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FIRST   LINES
                 07 •
PRACTI
B Y
        WILLIAM CULLEN, M. D.

i-ATM PR6FMSS0R  Of  TUX PHACTICI OF fttTSlC Iff THE
         vxirERfirr or Edinburgh, &c. t£c.
IN   TWO  VOLUMES*
 With  PRACTICAL and EXPLANATORY  NOTES,
                      B Y
      JOHNROTHERAM,   M. D.
             TO WHICH  :s  PREFIXED
The   LIFE   of   ihe   AUTHOR.
VOL.  I.
              NEW-YORK':
Printmd bt Samurl Camf&eil, Book-Sellm*. and Statjo:
          Mo. 37, Hanover-Square.
                 M,DCC,XGIII 
 
ADVERTISEMENT.
   The  character of Dr. Cullen's Firft
 Lines of the Practice of Phyfic is fuffici-
 ently eftablifhed, and its intrinfic value has
 been long acknowledged by practitioners
 of every denomination.

   The  original intention of this Work
 was to ferve as a Text-Book or Bafis for
 the ingenious  and experienced Author's
 Lectures in the practical chair of the Uni-
 vcrfity of Edinburgh. But, as the Author
 is now deceafed,  and the Book is fought
 after with avidity by Students, who can
no longer have an opportunity of  hearing
the Doctor's Explanatory Obfervations,
Notes explaining abftrufe points,  and ac-
commodating  young Practitioners with
                                   the 
      ADVERTISEMENT.

the Formulae  and Dofes  of  Medicine,
which are mentioned in the Text only in
general  terms, have been added  to  this
Edition.

   A strict  attention has been paid to
print the Author's  Text  verbatim from
the laft Edition publifhed before his death.

   N. B. The American Publifher has, in
this Edition,  carefully diftributed  the
Notes throughout the Work, under their
different references: whereas, in the  Bri-
tifti Editions, they were wholly printed at
the end of the Laft Volume, which tended
very much to embarrafs and perplex  the
Reader. 
SKETCH
       OF  THi


LIFE
                 OF  THE LATE


  WILLIAM   C U L L E N,  M.  D.

     DE mortuis nihil nifibonum, is an adage generally
      followed;  and  exemplifies,  in a very finking
manner, the innate benevolence of the human heart,
when not warped by paffion or intereft.   Among the
dead no rival  is to be feared ;  nor can pofthumous
celebrity  oppofe the profeflional advancement of  the
living.   Mankind frequently yield  to a fafcinating
delufion in drawing  the  characters of diftinguiflied
literary men ;  and, through the defect of not giving
to fuch their true proportion of light and  fhade, render
the whole an indiicriminate glare of fulfome adulation.
By paying a jufl tribute of refpecl to the memory of
the illuftrious ctead, we hold up their conduit to  the
imitation of the living, and excite  a generous wi/h to
emulate their virtues.   The fubfequent Biographical
Sketch moulcLhave uncommon influence ; it. proves,
that even  in the mod  confined and humble fituation,
                                             men 
(6)
 men of ability and application may arrive to the high-
 eft profeflional rank in phyfic.
   William Cullen was born in 1713, at Lanark.   His
 father had been magiftrate of Hamilton,  but his  cir-
 cumstances were narrow.   It  has been remarked  that
 in Scotland few young men receive a fijijfhed claflical
 education ; the time and expence neceflary to complete
 fuch a courfe,  the  Scotch either cannot, or generally
 do not afford.   Cullen had only fuch as was deemed
 iufficiently preparatory to be  bound apprentice  to a
 iurgeon and apothecary in Glafgow; with him he re-
 mained four years..   When his term of apprenticefhip
 had been  completed, he engaged asfurgeon to a trad-.
 ing  vefTel to the Weft-Indies; and,  in this capacity,
 made fome voyages. There are few Situations he could
 have chofen more oppofite to  the general direction of
 his genius; we therefore cannot be furprifed he foon
 grew weary of  it,  and looked to a more eligible efta«
 blifhinent.  That his views in this refpedt were very
 humble, the fituation he chofe  is a proof; for he fettled
 as a  furgeon in  the  parifh  of Shotts, practising among
 the farmers and country people.   But,  as the practice
 of furgery  neither accorded with his feelings or genius,
 he foon became difgufted with it, and we find him in
 the  year 1737  fettled at Hamilton,  as phyfician, fur-
 geon and apothecary.   Soon after this period,  he  re-
 ceived into his  houfeas an eleve the late doctor Willi-
 am Hunter, who remained with him three years, when
 it was mutually agreed on, that Hunter fhould  go  to
 London for fome  time to improve himfelf in the prac-
 tice of furgery,  and that on his return to Hamilton a
 partnerfhip fhould commence  ; Cullen was to  attend
the medical bufinefs and Hunter the furgica!.   From
fome fortunate contingencies in Hunter's favour, this
project ended with their feparation,  and  Cullen  re-
mained until the year 1743 at Hamilton, when he was
accidentally employed by the Duke of Argyle,  whom
                                               he 
C/)
he fuccefsfully treated for a complaint in his eyes.   It
generally fo happens that we date the epoch of a me-
dical man's rifing into public notice from fome con-s
tingent circumftance either of a cure performed on, or
an acquaintance  commenced with,  fome  great man;
that fuch circumftances ferve to introduce phyficians
even (f mediocrity  of  abilities into general  practice
which they would never  otherwife  attain,  is I believe
true ;  but  men  of  real genius Stand on very different
ground : a brilliant connexion may undoubtedly acce-
lerate their profeflional progrefs, but real medical abi-
lity is  a vigorous Shoot,  and needs not the  prop o;f
lordly fupport.                                 {
   When Cullen left Hamilton, and fettled in Glafgow,
he feems to have been confeious of ability in phyfic,
fuperior to his opportunities of acquirement, for he im-
mediately  offered himfelf to the univerfity as profef^g:
of the institutes, and without being formally nominal
ed, he was allowed  to lecture.   He foon after  was  ap-
pointed  both to the chair of practice and chemiftnr,
and received his diploma of doctor in the year 1746.
Curiofity may be anxious to enquire  by what means
he could qualify himfelf for fuch important fituations,
particularly when it is known that he at once difplayed
uncommon talents for arrangement, gteat medical eru-
 dition, and peculiar accuracy in his method of teach-
 ing-;   in fo much that  he eclipfed ail the other proref-
 fors, and became the ftandard of medical oratory.
    We have remarked how much  confined his prepa-
 ratory education was, and we may ealily judge  how
 little  leilutc his fubiequent engagements either as an
 apprentice,  Iurgeon to  a trading  vefTel, or country
 apothecary and Surgeon, could have left him for litera-
 ry improvement ; and yet by that  little, with the  help
 of ftrong  intellectual  powers particularly directed  to
 the ftudy of phyfic, joined to a  retentive memory, and
 unwearied application,  was he enabled  to lay a  folid
IQUil- 
(*9
    Foundation for the brilliant character he fo juftly  ac-
    quired.   His growing reputation as profefTor in Glaf-
    gow, foon attracted the notice of the directors of the
    univerficy of Edinburgh, and on the chair of chemif-
    try  becoming vacant by  the  death of Dr. Plumber,
    Dr. Cullen was immediately appointed  to  fuccecd
    him.
      As profefTor of chemiftry it  is faid his lectures were
    peculiarly attractive, in fo much that they excited the
    envy of the other medical profefTors.   To  be  envied
    is fuch  a criterion  of  merit,  as to  become a poetical
JL  axiom elegantly expreffed by one of our greateft poets.
    *^  " Envy will merit as its fhadepurfuc,
       " But like a fliadow proves the fubftance true."
     .Cullen defpifed thofe impotent attempts which were
  .directed to oppofe his growing reputation, and viewed
  jjiem in  filent contempt;  his  fuperior  abilities,  his
   methodical arrangement in lecturing,  and his general
   liberal conduct: as a phyiician,  foon gave him a decid-
  ed fuperiority over all  his  medical  cotemporaries.—
   To the  Students  of  phyfic he  was  particularly atten-
   tive ; he  was ever ready to give them his advice on
   all occafions, if accidentally diftreffed he relieved their
  wants in the moft gracious manner, and he was  the
  firft phyfician that refufed fees  from medical Students,
  a circumftance that does  infinite  credit botn  to his
  head and heart.  I have  heard a variety of traits^ of
  this kind, that exemplify in a Striking  manner his dis-
  interested benevolence,  and how  delicately  and judi-
  cioufly he directed  his views  either  to relieve   the
  wants, fupply  the neceiTities, or Stimulate the induftry
  of the Student.
     In 1763, on the  death  of Dr. Alfton he was ap-
  pointed profeflor  of  Materia Medica;  and  how  well
  he  Succeeded  in  this  department his treatife on the
  Mateiia  Medica fully proves.  He  alfo gave clinical
  Lectures in the  general hofpital with lingular advan-
                                                 tars 
(9)
tage to the ftudent; but the great epoch of his medi-
cal celebrity was referved to the year 1 ?66, when on
the death of Dr. Whytte he was  appointed in con-
junction with the late Doctor Gregory to give lectures
on the theory and practice of phyfic ; and on Dr. Gre-
gory's death, which happened foon after this arrange-
ment took place, he became fole profefTor,  and in this
fituation he  continued until within a few months  of
his deaths   When appointed to the practical chair,  in
order to give his entire attention to the'duties of this
new  department,  he  refigned the profefTorftiip  of
Chemistry to his pupil the  prefent celebrated Doctor
Black.
  Although few men  pofTeffed more general  medical
ability than Doctor  Cullen;  ftill  his genius feemed
particularly  directed to the inveftigation of difeafe, we
therefore  need  not be furprifed that his  enquiry was
immediately pointed to a revifion of the then prevail-
ing fyftems  of  phyfic.  He acknowledges that Boer-
haave's fyftem was the only he  had learned, and with
its imperfections he became early acquainted, and on
many occafions was ufed to diffent from it.  This  ex-
cited much medical  contention among the Students,
and  induced our profefTor to offer the firft lines of a
new fyftem.  But firft  he published in 1769 his Sy-
nopQs Nofologiae Methodicae;  it was  a  general no-
menclature of difeafes reduced to botanical arrangement,
as claffes,  orders, genera and fpecies.   This was  in-
tended  to facilitate the knowledge  of  difeafes by ar-
ranging them according to the  leading circumstances
of their feveral affinities.   The idea was ingenious, but
the end propofed was not attained, for by throwing too
many objects at once before the  ftudent, he  firft  be-
came confufed, uninterested with fuch general accounts
and  at  laft  difgufted.  This method of  claffification
   Vol. I.              B                    was 
(16)
was firft  introduced by  Sauvages,  and immediately
adopted by  Linneus and Vogel; Sauvages was un-
doubtedly a man of great genius, and uncommon me-
dical erudition.   So early as the year 1732, he pub-
lished his Synofpis Nofoligiae  Methodicae.   To the
improvement of this plan  he dedicated I may fay the
remainder of his life:  In  1763  he published his Nofo-.
logia Methodica Siftens Morborum  ClaSTes, Genera et
Species Juxta Sydenhami mentem et Botanicorurn  or-
dinem, in five volumes octavo, at Amsterdam,  and in
Pari?, in  two volumes quarto:  He died in  1767,  after
a long and painful ficknefs, which he fuffered with
philofophic fortitude: He was upwards of thirty years
profefTor  of phyfic in the  univerfity of Montpellier.
   Sauvages  acknowledges he was indebted to Syden-
ham for  the idea of  claffing difeafes in botanical  ar-
rangement, and undoubtedly he has a decided fuperio-
rity in point of erudition  over all thofe who have writ-
ten on the fame fubjedt, however he errs in redundan-
cy ;for, under ten clafies, he comprehends 295 gene-
ra, including 2400 difeafes; Linneus and Vogel both
circumfcribed this catalogue ;  and  Cullen judicioufly
abridged it to nearly (I believe) the one half.
   Cullen's Synopfis may be only confidered as an in-
dex to his lectures.  In  1777, he publifhed his firft
lines of the practice of phyfic;  this  work he confidered
in fomerefpect as original, although evidently found-
ed on the  fyftem  of  Hoffman :  However,  his chief
view feems to be, to difcard that of  Boerhaave, which
was the doctrine until then generally received.   To
fay that  in the arrangement of this  important work he
excels all his predeceffors in the Lucidus Ordo, would
 be allowing (but in part) his merits.   He undoubted-
 ly has placed many of the phenomena attending  dif-
 eafe in a new point  of  view, and thrown additional
                                             light 
(•O
 light on all.   How far his totally rejecting the Humo-
 ral Pathology, and placing the caule of difeafe intire-
 ly in the various changes the moving powers may un-
 dergo,  is a queftion that will undoubtedly admit Still
 of much difpute ;  however, his firft lines may be con-
 fidered (with every degree  of propriety) among the
 beft general fyftems of phyfic.
   Cullen now gradually  approached that period at
 which his literary  labours were to end ; and it  muft
 be acknowledged that he fet with uncommon luftre.
 At the age of yy, he publifhed his treatife on the Ma-
 teria Medica, a work of the firft merit,  and the refult
 of more  than half  a century's experience.   The li-
 mits of this biographical Sketch will not permit any de-
 tail of the many valuable articles to be found in this
 treatife.   It may be fufficient to remark,  that he has
 judicioufly weeded the Materia Medica of a farrago of
 frivolous articles, and with fuperior difcrimination has
 taught the ufeand abufe of the moft important medi-
 cines ; his remarks on opium and the peruvian bark
 are invaluable.
   Cullen had  long fince arrived at his literary achme,
 and  began fenfibly to feel the gradual effects of declin-
 ing years.  In 1789 he refigned  his profefTorfhip, and
 in an affecting fpeech bid adieu to an auditory fully
 imprefTed with his  lingular merits ;  the next day he
 was  paid every academic honour ;  he furvived his re-
 signation but  a few months.  Doctor Cullen  was in
 his Perfon tall and  thin; his general appearance, on
 account of an  habitual Stoop, rather inelegant; how-
 ever, his countenance was expreflive, and his  general
 deportment prepoffeffing.   He had  early  in life marri-
 ed, and he left, I believe,  three daughters, and two
 fons : Henry,  who  fucceeded his father as  profefTor,
furvived him but a few months.   Although Dr. Cul- 
(12)
len?s profeflional emoluments formany years muft have
exceeded £. iooo Sterl. a-year; yet fuch  was his ge-
nerous and hofpitable difpofition, that he is faid to have
left but a very Slender provifion for his family.  How-
ever,  it is  to be hoped this want has been lince fup-
plied by his country ;  for  it  would be a national re-
flection, that while penfions are frequently diftributed
among the moft unworthy, the family of fo illuftrious
a benefactor to mankind Should reft unnoticed.
CON- 
 CONTENTS

                     OF  THE

          FIRST   VOLUME.

              ,.<.«.<-<..<..<..<.l<.,<.*..<^^>..>..>v..li..>i->„>..>.>-.>.
                                V

Preface                                    Page xvii
Introduction                                      35
                PART     I.
Of Pyrexia, or Febrile Difeafes                    37
                BOOK      I,
Of Fevers                                        38
                CHAP.     I.
Of the Phenomena of Fevers                       ibid
               CHAP.     II.
Of the proximate caufe of Fevers                   47
               C  H<  A'  P.     III.
Of the Difference of Fevers,  and its Canfis          59
               CHAP.     IV.
Of the remote caufes of Fevers                     6y
                C   H   A  P.     V.
Of the Prognqfis of Fevers                         78
               CHAP.     VI.
Of the Method of Cure in Fevers                   89
   Sect.  I.   Of the Cure of Continued Fevers      ibid
   Sect.  II. Of the Cure of Intermittent Fevers    128
                BOOK     II.
Qf Inflammations, or Phlegmafia                  133
                CHAP.     I.
Pf Inflammation in general                       ibid
                                                oect. 
*4
CONTENTS.
   Sect. I.  Of the Phenomena of Inflammation     ibid
   Sect.  II. Of the proximate Caufe of Inflammation 135
   Sect. III. Of the Terminations of Inflammation  140
   Sect. IV. Of the remote caufes of Inflammation  147
   Sect. V. Of the Cure of Inflammation            148
               CHAP.     II.
 Of Inflammation,  moreflriclly Cutaneous          155
               C   H  A  P.     III.
 Of Ophthalmia^ or Inflammation of the Eye       J58
               CHAP.     IV.
 Of Phrerfy, or Phrenitis                        J £4
               CHAP.     V.
 Of the Quinfy, or Cynanche                      168
   Sect. I.  Of the Cynanche Toriflllaris           169
   Sect. II. Of the Cynanche Maligna             172
   Sect. III. Of the Cynanche Trachealis .          177
   Sect. IV. Of the Cynanche Pharyngaa          182
   Sect.V. Of the Cynanche Parotideea            ibid
               CHAP.     VI.
Of Pneumonic Inflammation                       j $4
              CHAP.     VII.
Of the  Peripneumonia Notba,  or  Baflard Peri-
    pneumony.                                  20?
              CHAP.     VIII.
Of the Gafirifis, or Iuflammation of the Stomach     200
               C   H  A  P.     IX.
Of the Enteris, or Inflammation of the Inteflines     216
               CHAP.     X.
Of the Hematitis, or Inflammation of the Liver     218
               CHAP.     XI.
Of the Nephritis,  or Inflammation of the Kidneys   22?
              CHAP.     XII.           '  D
Of the Rheumatifm                              226
             CHAP.     XIII.
Of the Toothache or Odontalgia                   24o
                                   CHAP. 
              CHAP.     XIV.
Of the Gout                                    246
              BOOK    III,
Of Exanthemata, or Eruptive Fevers              286
               CHAP.     I.
Of the Small-pox                               287
               CHAP.     IL
Of the Chicken-pox                             300
              CHAP.    III.
Of the  Meafles                                ol0
              CHAP.    IV.
Of the Scarlet Fever                            ojy
               C  H   A  P.     V.
Of the Plague                                 323
  Sect. I. Of the Phenomena of the Plague       ibid
  Sect. II. Of the Prevention of the Plague       326
   Sed. III. Of the Cure of the Plague            330
               CHAP.     VI.
 Of Eryfipelas, or St. Anthony's Fire             ?'*$
              CHAP.     VIL
 Of the Miliary Fever                          338
              CHAP.     VIII.
 Of the remaining Exanthemata:  Utticaria, Pemphi-
       gus, and Aphtha                       347
               BOOK    IV.
 Of Hemorrhagics                              340
                CHAP.    I.
 Of Hemorrhagy in general                     ibid
   Sect. I.  Of the Phenomena of Hemorrhagy    351
   Sect. II.  Of the Proximate Caufe of Hemorrhagy 352
   Sect. III. Of the Remote Caufes of Hemorrhagy  366
   Sect. IV. Of the Cure of Hemorrhagy *        368
                CHAP.    II.
 Of the Epiflaxis, or Hemorrhagy of the Nofe      379
               CHAP.     III.
 Of the Hemoptyfis, or Hemerrhagia from the Lungs 386
                                              Sect:. 
x6         CONTENTS.

