even what are fuppofed to be cooling purgatives, fuch as Glaubc.'s fait, foluble tartar, and cryftals of tartar, in fo far as any part of them pafs by urine, they, in the fame manner as we have faid of nitre, may be hurtful ; and fo far as they produce very liquid ftools, the matter of which is generally acrid, they irritate the reaum, and confequently the urethra. This laft effea, however, the acrid, and in any degree draftic purgatives, mare certainly produce* 1774. In cafes of a gonorrhoea attended with violent inflammation, bloodletting may be of fervice ; and in the cafe of perfons of a robuft and vigorous ha- bit, * A tei-fpoonful ofthe following ek^uary tik:n occasionally will keep the j^ily fufficiently open. R. Pulv. Jalap. 3i. Nitri 5ii. Ele&. Lenitiv. 31.. Syr. fimpl. q, 8.. M. f. Elect.. 400 PRACTICE bit, in whom the difeafe is commonly the moft vi- olent, bloodletting may be very properly employ- ed. As general bleedings, however, when there is no phlogiftic diathesis in the fyftem, have little effea in removing topical inflammation; fo in go- norrhoea, when the inflammation is confiderable, topical bleeding applied to the urethra by leeches, is generally more effeaual in relieving the inflam- mation*. J775- When there is any phymofis attending a gonor- rhoea, emollient fomentations applied to the whole penis are often of fervice. In fuch cafes it is ne- ceffary, and in all others ufeful, to keep the penis laid up to the belly, when the patient either walks about or is fittingt. i776. Upon occafion of frequent priapifm and chor- dee, it has been found ufeful to apply to the whole of the penis a poultice of crumb of bread moiften-i ed with a ftrong folution of fugar of lead. I have, however, been often difappointed in this praaice, perhaps by the poultice keeping the penis too warm, and thereby exciting the very fymptoms I wifhed to prevent. Whether lotions of the external ure- thra with a folution of the fugar of lead, might be ufeful in this cafe, I have not properly triedj. 1777. With * The good effects of leeches in thefe cafes are confirmed by experience. They may be applied on the under fide of the penis, and three or four thus applied have frequently produced amazing effects. The operation, however, is extremely pain- ful, and is feldom fubmitted to a fecond time by a patient who has once experienced it. + In all cafes of inflammation ef the urethra thefe emollient applications give great relief. The common white bread poultice may be ufed during the night time* or while the patient is in bed; and warm flannels impregnated with lintfeed tea while he is fitting up. | The fugar of lead folution may perhaps be objected againft on account of its ftopping the difcharge, and inducing a fwelled tefticle, which has fometimes follow- ed «^ ?pplic»tk\n, Wrapping the penis up in Ijnen, rags wet with «°14 water, fro-' fluently OF PHYSIC. 40i 1777. With refpea to the ufe of injeftions, fo frequent- ly employed in gonorrhoea, I am perfuaded, that the early ufe of aflringent injeaions is pernicious; not by occafioning a fiphylis, as has been common- ly imagined; but by increafing and giving occa- fion to all the confequences of the inflammation, particularly to the very troublefome fymptoms of fwelled testicles. When, however, the difeafe has continued for fome time, and the inflammatory fymptoms have very much abated, I am of opinion, that by injeaions of moderate aftringency, or at leaft of this gradually increafed, an end may be fooner put to the difeafe than would otherwife have happened; and that a gleet, fo readily occurring, may be generally prevented*. 