  Sect. I. Of the Phenomena and Caufes of Hemop-
       tyfis                                    ibid
  Sect. II. Of the Cure of Hemoptyfis            391
              CHAP.    IV.
Of the Phthifis Pulmonalis,  or Confumption  of the
       Lungs                                  395
  Sect. I. Of the Phenomena and  Caufes  of  the
       Phthifis Pulmonalis                      ibid
  Sed. II. Of the Cure of Phthifis                415
              CHAP.     V.
Of the  Remorrhois, or, of the Hemorrhoidal Swell-
       ing and Flux                            425
  Sea. I.  Of the Phenomena and Caufes of the He-
      morrhois                                ibid
  Sea. II. Of the Cure of Hemorrhoidal Affeclions. 432.
t. 
PREFACE.
"•naOtaeSEUBWw—..
 # X  O deliver a fyftem of the deftrines and 1 u!cs proper for direct-
 ing the practice of phytic, is an undertaking that appears to me to be
 attended with great difficulty ;  and, af';eran experience of more than
 forty years in that  practice,  a-; well as after much reading and re-
 flection, it was with great diffidence that I ever entered upon fuch a
 work.  It was, however, what feemed to be my duty r.s a profciTor
 that induced me to make th- attempt ;  and I was ena^oJ in  it by
 the fame fentiments that the  illuftrious Dr.  Boerhaa^e  h..^ expref-
 fed in the  following paffage of the preface to his inftitutions ; Simul
 enim docendo admctus cram fenfu, pru triora n cogitatorum explkat'ione do-
 tentem plus prof l ere, quam fi opus ab al'rj conferiptum interpretari f:fp}j.
 Sua quippe optime intelligit, fua cuique pra catcris ■'■Ljent, unde cimior
fere doflrina, atque  animata plerumque fcquitur oraiw.   .*-?.'.: vero  ! rfa
 alterius exponit, infel'uius fepenumcro eadem ajfequitur ; quumque fuo quif-
 que fetfu abuniat\ ntulta refutanda frequenter invenit, unde gravem ■"ruf-
 tra laborcm aggravat, niinufque incitata  didione  uthur.  It is  welt
 known, that a text-book is  not only extremely ufeful, but rite?effaiy
 to ftudents who are to hear lectures : and from the fame coU.uen'-
 tions that moTed.Dr. Bocrhaave,Ialfo wiflicd to have one for myft'f  ;
 while, at the fame time, from  fome peculiar circumftances in'my li-
 tuation, 1 had fome additional inducements to undertake  fuch  a
 work.
   Before I was cftablifhed as a profciTor of the practice of phyfic in
 this univeriity,  I had been  employed  in giying clinical  lectures in
 the royal infirmary ; and upon that occafion had delivered, whr.t, in
 my own opinion, feemed moft juft  with regard to both the nature
 and the cure of the difeafes of which I had occafoji to ticat.   Ba!:
 J (oon found, that  my doftrines were taken notf^Tof, as new,  ani
 peculiar to mylelf; and were accoidii.gr/feverelv criticiiid by thofe
 who, having long before been trained up in the fyftem of Boerhaave,
 had continued to think that  that fviUm neither required any change,
 nor admitted of any amendment.   I found, at the fame time,  th.it
 my doftrines  were frequently  criticifed by perfons who either had
 w.-t bc'Tn informed  of them correftly, or  v\ho feemed not to under-
                              C                       . ' ft.uid 
XV111
PREFACE.
ftand them fully ; and therefore, as foon as I was employed to teach
a more complete fyftem of the praftice of phyfic, I judged it necef-
fary to  publifh a text-book not  only for the benefit of  my hearers,
but that I might alfo have an opportunity of obtaining the opinion
of the public more at large, and thereby be enabled either to vindi-
cate my doctrines, or be taught to correct them.   Thefe were the
motives for my attempting the volumes I  formerly published ; and
now, from many years experience of their utility to my hearers, as
well as  from the favourable reception they have met with from the
public,  I am induced to give a new edition of this work, not only, as
I hope, more correct in many parts, but alfo more complete and
comprehenfive in its general extent.
   At the firft publication  of this work, it was intended chiefly  for
the ufe of thofe gentlemen who attended my lectures : although, e-
ven then, for the reafons I have mentioned, it was rendered moie full
than text-books commonly are ; and, in the repeated editions 1 have
iince had  occafion to give, I have beeu conltantly endeavouring to
render it more full and comprehenfive.  In thefe refpedts, I hope the
prefent edition  will appear to be rendered  more fit for general ufe,
and better calculated to afford  fatisfaction to all thole who think
they may ftill receive any inftruction from reading on this fubject.
   While  I thus deliver my  Work in its now more improved ftate,
with the hopes that it may be of ufe to others as well as to thofe who
hear my Lectures, I  muft at the fame time obferve, that it prefents
a fyftem which is in  many refpects new, and therefore 1 apprehend
it to be not only proper, but neceflary, that I  fhould explain here
upon what grounds, and from what conliderations, this has been at-
tempted.
   In the firft place,  I apprehend that,  in every branch of fcience
with refpeft to which new facts are daily acquired, and thefe confe-
quently giving occafion to new reflections, which correct the princi-
ples formerly adopted, it is neceflary, from time to time,  to reform
and renew the whole  fyftem, with all the additions and amendments
which it has received and is then capable of.  That at  prefent this
is requifite with regard to the Science of Medicine, will, I believe,
readily occur to every perfon who at all thinks for himfelf, and is
acquainted with the Syftems which have hitherto prevailed.   While,
therefore, I attempt this, I think  it may be allowable, and upon this
occafion even pf$per, that I  fhould offer fome remarks  on the prin-
cipal Syftems of Medicine  which  have of late prevailed in Europe,
and that I fhould take notice of the  prefent ftate of Phytic as it is
influenced by thefe.   Such remarks, I hope, may be of fome ufe to
thofe who attempt to improve their knowledge by the reading of
books.
   Whether the Practice of Phyfic fhould admit of realbning,  or be
entirely refted upon experience, has long been, and n.ay tlill be, a
                                                         matter 
PREFACE.
XOi
matter of difpute,   I fliall not, however, at prefent, enter upon the
difcoffion of this ; becaufe I can venture to affett, that, at alnioft all
times, the practice has been, and ftill is,  with every perfon, found-
ed,  more or lefs, upon certain principles eftablifhed by  reafoning  ;
and therefore, in attempting to offer fome view of the prefent  ftate
of Phyfic, I  muft give an  account of thofe fyftems of the principles
of the fcience which have lately prevailed, or may be fuppofed ftill
to prevail in Europe.
   When, after many ages of darknefs,  which had deftroyed  almoft
the whole of ancient literature, learning was again re/tored in  the fif-
teenth century ; fo, from  eaufes * which are well known, it was the
fyftem of Galen alone that the Phyficians of thofe day? became ac
quainted with ;  and during the courfe of the fixteenth century, the
ftudy of Phyficians was almoft  folely  employed in  explaining and
(confirming that fyftem.   Early indeed, in the fixteenth century, the
noted  Paracelfus f had laid  the foundation of a Chemical Syftem
                                                             which
   * At this  period the medical knowledge of Europe <was chiefly,  and in-
deed folely, fuch as had been derived from the Arabians.   At the conquejl
of Confantinople by the Turks, about the middle of the fifteenth century, fe-
veral of the  Greeks fled into Italy, and the people of Europe  communicat-
ing <with them, found them to be intelligent, and fome of them  even learned
men ;  the Europeans were thence led tofludy the Greek language, in  order
to read the   valuable books which thefe fugitives had fo much extolled;
and among other  •works, thofe of Galen particularly attracted the notice of
the phyficians, which, to their great aflonifhment, contained all the medical
knowledge that had been attributed to the Arabians.   To the  Greek  writ-
ers, therefore, the phyficians of thofe times clofely applied their attention,
thinking thefe books the only true fountains of medical knowledge ; and
thus it was that the  Galenical doctrines became prevalent all over Europe.

   f The remarkable circumflances in the life of Aureolus Philippus The-
 ophrafus Bombaflus Paracelfus  de Hohenheim, as he called  himfelf,  are
 too  numerous for infertion in the narrow limits allotted to thefe notes.  He
 •was born at  the  village of Einfdlen,  about 2 German miles from  Zurick,
 in the year 1493.   At 3 years old he was made an eunuch by an accident.
 He travelled all over the continent of Europe, obtaining knowledge in che-
 miflry and phyfic, and then  travelled  about the country praSifmg what he
 had learned. His chief remedies were Opium and Mircury, and his great
 fuccefs increafedhis  celebrity.   He cured the famous printer  Frolenius of
 Bafil of an inveterate difcafe ; this cure brought him acquainted with Eraf-
 mus, and made him known to the magiflracy of Bafil, who elected him pro-
 fffor in 1527.  He lectured two hours  everyday.   While feated in his
 chair, he burnt, with great folcmnity, the writings  of Galen  and Avicen-
 na ; and declared to his audience, that if God would not impart the feoets
 of phyfic, it  was not only allowable, but even jujlifiable to confult the de-
 vil.   He foon left B<fd, and continued io ramble about the country, gene- 
P   R  L   I   A  C  E.
 '-. hieh was in direct opp.fition to that of Galen ; and, by the tinea
 ry of the medicines employed by  Paracelfus and his followers, their
 iyiffin came to be received by many :  but the fyftematic Phyficians
 continued to be chiefly Galenifts, and kept poffeflion of the Schools
 til! the middle of the feventeenth centuiy.   It is not, however, ne-
 cefihry here to enter  into  any further detail refpecting the fate of
 thofe two oppofite lefts;  for the or'-circumftance concerning them,
 wuicii I would wifli at prefent to  point out, is, that, in the writings
 of both, the  explanations they feverally attempted to give of the
 phenomena of health or  ikknefs,  turned  entirely upon  the ftate
 of the fluid.; of the body.
    Such was the ftate of the fcience of Phyfic till ahout the  middle
 cf the feventeenth century, when the circulation of the blood came
 to be generally known and admitted ;  and  when this, together with
 the difcovery of the receptacle of the chyle, and of the thoracic duct,
 fi  .:!v exploded the Galenic fydem.   About the fame period a con-
 fide, able revol;i;i:)n had taken place in the  fyfttm of N.ituivl Philo-
 fophy.   In the courfe of the feventeenth century, Galileo had ititro-
 t.uccd mathematical reafoning ; and  Lord Bacon  having propofed
 the .nethod of induction, had thereby excited a difpofition to obferve
 fuCts, and  to  make experiments.  Thefe new modes of philofophiz-
 ing,  it might be fuppofed, would foon have had fome  influence on
 the ftate of  medicine ;  but the pro;uefs  of this  was  flow.   The
 knowledge of the  Circulation did indeed neceflarily lead to the con-
 iideratioii  as well as to k clearer viev of the 0'g:.r,i'c Syftem in ani-
 mal bodies ; which again led  to the  application of the mechanical
 philolophy towards exi Lii;n^ the phenomena of the  animal cecono-
 mv ; and it ".'as ."pplie.i accordingly, and continued,  till very lately,
 to b- the fafhionaV-i-   .ode of •:..fcnjn;;.on the fubjeft.   Such  rea-
 {v,.\ng, indeed, tnu't f.dil in feveral'icfpcfts continue to be applied :
 but it would be eafy to fh >w,  ti at it neither could, nor evercan be,
 applied to  any great extent in evplain;:w; the animal ceconomy ; and
 we mu'1 therefore lode for other cm;eimftar,e.-.s which had a greater.
 fire in  mo.'elNn--  t .-, e  ftem of i'bvfJC.
   With thie, -. ew,  ■':  may be remarked, th?t. till the period juft now
 r.--. .tieued, v. very phyfician, wiicthcr Galenift or Chemiit, had been
 fo much eccuftomed to cufuler the ftate and condition of the fluids,
 boih as the caufe «f iJiftafe,  aulas  the foundation for explaining
 the operation of  nfejicints, thdt what we n, y ten:: an Kumokal,
 Pathology  flill .; -.tinned to make  a great rot  of every fyftem.
 In Oi-.-ie c:rc!!:rift:n;rcs, it  was foon perceived, that cheuii? ry pro-
 milcd a  much better  explanation  th.tu the G denic  or Ariftoteliun
                                                      philofuphy
 ral'y intoxicated, an'-  z r changing his clothes, or even  going to bed.  He
 died afier an H-.f  ofaf zv day:, in an in,i:.-L Salfl'ir-,  in 1541, inh>s
firtytighlh year, though he had fro-"{fed himf',', ih,,i, by the ufe of his
 eJt.ir, hefaould 1. ee  ta the age of ATeihuf ih-.-u. 
PREFACE.
x*i
philofophy had done ; and, therefore, while the latter was entirely
laid afide, a chemical reafoning was every where received.  Lord Ba-
con, with his ufual fagacity, had early obferved, that chemiflry pro-
mifed  a greater number of facts, and he thereby gave it credit;
whilft the Corpufeularian philofophy, reftored by Gaffendi, readily
united with the rcafonings of the Chemifts ; and the philofophy of
Dcs Cartes readily united with both.  From all thefe circumftances,
an Humoral, and chiefly a Chemical Pathology, came to prevail ve-
ry much till the end of the laft century ; and has indeed, continued
to have a great fliare in our fyftems down to the prefent time.
   It is proper now, however,  to obferve, that about the beginning
of the prefent century, wheneveiy part of fcience came to be on a
more improved and correct footing, there appeared in the writings
of Stahl, of Hoffman, and of Boerhaave, three new, and con-
fiderably different, Syftems of Phyfic ; which  have ever  fince  had a
great (hare in directing the practice of it.  In order,  therefore, to
give a  nearer view of the prefent  ftate of Phyfic,  I  fhall offer fome
remarks upon thefe different fyftems ;  endeavouring  to point out the
advantages, as well as the difadvantages of each,  and  how far they
ftill prevail; or, according to my judgment, deferve to dofo.
   I fhall begin with confidering  that of Dr. Stahl, which  I  think
appeared firft, and for a long  time after  was the prevailing fyftem
in Germany.
   The chief and leading principle of this fyftem is, that the rational
foul of man governs the whole ceconomy of his body.   At all time^,
Phyficians  have obferved^ that the animal ceconomy  has  in  itfclf
a power or condition,  by which,  in many inftances,  it iefifts the in-
juries which threaten it ;  and by  which it alfo,  on many occafiona,
correfts or removes the diforders induced, or arifing in it.  This
power, Phyficians very anciently  attributed, under a vague idea,  to
an agent  in the fyftem,  which they called nature; and  the lan-
guage of a vis confervatrix et medicatrix natura, has continued in the
fchools of medicine from the moft ancient times to the  prefent.
   Dr.  Stahl has explicitly founded  his fyftem on the  fuppofition
that the power of nature,  fo much talked of, is entirely in the ra-
tional foul.   He fuppofes that, upon many occafions, the foul acts
independently of the ftate of the body ; and that, without any phy-
fieal neceflity arifing from that ftate, the fou!, purely in confequence
of its intelligence perceiving the tendency of noxious powers threat-
ning, or of diforders any wife  arifing in the fyftem, immediately ex-
cites fuch motions in  the body as are fuited to obviate the hurtful
or pernicious confequences which  might  otherwife take place.—
Many  of my readers may think  it was hardly  neceffary for me to
take notice of a fyftem founded upon fo fanciful an hypothefis ; but
there is often fo much feeming appearance of intelligence anddefign
in the operations of the animal ceconomy,  that many  eminent per-
                                                         fons, 
xxii
PREFACE.
fons, as Perrault in France, Nichols and Mead in England, Porter-
field and Simfon in Scotland, and Gaubius in Holland,  have very
much countenanced the fame opinion, and it is therefore certainly
entitled to fome  regard.  It is not, however, neceflary for me here
to enter into any refutation of it.  Dr. Hoffman has done this ful-
ly, in his Commentarius de differentia inter Hoffmanni dottrinam medico-
muhanicam et G. E. Stahiii medico-organicam ;  and both Boerhaave
and  Haller,  though no favourers of rnaterialifm,  have maintained a
doctrine very oppofite to that of Stahl.
   In my Phyfiology  I  have offered fome arguments  againft the
fame ;  and I fhall only add  now, that whoever confiders what has
been faid by Dr. Nichols in his Oratio de Anima Medica,  and by
Dr.  Gaubius in fome parts  of his Pathology, muft perceive, that
the admitting of fuch a capricious government of the animal  ceco-
nomy, as thefe authors in fome inlfances fuppofe would at once lead
us to reject all the phyfical and mechanical reafoning we might em-
ploy concerning the  human body.  Dr. Stahl himfelf feems  to have
been aware  of this ;  and  therefore, in  his Preface to Juncker's
Confpeclus Therapeia Specialis, has acknowledged, that  his  general
principle was not at all neceflary ; which  is in effect faying that it
id not compatible with any fyftem of principles that ought to govern
our practice.  Upon this footing, I might have at once rejected the
Stahlion principle : but it is even dangerous to bring any fuch prin-
ciple into view ;  for, after all Dr. Stahl had faid in the paffage juft
n.> v referred to, I find, that, in the whole of their praftiee,  both he
and  his followers have been very much  governed by their general
principle.  Truftiug much  to  the conftant attention and  wifdorn
of nature, they have propofed the Art of curing by  expectation', have
therefore, for the moft part, propofed only very ineit and frivolous
remedies ; have  zealoufly oppofed the ufe of fome of the moft cfli-
eacious, fuch as opium and the Peruvian bark ; and are extremely re-
ferved in the ufe of general remedies, fuch as bleeding, vomiting, &c.
   Although thefe remarks, upon a fyftem which may now  be con-
fidered as exploded or neglected, may  feem fuperfluous ;  I have been
willing to give thefe ftrictures on the Stahlion fyftem, that  I might
carry my remarks  a  little farther,  and  take this opportunity  of
obferving, that,  in whatever manner we may explain what have been
cal ed  the operations of nature,  it appears to me, that  the  general
doctrine of Nature curing difeafes, the fo  much vaunted  Hippocratic
method  of curing, has often had a baneful influence on  the  practice
of phyfic ; as either leading phyficians into, or continuing them in,
a weak and feeble practice; and at  the  fame time fupeVfeding or
uicouraging all the attempts of art.   Dr. Huxham has properly ob-
ferved that even in  the hands of Sydenham it had this effect.  Al-
though it may fometimes avoid the  mifchiefs of bold and rafh prac-
titioners, yet it  certainly produces that caution and timidity which
                                                           have 
                   P  R  E  F  ACE.             xxiii

have ever oppofed the introduftion of new and efficacious remedies.
The  oppofition to chemical medicines  in the fixteenth and feven-
teenth centuries, and the noted condemnation of Antimony by the
Medical Faculty of Paris,  are to be attributed chiefly to thofe pre-
judices, which the phyficians of France did not entirely get the bet-
ter of for near an hundred years after.  We may take notice of the
refervt it produced in  Boerhaave, with refpect to the ufe of the Pe-
ruvian Bark.  We have had lately  publifhed, under the title of Con-
flitutiones Epidemics, notes of the particular praftice of the late Baron
Van  Swieten ; upon which the editor very properly  obferves, That
the ufe of the bark, in intermitting fevers, appears very rarely in
that  praftice ; and we know very well where Van Swieten learned
that refervei
   I might go farther, and  fliow  how much the attention to the Au-
Ucrateia,  allowed of, in one fhape  or other, by every feet, has cor-
rupted  the  praftice among  all  phyficians,  from  Hypocrates to
Stahl.   It  muft,  however be fufficiently obvious,  and I fhall con-
 clude the fubject with obferving, that altho' the vis medicatrix natu-
res, muft unavoidably  be received  as a faft ; yet wherever it is ad-
mitted, it throws an obfeurity upon our fyftem ; and it is only where
the impotence of our art is very  manifeft and  confiderable,  that we
ought to admit of it in practice.
   To finifh our remarks upon the Stahlion Syftem,  I  fhall fhortly
obferve,  that it did not depend entirely upon the Autocrateia,  but
alfo  fuppofed a  ftate of the body  and difeafes, that admitted of re-
medies;  which,  under the power and direction of the foul, acted
upon the organization and  matter of the body, fo as to  cure its dif-
eafes.  Upon this footing, the  Stahlion  pathology  turned entirely
upon Plethora and Cacochymy.   It was with refpect to the former
that they efpccially applied their doctrine of the Autocrateia in a ve-
ry fanatical manner; and, with refpect to the latter,  they have been
involved in  a humoral pathology as much as the fyftematic phyfici-
ans who had gone before them,  and with a theory fo  incorrect as
not to merit the  fmalleft  attention.   After  all I  ought  not  to
difmifs the  confideration  of the Stahlion fyftem, without  remark-
ing,  that as the  followers of this  fyftem  were very intent upon
obferving the method  of nature, fo they were very attentive in ob-
ferving the  phenomena of difeafes,  and have given us in their writ-
ings many facts not to be found elfewhere.
   While the doctrines of  Stahl  were prevailing in the  univerfity of
Halle, Dr. Hoffman, * a profefTor  in the fame univerfity piopofed a
                                                         fyftem
* Frederick  Hoffman was born at Halle, in the year 1660.  He graduated
in 1681 ; was made profeffor of phyfic therein the year  1693 ; and filled
that chair till his death in 1742.   A very remarkable circumfance of his
life is, that he never took fees from his patients, but  was content with his
ftipend.  He was in high repvtc as a prattiiiontr, and curing the  Empc 
XXIV
PREFACE.
 fyftem that wa3 very different.   He received into his fyftem a gr :s«
 deal of the mechanical, Cartefian, and chemical doctrines of the fyf-
 tems which had appeared before : but, with refpect to thefe, it is of
 no confequence to obferve in what manner he modified the doctrines
 of his predeceflbis,  as his improvements in thefe refpects; were no
 ways confiderable, and no part of them now remain ; and the real
 value of his works, beyond what  I am juft now going to mention,
 refts entirely on the many fafts  they contain.  The merit  of  Dr.
 Hoffman and of his works is, that he made, or rather fuggefted, an
 addition to the fyftem,  which highly deferves our attention.   Of
 this  I cannot give a cleater account than by giving it in the author's
 own words.  In his Medicine Ri:ii:nalis fyflematica, Tom, III.  § I.
 chap. iv. he has given his Genealogia morborum ex  turlato folidorum et
fuidorummechanifmo; and in the 47th and laft paragraph of this chapter
 he fums up his  doctrine in the foliowiig  words :  Ex hifce autem  om-
 nibus ubtrius hattenus  excuffs, per quam diiucide apparere arbitror quod
 folus spasmus etfimplex Aionia,  aquabiletn, liberum, 11cproportionatum
 fangvinis tmnifque generis fiuido urn motum, quibus excretionum fucctffus
 fl integritas functionum animi et corporis proxims nititur, turbando ae per-
 vertendo, univerfam v'ualem economiamfubruantacdejlruant;  atque hinc
 vni-verfapathologialonge  rettius atque facilius ex vitiomotuum  mi-
 CROCOSMICORUM IN SOLID!*, quam EX VARUS AFF F.CTION IBUS VIT1-
 osorum humorum, deduct atque exf Hearipoffit, adeoque omnisgeneris
 agridudints interns, ad prjeternaturales  generis  nervori af-
 FeCtiohes fint referenda.   Etcenim la-fis quocunque modo, velntrvisper
 corpus difcurrentibus,  vel memlrannfis quibufvis nervofs partibus. Hike
 motuum anomalia, modo leviores, modo graviores fubfequuntur.   Deindi
 attenta obfervatio docet, mot us quofvis morbofos principalite> fedem figere
 et tyrannidem exercere  in nervofis corporis parlibus,  cujus generis prater
 emnes canales, qui fyjlaltico et diaflaltico motu pollentes,  contentos fuccos
 tradunt univerfum nimirum infiinorum et ventriculi ab tfophago ad anum,
 canalem, fotum fyflema vaforum arterioforum, duttuum biliar'wum,Ja-
 livalium, urinariorum etfubcutaniorum, funtquoque membrana nerveo muf-
 cularescerebri et  medulla fpinalis, prafertim h*c, qua: dura mater vo.atur
 organis fenforiis  obducta, nee non tunica ill* ac ligamenta, qua offa cingunl
 artufquefirmant. Nam nullus dolor, nulla infiamatio, nullus fpoftnus, null,
 motus fenfus impotentia,  nulla febris aut humoris illius excretio, accidit
 in  qua non  ha partespatiantur.  Porrt eteam omnes, qua morbos gignunt
 caufa operatisnemfuam poiiffimam perficiunt  in partes  motu et fenfu pra-
 diias, et  canales ex his coagmentatos,  eo'-um motum,  et cum hocfiuidorum
 eurfum pervertendo ;  itatamen, utfeuti variee indolis funt, fie etiam va-

 ror Charles VI.   and Emprefs, and Frederick I. of Pruffia, of inveterate
 difeafes greatly increafedhis  reputation. His  works are collected into fix
 volumes  folio,  publfhed at different timet from  174S  to  1 "54.  Thei
 abound with many ufeful practical directions ; but at  the fame time contain
 many frivolous remarks, and an abundance of conjectural theory. 
PREFACE.
xxv
rie in nerveaspartes agant, iifdemque no::am affri:e:,t.  Demum omnia quo-
que eximta virtutis medicamenta, non tarn in paries fiuidas, earum crafin ac
intemperiem corrigendo, quam potius in folidas et nervofas,  earundem mo-
tus alterando ac moderando, fuam edunt operationem : de quibus tamen om-
nibus, in vulgari ufque eo recepta morborum doctrina, alt urn efifilentium.
  It is true that Dr. Willis* had laid a foundation for this doctrine,
in his Pathologia Cerebri et Nervorum ;  and  Baglivi had propofed a
fyftem of  this kind in  his Specimen  de fibra motrici et mofbofa.  But
in thefe writers it was either not extenfively applied  to difeafes, or
was ftill fo involved in  many phifiological errois, that  they had at-
tracted little attention ; and Dr. Hoffman was the firft who gave a»
ny  tolerable  fimple and clear  fyftem  on  the fubject, or pointed
out any extenfive application of it to the explanation of difeafes.
  There can be no fort of doubt that  the phenomena of the animal oe •
conomy in health and in ficknefs, can only be explained by confider-
ing the ftate and  affections of the primary moving powers  in it. It is
to me furprifing that phyficians were fo long in perceiving this, and
I think  we  are  particularly indebted to  Dr.  Hoffman for  put-
ting us into the proper train of invdftigation; and it every day appears
that Phyficians perceive the neceflity of entering more and more into
this inquiry. It wasthis, I think, which engaged Dr. Kaaw  Boerhaave
to publifh his work entitled Impetum faciens ; as weft as Dr.  Gaub-
us to give the Pathology of the Solidum vivum.  E.ven the  Baron
Van  Swieten bias upon  the  fame view thought  it  neceflary, in  at
leaft one particular, to  make a very confiderable change in the doc-
trine  of his mailer, as he has, done in his  Commentary upon the
755th Aphorifm. Di. Haller has advanced this part of fcience very
much  by his experiments on irritability and fenfibility.   In thefe
and in many other inftances, particularly in the .writings of Mr. Bar-
thez of  Montpelier, of fome progrefs in  the ftudy of the affections
in the Nervous Syftem, we  muft perceive how much we are indebt-
ed to Dr. Hoffman for his fo properly beginning it.  The fubjeft,
however, is difficult: the laws of the Nervous Syftem, in the various
circumftances of the animal ceconomy, are by no means afcertained;
and, from want  of attention and obfervation with  the  view  to  a
fyltem on this fubject, the bufinefs appears to many as an  inexplica-
"  r    ......   .                                            ble
  * 7his illuflrious phyfeian  was born at great Bedwinin Wiltfhire in
I 621.  He took the degree of majler of arts in 1642 at Oxford, when
he was made profeffor of natural philofophy in 1660 : and that fame year
he took the degree of M.  D.  His practice was extenfive and fuccefsful.
He was one of the jirjl members of the royalfociety in London,  whither he
removed in 1666  ; and foon made his name as il uflrious by his writings,
as he  had already  done by his practice.   His  works had been often printed
frparately ; but they were not eolleSed, till after his death, which happened
on the l ith of November  167 5.   One edition was publifhed at Geneva ih
16 76, and another at Amflerdam in 1682, both  in quarto. 
P   R  E   F   A   C  S.
 ble myfteVy,   There is no  wonder therefore that on fuch a diflkrlt
 fubject, Dr. Hoffman's fyllem was imperfect and incorrect ; and has
 had lefs influence on the writings and practice of  Phyficians  fmce
 his time, than might have been expected.   He himfelf has not ap-
 pied his fundamental doctrine  fo'extenfively  as he  might  have
 done;  and he has  every where intermixed an Humoral Pathology,
 as incorrect and hypothetical as any other.  Though he differed1
 from his colleague Dr. Stahl in the fundamental doctrines of his
 fyftem,  it  is but too evident that he was very  much infected with
 the  Stahlian doctrines of Plethora and Cacochymy, as may be ob-
 ferved throughout the whole courfe of his work ;  and  particiflarly
 in his chapter De  morborum generatiohe  ex nimia  fanguims  quanli-
 tate et humcrum impuriia'.e.
   But it is needlefs for me to  dwell any longer upon the fyftem of
 Hoffman : and I am next to offer fome remarks  on the  fyftem of
 Dr.  Boerhaave,  the cotemporary of both the  other  Syflematics,
 and who, over all Europe, and  efpecially  in  this part of the world,
 gainedhigher reputation than either of  the others.
   Dr. Boerhaave * was a man of general erudition ; and, in apply-
                                                               ing
 * Voorhoct, c.fmall village about two miles from L--yden, gave birth to this
 eminent plyfician on the tafi day of the year  1668.   He was educated at
 Leyden, and took his firft degree  in philofophy  in  1696.   His thefts on
 this  occafion ivas a confutation of the dotlrines of Epicurus, Hobbes and
 Spine fa, in which he fhewed great fiiength of genius and argument.   Al-
 though he was at this time tveU qualified to enter vito  the church, which
 was his father's intent'wi, yet he was diffident of his abilities, and choje to
 attend the lectures of divinity longer.   His patrimony ivas however  now
 e'xhaufled, and he fupported himfelf at the univerfity  by teaching mathema-
 tics, while he  profecuted his theological fludies.    This conduct was much
 approved by the eminent men both of the  Univerfity and City, and procured
 for Boerhaave the friendfhip of Mr.  Vanderburg the Buigomafler of Ley-
 den.  Under the putt  on. e-e, and at theperfuafwn ofthis gentleman, Boer-
 haave applied himfelf to thejludy of phyfic with great ardor and indefa-
 tigable diliger.ee.   In  aji'<rt time he became a  proficient in anatomy, che-
 miflry, and the materia medica, which indeed are the bafis of phyfic.  Leav -
 ing Leyden, he went  to the univerfity of Harder wick in Guelder! and, and
 there took his degree of Da or of Phyfic in July 1693.  On his return to
 Le\den  he fill perfifledin his intention of entering into  the miniflry, which
 luckily, for the fake of Phyfc, was fruf rated by the following adventure :
 in a pajf.ge-boat where Boerhaave was, a difcourfe was accidentally fat-
 ed about the doctrines of Spin of a, as fubverftve  ofieligion ;  and one of the
paffergc
pretti
 had 1
 
PREFACE.
XXVil
jng to medicine, he had carefully ftndied the  auxiliary branches of
Anatomy, Chemiftry, and  Bolany fo that he excelled in each.  In
forming a Syftem of  Phyfic, he feems to have ftudied diligently all
the feveral writings of both ancient and  modern Phyficians ; end
without prejudice in favour of any former  fyflcms, he endeavoured
to be a candid and  genuine eccleftic.  Poffeffed of an excellent fyf-
tematic genius, he gave a fyftem fuperior to any that had ever before
appeared.  As in the great extent, and feemingly perfect confitten-
cy, of fyftem, he appeared to improve and refine upon every  thing
that had before been offered ;  and as in his lectures he explained his
doctrines with great clearnefs and elegance ;  he foon  acquired a ve-
ry high reputation,  and his fyftem was more generally received than
any former had been fince the time of Galen.  Whoever will cor.li-
der the meiits of Dr. Boerhaave, and can compare his fyftem with
that  of former writers,  muft acknowledge that he was very jufliy
e!leemed,and gave  a fvftem which was at that time dtfervtdly valu-
ed.
   But, in the progrefs of an inquifitive and induftrions age, it was
not to be expected  that any fyftem fhould laft fo long as Boerhaave's
has  done.  The elaborate commentary of Van  Swieten  on Boer-
haave's fyftem of praftice,  has  been  only finifhed a few years aero ;
and   tho' this Commentator has added many fafts, and made fome
corrections,  he has not, except in the particular mentioned above,
made any improvement in the general fyftem.   It is even furprifing
that  Boerhaave himfelf, tho' he  lived near forty years after he had
fit ft  formed his fyftem, had hardly in all that  time made any correc-
tions of it, or additions to  it  the following  is the  moft remarka-
ble.   In Aphorifm 795, the words  forte et nervofi, tarn cerebri quam
cercbelli cerdl deflinati inertia, did not appear in any edition before the
fourth ; and what  a difference of fyftem this points at, every phy-
fician muft perceive.
   When I firft applied to the  ftudy  of  Phyfic,  I learned only  the
fyftem of Boerhaave ;  ai\d even  wlien I came  to take  a Profcffor's
                                                           chair
fuddenlyJlruck dumb, and became fired withfileni refentment.  As foon as
he arrived at Leyden, hefpread abroad a  rumour that Boerhaave was
become a Spinoff.   Boerhaave finding thefe prejudices to gain ground,
thought it more prudent to purfue the fcience  of phyfic, than rifk the refufal
of a licence for the pulpit.   He now joined [he practice of phyfic to the  the-
ory.  On the  \%th of May,  1701, he commenced his lectures en the  In-
fiiiutes of phyfic.   In 1 7 09 he was createdp- offfor of Medicine and Bo-
tany ; arid in 171-8 he furceeded Le Mori in theprofefforfhip of Chemifl>y .
In Augufl I 722, he  was feized with the gout, and was obliged to refign
his profefforfhip  of Chemflry and Botany in  I 729.   He  continued for
fome time  to praltife, but was at length obliged to quit that alfo ; and he
died on the 23d of September, 173^?.. 
"..Kviii
PREFACE.
chair  in this Univerfity, I found that  fyftem herein its entire and
full force ; and  as I believe it ftill fubfifts in credit  elfewhere, and,
that no other fyftem of reputation has been yet offered to the world,
I think it neceflary for  me to point  out  particularly the imperfec-
tions and deficiencies of the Boerhaavian fyftem, in order to fhow the
propriety and ncceffity of attempting a new one.
  To execute this, however, fo fully  as I might, would lead me in-
to a detail that can hardly be admitted  of here ; and  I hope  it is
not neceflary, as I think, that every intelligent  perfon,  who has ac-
quired any tolerable knowledge  of the prefent ftate of our fcience,
muft, in many inftances,  perceive  its imperfections.   I fhall there-
fore touch only upon the great lines of this fyftem ; and  from the
remarks I am to offer,  truft that both  miftakes  and deficiencies
which run through the whole of his works will appear.
   Dr.  Boerhaave's treatife of the difeafes of the fimple folid, has
the appearance of being very clear and -confident, and  was certainly
confidered by him  as a fundamental doftrine :  but, in my apprehen-
fion, it is neither correct nor extenfively  applicable.   Not  to men-
tion the  ufelefs,  and perhaps erroneous,  notion of the compofition
of  earth and gluten:  nor his  miftake concerning the ftrufture of
compound membranes ; nor his inattention to the ftate of the cellu-
lar texture ; all  of them circumftances which render  his doctrine
imperfect: I fhall  infill only  upon the  whole being very little ap-
plicable to the explaining the phenomena of health or ficknefs.   The
laxity  or rigidity of the fimple folid,  does, indeed, take place at the
different periods of life, and may perhaps, upon other occafions, oc-
cur as the caufe  of difeafc : but I  prefume, that the ftate of the fim-
ple folid i:, upon few occafions, either changeable or actually chang-
ed ; and that,   in ninety-nine cafes of an hundred, the phenomena
attributed to fuch a change, do truly depend on  the ftate of the
folidum vivum ;  a circumftance  which Dr. Boerhaave has hardly ta-
ken notice of in any part of his work. * How much this fhows the
 deficiency and imperfection of his fyftem, I need not explain.   The
 iearned  work of Dr. Gaubius,  above referred to, as  well as many
other treatifes of late authors, point  out  fufftciently the defects and
imperfeftions of Boerhaave on this fubject.
   After Dr. Boerhaave has confidered the difeafes of the folids, he
 in the  next place attempts to explain  the more  fimple  difeafes of
 the fluids ; and theie, indeed, he delivers  a more correft doftrine of
 acid and alkali  than had been given  before : But, after all, he has
 done  it very imperfectly.   We have,  indeed, fince  his time, "ac-
 quired more knowledge upon the fubject of digeftion ; and fo much as
 to know, that a great dealmore is yet neceflary toenable us tounder-
 ftand in what'manner the animal  fluids are formed from the aliments
 taken in.   And although Dr. Boerhaave has fallen into no confi-
 derahle error with refpect to a  morbid acidity in the ftomach, he
                                                          could 
PREFACE.
could not poffibly be complete upon that fubjeft ; and his notion of
the effefts of acidity in the mafs of blood feems to have been entire-
ly miftaken, and is indeed not confident with what he himftlf has
delivered elfewhere.
   His doctrine of alkali is fomewhat better founded, but is probably
carried too far; and the  ftate of alkalefcency and putrefaction, as
well as all the  other changes which can take place in the condition
of animal fluids, are particulars yet involved in great obfcurity, and
are therefore ftill fubjefts  of difpute.
   There is another particular, in which Boerhaave's doctrine con-
Kerning the fluids appears to me imperfeft and unfatisfaftory ; and
that is,  in  his doftrine de Glutinofo fpontaneo.  The caufes which he
has affigned for it are  by no means probable,  and the actual exift-
enceof it is feldom to  be proved.  Some of the proofs adduced for
the exiftence of a phlegma calidum, are manifeftly founded on a mif-
take with  refpect to what has been called the inflammatory crtift,
(fee Van Swieten's Commentary,  page 96.) and the  many exam-
ples given by Boerhaave of a glutinojum appearing in  the human bo-
dy, (Aph.  1$.) are all of them  nothing more than inllances of col-
lections or concretions found out of the courfe of the circulation.
   If, then, we confider  the imperfection of Dr. Boerhaave's  doc-
trine with refpeft to the ftate and various condition of  the animal
fluids ; and if at the fame time we reflect how frequently he and his
followers have employed the fuppofition of an acrimony or lentorof
the fluids,  as  caufes of difeafe, and for directing  the praftice ; we
muft, asl apprehend, be fatisfied, that his fyftem is not only deficient
and incomplete, but  fallacious and  apt to miflead.  Although it
cannot be  denied, that the fluids of the human body fuffer various
morbid changes ; and that upon thefe, difeafes may primarily de-
pend ; yet 1 muft beg leave to  maintain, that the nature of thefe
changes is feldom underftood, and more feldom ftill is itknownwhen
they  have  taken place : that our reafonings  concerning them have
been, for the rnoft part, purely  hypothetical; have  therefore con-
tributed nothing to improve, and have often mifled,  the practice of
phyfic.   In this, particularly, they have been hurtful, that they ha\ 0
withdrawn our attention from,  and prevented our ftudy of, the mo-
tions of the animal fyftem, upon the ftate of which the phenomena
of difeafes do  more certain and generally depend.  Whoever, then,
(hall  confider the almoft total neglect of  the ftate of  the moving
powers of the  animal  body, and the  prevalence of an  hypothetical
humoral pathology, fo confpicuous in every part of the Boerhaavian
Syftem,  muft  be convinced of  its  very great defefts,  and perceive
the necefiity of attempting one more correct.
   After giving thisgeneral view, it is not requifite to enter into par-
ticulars ; but,  I believe, there are very few  pages of his aphorifms hi
which there docs not occur fome error or defect; although, perhaps,
                                                           ne-t 
jfeK             PREFACE.
  ■Mt to be imputed to the fault of Boerhaave,  fo much as to ihi-e,
  that fince his  time a great collection of new fafts has been acquired
  by obfervatioa and experiment.  This,  indeed, affords the beft and
  molt  folid  reafon  for  attempting  a new fyftem : for when  many
  new facts havebern acquired,  it becomes requilite that thefe fhould
  be incorporated  into a fyftem, whereby not  only particular fubjeets
  ::,ay be improved,  but  the whole may be rendered more complete,
  confident, and ufcful.   Every fyltem,  indeed, muft be valuable in
  propoition to the number of  fafts  that  it embraces and  contort-
  bends ; and Monf. Quefney  could  not pay a higher compliment  to
 the Syftem of Boerhaave, than by faying that it exhibited La medi-
 cine co lecti-ve.
    But here it wi'l, perhaps,  be fnggefted to  me, that the only ufe-
 ful work on the fubject of Phyfic, is the  making a collection  of all
 the fafts that relate to the art, and therefoie of all th.it experience
 has taught us with refpeft to the cure of difeafes.  I agree entirely
 in the opinion ; but doubt if it can ever be properly  accomplished,
 without aiming at fome  fyftem of principles,  by a proper induSUon
 and generalifation of fjfts :  at lealt  I am  ocrfuaded  that it can be
 done not only  very  fafely, but moft. ufefully in this  way.  This,
 however muft be determined by a trial.   I kr.'^v that the late Mr.
 Eieutaud has attempted  a work on a vian of collecting  facts with-
 out any reafoning concerning their caufes :  And while I am endea-
 vouring to give fome account of the prefent ftate of Phvlic, I  cao-
 not difmifs the  fubject  without offering fome remarks upon the
 promifing  Synopfis univefe medicinse?  compofed by the firft phyfician
 of a learned and ingenious nation.
   In this work there are many fafts and much obfervatiun from the
 Author's own experience, which may be ufefi.l lo thofe who have
 otherwife fome knowledge and difcernment ; but,  throughout the
 v;hole woik. there is fuch total want of method, airangement, fyf-
 tem, or decifion,  tha% in my humble opinion, it can be of little ufe,
 and may prove very perplexing to thofe who are yet to K-arn.   The
 diftinftion of the genera  of difeafe*,  the diftinftion of the fpeciesof
 each, and often even that of the varieties, I hold to be a neceflary
 foundation of every plan of Phyfic, whether Dogmatical'or Empiri-
 cal.  But  very little of this diftinftion is to be found  in the work of
 Mr. Lieutaud ; and in his preface he tells us, that he  meant toneg-
 left fuch arguta fedulitas.  And indeed his method of managing his
 fubject muft certainly interrupt and  retard all methodical nofology.
 His arrangement of difeafes is according to no  afrmity,  but that of
 the flight eft and  moft  uninftiuCtive kind, the place of the  body
 which they happen  to affect.  His Generalia  et incertce fedis, have
 hardly any connection at all; the titles, Rheumatifms,  Hyoochondria-
fis, Hydrops,  follow one another.   When he docs attempt any gene-
 ral doftrine,  it is  not  till long aft-er he has treated  of the widely-
                                                       featteied 
                   P  R  E~T  ACE.              xx r"