1778. Besides the ufe of aflringent injeaions, it has been common enough to employ thofe of a mercurial Vol. II. 3 E kind. quently anfwers the purpofe of preventing the violence of the fymptoms, as well ai any more complicated application. The cold wet rags ought to be renewed when- ever they grow warm. * The practice of ufing aflringent injections is extremely common ; but, as the author juftlyobferves, their ufe is frequently attended with difagreeable confequences. In general they always do harm when ufed during the continuance of the inflamma- tory fymptoms, or even too foon after thefe fymptoms have difappeared. It, how- ever, (after the inflammatory fymptoms are overcome, and mercury has been ufed for fix weeks or two months in the manner defcribed in the note on article 1771) the running ftill continues, we may then have recourfe to thefe aitriugent injections.— They may be made of fugar of lead and white vitriol well diluted with water, as in the following formula: R. Sacch. Saturn. Vitriol, ab. aa 3 fs« Aq. font. § viii. M. . r 1190 remote caufes of, 1198 proximate caufe of, "93 cure of, 1201 flatulence in it, cure of, 1221 heartburn in it, cure of, 1221 pains of ftomach in it, cure of, 1221 vomiting in it, cure of, 1221 Dyfpnce,a, 1366 Effluvia, 43° ..INDEX. Effluvia, human, ' from marfhes, Emaciations, caufes of, cure of, Emanjio menjium Emetics, fuited to the cure of fevers, their effects, a mean of removing fpafm, the adminiftration of in fevers, their ufe in intermittent fevers, Emprqfthotonos, Enteritis, phlegmonic or erythematic, caufes of, cure of, phenomena of, proximate caufe of, remote caufes of, predifponent caufes of, fympathic, cure of, idiopathic, cure of, Epiftaxis, the caufes of it, the various circumftances of, the management and cure of, Ery/ipelas, of the face, fymptoms of, prognofis of, proximate caufe of, cure of, phlegmonodes in different parts of the body, attending putrid fever, Erythema, Exanthemata Exercife, ufeful in intermittent fevers, *5 85 1601 1603—19 1620 997 , JH 170—180 170 J75 230—233 1267 404 404 406 408 1283 1284 1285 1286 1311 1317 1318 1317 1320 805 807 806—817 818—828 274 707 704—707 705 696 707—710 711 712 274 584 231 Fainting. See Syncope. Fatuity, Fear, a remote caufe of fever, Fever, 1170 *53° 97 8 Fever, INDEX. 43t Fever, ftrictly fo called, the character of, 8—32 phenomena of, 8 remote caufes of, are of a fedative nature, 36 proximate caufe of, 33 atony of the extreme veffels, a principal circumftance in the proximate caufe of it, 43—44 fpafm, a principal part in the proximate caufe of it, 40 general doctrine of, 46 the caufes of death in it, ioi the prognofis of, 99 indications of cure in, 126 differences of, 53 continent, 28 continued, 2 7 inflammatory, 67 miliary. See Miliary Fever. nervous, 67 bilious, 71 fcarlet. See Scarlet Fever. putrid, 72 named fynocha, 67 fynochus, 69 typhus, 67 bcctic, 74 intermittent, the paroxyfms of, defcribed,- 10 the cold ftage of, 1 i the hot ftage of, 11 the fweating ftage of, n of a tertian period, 25 of a quartan period? 25 of a quotidian period, 25 caufed by marfh effluvia, 84 bile not the caufe of it, 51 cure of, 228 its paroxyfms, how prevented, 229 attended with phlogiftic diathefis, 234 attended with congeftion in the abdomi- nal vifcera, 234 remittent, 26 Fluxes, without fever. See Proftuvia. Fluor albous. See Leucorrhcea. Fomentation ofthe lower extremities, its ufe in fevers,- 109 Fomites of contagion, 82 FunSions, intellectual, diforders of, 1529—30 Gangrene of inflamed parts, the caufe of, 255—256 marks of the tendency to, 257 marks of its having come on, 257 Gaftritis. 