Scattered  particulars.  Under  each particular title  which he  af»
fumes, he has endeavoured to enumerate the whole of the fymptoms
thar ever appeared in a difeafe  under that title ;  and this without
piming at any diftinftion between the effential and  accidental fymp*
tin s,  or  marking the feveral combinations under which thefe fymp-
toms do for the moft part fteadily  appear,   p'rom the concurrence
c «-. .-icentai fymptoms, the variety of the fame difeafe is frequently
c  ifi er;dole, a ciicumftance neeeffarily perplexing anddiftrafting to
young praetitioners ; but  it feems  flrange to me, that an experience
of thirty  years, in confiderable praftice,  could do nothing to relieve
turn.
   Mr. Lie ltaud iois at the fame time  increafed the confufion that
mutt arile from this want of diftinftion, by his confidering as pri-
mary difeafes. what  appear to me to be the fymptoms, effefts, and
fequels, of other difeafes only.   Of this I think the Jfflus morbofus,
 Firum erolutio,Dolores, Stagnatiofangu\nis,Purulentia, Tremor. Pervi-
gilium, Ri:m.?do,  Suffocatio,  Vomica, Emphvema, Singultus,  Vomitus,
 Dolor Stomachi,  Tenefmus,  all treated of under feparate titles, are  ex-
 amples.   A general  .7m tomatologia may be  a very ufeful work,
 with a view to  a Syftem  of Pathology ;  but, with a view to  prac-
 tice without any Syftem, it muft have bad effefts, as leading only to
 a palliative practice, and  diverting  from the proper efforts  towards
 •detaining a radical cure.   Mr. Lieutaud, indeed, has endeavoured
 to exhibit the  fvmptoms  above mentioned as fo  many primary dif-
 eafes : but^he has feldom fucceeded in this ; and,  in  delivering  the
 praftice, he commonly finds it neceflary to confider them as fymp-
 toms, and that  not without fome theory, implied or expreffed, with
 refpect  to their  proximate  caufes.   His title  of Dolores may be
 taken as  an example of this ;  and from which it may  be readily per-
 ceived hoiy far fuch trtatifes can be really ufeful.
    In  eftablifhing a proper pathology, there is nothing that has been
 of more  fervice than the  diffeftion of moibid bodies.  Mr. Lieu-
 taud  has been  much and moft commendably employed in this way,
 and in this Synopfis he has endeavoured to communicate his know-
 ledge on the fubjeft ; but,  in my humble opinion, he  has feldom
 done  it in a manner that  can be ufeful.  In the  fame way that he
 has delivered  the fymptoms of difeafes  without any  inilruftive ar-
 rangement ; fo, on  the  fubjeft of the  appearances after death, he
 has"mentioned evCry morbid appearance that had ever been cbfcrv-
 ed after  the difeafe  of which he is then treating :  but thefe appear-^
 slices are ftrangely huddled together, without any  notice taken os.
 thofe which belong to one Pet of fymptoms or to another;  and, with
 regard to the whole, without any attempt to didinguifh between the
 caufes of difeafes  and the caufes of death ; although the  want of
 fuch diftinftion is the well-known  ground of fallacy  upon this fub-
 jeft.   I  take for an example, the appearances mentioned as having
 bwen obfeived after dropfy.  Here r.:crbid appearances,  fov.nd in e- 
 xxxii             PREFACE,

 very part of the body, in every cavity of it, and in every vifcus con-
 tained in  thefe cavities, arc enumerated ; but  which of thefe mor-
 bid ftates are more frequent or more rare, and which has been more
 particularly connected with  the different caufes, or with the different
 ftate of fymptoms previoufly recited, we are not informed, nor  has
 he enabled us to difcover.   In fhort, the diffection of morbid bodies
 has been, and may be, highly  ufeful; but in order  to be fo, muft
 be under a different  management from what we find,  either in this
 Synopfis, or even in  the Hifloria Anatomico medica.
   I cannot difmifs this fubject  without remarking, that the diffec-
 tionofmorbidbodies, ischiefly valuable uponaccountofitsleadingusto
 difcover the proximate caufes of difeafes; and the great and valuable
 work of the  illuftrious  Morgagni is,  properly intitled De fedibus et
 causis.    It may well feem furprifing, then, that  Lieutaudfhould
 find the whole of proximate caufes atra caligine  merfas ;  and that he
 fhould never have  thought of applying his  diffeftions towards  the
 afcertainingat leaftfome of thefe.
   But let me now proceed to  confider the important part of every
 practical work, and  of this Synopfis univcrfa medicine : that is,  the
 method of curing difeafes.
   Here, again, upon  the fame plan as in giving the hiftories of dif-
 eafe, the method  of  cure is delivered  by enumerating  the whole of
 the remedies that have ever been employed in a difeafe under the ti-
 tle prefixed ; without afligning the  fpecies,  or the circumftances to
 which the remedies,  though of a very different and fometimes oppo-
 fite nature,  are particularly adapted.   On  the fubject of Afthma,
 lie very juftly obferves that phyficians have  been to blame  in con-
 founding, under this  title, almoft all the fpecies of Dyfpncea ; and he
 himfelf very properly confiders Afthma as a difeafe diftinft from all
 the other cafes of Dyfpncea.  Still, however, he confiders Afthma as
 of many different fpecies, arifing from many different caufes, which
 till we underftand better,  we cannot attempt to remove.  Notwith-
 ftanding all this, he proceeds to deliver a very general cure.   Parum
 abefi, fays he, quiafpecifei titulo gaudeant pecloralia,vulneraria, et in/i-
 dentia ! But from  fuch language I receive no clear idea ; nor can  I
 obtain  any clear  direction from the enumeration of his medicines.
 Bacca junipe'i, gummi, tragacanthumvel ammoniacum, fapo, aqua picec,
terebinthina, &c. qua tamen baud indifcriminatim funt ufurpanda, fed pro
re not a, deluclu opus eft.  Very juftly indeed, delectu opus eft; but here,
as in many other inftances, he  gives us no fort of affiftancc.
   From his endeavours, though not always fuccefsful, to neo-lect all
fyftem, his practice is generally delivered in a very indecifive manner  ;
or, what has the fame effeft, in  a way fo conditional as will render it
always difficult, and  often impoflible,  for a young practitioner to
follow him.  Let us take, for example, his cure of Dropfy.  " The
"  cure may be begun by blood letting in certain conditions ; but,
**  in ethers, it cannot leemplcyd  -jcit'-jout  danger.  It gives relief in dif-
                                                       " fitult, 
PREFACE.
XXXIII
" ficult breathing ; but, after it is practifed, the fymptoms are aggravat-
" ed,  and  rendered more obftinate.  It  is  not to be  concealed that
" fome perfons have been  cured by repeated blood-lettings, or fpon-
" taneoushasmorrhagies ;  but it is at the fame time known, that fuch a
" remedy inopportunely employed,  has in many inflances haflenedon thefa-
" tal event."
   In the fame manner he treats of vomiting, purging, fweatincr, and
the ufe of mineral waters ;  but I muft confefs, that  he has no where
removed any of my  doubts or difficulties,  and indeed he has fome-
times increafed them.  He fay,  that hep.aics,  or aperients,  fuch
as the lingua cervina, herba capdlares, Iffc. defcrve commendation ; but
that, when  the difeafe has  anfen to a  certain degree, they have been,
for the mof part, found to be ufelefs.   He obferves,  that the powder of
toads given in wine, to the quantity of a fcruple or  more,  has fuc-
ceeded with feverals.
   Such are, commonly, the methods  of cure delivered by Mr. Lieu-
taud, longiori  et forte feliciffimn praxi edoctus-
   It would be tedious to enter further into that detail, which a cri-
ticifm of this immethodical and uninftruftive  work  might lead me
into ;  but,  if the bounds proper for this preface did not prevent  me,
I would particularly fhow that the work is far from being free from
thofe reafonings  which the author pretends to  avoid, and would af-
fect even to defpife.  He ftili holds the doctrines of  the concoction
and  critical evacuation of morbific matter,  doctrines depending upon
fubtile theories,  and which, in my opinion, can i:i jjo wife be afcer-
tained as matters of fact.   Mr. Lieutaud  likewife is  ftill very much
upon the old plan of following Nature, and therefore gives often what
I confider as a feeble and inert praftice.   The humectantia, diluentia,
demulcentia,  et temperantia, are with him  very univerfal remedies,  and
often thofe  which alone are to be employed.
   The mention of thefe medicines might lead me  to take notice of
Mr  Lieutaud's fecond  volume, in which ab infula remediorum farra-
ginealienus,  he promifes a  great reformation upon  the fubjeft :  but
this falls fo  far fhort of the idea of Britifh phyficians,  that 1 need not
make  any remarks  upon it.   With refpect to  his lift of fimples, or
Emporetica, as  he  is pleafed to term them, an Englifh apothecary
would fmile at it;  and with refpect to his offxinalia, I believe they
aie to be found no where but in the Codex  Medicamentarius of Paris ;
«nd  in his MagiflraRa his dofes are generally fuch as  the moft timid
practitioner of  this country would hardly defcend to,  and fuch as
none of our  pradtitioncrs of experience would depend upon.   In
fhort, the whole of  the work, both with refpect to the theories with
which it abounds, and to  the  fafts   whieh it gives,  will not, in  my
apprehenfion, bear any feriouscriticifm.   But I  muft conclude, and
fliall only  fay further, that fuch as I have ieprcfented  it, is  this
work, executed  by a man of the  firft rank in  the  profeffion.   It is
indeed for that reafon  1 have ch.dcn it as the example of a work,
                                L                           upon 
xxxiy             PREFACE.

upon the plan of giving  fafts only, and of avoiding the ftudy or
even the notice of the proximate caufes of difeafes : and with what
advantage fuch a plan is purfued, I fhall leave my readers to confider.
   In the following treatife I  have  followed a  different courfe.  I
have endeavoured to  colleft the facts relative to the  difeafes of the
human body, as fully as the nature  of the work and the bounds  ne-
ceffarily prefcribed  to it would admit;  But I have not been fatisfi-
ed with giving the  fafts, without endeavouring to apply them to the
inveftigation of proximate caufes, and upon  thefe to eftablifh a more
fcientific and decided method  of cuie.  In aiming at this, I flatter
myfelf that I have avoided hypothefis, and what have been  called the-
ories.   I have, indeed, endeavoured to eftablifh many general doc-
trines, both phyfiological and pathological; but I truft that thefe are
only a generalifation of fa6ts, or couclufions from a cautious and full
induction : and if any one fhall refufe to admit,  or directly fhall op-
pofe,  my general doctrine?, he muft do it  by  fhowkig that I have
been deficient or  miflaken in affumingand applying facts..  I  have,
myfelf, been jealous of  my being fometimes imperfect in thefe re-
fpects;  but I have  generally endeavoured to obviate the confequen*
ces of this, by provinj,  that the preximate  caufes which  I  have af-
figned, are true in faft, as  well  as deductions from any reafoning that
I may  feem to have employed.  Further, to obviate any  dangerous
fallacy in propofinga method of cure, I have always been  anxious to
fuggeft that which, to  the beft of my judgment, appeared to be the
method approved of by experience, as much  as it wa&theconfequence
of fyftem.
   Upon this general plan I have endeavoured to form a fyftem of
phyfic that fhould  comprehend the whole  of  the fafts relating to
the fcience,  and that will, I hope, collect and  arrange them in bet-
ter order than has  been done before, as well as  point out  in particu-
lar thofe which are ftill wanting to eftablifh general principles.  This
which I have attempted, may, like other fyftems, hereafter fuffer a
change ; but I am  confident,  that we are at prefent in a better train
of inveftigation than phyficians were in before the time of Dr. Hoff-
man.  The affections of the motions and moving powers  of the ani-
mal ceconomy, muft certainly  be the leading inquiry  in confidering
the difeafes of the human body.  The inquiry may be difficult ;but
it rauft be attempted, or the fubjeft muft be deferted altogether.   I
have, therefore,  affumed the  general  principles of Hoffman, as laid
down in the paffage which I have quoted above : and  if I have ren-
dered them more correct, and  more extenfive in their application ;
and, more particularly, if I have avoided introducing the  many hy-
pothetical  doctrines of the Humoral Pathology which  disfigured
both hfe and all the other fyftems which have hitherto prevailed ;  I
hope i fhall be excuied  for attempting a  fyftem, which upon the
whole may appear new.
     Edinburgh, Nov.  1789. 
    FIRST    LINES


                    O F  T H E

 PRACTICE   of    PHYSIC,




            INTRODUCTION.

                         I.

   IN teaching the Practice of Physic, we endeavour
   to give inft.ruct.ion for difceming, diflingui/hing, pre-
 venting, and curing  difeafes, as they occur in particu-
 lar perfons.
                        II.
   The art of discerning and distinguishing difea-
 fes, may be bed attained by an accurate and complete
 observation  of their phenomena, as thefe occur in con-
 courfe and in fucceflion, and by conftantly endeavour-
 ing to diftinguifh the peculiar and infeparable concur-
 rence of fymptoms, to  eftablifh a Methodical Noso-
 logy, or an arrangement of difeafes according to
 their genera and fpecies,  founded upon obfervation a-
 lone, abftra&ed from all reafoning.   Such an arrange-
 ment I have attempted in another work,  to which in
 the courfe of the prefent I fhall frequently refer.
                        III.
   The  Prevention of difeafes depends upon  the
knowledge of their  remote caufes* ;  which is partly
                       E  2               delivered
  * Remote caufes are of two kinds, vix. the predifpofing and the
exciting, or, as it is fometimes called, the occasional. The predif-
pofing i» that which renders the body liable or capable of being af- 
36              PRACTICE

delivered in the general Pathology, and partly to be
delivered in this treatife.
                        IV.
  The Cure of difeafes is chiefly, and almoft unavoid-
ably, founded  in the knowledge of their proximate
caufes*.  This requires an acquaintance with the In-
ilitutions of Medicine; that is, the knowledge of the
ftrufture, action, and functions of the human body;
of the feveral changes which it may undergo  ; and of
tho feveral powers by v hich it can be changed.  Our
knowledge of thefe particulars, however, is ftill incom-
plete, is in many refpects doubtful,  and has been often
involved  in mi (lake and error.  The doftrine, there-
fore, of proximate caufes,  founded upon that know-
ledge,  muft  be frequently precarious  and uncertain.
It is, however,  poffible for a judicious  phyfician to a-...
void what is  vulgarly called theory, that is, all reafon-
ing founded upon hypothefis, and thereby many of the
errors which  have formerly taken place in the Inftitu-
tions of Medicine.   It is poffible alio for a perfon  who
has an extenfive knowledge of the fafts relative to the
anim.d economy  in health and  in  iicknefs, by a cau-
tious and  complete induction, to eftablifh many gene-
ral principle, which may guide his rcaibning with  fafc-
tyj  and while,  at the fame time, a phyfician admits as
a foundation of practice thofe rcafonings only which
                                                 are
f.Ctcd by difeafe when the exciting caufe  is applied.  No difeafe
can exift without an occafional caufe; yet it is neceflary,  that at the
fame  l;;m, trie ftate of ths body be fuch as to -.dmii that caufe to
take ...ect, or aft.  The predion* caufe is inherent in the body :
Put it may nevtf;he!cfr be induced or changed by an external caufe
ftnl a.ore remote  Thus p]vtiu,ra may be the p.edifpoiW caufe of
m£;iy u.fcafc,  vet rSat la.nc plethora may be indeed by various
cauu-s previo;,fly>aa.„g on the body.  The prevention of difeafes ig'
to avoid thcexcitingre^,  and to  con-ect  that ftate of the body,
wmch render, .c capable of being affefttd by the exciting caufe.
  * Proximate caufes are thofe which immediately produce the <H\
cafe, and who:, removal cures the difu;:f.-. 
              OF   PHYSIC.            37

arc fimple,  obvious and certain, and for the moft part
admits as proximate  caufes thofe alone that  are efta-
blifhed as matters of fad rather than as deductions of
reafoning, he may with great advantage eftablifh a fyf-
tem of pradice  chiefly  founded on  the dodrine of
proximate  caufes.  But  when this  cannot  be done
with fufficient certainty, the judicious and prudent phy-
fician will  have recouife to Experience  alone; al-
ways, however, aware of  the hitherto incomplete and
fallacious ftate of Empiricifm.
                        V.
   With a ftrid attention  to thefe confiderations in the
whole of the following Treatife, I proceed to treat of
particular difeafes in the  order of my Methodical No-
fology.

           »<..<. .<..<..<..<..< ..<..<..<„.<...<,£,£,£>. >..».•>•■>■»•>• >.>.>..>..».

               PART    I.

   OF  PYREXIAE,  OR  FEBRILE DISEASES.

                       VI.
    PYREXIAE, or febrile difeafes,  are  diftinguiihed
      by the following appearances.   After beginning
with fome degree of cold iliivering, they ihow fome in-
creafe of heat, and an increased frequency of pulfe, with
the interruption and  diforder of feveral functions, par-
ticularly feme  diminution of ftrength in the animal
fundions.
                       VII.
   Of thefe Pyrexiae  I have formed  a clafs,  and have
fubdivided it into five orders of Fevers, Inflamma-
tions, Eruptions,  Hemorrhages, and  Fluxes,
See Synopfis Nofologise Methodicae, Edit. 3. 1780.
BOOK 
3*              PRACTICE
         BOOK       L

          OF    FEVERS.

           .4.+.4-.<..<..<..<--<.«.-4--<*?4r%$>-->">">">-->">">->">->"

               CHAP.    I.

     OF THE PHENOMENA OF FEVERS.

                      VIII.

     THOSE difeafes are more ftridly called  Fevers,
     which have the general fymptoms of pyrexia, with-
out having along with them any topical affe&ion that is
efiential and primary, fuch as the other orders of the
Pyrexiae always have.
                       IX.
  Fevers, as  differing in  the number  and variety of
their fymptoms, have been very properly confidered as
of diftind genera and fpecies.  But we fuppofe, that
there are certain circumftances in common to all the
difeafes comprehended under this order, which are
therefore thofe  eflentially  neceflary to, and properly
conftituting the nature of fever.   It is our bufinefs e-
fpecially, and in the firft  place, to investigate thefe j
and I exped to find them as they occur in the parox-
yfm, or fit, of an  intermittent fever, as  this  is moft
commonly formed.
                       X.
  The phenomena to be obferved in fuch a paroxyfm
arc the following.   The perfon is affeded, firft, with
a languor or fenfe of debility, a fluggiftinefs in  motion,
and fome uneafinefs in exerting it, with frequent yawn-
ing and ftretching.   At the  fame time, the face and
                                       extremitiei 
OF  PHYSIC.
3*
extremities become  pale ; the features  flirink;  the
bulk of every  external part is diminifhed ;  and the
fkin,  over the whole body, appears conftrided, as if
cold had  been applied to  it.  At the coming on of
thefe  fymptoms,  fome coldnefs  of the extremities,
though little taken notice of by  the patient, may be
perceived by another perfon.  At length, the patient
himfelf feels a fenfation of cold, commonly firft in  his
back, but, from thence, pafling over the whole body;
and now his fkin feels warm to another perfon.  The
patient's fenfe of cold increafing, produces a tremor
in all his  limbs, with frequent fucceflions or  rigors of
the trunk of the body.  When this fenfe of cold, and
its eflfe&s, have continued for fome time, they become
lefs violent, and are alternated with  warm flulhings.
By degrees, the cold goes off entirely;  and a heat,
greater than natural, prevails, and continues over  the
whole body.  With this heat, the colour of the ikin
returns,  and a preternatural rednefs appears, efpecial-
ly in the  face.   Whilft the heat and rednefs come on,
 the fkin, is relaxed and fmoothed, but, for forne time,
 continues dry.  The features of the face, and other
 parts of the body, recover their ufual fize, and become
 even more  turgid.  When the heat, rednefs, and  tiar-
 gefcence have increafed and continued for fome time,
 a moifture appears upon the  forehead, and by degrees
 becomes  a fweat, which gradually extends downwards
 over the  whole body.  As this fweat continues to flow,
 the heat  of the body abates ; the fweat, after continu-
 ing fome time,  gradually ceafes;  the body returns to
 its ufual  temperature : and  moft of the fundions are
 reftored to  their ordinary ftate*.
                       XI.
   This feries of  appearances give occafion to divide
                                                the
   * This defcription of a paroxyfm is truly admirable.  The fymp-
toms are moft accurately defcribed,  and the order of their fucceffioB
moft ftri&ly attended to by the author. 
4©
PRACTICE
the paroxyfm into three different  flanges ; which  are
called the Cold, the Hot, and the Sweating Stag-
es or Fits.
  In the courfe of thefe, confiderable  changes hap-
pen in the ftate of feveral other fundions,  which are
now to be mentioned.
                      XII.
  Upon the firft approach of languor, the pulfe  be-
comes fomerimes flower, and always  weaker than be-
fore.   As the fenfe  of cold comes on,  the pulfe be-
comes fmaller, very frequent, and often irregular.  As
the cold abates, and the heat com?s on, the pulfe be-
comes  more regular, hard, and full;  and in thefe re-
fpeds, increafes till  the fweat breaks  out.  As  the
fweat flows, the pulfe becomes fofter,  and lefs frequent,
till, the fweat ceufing altogether, it returns to its ufual
ftate.
                      XIII.
  The refpiration alfo fuffers fome changes.  During
the cold ftage, the refpiration is fmall,  frequent, and
anxious, and is fometimes attended with a cough : as
the hot ftage comes  on, the refpiration becomes fuller
and more free ;  but continues ftill frequent and anxi-
ous, till the flowing of the fweat relieves the  anxiety,
and renders the breathing lefs frequent and more free.
With the ceafing of the fweat,  the breathing returns
to its ordinary ftate.
                      XIV.
  The natural fundions alio fuffer a  change.  Upon
the approach of the cold ftage, the  appetite  for food
ceafes, and does not return till the paroxyfm be over,
or the fweat has flowed for fome  time.  Generally,
during the whole of the paroxyfm, there  i, not only
a want of appetite, but an averfion from all folid, and
eipecially animal food.  As. the cold ftage advances,
there frequently comes on a ficknefs and naufea, which
often increafe to a vomiting of a matter that is for the
moft part bilijus.   This vomiting commonly puts an
                                             end 
OF   PHYSIC.
4*
 end to the cold ftage, and brings on the hot.   As the
 hot ftage advances, the naufea  and vomiting abate ;
 and when the fweat breaks out, they generally ceafe
 altogether,              XV.
   A confiderable degree of thirft is commonly felt dur-
 ing the whole courfe of  the  paroxyfm.   Puring  the
 cold ftage, the thirft feems to arife from the drynefs
 and clamminefs of the mouth and  fauces, but during
 the hot ftage, from the heat which then prevails over
 the whole body ; and, as the fweat flows,  the mouth
 becomes moifter,  and the thirft,  together  with  the
 heat, gradually abates*.
                       xvi.
   In the courfe of a paroxyfm,  there is often a con-
 fiderable change in the  ftate of the fecretions.   The
 circumftances juft now mentioned fhow it in the fecre-
 tion of the faliva and mucus  of the mouth ; and  it is
 ftill more remarkable with refped to the urine.   Dur-
 ing the cold ftage, the urine is almoft colourlefs,  and
 without cloud or fediment.   In the hot  ftage,  it be-
 comes  high coloured, but is ftill  without  fediment.
 After the fweat has flowed freely, the urine depofits a
 fediment, commonly lateritious, and continues to do
 fo for fome time after the paroxyfm is over.
                       XVII.
   Excepting in certain  uncommon cafes which are
 attended throughout with  a  diarrhoea,  ftools  feldom
 occur till towards che end of a paroxyfm, when com-
 monly  a ftool happens,  and which is generally of a
 loofe kind f.
                          F                 XVTII.
  * The thirft in the cold and hot ftages of the paroxyfm feems to
 be a provident defign of nature, and has been held foith as an argu-
 ment for the exillence of the vis medicatrix naturae.  The paroxyfm
 concludes with a profufe fweat;  the  production of this fweat re-
 quires an additional quantity of fluidity; r.nd nature, by means of
the  thirft, feems  anxious to fupply the quantity of fluid  matter
neceflary for the perfpiration that is requifite to remove the difeafe.
  f  The author's exprefiion is here fomewhat aukward j the mean- 
4*
PRACTICE
                      XVIII.
  Analogous to thefe changes in the ftate of thefecre*
tions, it frequently happens, that tumours fubfiftrng on
the furface of the body, fuffer,  during the cold ftage
of  fevers,  a fudden  and  confiderable detumefcence ;
but generally, though not always, the tumours return
to their former fize during the fweating ftage.   In like
manner, ulcers are fometimes dried up during the cold
ftage; and return again to  difcharge matter during
the fweating ftage, or after the paroxyfm is over.
                       XIX.
   Certain changes appear alfo in fenfation and thought.
During the cold ftage, the  fenfibility is often greatly
impaired ; but when the  hot ftage is formed, the fen-
fibility is recovered, and often confiderably increafed.  '
                       XX.
   With refped  to the intelledual fundions,  when  '
the cold ftage comes on, attention  and  recolledion
become difficult, and continue more or lefs fo during
the whole paroxyfm. Hence fome confufion of thought
takes place, and often arifes to a delirium, which fome-
times  comes on  at the beginning  of the  cold ftage,
but more frequently not  till the hot ftage  be formed.
                       XXI.
   It belongs alfo to this place to  remark,  that  the
cold ftage fometimes comes on with a drowfinefs and
ftupor, which often  increafe to a degree that may be
 called comatofe, or apopledic.
                                              XXII.

ing of the paffage is, that ftools feldom occur in the two firft ftage»
 of a paroxyfm, except in peculiar cafes attended with diarrhoea;
 and if a ftool happens about the end of the paroxyfm, it is general-
 ly of a loofe kind.
   A fpontaneous diarrhoea always increafes the violence of the fymp-
 toms, and the obftinacy of the difeafe. Hence the abfurd praftice
 of prefcribing purges in agues, which never fail to exacerbate the
 paroxyfms, and prolong their continuance.   If any uneafinefs arifei
 from accumulated faeces in the colon or rectum, they may be re-
 moved by emollient clyftcrs. 
OF   PHYSIC.            43
                     XXII.
  We have ftill to add, that fometimes, early  in the
cold ftage,  a headach  comes on; but  which,  more
commonly, is  not felt till the hot ftage be formed,
and then is ufually attended with a throbbing of the
temples.  The headach continues till the fweat breaks
out j but as this flows more freely, that gradually
goes off.   At the fame time with the headach, there
are commonly pains of the back, and of fome of the
great joints; and thefe pains  have the fame courfe
with the headach.
                       XXIII.
  Thefe are nearly the whole, and are at leaft the
chief of the phenomena which more conftantly appear
in the paroxyfm  of  an intermittent  fever ;  and we
have pointed out their  ordinary concourfe and fuc-
ceflion.  With refped to the whole of them, howe-
ver, it is to be obferved, that, in different cafes, the
feveral phenomena are in different  degrees ; that the
fcries of them is more or lefs  complete ; and that the
feveral parts or ftages in the time they occupy, are in
a different proportion to one another.
                     XXIV.
  It is very feldom that a fever confifts of a fingle
paroxyfm, fuch  as we have  now  defcribed ;  and it
more generally happens, after a certain length of time
has elapfed from the ceafing of the paroxyfm, that the
fame feries of phenomena again arifes,  and obferves
the fame courfe as before ; and thefe ftates of Fever
and Apyrexia often continue  to alternate with one
another for  many times.  In fuch cafes, the Jength
of time from the end of one paroxyfm to the beginning
of another, is called an Intermission ; and the length
of time from the beginning of one paroxyfm  to the
beginning of another next fucceeding,  is called  an
Interval.
                       F 2                XXV. 
44               PRACTICE

                       XXV.
  When the difeafe confifts of a number of paroxyfms,
it is generally to be obferved,  that  the intervals be-
tween them  are nearly  equal ; but  thefe  intervals
are of different lengths in different cafes.  The  moft
ufual interval is that of forty-eight  hours,  which  is
named the Tertian period.  The next moft common
is that of feventy-two hours, and is named the Quar-
tan period.  Some other intervals are alfo obferved,
particularly one  of twenty-four hours, named there-
fore the  Quotidian ; and the appearance  of this  is
pretty frequent.   But all other intervals longer than
that  of  the quartan  are extremely  rare,  and  pro-
bably are only irregularities of the tertian or quartan
periods*.
                       XXVI.
   The paroxyfms of pure  intermittent fevers are al-
ways finifhed in lefs than twenty-four hours:  and
though it happens that there are fevers  which confift
of repeated paroxyfms, without any entire intermiflion
between them ;  yet in fuch cafes it is obferved,  that,
though the hot and fweating ftages of the  paroxyfm
do  not entirely  ceafe  before the twenty-four hours
from their beginning have expired, they fuffer,  how-
ever, before that time, a confiderable abatement  or
Remission of their violence ; and  at  the  return  of
the quotidian period, a  paroxyfm  is in fome  fhape
                                              renew-

  * Of the quotidian, tertian, and quartan intermittents there are
many varieties and forms ; as the double tertian, having a paroxyfm
every day, with  the  alternate  paroxyfms fimilar  to one another.
The double tertian,  with two paroxyfms every other day. The
triple tertian, with two paraxyfms on one day, and another on the
next.  The double quartan, with two paroxyfms  on the  firft day,
none on the  fecond  and third, and two again on the fourth day.
The double quartan, with a patoxyfm  on the firft  day, another on
the fecond, but none on thethiid.  The triple quartan, with three
paroxyfms every fourth day.  The triple quartan, with a paroxyft*
every day, every fourth paroxyfm being fimilar. 
OF  PHYSIC.
45
renewed,  which  runs the  fame courfe  as  before.
This conftitutes what is called a Remittent Fever.
                     XXVII.
  When in thefe remittents the  remimon is confiuer-
able, and the return of a new paroxyfm is diftindly
marked by the fymptoms of a cold ftage at the begin-
ning of it; fuch fevers retain ftridly the apcllation of
Remittents.  But when it happens, as  it does in
certain  cafes,  that the remiflion  is  not confidcra^e,
is perhaps without fweat, and  that  the returning pa-
roxyfm is not marked  by the moft ufual fymptoms of
a cold ftage, but chiefly by  the aggravation or  Exa-
cerbation of a hot ftage, the difeafe is called a Con-
tinued Fever.   ,
                      XXVIII.
  In fome cafes of continued fever, the re millions and
exacerbations  are fo inconfiderable as not to be e. iiiv
obferved or diftinguifhed ; and this has led phyficians
to imagine, that  there is a fpecies of fever fubfiilimT
for feveral  days together, and feemingly conll fling ot
one paroxyfm only   This they have called a Conj'i -
nent  Fever  ;  but,  in a long courfe of pradice, I
have not had an opportunity of obferving inch a fever.
                      XXIX.
   It is, however, to be obferved here, that the fevers
of a continued form are to be diftinguihVd from one
another;  and that, while fome of a very  continued
form do ftill belong to the fedion of intermittents,
there are others which, though ftill confining of fepa-
rate and repeated  paroxyfms, yet, as different by their
caufes  and circumftances from intermittents, are to be
diftinguifhed from the whole of  thefe, and are more
ftridly  to be called and confidered  as Continued-}-.
                                             Such

  f This paffage is very obfenre  :.the author's meaning  is, that
fome continued fevers put on the appealance of intermittents ;  but
being different, in fome peculiar and material circumflance?, from
intermittents, are not to be clafied with them. 
 46           PRACTICE

 Such are mod of thofe  which have been commonly
 fuppofed  to  be Continent ; and  thofe which by
 moft writers have been limply named Continued ;
 and which term I have employed as the title of a fec-
 tion, to be diftinguifhed from that of Intermittent.
   I fhall here add the marks by which, in  pradice,
 thefe different continued fevers may be diftinguifhed
 from one another.
   Thofe fevers of a continued form, which,  however,
 ftill belong to the fedion of Intermittents, may be dif-
 tinguifhed by their having palled from an  intermit-
 tent or remittent form, to  that  of a  continued ; by
 their fhowing fome tendency to become intermittent,
 or at leaft remittent; by their being known to have
 been occafioned by marfh miafmata ; and, for the
 moft part, by their having but one paroxyfm,  or one
 exacerbation and remiflion, in the courfe of twenty-
 four hours.
   On the other  hand, Continued Fevers,  to be more
 ftridly fo called, may be diftinguifhed  by  their fhow-
 ing  little  tendency to become intermittent  or remit-
 tent in any part of their courfe, and efpecially after
 the  firft week of their continuance ; by their being
 occafioned by human contagion, at leaft by other cau-
 fes  than  the  marfh miafmata; and by their having
 pretty conftantly an exacerbation and remiflion twice'
 in the courfe of every twenty-four hours.'  In both
 cafes, the knowledge of the  nature of the epidemic
for the time prevailing, may have a great fhare in de-
 termining the nature of the particular fever.
                     XXX.
  With refped to the form,  or Type,  of fevers, this
further may be obferved, That the quartan,  while it
has  the longeft interval, has,  at the fame time, the
longeft and moft violent cold ftage;  but, upon the
whole, the lhorteft paroxyfm : That the tertian, ha-
^ing a fhorter interval than the quartan, has,  at the
                                            fame 
               OFPHYSIC.             47

fame time, a fhorter and lefs violent cold ftage; but a
longer paroxyfm : And, laftly, that the quotidian, with
the lhorteft  interval, has the  leaft of a cold ftage, but
the longeft paroxyfm.
                       XXXI.
   The type of fevers is fometimes  changed in their
courfe.  When this happens, it is generally in the fol-
lowing manner:  Both tertians and  quartans  change
into quotidians, quotidians into  remittents, and thefe
laft  become often of the moft continued kind.  In all
thefe  cafes, the  fever has its  paroxyfms  protraded
longer than ufual, before it changes  into  a type  of
more frequent repetition.
                       XXXII.
   From all this a prefumption arifes, that every fever
confifts of repeated paroxyfms, differing from others
chiefly in the circumftances  and repetition  of the pa-
roxyfms ; and therefore,  that it was allowable for us
to take the paroxyfm of a pure intermittent as an ex-
ample and model of the whole.

              ,.«..< .«..<..<..<..<..<..<..«..<i$<~i£>..>..,..>..>.>..>..>..> ..>..»*

                 CHAP.    II.