432 I N D E X. Gaftritis, 3^4 phlegmonic or erythematic, 385 phlegmonic, the feat of, 385 the fymptoms of, 386 the caufes of, 387 the cure of, 393—397 erythematic, how difcovered, 400 the feat of, 385 the cure of, 401 Gaftrodynia, 1428 Gleet, 1770 Gonorrhoea, 1766 phenomena of, 1768—70 cure of, 1771—79 Gout, the character of, 491 a hereditary difeafe, 499 diftinguifhed from rheumatifm, 525 predifponent caufes of, 492—499 occafional caufes of, 501—504 proximate caufe of, 526—532 not a morbific matter, 528 Regular, defcribed, 505—517 pathology of, 532 cure of, 563—572 no effectual or fafe remedy yet found for the cure of it, 538 medicines employed for it, 5SS whether it can be radically cured, 539 treatment in the intervals of paroxyfms, 541 treatment in the time of paroxyfms, 559 regimen during the paroxyfms, 560 external applications, how far fafe, 567-568 bloodletting in the intervals of paroxyfms, 552 562 coftivenefs hurtful, 558 laxatives to be employed, 558 effects of alkalines, 557 effects of Portland powder, 55^ Irregidar, 517 Aionic, 573—578 pathology, of, 533 cure of, 579—581 RctrOcedent, 521 pathology of, 534 cure of, 579—581 MifplaaJ, 522 pathology of, 535 cure of, 582—583 Tr.'ffated, two particular cafes of, 524 Hanaiemeji INDEX. 433 H. Hematemefts, 1016 arterial and venous, 1026 from obftructcd menftruation, 1019 from fuppreffion of the hemorrhoidal flux, 1024 from compreffion of the vafa brevia, by the fpleen, 1026 from obftruction ofthe liver, 1027 Hematuria, io32 idiopathic, improbable, 1052—33 calculofa, 1036 cure of, 1037 violenta, 1038 from fuppreffion of accuftomed discharges, 1040 putrida, ' 1042 fpuria et lateritia, io43 Hemiplegia, J * 3 9 caufes of, 1140 frequently occafioned by apoplexy, 1141 frequently atlernates with apoplexy, 1143 cure of, ' "51 ftimulants, of ambiguous ufe in, "59 ftimulants, external, in, 1160 Hamoptyfis, the fymptoms of, 837—839 the caules of, ' 759—62—829—S35 how diftinguifhed from other fpittings of blood, 840—44 cure of, 845—5l Hamorrhagia uteri, 9"5 Hemorrhagy, active or paffive, 734 character of, 735 arterial, 743 venous, 7 "7 the caufes of the different fpecies appearing at different periods of life, 749—772 the general phenomena of, 737—742 the remote caufes of, 773 cure of, 775 -------whether to be attempted by art, 775—80 prevention cf the firft attacks, or of the recurrence of, 781—788 treatment of when prefent, 788'—804 fymptomatic, 1014 Hamorrhcides veftca, 1041 Httmorrhois external and internal, 924 Vol. II. 3 I Hemorrhois, 434 INDEX. Hamorrhois, phenomena of, 924—93°" iiuture of the tumours, 931 caufes of, 93 2~942 acquire a connection with the fyftem,. 942—943 particularly with the ftomach, 945 cure of,. ' 946—964 Hcpjiirrhaa, J4<'2 Hepatitis, 41 r acute and chronic, 411 acute, the fymptoms of, 412—414 combined with pneumonic inflammation, 415 remote caufes of it, 4*5 feat of, 4J7 various exit of pus produced in, 420 cure of, 421 chronic, the feat of, 417 how difcovered, 422 Hoopingc-.ugh. See Chincough. J4°3 Horrcr, impreffion of, employed in intermittent fevers, 231 Human effluvia, the caufe of fever, 81 body, its temperature, 88 body has a power of generating heat,. 88 Hydrophobia, 15 2 J Hydrothorax, 1698 where feated, 1699 fymptoms of, 1702.—04 often combined with univerfal dropfy, 17°5 proximate caufe of, I7°7 cure of, 1708—09 paracentefis in it, when proper, 1709 Hypercafhaifis, *478 Hypochondriafis, 12 2 3 phenomena of, 1223 diftinguifhed from dyfpepfia, 1227 proximate caufe of, 1231 cure cf, I233 treatment of the mind inx 1245 Ifyfcria, 1515 fyrr p t c ms o f, 1516— 17 paroxyim or fit defcribed, 1516—17 rarely appears in males, 1518 how diflinguiftied from hypochondriafis, 1519—?0 proximate caufe of, x523 analogy between and epilepfy, *524 cure of, 1525 lihidinofa, 151 % Hyfteric difeafe. See Hyfteria. James's INDEX. 435 James1* powder, its ufe in fever, 183 Jaundice, 1816 —H caufes of, 1817 —22 cure of, 1824 —30 l8erus. See Jauvlice. Iliac paifion. See lit us. Ileus, 1438 Impetigines, 17^8 character of the order, 1738 Indigeflion. See Dyfpepfia. IiifLimmation, the phenomena of, 235 internal, the marks of, 236 the ftate of the blood in, ^37 the proximate caufe of, 239 not depending upon a lentor of the blood, 241 fpafm the proximate caufe of, 243- -248 terminated by refolution, 249 by fuppuration, 250 by gangrene, by fcinhus, 25S 258 by effuf en, 259 by blifters, . 260 by exfudation, 261 the remote caufes of, .262 the cure of in general, 264 by refolution, 264 the cure of, when tending to fuppura- tion, 268 —70 when tending to gangrene, 271 its general di\iiion>, 273 more ftrictly cutaneous, 274 of the bladder. See Cyftitis. of the brain. See Phreniiit. of the heart. See CarJiiis. ofthe inteftines. See Enteritis. ofthe kidneys. See Nephritis. oft lie liver. See Hepatitis. of the lungs. See Pneumonia. of the pericardium. See Pericarditis of the peritonaeum. See Peritonitis. of the lpleen. See Splenitis. of the ftomach. Sec Gaflritis. of the uteiUJ, 43i Infanity, l536 caufej of, 1551- -58 of different fpecies, l558 p.rtial and general, difference-of, 1576 IiUemperanci 436* INDEX. Intemperance in drinking, a remote caufe of fever, 97 Jntermifjion of fever, 24 Interval of fever, 24 Intunufcentie, 1621 character of the order, 1621 K. King's Evil. See Scrophula. Leucophlegmatia, 1670 Leucorrhcea, 984 character of, 985 appearance of the matter difcharged in, 986—991 the cauies of, 987 the effects of, 989 the cure of, 992 Lethargus, I093 Lientery, 1470 Loofenefs. See Diarrhcea. M. Madnefs. See Mania. Canine. See Canine. fllania, 1559 the fymptoms of, *559 the remote caufes of, 1560—62 the treatment of, 1563—75 occurring in fanguine temperaments, 1577 in fanguine temperaments, cure of, 1578 Marcores, 1601. Mar/h effluvia, a caufe of fever, 84 MeaJles, 632 the fymptoms of, 636—641 the nature of, 643 the cure of, 644—649 of a putrid kind, 642 Medicine, the inftitutions of, 4 Melana, 1016 Melancholia, ,_ !576 how diftinguifhed from hypochondriafis, 1588—89 the character of, 1583—90 the proximate caufe of, 1591 the treatment of, J593—98 Melancholic temperament, l230 Melancholy. See MelanchoTia. Menorrhagia, 965 Menor- INDEX. 487 Minorrhagia, active or paffive, 965 when a difeafe, 967—74 effects of, 97 x proximate caufe of, 976 remote caufes of, 977 cure of, 979 Menfes, immoderate flow of them. See Menorrhagia. Metallic tonics, employed in intermittent fevers, 231 falts, refrigerant, 136 Meteorifnus, J"34 Miafmata, '78 Miliary fever, the general hiftory of, 713^7 * 4 of two kinds, red 'and white, 715 white, the fymptdms of, 716—718 the cure of, 7*9 Morbus cxliacus, 1494 mucofus, 1069 niger, 1028 N. Nephritis, 425 the fymptoms of, 42 <; the remote caufes of, 426 the cure of, 429 Nervous Difeafes. See Neurofs. Neurofes, 1089 Neutral Salts, diaphoretic in fevers, 159—l€i refrigerant in fevers, 135 Nofotog>>, Methodical, 2 o. Obefity, when a difeafe, 1622 Oneirodynia, I5 9 9 Ophthalmia, 278 membranarum, 278 its different degrees, 279—280 its remote caufes, 280 the cure of, 288—290 tarfi, 278 the cure of, 288—290 Opiates, employed in the hot ftage of intermittent fevers, 233 in the interval of intermittent fevers, 231 Opifthatonos. See Tetanus. Palpitation of the heart, 13S^ the phenomena of, 1356 Palpitation 438 INDEX- Palpitation of the heart, the caufes of, l ?57 