  OF THE  PROXIMATE CAUSE OF  FEVER.

                      XXXIII.
     THE proximate caufe* of fever feems hitherto to have
     eluded" the  refearch of phyficians; and I fhall not
                                         «     pretend
   * The author, in this chapter, delivers his favourite doftrine of
 univerfal fpafm.  It is by no means new, as he himfelf confeffes in
 the preface, but borrowed from Hoffman.  The author, however,
 greatly improved the original idea, and brought the fyftem to a
 greater degree of perfection than it had been before. That there are
 weighty objections againft it, cannot indeed be denied  ; it contains
 however, much ingenuity ; and Dr.  Cullen, (by introducing it into
 this univerfity,) raifed his name high in the annalj of medical fame. 
d.8           PRACTICE
 pretend to afcertain it in a manner that may remove
 every difficulty ; but  I fhall endeavour to make an ap-
 pro ten towards it, and inch as, I hope, may be of ufe
 in conduding the practice in this difeafe :  while  at
 the fame  time I  hope to  avoid  feveral  errors which
 have formerly prevailed  on this fubjed.
                     XXXIV.
   As the hot ftage of fever is to conftantly preceded
 by a cold ftage, we prefume that the latter is  the caufe
 of the former ; and,  therefore, that the caufe of the
 cold ftage is the caufe of all that follows in the courfe
 of the paroxyfm.   See Boerh. Aph. 756-
                     XXXV.
   To difcover  the caufe of the  cold ftage of fevers,
 we may obferve,  that it is always preceded by ftrong
 murks of a general debility prevailing in the fyftem.
 1 he fmallnefs and weaknefs of the pulfe, the palenefs
 and coldnefs of the extreme parts, with the fhiinking
 of the whole body, fufticiently fhow that the adion  of
 the heart and larger arteries is, for the time,  extreme-
 ly weakened.   Together with this, the languor, inac-
 tivity, and debility of the animal motions, the imper-
 fed fenfations,  the feeling of cold, while the body 'u
 tiuly warm, and fome other fymptoms, all  fhevv that
 the energy of the brain is,  on this occafion, greatly
 weakened ; and I prefume, that, as the weaknefs of the
 action of the heart can hardly be imputed to any other
 cao.fe, this  weaknefs alio is a proof of the diminilhed
 eocrgy of the b:a:n.
                    xxxvr.
  I mall hereafter endeavour to fhow, that the  moft
 noted of the remote caufes  of fever, as contagion, mi-
 afv.ata,  cold, and fear, are of a fedative nature ; and
 therefore render it probable that a debility is induced.
 Likewife, when the paroxyfms of a fever have ceafed
to be repeated,  they  may again  be renewed, and are
moft coooiaonly renewed by  the application of debili-
                                            tating 
OF  PHYSIC.
49
tating powers.   And, further, the debility which fub-
fifts in the animal motions and other fundions through
the whole of fever,  renders it pretty certain that ie-
dative or debilitating powers*  have been applied to
the body.
                    XXXVII.
   It is therefore evident,  that there are three ftates
which always take place in fever : a ftate of debility,
a ftate of cold,  and a ftate of heat; and as thefe three
ftates regularly and conftantly fucceed  each other in
the order we have mentioned them, it is  preuimed that
they are in the feries of caufe and effed with refped
to one another.    This we hold as a matter of fad, even
although we fhould  not be able  to  explain in  what
manner, or by what mechanical means thefe ftates fe-
verally produce each other.
                    XXXVIIL
   How the ftate of debility produces  fome of the
fymptoms of the cold ftage,  may perhaps be readily
explained ; but how it produces all of them, I cannot
explain otherwife than by  referring the matter to a ge-
neral law of the animal ceconomy, whereby it happens,
that  powers which have a tendency to  hurt and de-
ftroy the  fyftem, often excite fuch  motions as are
fuited to obviate the effeds  of  the noxious  power.
This is the vis  medicatrix  nature,  fo famous in
the fchools  of phyfic ; and  it feems probable, that ma-
ny of the motions excited in fever are the effeds of
this power.
                     XXXIX,
   That the increafed adion of the heart and arteries,
which takes place in  the hot  ftage of fevers, is  to be
   Vol. I.                G              confidered

  * A purge adminiftered fix or feven days after the appearance of
any paroxyfm, has frequently occafioned a relapfe, and is a praftice
that ought to be carefully avoided,  I have generally  found that
purges given in the beginning of the difeafe, increafe the difficulty of
cuiing it. 
50           PRACTICE
 confidered  as  an effort of the vis medicatrix nalucv,
 has been long a common opinion among phy (loans ;
 and I  am difpofed to affert, that fome part of the cold
 ftage may be imputed to the fame power.  I judge f..,
 becaufe the cold ibge appears to be univerfally a means
 of producing the hut; becaufe cold, externally appli-
 ed, has very often fimilar effeds  ; and more certainly
 ftill,  becaufe it feems to be  in proportion  to the de-
 gree of tremor in the cold ftage, that the hot ftage
 proceeds more  or lefs  quickly to a termination of the
 paroxyfm, and to a moie complete iolution and long-
 er intermilli' n.  See xxx.
                       XL.
   It is to be particularly obferved, that, during the cold
 ftage of fever, there feems tp be a fpafm induced every
 where on  the extremities of the  arteries, and more e-
 fpecially of thofe upon the furface of the body.  This
 appears from the fuppreflion of all  excretions,  and
 from the fhiinking of the external parts: and although
 this may perhaps be imputed, in part, to the weaker
 adion of the heart in propelling the blood into the ex-
 treme  veffels ; yet, as thefe fymptoms often continue
 after the adion of the heart is reltored, there is reafon
 to believe, that a fpafmodic conftridion  has taken
 place ; that it fubfifts for fome time, and fupports the
 hot ftage ; for this ftage ceafes with the flowing of the
 fweat,  and the return of other excretions,  which are
 marks of the relaxation of veiTels  formerly conftrided.
 Hoffman. Med.  rat. Syftem. Tom. IV. P. I. Sed. I.
 Cap. I. art. 4.
                      XLI.
   The idea of fever, then, may be, that a fpafm of the
 extreme veileis, however induced, proves an irritatiun
 to the heart and arteries ; and that this continues till
 the fpafm  is relaxed or overcome.  There  are many
appearances which fupport this opinion ; and there is
little doubt that a fpafm docs take place, which proves
                                               an 
OF  PHYSIC.
5i
nn irritation to the heart, and therefore may be confi-
dered as a principle part in the proximate caufe of fe-
ver.   It will  ftill, however remain a queftion, what is
the caufe of this fpafm ; whether it be diredly produc-
ed by the remote ciufcs of fever, or if it be only apart
of the operation of the vis medicat-ix natures.
                     XL1I.
  I nm difpofed to be of the latter opinion, becaufe,
in the fir(I place,  while it remains fljll certain that a
debility lays the foundation of fever, it is not obvious
in what manner the debility produces the fpafm, and,
what feems  to be  its effed,  the increafed adion of
the heart and arteiies ; a.T\d,fecondly, becaufj, in almoft
all the cafes in  which an effort is made bv the vis me-
dicotrix nature, a cold fit and a fpafm of the extreme
veffels are almoft always the beginnings of fuch an ef-
fort.  See Gaub. Pathol. Medicin. art. 750.
                     XLIII.
  It is therefore prefumed, that fuch a cold fit and
fpafm at the  beginning of a fever, is a  part of the
operation of the vis medicatrix ; but, at the fame time,
it feems to me probable, that, during the whole courfe
cf the fever, there  is an atony  fubfifting  in the ex-
treme veffels, and that the relaxation of the fpafm re-
quires the reftorating of the tone and adion of thefe.
                     XLIV.
  This it  maybe difficult  to explain ; but  I think it
may  be  afcertained  as a fad, by the confideration of
the fymptoms which  take  place  with refped to the
fandionsof the ftomach in  (overs, fuch as the anorex-
ia, naufea, and vomiting, (xiv.)
  From many circumftances it  is iuiuciently certain,
that  there is a confent between the ftomach and  fur-
face of the body ; and in  all cafes of the confcnt of
diflant parts, it is prefumed to  be by the  connedion
of rhe nervous fyftem, and that the confent which ap-
pears is between the fentient and moving fibres of the
                      G  2                   one 
52
PRACTICE
one part with thofe of the other ; is fuch, that a cer-
tain  condition prevailing in the one part occafions a
fimilar condition in the other.
  In the cafe of the ftomach and furface of the body,
the confent  particularly  appears by the connedion
which is obferved between the ftate of the perfpiration
and the ftate of the appetite  in healthy perfons ; and
if it may be  prefumed that the appetite depends upon
the ftate of tone in the mufcular fibres of the ftomach,
it will follow, that the connedion of appetite and per-
fpiration depends upon a confent between the mufcu-
lar fibres of the ftomach and the mufcular fibres of the
extreme veffels, or of the organ of perfpiration, on the
furface of the body.
  It  is further in proof of the connedion between the
appetite and  perfpiration,  and at the fame time of the
circumftances on which it depends, that cold applied
to the furface of the body, when it does not  ftep per-
fpiration, but proves a ftimulus to it, is always a pow-
erful means  of exciting appetite.
  Having- thus eftabliihed the connedion or confent
mentioned, we argue, that as  the fymptoms of anorex-
ia, naufea, and vomiting, in   many cafes, manifeftly
depend upon a ftate of debility  or lofs of tone in the
mufcular fibres of the ftomach ; fo it may be prefum-
ed, that thefe fymptoms, in  the  beginning of fever,
depend  upon an atony communicated to the mufcular
fibres of the ftomach, from the mufcular fibres of the
extreme veffels on the furface of the body.
  That the  debility  of the  ftomach which  produces
vomiting in the beginning of fevers adually depends
upon an atony  of the extreme veffels on the furface of
the body,  appears particularly from a fad obferved by
Dr. Sydenham. In the attack  of the plague, a vomiting
happens, which prevents any  medicine from remain-
ing on the ftomach :  and Dr. Sydenham tells us, that
in fuch cafes  he could not overcome this vomiting but by
                                         external 
OF  PHYSIC.
53
external  means applied  to produce a fweat : that is,
to excite the adion of the veffels on the furface of the
body.
   The fame connedion between the ftate of the fto-
mach and that of the extreme veffels en the furface of
the body, appears from  this  alfo, that the vomiting,
which fo frequently happens in the cold ftage of fevers,
commonly ceafes upon the coming on of the hot, and
very certainly  upon any fwcat's  coming cut,  (xiv.)
It is indeed probable, that the vomiting in the cold
ftage of fevers, is one of the  means employed by na-
ture for rcftoring the determination to the fu face of
the body ; and  it is a  circumftance affording proof,
both of this, and of the general  connedion between
the ftomach  and furface  of the body, that emetics
thrown into the ftomach,  and  operating there,  in the
time of the cold ftage, commonly  put an end to it, and
bring on the hot ftage.
   It alfo affords  a proof of the fame connedion, that
cold water taken into the ftomach produces an increafe
of heat on the  furface of the body, and is very often a
convenient and effedual means of producing fweat.
   From the whole we have  now faid on this fubjed,
I think it is fufficiLntly probable, that the fymptoms
cf anorexia, naufea, and vomiting, depend upon, mid
arc a proof of, an atony fubfifting in the extreme vef-
fels on the furface of the body ;  and that this  atony
therefore, nowafcertained as a matter of fad, may be
confidered as a principle  circumftance in the  proxi-
mate caufe of fever.
                       XLV.
 . This atony * we fuppofe to  depend upon a diminu-
tion of toe energy of the brain  ; and that this diminu-
tion takes place in fevers, we c nclu le, not only from
the debility pr.-v.-iling in  fo many of the  fundi'.ns »-f
one body, mentioned above,  (xxxv.) but  particularly
                                             from
   * The reader will perceive, that the whole of the do.lndie deli-
vered in this chapter is hypothetical.
\ 
 54            PRACTIC E

 fi-mri fymptoms which are peculiar to the bra:n Kielf.
 Delirium is a frequent fymptom of fever: and as from
 the phvilcloriy and pathology we learn that this fymp-
 tom commonly depends upon  ibme inequality in the
 excitement rt the brain ort int< lledual organ ;  ve
 hence conclude, that, in fever, it denotes fome diminu-
 tion in-the energy of the brain.   Delirium, indeed.
 feems often to dep-nd upon an increafed impetus of
 the  blood  in the veffels of the  brain,  and therefore
 attends  phrenitis.  It frequently  appears alfo in the
 hot ftage of fevers,  accompained with a headach and
 throbbing of the temples.  But as the impetus of the
 blood in the veffels of the head is  often  coniiderahly
 increafed by exircife, external heat, pa file os, and o-
 thcr caufes, without occasioning any  delirium ;  f>,
 fuppofing that the fame impetus, in the caufe  of fever
 produces delirium,  the reafon muft be, tl at, at the
 lame  time, there is fome caufe  which diminifhes the
 energy of the brain, and prevents a  free communi-
 cation between the parts concerned in the intelledual
 funcliors.   Upon the fame  principles alfo, I fuppofe
 there is-another fpecies of delirium, depending  more
 rmirely en the  diminifbed  energy of the brain, and
 vliich may therefore aiife when there is no unufual
 io.-reafe or'the impetus of the blood in the veffels of
 too- b'ain   Suah feems to be the delirium occurring
 at the beginning of the cold ftage of fevers, or in the
 hot ilage of fuch fevers as fhow ftrong marks of debi-
lity in the whole fyftem.
                     XL VI.
  Upon thcw'.mle, our dodrine of fever is explicitly
thi*.  The r-mote  caufes (xxxv.) are certain fecl-
arive powers applied  to the nervous fyflem, which di-
 mmiliiing to-  energy  of the  brain, thereby produce
 a  cebility  in  the whol^of the functions'!  (xxxv.)
and p-.'.rticubrly in the adion of the  extreme veffeb
 (.xliii. x'ov.) Such,  however, is, at  the  f me time]
                                              the 
U  F~~rTTT S  I  C.
55
 the nature of the  animal ceconomy, (xxxviii.) that
 this  debility proves an indited ftimulus to the fan-
 guiferous fyftem; whence, by the intervention of the
 cold ftage, and fpafm conneded with it,  (xxxix.
 xl.)  the adion of  the heart and larger arteries is in-
 cieafed,  (xl.) and continues fo (xJi ) fill it has had
 the effed of leftoiingthe energy of  the brain, of ex-
 tending this energy to the extreme veffels, of reftor-
 ing therefore their adion, and thereby efpecially o-
 veicoming the fpafm affeding them ; upon the remov-
 ing of which, the excretion of  fweat, and other marki
 of the relaxation of excrttories, take place.
                    XLVII.
    This dodrine will, as 1 fuppofe, ferve to explain not
 only the nature of fever in general, but alfo the va-
 rious cafes of it which  occur.   Befoie proceeding,
 however, to this, it may be proper  to point  out the
 opinions,-and,  as I apprehend,  the miftakes, which
 have formerly prevailed on this fubjed.
                     XL VIII.
    It,has been fuppofed, that a  lentor or vifcidity pre-
 vailing in the mafs of bloud, and ftagnating in the ex-
• treme veffels is the caufe of the cold ftage of fevers
 and  its'confequences.   But there is  no evidence  of a-
Nny fuch vifcidity previoufly  fubiifting in the  fluids;
 and  as it is very improbable'that fuch a ftate of them
 can  be very quickly produced,  fo the fuddennefs with
 which the paroxyfms come on, renders it more likely
 that the phenomena depend upon feme caufe ading
 upon the nervous fyftem, or the primary moving pow-
 ers of the animal ceconomy. See Van Swieten apud
 Boerh.  Aph. 755.
                      XLIX.
   Another opinion which has been almoft univerfally
 received, is, that a noxious matter introduced into, or
 generated in  thebody, is the proximate caufe of fever;
 and that the increafed adion of the heart and arteries,
                                      ,.     which 
 56          ? R  A  C  T  I C L

 which forms fo great a part of the difeafe, is an effort
 of the vis medicatrix natures to expel this morbific mat-
 ter ; and particularly to change or concod i;, fo as to
 render it cither altogether innocent, or at leaft, fit for
 being more eafily thrown out of the body. This doc-
 trine, however, although of as great antiquity as any
 of the records of phytic now remaining, and although
 it has been received by alnioft every fchool of medi-
 cine, yet appears to me to reft upon a very uncertain
 foundation.  There are fevers produced by cold, fear,
 and other caufes, accompanied  with all the eftential
 circumftances of fever, and terminating by fweat; but,
 at the fame time, without any evidence or  fufpicion
 of morbific matter.
   There have been fevers fuddenly cured by a hem-
 orrhagy, fo moderate as could not carry out any con-
fiderable portion of a matter diffufed over the whole
 mafs of blood;  nor can we conceive how the morbi-
fic matter could be colleded or determined to pafs oft
by fuch an outlet as in that cafe is opened.
  Even fuppofing a morbific matter were prefent, there
is no explanation given in what manner the concodion
 of it is performed; nor isitihownthatany fuch change
 does in  fad take place.   In certain cafes, it is indeed
evident, that a noxious matter is introduced  into the
body, and proves the caufe of fever: but, even in thefe
cafes, it appears that the noxLus matter is thrown out
again, without  having  fullered any change; that the
fever  often terminates before the matter is expelled;
and that, upon many occalions, without waiting the
fuppofed time of concodion, the fever can be cured,
and that by remedies whioh do not feem to operate
upon  the fluids, or produce any evacuation.
                      L.
  While we thus reafon againft the notion  of fever
being an eft'ort of nature, for concoding  and expelling
 a moibitic matter; 1 by no means intend to deny that
                                              the 
              O F  P H Y S I C.             57

the caufe of fever frequently operates upon the fluids,
and  particularly produces a  putrefcent ftate of them.
I acknowledge that this is frequently the cafe: but, at
the fame time, I maintain,  that fuch a change of the
fluids is  not commonly the caufe of fever, that very
often it is an effed only ; and that there is no reafon
to believe the termination of the fever to depend up-
on theexpulfion of the putrid matter.
                        LI.
   Another opinion which  has prevailed, remains ftill
to be mentioned. In intermittent fevers, a great quan-
 tity of bile is commonly thrown out by vomiting ;  and
this isfo frequently the cafe, that many have fuppofed an
unufual  quantity of bile, and perhaps a peculiar qual-
ity of it, to be the  caufe of intermittent fevers.  This,
however, does not appear to be well founded.   Vo-
mitting, by whatever means excited, if too often re-
peated,  with violent {training, feems to be powerful
in emulging the biliary duds, and commonly throws
out a great  deal of bile.   This will happen efpecially
in the cafe of intermittent fevers.   For as, in the ftate
of debility and cold ftage of thefe fevers, the  blood is
 not propelled in the ufual quantity  into the extreme
 veffels,  and particularly  into tho/e on the furface of
 the body, but is accumulated in the veffels of the in-
ternal parts, and particularly in the vena portarum; fo
this may occafion  a more copious  fecretion of bile.
   Thefe confiderations will,  in fomemeafure,  account
 for the appearance of an unufual quantity of bile in in-
termittent fevers;  but the circumftance which chiefly
occafions the appearance of bile in thefe cafes, is the
influence of warm  climates and feafons.   Thefe feldom
fail to produce a ftate of the human bedy, in which
the bile  is difpofed to pafs off, by its  fecretories, in
greater quantity than  ufual; and perhaps alfo changed
in its quality, as appears from the dn^afe of cholera,
which fo frequently occurs in warm feafons.  ,„ At the
   Vol.  1.                   H                 fame 
58            PRACTICE

fame time, this difeafe occurs often without fever ; and
we fhall hereafter render it futficiently probable, that
intermittent fevers, for  the moft part, arile from ano-
ther caufe,  that is, from marfh  effluvia; while on the
other hand, there is no  evidence of their arifing from
the ftate of  the bile alone.   The  marlh effluvia, how-
ever, commonly operate moft powerfully in the fame
feafon that produces the change of and redundance ot
the bile; and therefore confidering the vomiting,  and
other circumfta"ces of  the intermittent  fevers which
here concur, it is-not furprifing that autumnal intermit-
tents are fo often attended with effufions of bile.
   This  view of the fubjod does not  lead us to confider
the ftate of the bile as the caufe of intermittents, bat
merely as  a  circumftance accidentally  concurring with
them, from the ftate of the feafon in which they arifc.
What attention this requires in the conduct of the dif-
eafe, 1 ihall confider hereafter.
                       LIE,
   From this view of the principal hypothefes which
have hitherto  been maintained with refped to the
proximate caufe of fiwer,  it will appear, that fevers
do not arife from changes  in the ftate of the fluids;
but that,  on the contrary,  almoft  the whole  of the
phenomena of fevers lead us to believe, that they chief-
ly depend upon  changes  in the ftate of the mov-
ing powers of the amimal fyftem.   Tho' we  fhould
not be able to  explain ail the circumftances of the dif-
eafe, it  is  at leaft of fome advantage to be led into the
proper  train of inveftigation.   I have  attempted to
purfue it; and ih.ill naw endeavour to apply the doc-
trine already delivered,  towards explaining the diver-
fitv of fevers.
C  II  A f\ 
              OF  PHYSIC.            59


              CHAP.    VI.