the cure of, J3°4 Palfy, ll39 diftinguifhed from apoplexy, io93 caufes of, JI4° Paracentefis in afcites, when to be attempted, I7l8 in hydrothorax, when proper, 1709 Paraphrenias, 343 Paroxyfm of intermittent fevers, the recurrence how to be prevented, 229 Pemphigus, 731 Pericardii is, 3H3 Peripneumonia notha, 37° fymptoms of, 379 pathology of, 3 80 the cure of, 38*—382 fome of the fymptcrr.s explained, 350 Pfi'itmeufjo'iy, 3> Peritonitis, 3 "4 Peruvian Bark, not a fpecific, 213 its tonic power, 214 when proper in fever, 215 how moft effectually employed, 216 the adminiftration of, in intermittent fevers, 232 the tonic chiefly employed in intermittent fe- vers, 232 Petechia, 733 Phlegmasia, 235 Ph'egmon, 274 Fhnnitis, 29l the character of, 293 the remote caufes of, 294 the cure of, 295—299 Phrenjy. See Phrenitis. Phyfic, the practice of, how taught, 1 the theory of, how to be employed, 4 Phyfconia, ^7*9 Phihifis Pulmonalis, the general character of, 852 always with an ulceration ofthe lungs, 854 the pus coughed up in, how diftinguifh- ed from mucus, 855 accompanied with hectic fever, 856 the varipus caufes of it, 862 from haemoptyfis, 863—8-64 from pneumonia, 865—868 from catarrh, 869—872 from afthma, 874 from tubercles, 875—881 from calcareous matter in the lungs, 883 if contagious, 885 Phihifts INDEX. 439 Phikifs Pulmonalis, from tubercles, fymptoms of, 888 its different duration, °95 the prognofis in, "9" the cure of, . 898—923 the treatment of when arifing from tuber- cles, 905—920 the palliation of fymptoms, 921 —923 Plague, f-f- the general character of, °°4 phenomena of, ,4 principal fymptoms of, ° J* proximate caufe of, 7 r • nc 6Cq—084 prevention or, ~. J T cure of, 685-694 Pleurify, 341 Pleurofthotonos. See Tetanus. Pneumonia, or Pneumonic Inflammation, 334 general fymptoms oi, 335 339 feat of, 54<>-344 prognofis of, 352~3^0 cure of, 3° the management of bloodletting in the cure of, " 362-367 the ufe of purgatives in, 37° the ufe of emetics in, 37 r the ufe of blifters in, ^ 3/2 the means of promoting expectoration in, 373 the ufe of fweating in, 374 the ufe of opiates in, 375 Polyfarcia, when a difeafe, l022 cure of, 1624—26 Profluvia, 1Q44 charafter of the clafs, . IC44 Pulfe, the ftate oftlie, during the paroxyfm of an inter- mittent fever, J 7 Purging, its ufe in continued fevers, J44 intermittent fevers, "34 Pus, how produced, 25° Puirefcency of the fluids in fever, the fymptoms of, 105 the tendency to in fever, how to be correct- ed 222—226 Pylorus, Scirrhous. See Dyfpepfia. Pyrexia:, " character of the clafs, " orders of the clafs, .•' 7 .:. . 1 j 28 Pyrofs, fymptoms of, M52 proximate caufe of> x434 remote caufes of, *433 cur, of, H35 Pyrofs 440 INDEX. Pyrofis Suecica of Sauvages, *429 Sfuinfy. See Cynanchc. R. Rachitis, 1720 its origin, 1721 remote caufes of, 1722—1724 phenomena of, 1725 proximate caufe of, 1726—1729 cure of, 173°—r737 ReaSion of the fyftem, 59 violent in fever, fymptoms of, 103 violence of, how moderated, 127 Refrigerants, the ufe of them in fever, 134 Remedies, table of thofe employed in continued fevers, 227 Remiffion of fever, 26 Refolution of inflammation, how produced, 249 Refpiration, the changes, during the paroxyfm of an int-Tmittent, 13 Revolution, diurnal, in the human body, ^ Rhciiiiuu'fin, acute or chronic, 432 Acute, the remote caufes of, 435 the proximate caufe of, 444—459 fymptoms of, 438—446 cure of, 460—469 Chronic, fymptoms of, 449 how diftinguifhed from the acute, 450 proximate caufe of, 471 cure of, 472—475 how diftinguifhed from gout, - 525 R'u-lets. See Rachitis. Rofe. See Erylhenw. Scarlet Itver, 650 the fymptoms cf, 655 diifewnt from cynanche maligna, 6.50—654 the- cure of, 656—663 Scrophula, 17 39 the phenomena of^.. 