OF  Till:  DIFFERENCE  OF  FEVERS, AND
                 ITS CAUSES.

                      L1II.
    TO afcertain the difference of fevers, I think it necef-
     lary to obferve, in the firft p'ace, that every fever
of more than one day's duration, confifts of repeated
and in fome meafure feparate, paroxyfms; and thatthe
difference of fevers token notice of above (iromxxv. to
xxx.) appear^ toconfiftinthe different ftate or paroxyfms,
and in the  different circumftances of their repetition.
                      LIV.
   That fevers generally confift of diftind, and in fome
meafure feparately  repeated, paroxyfms,  I  have al-
leged above to be a matter of fad ;  but I fhall here
endeavour to confirm it, by afligningthe caufe.
                       LV.
   In every fever, in which we can diftindly obferve a-
ny number of feparate  paroxyfms, we conftantly find
that each paroxyfm is finifhed in lefs than twenty-fcur
hours ; but as I cannot perceive any thing in the caufe
of fevers determining to this, I muft prefume  it to de-
pend on fome generallaw *  of the animal ceconomy.
Such a law  feems to  be that  which fubjeds  the
ceconomy,  in many refpeds, to  a diuvnft revolu-
tion.   Whether this depends upon the original con-
formation of tfie  body, or upon certain  powers con-
ftantly applied to it, and inducing a habit,  I cannot
pofitively determine :  but  the  returns of fleep and
Watching, of appetites  and excretions, and the chan-
                        H 2                   ges
   * The reader will  finH entertainment in admiring the ingenuity
of the author, in contriving feveral articles for maintaining his doc-
trine.  Ont hvp< tin i'S piled on the top of another, almotl without 
Co             PRACTICE
ges which regularly occur in the ftate of the pulfe,
mow furficiently, that in the human body a diurnal re-
volution takes place.
                       LVI.
   It is this diurnal revolution which, I fuppofe, deter-
mines the duration of the paroxyfms of fevers ;  and
the conftant and univerfal limitation  of thefe parox-
ifms, (as  obferved in lv.) while no other caufe of it
can be afligned, renders  it fufficicntly  probable that
their duration depends upon, and is determined by,
the revolution mentioned.  And that thefe paroxyfms
are cenneded with  that diurnal revolution,  appears
further from  this, that though the intervals of parcx-
yfms  are different in different cafes,  yet the times of
the acceftion  of paroxyfms are generally fixed to  one
time of the day  ; fo  that Quotidians  come on in  the
morning, Tertians at noen, and Quartans in  the after-
noon.
                      LVII.
   It remains to be remarked, that as Quartans  and
Tertian* are  apt to become Quotidians, thefe to  pafs
into the ftate of Remittents, and thefe laft to become
Continued ;  and that, even in  the Continued form,
daily exacerbations and remifiions are generally to be
obferved : fo all this fhows fo much  the power of di-
urnal revolution, that when, in certain cafes,  the daily
exacerbations and remifiions are with difficulty diftin-
guifhed, we may ftill prefume, that the general tenden-
cy of the ceconomy prevails, that the difeafe ftill c©n-
fifts of repeated paroxyfms, and, upon the whole,  that
there is no fuch difeafe as that which  the fchools have
called a Continent fever.  I exped that this dodrine
will be confirmed by  what I  fhall fay hereafter con-
cerning the  periodical movements obferved  in conti-
nued fevers.
                     LVIII.
   It being thus proTed, that every fever, of more than
                                               one 
              Or"  PHYSIC.            61

one day's  duration, confifts of repeated paroxyfms ;
we in the next place remark, that the repetition of pa-
roxyfms depends upon the circumftances of the parox-
yfms  which have  already  taken place.   From what
was obferved in xxx, and xxxi, it appears,  that  the
longer paroxyfms are protraded, they are the fooncr
repeated;  and, therefore, that the caufe of the frequent
repetition  is to be fought for in the caufe of the pro-
tradion of paroxyfms.
                       LIX.
  Agreeably to what  is laid down in xlvi, and to
the opinion of moft part of phyficians, 1 fuppofe, that,
in every fever, there is a power applied to the  body,
which has a tendency to hurt and deftroy it, and pro-
duces in it certain motions which deviate from the na-
tural.ftate ; and, at the fame time, in every fever  which
has its full courfe, I fuppofe, that, in  confequence of
the conftitution of the animal ceconomy, there are cer-
tain motions excited, which have a tendency to obvi-
ate the effeds of the noxious power, or to corred and
remove them.   Both thefe kinds of motion ate confi-
dered as conftituting the difeafe.
  But the former is perhaps ftridly the morbid ftate,
while the  latter  is to be confidered as the operation
of the vis medicatrix natures^ of falutary tendency,
and which I fhall hereafter call the react-ion of the
fyftem.
                       LX.
  Upon the fuppofition that thefe two ftates take place
in every paroxyfm of fever, it will appear to be chiefty
in the time of the hot ftage that the readion operates
in removing the  morbid ftate ;  and therefore, as this
operation  fucceeds  more or  lefs quickly, the b°t ftage
of paroxyfms will  be  fhorter or longer.   But as  the
length of paroxyfm depends chiefly upon the duration'
of the hot ftage,  fo the longer duration of this and of
paroxyfms, muft be owing either to the  obftinacy of ie-
                                        Tefiftance 
62              PRACTICE
reful-mce in the morbid  ft ite,  or to the weaknefs of
the falutary readion ; and it  is probable that fome-
times the one and fometimes the other of thefe circum-
ftances tr.kes place.
                      LXI.
  It feems to be oply bv the ftate of the fpafm, that
we can judge of the rcfiftance of the morbid ftate ot
fever: and  with refped to this fpafm I obferve, that
either the caufe  excit'ing it may be different in different
cafes ; or, though the caufe fhould be the fame in dif-
ferent perfons,  the  different degree of irritability, in
each may give occafion to a greater or leffer degree of
fpafm; and therefore, the readion ip fever being giv-
en, the continuance of the hot  ftage, and of the whole
paroxyfm, may  be longer ox fhorter, according to the
degree of fpafm that has been formed.
                      LXII.  '
  One caufe of the obftinacy  of fpafm in fevers may
be clearly perceived.  In inflammatory difeafes, there
is a diathefis phlogiftica prevailing  in  the body, and
this diathefis we fuppofe to confift  in an increafed tone
of the whole arterial f)ftem.   When, therefore, this
doaohefi': accompanies fever, as  it  fometimes does, it
may be fuppofed to give occafion to the febrile fpafm's
being f-rmed more ftrongly,  and thereby to produce
more protraded paroxyfms.   Accordingly we  find,
that ail inflammatory  fevers  are  of the continued
kind ; and that  all the caufes of the diathefis phlogifti-
ca have a tendency to change intermittent into con-
tinued fevers.   Continued fevers,  then, being often
attended  with the diathefis phlogiftica, we conclude,
that,in many cafes, this is the caufe of their continu-
ed form.
                     LXIII.
  In many fevers,  however,  there is no evidence of
any diathefis phlogiftica being prefent, nor of anv o-
ther caufe of .more confiderable fpafm ; and in  fuch
                                             cafes, 
             OF   PHYSIC.             63

cafes, therefore, we  muft  impute the protradion of
panxyfn.s, and the continued form of the fever, to
the weaknefs of readiun.   That this caufe takes place,
we coi.elude from  hence, that, in  many cafes of fe-
ver,  wherein the feparate paioxyfms are the  longeft
protraded, and  the moft. difficultly obferved, we  find
the moft confiderable fymptoms of a general debility :
and therefore We infef, that,  in fuch cafes', the pro-
traded paroxyfms, and continued form} depend upon
a weaker readion ; owing either to the caufes of de-
bility applied having been of a more powerful kind,
or from  circumftances of the patient's  cor.ftitution
favouring their operation.

   ttpoh  thefe principles we make a ftep towards ex-
plaining  in general, with fome probability, the differ-
ence of fevers; but muft own,  that there is much
doubt and difficulty in applying the dodrine to par-
ticular cafes.  It applies tolerably well to explain the
different ftates of intermittents, as they are more pure- ..
ly  fuch, or as they  approach more and more to the
continued form: But feveral difficulties ftill remain
with'refped to  many circumftances of intermittents ;
and more ftill  with refped to the difference of thofe
continued fevers, which we have diftinguifhed in our
Nofology as different from intermittents, and as mo.e
efpecially  entitled  to the  appellation of Continued,
 (fee  Syn.  Nof. Meth.  P.  V.  Ch. I. Sed. II.)  and!
explained more fully above.
                       LXV.
   From  the view given (Ixiii. and Ixiv.) of the caufes
of the protradion of parox>fms, and therefore of the
form of  Continued fevers, ftiidly fo  called, it feems
 probable, that the remote caufts  of thefe operate by
occafioning either a phlogiftic diathefis, or a  weaker
 readion  ;  for we can obferve,  fhat the moft obvious
                                         difference; 
64          PRACTICE
difference of continued  fevers depends upon the pre-
valence of one or other of thefe ftates.
                      LXVI.
   Continued fevers have been accounted of great di-
verfity ;  but phyficians have not been fuccefsful in
marking thefe differences, or in reducing them to any
general heads. •  The diftindions made by the ancients
are  not  well underftood ; and, fo far as either they
or the modem nofologifts have diitinguifhed continu-
ed  fevers by a difference of  duration, their diftindi-
ons are 'not  well founded, and do not  apply in fuch a
manner as to be  of any ufe.'  We think it agreeable
to obfervation, and  to the principles above laid down,
(lxiii. lxiv.)  to diftinguifti  continued fevers  accord-
ing as  they fhow either an inflammatory irritation or a
weaker redaion.
                     LXVIL
  This diftindion is the fame v\ith that of fevers into
the Inflammatory and Nervous ; the diftindion at
prefent moft generally received  in Britain.  To the
firft, as a genus,  I have  given the name of Synochus;
to the  fecond,  that of Typhus ; and little ftudious
whether thefe names be authorifed by the ancient ufe
of the fame terms,  I depend upon their being under-
ftood by the charaders*  annexed  to them in our No-
fology, which I apprehend to be founded on obferva-
tion.
                      LXVIII.
  By thefe charaders I think continued fevers may in
pradice be diftinguifhed ; and if that be the cafe, the
principles above laid down will be confirmed
                       LXIX.
  Befide thefe  differences  of continued fever,  now
mentioned,  I am not  certain of having obferved any
                                             other
  * Thefe characters are, Synocha.  Calor plurimum auftus ; pul-
fns ftequeus, validus, et durus ;  urina ruhia ; fenforii fun&ioncs
plurimum turbatae ; vires multum : mininutse. 
              OF   PHYSIC."           65

other that can be confidered  as fundamental. ' But
the moft common form of continued fevers, in this
climate, feems to be a combination of thefe two gene-
ra ; and I have therefore given fuch  a g mus a place in
our Nofology, under the title of  Synochus.  At the
fame time, I think that the  limits  between the Svno-
chus and Typhus will be with difficulty afligned ;'and
I am difpofed to believe, that the Synochus aiifes
from the fame caufes  as the Typhus, and is therefore
only a  vaiLty  of it.
                      LXX.
  The  Typhus  feems to be a genus  comprehending
feveral fpecies.   Thefe, however, are not yet well af-
certained by obfervation ;  and in the mean  time w«
can perceive that many of the different cafes obferved
do not  imply any fpecific difference, but feem to be
merely  varieties, arifing  from a different  degree of
power in the  caufe,  from different circumftances  of
the climate or feafon in which they happen, or from
different circumftances in the conftitution of the per-
fons affeded.
                     LXXI.
  Some of the effeds arifing from thefe circumftances
require  to be particularly explained.
  One is, an unufual quantity of bile appearing in the
courfe  of the  difeafe.  This  abundance of  bile may
poffibly attend fome continued fevers, ftridly fo call-
ed ; but, for the  reafons above explained,  it more com-
monly attends intermittents, and, we believe, it might
have been  enumerated (xxix.) among the marks dif-
tinguifhing the latter kind of fevers from the  former.
But though an unufual quantity of bile fhould appear
with continued fevers, it is confidered in this  cafe, as
in that of intermittents, to be a coincidence  only, ow-
ing to the ftate of the feafon, and producing  no differ-
ent fpecies or fundamental diftindion, but merely a
variety  of the difeafe. I think it  proper to  obferve
  Vol. I.               I                   here, 
66            PRACTICE
here, that it is probable that the moft part of the con-
tinued fevers named Bilious  have been truly fuch as
belong to the fedion of Intermittents.
                     LXXII.
  Another effed of the circumftances occafionally va-
rying the appearance  of typhus,  is a putrefcent ftate
of the fluids.  The ancients, and bkewife the moderns,
who are in general much difpofed to follow the form-
er,  have diftinguifhed fevers, as putrid, and non pu-
trid : but the notions  of the ancients, on this fubjed,
were not fufficiently corred to  deferve much notice;
and it is only of late that the matter has been more ac-
curately obferved, and better explained.
  From the diffolved ftate of the blood, as it prefents
itfelf when drawn  out of  the veins, or as it  appears
from the red blood's being difpofed to  be effufed and
run off by various outlets, and  from feveral  other
fymptoms to be hereafter mentioned, I have now no
doubt, how much foever it has been difputed by fome
ingenious men, that a putrefceney of  the fluids to a
certain degree does really take place in many cafes of
fever.  This putrefceney, however,  often attends in-
termittent, as well as continued fevers, and, of the con-
tinued kind, both the fynochus  and typhus, and all of
them in very different degrees; fo that, whatever at-
tention it may deferve in pradice, there is no  fixing
fuch limits to it  as  to admit of eftablifhing a  fpecies
under the title of Putrid.
                     LXXIII.
  Befide differing  by the circumftances already men-
tioned,  fevers differ alfo by their being accompanied
with fymptoms which belong to difeafes of the other
orders of pyrexiae.   This fometimes happens in fuch
a manner, as to render it difficult to determine which
of the two is the primary  difeafe.  Commonly, how-
ever,  it may be afcertained by  the knowledge of the
                                           remote 
OF  PHYSIC.            67
remote caufe, and of the prevailing epidemic, or by
obferving the fcries and fucceflion of fymptoms.
                     LXXIV.
   Moft of our fyftems  of phyfic have marked,  as a
primary one, a fpecies of fever under the title of Hec-
 tic ; but, as it is defcribed,  I have never feen it as a
primary difeafe.   I have conftajitly found it as a fymp-
tom of fome topical affedion, moft commonly of an
internal fuppuration ;  and as fuch it fhall be confider-
ed in another place.
                     LXXV,
   The diftindion of the feveral cafes of intermittent
fever I have  not profecuted  here;  both becaufe we
.cannot aflign the caufes  of the differences which ap-
pear, and  becaufe I apprehend  that  the differences
which in fad occur may  be readily underftood from
what is faid above (xxv, xxvi, xxvii.), and more ful-
ly from our Methodical Nofology, Ch. I. Sed. I.



              CHAP.    IV.

   OF THE  REMOTE  CAUSE  OF  FEVER.