1739,—1750 the proxinr. to cauie' cf, 1 751 not contagious, \ J 752 11 ot ari(in, r from the 1 u _s ve 11 crea, 1753 the cure of, I?54—(,Q MefmLrLt, jgoy Scn.-vy, INDEX. 441 Scurvy, 1790 remote caufes of, 1 793—1803 cure of, 1805—10 proximate caufe of, 1812—15 Sinapifms, the effects of them, 197 Skin, affections of. See Impetigines. Small Pox, general character of, 586 fymptoms of the diftindt kind, 588 of the confluent kind, 589—592 general differences between diftinct and confluent, 593 caufes of thefe differences, 594—599 prognofis in, 592 cure of, 600—629 inoculation of, 601 the feveral practices of which it confifts, 602 the importance of the feveral practices belonging to, 603—614 management of fmall pox received by infection, 615—629 Soda, 1428 Spafm, internal, means of removing in fevers, 152—187 the proximate caufe of inflamma- tion, 243—248 Spafmodic affections without fever, 1251 of the animal functions, _ i254 of the vital functions, 1356 of the natural functions, 1428 Sphacelus, 255 Splenitis, 424 Stimulants, when to be employed in fevers, 217 their ufe in intermittent fevers, 230 Stomach, its confent with the veffels on the furface of the body, ^ Sudorifics, arguments for their ufe in fevers, 163—167 againft their ufe in fevers, 164 Suppuration of inflamed parts, the caufes of, 251 the marks of a tendency to, 251 formed, the marks of, 251 Surface ofthe body, its confent with the ftomach, 44 Swellings, general. See Intumefcentia. adipofe, 1622 flatulent, 162 7 watery. See Dropftes. Sweating, when hurtful in continued fevers, 16^ rules for the conduct of in continued fevers, 168 ufe of in intermittent fevers, 230 Syncope, n7o 3 K Syncope, 442 INDEX. Syncope, phenomena of, remote caufes of, predifpofition to, cure of, diftinguifhed from apoplexy, Synocha. See Fever. Synochus. See Fever. Syphilis, originally from America, how propagated, and gonorrhoea, how diftinguifhed, cure of, 1170 "73—"78 1184 1189 1093 1761 1762 1763 1765 1784—1789 Tabes a hydrope, a fanguifluxu, dorfalis, glandularis, mefenterica, nutricum, ischialgia, , fcrophulofa, Tartar Emetic, its ufe in fevers, Tetanus, remote caufes of, cure of, piffileum Barbadenfe, or Barbadoes tar, in, Lateralis, Tonic medicines employed in continued fevers, in intermittent fevers, Toothach, how far different from rheumatifm, fymptoms of, predifpofition to, remote caufes of, proximate caufe of, cure of, Trifmus. See Tetanus. Nafcentium, Tuffs. See Catarrh. Tympanites, the character of, the different fpecies of, inteftinalis, enterophyfodes, abdominalis, afciticus, phenomena of, proximate caufe 61, cure of, Typhus. See Fever. 1610 1609 1611 1607 1607 L609 1607 1607 185 1257 1268 1270 1280 1268 211 231 476—479 477 480 480—481 482 484—490 1282 1628 1629—31 1629 1629 1629 1629 ^33 1636—37 1638—45 Typhus, I N D E X. 443 Typhus, the fpecies of, V. 70 Vapours, or low fpirits. See Hypochondriafis. Venereal Difeafe. See Siphylis. Venery, excefs in, a remote caufe of fever, 97 Vefania, in general, I5i9 Vis Medicatrix Natura, 38 St. Vitus''s dance. See Chorea. Vomiting of blood. See Hematemefis. effects of in continued fevers, 172—173 the ufe of in intermitting fevers, 230—234 Urine, bloody. See Hematuria. Urticaria, the hiftory and treatment of, 729 w. Water Brafh. See Pyrofis. Whites. See Leucorrhcea. Warm Bathing, the effects of in fever, 198 the adminiftration of in fevers, 199 the marks ofthe good effects, 200 Wine, the moft proper ftimulant in fevers, /2i8 its convenient ufe in fevers, 219 when hurtful or ufeful in fevers, 220 THE END. MacLHist. no £