                     LX^VI,

     AS fever has been held to confift chiefly in an in-
      creafed adion of the heart and arteries, phyficians
have  fuppofed its remote caufes  to be certain dired
ftimulants fitted to produce this increafed adion.   In
many cafes, however, there ?s no evidence of fuch  fti-
mulants being applied ; and,  in thofe  in which they
are applied,  they  either  produce only a temporary
frequency  of the pulfe, which cannot be confidered as
a difeafe ;  or, if they do produce a permanent febrile
ftate,  it is by the  intervention of a topical inflamma-
                        I 2                  tion, 
68           PRACTICE
tion, which produces a difeafe different from what  13
ftridly called fever, (viii.)
                    LXXVII.
  That dired ftimulants are the remote caufes of fe-
ver,  feems farther improbable ; becaufe the fuppofi-
tion does not account for the phenomena  attending
the accefiion of fevers, and becaufe other remote cauf-
es can with greater certainty be afligned.
                    LXXVIII.
  As fevers are fo generally epidemic,  it is probable,
that fome matter  floating in the atmofphere,  and ap-
plied to the bodies of men, ought to be confidered as
the remote caufe of fevers; and thefe matters prefent
in the atmofphere, and thus ading upon men, may be
confidered,  either as Contagion,  that  is, effluvia
arifing diredly  or originally from the body of a man
under a particular difeafe, and exciting the fame kind
of difeafe in the body of the perfon to whom they are
applied; or Miasmata, that is,  effluvia arifing from
other fubftances than the bodies of men, producing a
difeafe in the perfon to whom they are applied.
                    LXXIX.
  Contagions have been fuppofed to be of  great vari-
ety ; and, it is poffible this may be the cafe :  but that
they truly are fo,  does  not appear clearly from any
thing we know at  prefent.  The genera and fpecies  of
contagious difeafes of the clafs of Pyrexiae, at prefent
known, are in number not very great.   1  hey chiefly
belong to the order of fevers,  to that of Exanthemata,
or that of Profluvia.  Whether there be any  belong-
ing to  the order of Phlegmafiae, is doubtful; and
though  there fhould,  it will not much increafe the
number of contagious pyrexiae.  Of the contagious ex-
anthemata and profluvia, the number of fpecies is near-
ly afcertained ;  and each of them  is fo far  of a deter-
mined nature, that though they  have now been ob-
ferved and diuingiiifhed for  many ages, and in  many
                                          different 
OF  PHYSIC.
09
different  parts of the world,  they have been always
found to  retain the fame general character, and to dif-
fer only in circumftances, that may be imputed to fea-
fon, climate, and other external caufes, or to the pe-
culiar  conftitutions  of the feveral  perfons  affeded.
It feems, therefore,  probable, that, in each  of thefe
fpecies, the contagion is of one fpecific nature ; and
that the number of contagious exanthemata or proflu-
via is  hardly greater  than the number of fpecies enu-
merated  in the fyftems of nofology.
                      LXXX'.
  If,  while the contagious exanthemata and  profluvia
are thus limited,  we  fhould fuppofe the  contagious
pyrexiae  to be ftill of great and unlimited variety,  it
muft  be with refped  to the genera and fpecies of con-
tinued fevers.  But if I be right in limiting,  as  I have
done, the genera of thefe fevers, (lxvii.-----Ixx.) it will
appear likely that the contagions which produce them
arc not of great variety: and this will be much con-
firmed, if we  can render it probable that there  is one
principal, perhaps one common, fource of iuch  conta-
gions.
                       LXXXI.
  To this purpofe it  is now well known, that  the efflu-
via conftantly arifing from  the living human body, if
long retained in the fame place, without being diffufed
in the atmofphere, acquire a  fingular virulence ; and,
in that ftate, being applied to the bodies of  men, be-
come the caufe of a fever which is highly contagious.
   The exiftence of fuch a caufe is fully proved by the
late obfervations on  jail and hofpital fevers : and that
the fame virulent matter may be produced in many o-
ther places, muft be  fufficiently obvious: and it is pro-
bable that the contagion arifing in this manner, is not,
like many other contagions, permanent and conftantly
exifting; but that, in the circumftances mentioned, it
is occafionally generated.   At the fame time, the na-
                                              ture 
70            PRACTICE
 tare of the fevers from thence, upon different occafi-
 ons, arifing, renders it probable that the virulent ftate
 of human effluvia is the common caufe of them, as
 they  differ only in  a ftate of their fymptoms;  which
 may be imputed to the circumftances of  feafon, cli-
 mate, &c.  concurring with the contagion, and modi-
 fying its force.
                     LXXXII.
  With refped to thefe contagions, though we have fpor
 ken of them as of a matter floating in the atmofphere,
 it is proper to obferve,' that they are never  found toad
 but when  they are near to the fources from whence
 they arife; that is, either near to the bodies of mea,
 from which they immediately  iffue \  or  near to fome
 fubilances which, as having been near to the bodies of
 men, are imbued with their effluvia, and  in which fub-
 ftances thefe effluvia are fometimes retained in an act-
 ive ftate for a very long time.
   The fubftances thus imbued with an adive and in-
 fedious matter, may be called,, Fomites;  and it appears
 to me probable, that contagions, as they arife from fo-
 mites, are more powerful than as they arife immedi-
 ately from  the human body.
                    LXXXIII.
   Miafmata are next to be  confidered.   Thefe may
 arife from various fources, and be  of different kinds;
 but we know little of their variety, or of their feveral
 effeds.   We know with certainty only one fpecies of
 miafma, which can be confidered as the caufe of fever;
and, from the univerfality of this, it  may be doubted
if there be any other.
                    LXXXIV.
  The miafma, fo univerfally the caufe of fever, is that
which arifes from marines or moift ground,  aded upon
by heat.   So many obfervations have now  been  made
with refped to this, in fo many different regions of the
earth,  that there is neither  any doubt ofits being in
                                          general 
OF  PHYSIC.
7*
general a caufe of fevers, nor of its being very univer-
fally the caufe of intermittent fevers, in all their differ-
ent forms.   The fimilarity of the climate, feafon, and
foil, in the different  countries in which intermittents
arife,  and the fimilarity of the difeafes, though arifing
in diftetent regions, concur in proving, that there is
one common caufe of thefe difeafes, and that this is the
marfh miafma.
  What is  the particular nature of this miafma, we
know not; nor do we certainly  know whether or not
it differs in kind; but it is probable that it does not; and
that it varies only in the degree of its power, or per-
haps  as to its quantity, in a given fpace.
                    LXXXV.
  It has been now rendered  probable, that the remote
caufes of fevers fviii.) are  chiefly Contagions or Miaf-
mata, and neither of them of great variety.  We  have
fuppofed that miafmata are the caufe of intermittents,
and contagions the  caufe  of continued fevers, ftridly
fo named; but we cannot with propriety employ  thefe
general terms.  For, as the caufe of continued fevers
may  arife from fomites, and may, in fuch cafes, be cal-
led a  Miafma ; and as other miafmata alfo may produce
contagious difeafes; it will be proper to diftinguiih the
caufes of fevers, by ufing the terms Human or Marfh
Effluvia, rather than  the general ones of Contagion
Miafma.
                   t LXXXVI.
   To render our dodrine of fever confiftent and  com-
plete, it is  neceffary to add here, that  thofe  remote
caufes of fever, human and marfh effluvia, feem  to be
of a debilitating or fedative quality.   They arife .from
a putrefcent matter.   Their produdion  is favoured,
and their power increafed, by circumftances which fa-
vour  putrefadion ; and  they often prove putrefadive
ferments with refped to the' animal fluid.-*.   As putrid
matter, therefore, is  always, with refped to animal bo_ 
 yi           PRACTICE

 dies, a powerful fedative, fo it can hardly be doubted,
 that human and marfh effluvia arc  of the lame quali-
 ty ; and it is confirmed by this, that the debility which
 is always induced, feems to be in proportion to the o-
 ther marks that apoear of the power of thofe caufes.
                      LXXXVJI.
   Though we  have endeavoured to fhow that fevers
 generallv arife from marfh or human effluvia, we  can-
 not,  with any ceitainty, exclude fome other remote
 caufes, which are commonly fuppofed to have at leaft a
 lhare  in producing thofe difeafes.   And  I  proceed,
 therefore to enquire concerning thefe caufes ; the firft
 ci: which that  merit-; attention, is the power of  cold
 applied to the human bod v.
                    LXXXVIII.
   The operation of cold on a living body, is fo differ-
 ent in  different circumftances, as to be of difficult ex-
 planation ; it is hcre^ therefore, attempted with fbmc
 (dimdence.
   The power of cold  may be confidered as abfolute
 or relative.
   The ahfclute power is that by which  it can diminifh
 the temperature of the body to which it is  applied.
 And thus, if the  natural temperature of the human
 body is,  as we  fuppofe it to be, that of 98 degrees of
 Farenheit's thermometer*; every degree of tempera-
 ture lefs  than thar, may be confidered as cold with re-
 fped to the human body; and,  in  proportion to its
 degree, will have a tendency to diminifh the temper-
 ature cf the body.   But as the living human body has
 in itfelf a power of generating heat, fo it can fuftain
 its own proper  heat to the degree above mentioned,
 though furrounded by  air or other bodies of a lower
 temperature than itfelf; and it appears  from obferva-
                                             tior,
  * In every inflrjice of our mentioning degrees of heat or cold, we
fliall mention th^m bv the degrees in Farenheit's fcale ; and the ex-
pnaTu.;i. of higher i 1 lower fliall always be according to that fca!e. 
OF  PHYSIC.
73
tion, that, in this climate, air, or other bodies applied
to the living man, do not diminifli the temperature
of his body, imlefs the temperature of the bodies appli-.
edbe below 62 degrees. From hence it appears, that
the abfolute power of cold in this climate, does not
ad upon the living human body,  unlets the cold  ap-
plied be below the degree juft now mentioned.
   It appears alfo( that the human body's being fur-
rounded by air of a lower temperature  than itfelf, is
neceflary to its being retained in its prooer temperature
of 98 degrees: for, in this climate, ever/ temperature
of the air above 62 degrees,  applied  to the human
body, though ftill of a lower temperature than itfelf,
is found to increafe the heat of it.   And from all this
it appears, that the abfolute power of cold with refped;
to the human body,  is very different from what it is
with refped to inauimate bodies.
                    LXXX1X.
   The relative power of cold with refped to the liv-
ing human body, is  that power by which it produces
a fenfation of cold in it; and with refped to this, it is
agreeable to the general principle of fenfation, that the
fenfation produced, is not in proportion to the abfo-
lute force of impreffion, but according as the new im-
preflion is  ftronger or weaker  than that which  had
been applied immediately before.  Accordingly, with
refped to temperature, the fenfation produced by any
degree of this, depends upon the temperature to which
the body had  been  immediately before expofed; fo
that whatever is higher than this feels warm, and whaN
ever is lower than it, feels cold; and it will therefore
happen that the oppofite fenfations  of heat and cold
may on different occafions arife from the fame tempe-
rature, as marked by the thermometer.
   With refped to this, however, it is to be obferved,
that though every change of temperature gives a fenfa-
lion of cold or heat as it is lower or higher  than the
   Vcl. I              K                     tem-r 
74            P R A C  T 1 C f
temperature applied immediately before,  the ienfation
produced is, in different cafes,  of different duration.
If the temperature at any time applied is under 62 de-
grees, every increafe of temperature applied will give
a fenfation of heat; but if the increafe of temperature
does not arife to 62  degrees, the  fenfation produced
will not continue long, but be foon changed to a fen-
fation of cold.  In like  manner, any temperature, ap-
plied to the human body, lower than  that of the bo-
dy itfelf, gives a fenfation of cold ; but if the temper-
ature applied does not go  below 62 degres, the fenfa-
tion of cold will not continue long, but be foon chang-
ed to a fenfation of heat.
   It will appear hereafter, that the effeds  of the fen-
fation  of cold will be very different, according as it is
moie permanent or traniitory.
                       XC.
   Having thus explained  the operation of cold as ab-
folute  or relative with  refped to the human body, I
proceed to mention the general effeds of cold  upon it.
   i.  Cold, in certain circumftances, has manifeftly a
fedative power,   it can extinguifh the vital principle
entirely, either in particular parts, or in the whole bo-
dy; and  confidering how  much the vital principle of
animals depends upon heat, it cannot be doubted that
the power of cold is always more or lefs diredly feda-
tive.
   This effed  may be faid  to take place from every de-
gree of abfolute cold ; and, when the heat of the body
has upon any  occafion  been preternaturally increafed,
every lower temperature may be ufeful in diminilhing
the activity of the fyftem ;  but it cannot diminifh the
natural vigour of the vital  principle, till the cold appli-
ed is under 61 degrees ; nor even then will  it have this
effed, unlefs the cold applied be  of an intenfe degree,
or be applied for fome length of time to a large  por-
tion of the body.
   2.  It is equally  manifeft, that, in certain  circum-
                                            ftances 
OF  PHYSIC.
75
fiances, cold proves afiimultts to the living body, and
particularly to the fanguiferous fyftem.
  It is probable, that this effed takes place in every
cafe in which the temperature applied produces a fen-
fation of cold : and this, therefore, as depending en-
tirely on the relative power of cold, will be in  propor-
tion to the change of temperature that takes place.
  It appears to  me probable, that every change of
temperature from a  higher to a lower degree, will
prove more or  lefs  ftimulant; excepting when the cold
applied is  fo intenfe,  as immediately to extinguifh the
vital principle in the part.
  3, Befide the fedative and ftimulant powers of cold,
it is manifeftly a powerful aflringent? caufing a con-
tradion of the veffels  on the furface of  the body, and
thereby producing a palenefs of the  fkin and a fup-
preftion of perfpiration ;  and it  feems to have fimilar
effeds  whet) applied  to  internal parts.  It is likewife
probable, that this conftridion, as it takes place efpe-
cially in confequence of the fenfibility of the parts to
which  the  cold is applied, will  in fome meafure be
communicated to  other parts of the body ;  and that
thereby the application of cold  proves a ^wfc power
with refped to the whole  fyftem.
  Thefe effeds of tonic  and aftringent  power feem to
take place  both from  the abfolute and relative power
of cold: and therefore every application of it which
gives a fenfation of cold, is, in its firft effed,  both a-
ftringent and ftimulant,  though the former may be
often prevented from being either confiderable or per-
manent when the latter immediately takes place.
                      XCI.
  It will be obvious,  that thefe feveral effeds of cold
cannot  all take place at the fame time, but  may  in
fucceffion be varioufly combined.   The ftimulant pow-
er taking place obviates the effeds,  at  leaft  the per-
manency of the effeds, that might otherwife have a-
                         K  2                 rifen 
76              PRACTICE
rifen from the fedative power.  That the fame ftimu-
lant  power prevents thefe from the aftringent, 1 have
faid above ; but the ftimulant and tonic powers of cold
are commonly, perhaps always, conjoined.
                      XCII.
   Thefe general effeds of cold now pointed out  are
fometimes falutary, frequently morbid ;  but it is  the
latter only I am to'confider here, and they feem to be
chiefly the following.
   i. A general inflammatory difpofition of the fyf-
tem, which is commonly accompanied with Rheuma-
tifm, or other Phlegmafiae.
   2. The fame inflammatory difpofition accompani-
ed with Catarrh.
   3. A Gangrene of particular parts.
   4. A palfy of a fingle member.
   5. A Fever, or Fever ftridly fo called (viii.) which
it  often produces by its own power alone, but more
commonly it is  only an exciting caufe of fever by Con-
curring with the operarion of human or marfh effluvia.
                     XCIII.
   Cold is often  applied to the human body without
producing any of thefe morbid effeds, and  it is diffi-
cult to determine in what circumftances it efpecially
operates in producing  them.   It appears to'me, that
the morbid effeds of cold depend partly upon certain
circumftances of the cold itfelf, and partly on certain'
circumftances of the  perfon to whom it is applied.
                      XCIV.
   The circumftances of the cold applied, which  faem  .
to give it effed, are,  1.  The intenfity or degree of the  ::
cold : 2. The length of time during which it is appli-  •
ed ;  3. The degree of moifture at the fame time ac-  ■
companying it;  4. Its being applied by  a wind or  r
current of air ; 5. Its  being a viciffitude, or fudden  1
and  confiderable change of temperatare, from heat to  )
Cold.
                                           XCV.  . 
             O i   *? H Y S.I C.            77

                      XCV.
  The ci.Tumftances of perfons rendering them more
liable to be affeded by cold,  feem to be, i. The weak-
nefs of the fyftem, and particularly the leffened vigour
of the circulation, occalioned, by faffing, by evacua-
tions, by  fatigue,  by a laft  night's debauch, by ex-
cefs in venery, by long watching, by much ftudy, by
reft immediately after great exercife, by fleep, and by
preceding difeafe.  i. The body, or its  parts,  being
deprived of their accuftomed  coverings.  3. One part
of the body being expofed to cold,  while  the  reft  is
kept in its ufual or a  greater  warmth.
                      XCVI.
  The power of thefe circumftances (xcv.) is demon-
ftrated by the circumftances enabling perfons to refill:
cold.   Thefe are, a certain vigour of conftitution, ex-
ercife of the body, the prefenceof adive paffions, and
the ufe of cordials.
  Befide thefe, there are other circumftances which,
by a different operation,  enable perfons to refift cold
ading as  a  fenfation ;  fuch as,  paffions engaging  a
clofe attention to one objed,  the ufe  of narcotics, and
that ftate of the body in  which  fenfibility is greatly
diminifhed, as in maniacs.  To all which is to be add-
ed, the power of habit with refped to thofe parts of the
body  to which cold is more conftantly applied, which
both diminifhes fenfibility, and incrcafes  the power  <F
the adivity generating heat.
                     XCVII.
  Befide cold, there  are  other powers that feem to be
remote caufes of fever; fuch, as fear, intemperance  in
drinking,  excefs in  venery,  and other circumftan  eo\
which  evidently weaken the fyftem.  But  whether
any of thefe fedative  powers  be alone the remote caufe
of fever, or if they only operate either a? concurring with
the operation of marfh  or human effluvia, or as giving
an opportunity to the operation of cold,  are qumions
                                              not 
78          PRACTICE
 not  to  be pofitively anfwered :  they may poffibly of
 themfelves produce fever ; but  moft' frequently they
 operate as concurring in one or other of the  ways a-
 bove mentioned.
                     XCVIII
   Having now mentioned  the chief of  the  remote
 caufes of fevers, it may be further obferved, that thefe
 will arife more or lefs readily, according as miafmata
 and contagions are more or lefs prevailing or power-
 ful,  or  as thefe are more or lefs favoured by the con-
 currence of cold and other fedative powers.



               CHAP.   V.

      OF THE PROGNOSIS OF FEVERS.

                      XCIX.
     AS fevers (by Ix.) confift of both morbid ad falu:
      tary motions and fymptoms, the tendency  of
 the difeafe to a happy or fatal iffue, or the prognoftic
 in fevers, has been  eftablifhed by marking the preva-
 lence of the morbid or of the falutary fymptoms ; and
 it might be properly fo eftablifhed, if we could certain-
 ly diftinguifh between the one and the  other of thefe
kinds of fymptoms:  but the operation of the readion,
 or falutary efforts of nature in curing fevers, is ftill in-
volved in fo much obfcurity, that I cannot explain the
feveral fymptoms of it  fo clearly as  to  apply them to
the eftablifhing prognoftics ; and this,  I  think, may
be done better,  by marking  the morbid /ymptoms
which fhew the tendency to death in fevers.
                        C.
   This  pl,m of the prognoftics in fevers miift proceed
upon our knowledge of the caufes of death in general,
and in fevers more particularly.
                                             The 
OF  PHYSIC.
79
   The caufes of death,  in general, are either diredor
indirect.
  The firft are thofe which diredly attack and deftroy
the vital principle, as lodged in the nervous fyftem ; or
deftroy the organization of the brain immediately ne-
ceflary to the adion of that principle.
  The fecond, or the  indired caufes of death, are
thofe which interrupt  fuch fundions as are neceflary
to the circulation of the blood, and thereby neceffary
to the due continuance and fupport of the vital prin-
ciple.                         ,
                        CI.
   Of thefe general caufes,  thofe which operate more
particularly in fevers  feem to  be, firft, The violence of
reudtion j  which either, by repeated violent excite-
ments, deftroys the vital power itfelf; or, by its vio-
lence, deftroys the organization of the brain neceffary
to the adion of that power; or, by the fame violence,
defti-oys the organization of the parts more immediate-
ly neceffary to the circulation  of the blood.
   Secondly, The caufe of death in fevers may be apti-
Jon, that  is, a power capable  of deftroying the  vital
principle ;  and this poifon may be either  the miafma
or contagion which wasthe remote caufe of the fever, or
ic may l^e a putrid  matter  generated in the courfe of
the  fever.   In  both cafes, the operation of fuch a
power appears either as ading chiefly on the nervous
fyftem, inducing  the fymptoms of debility ; or as ad-
ing upon the fluids of the body, inducing a putrefcent
ftate in them.
                       CII.
   From all this it appears, that the fymptoms fhowing
the tendency to death in fevers, may be difcovered by
th.rr being either the fymptoms
   Of violent reaction ;
   Of great debility ;
   Or, of aflrong tendency to putrefaction in the fluids.
                                             And, 
80             PRACTICE
  And,  upon this fuppofition, I proceed now to mark
thofe fv mo coins more particularly*.
                        cm.
  The fymptoms which denote the violence ofreaclion,
are,  i. The increafed force, hawdnefs, and frequency,
uf the pulfe.   2.  The increafed heat of the body.  3.
The fymptoms which are the marks of a geneial in-
flammatoiy diathefis, and more efpecially of a parti-
cular determination to the brain, lungs, or other im-
portant  vifccra.   4. The fymptoms which are  the
murks of the caufe of viol it readion ; that  is, of a
ihrong ftimulus applied, or ui a ftrong fpafm formed,
the  latter appear 111 j- in a confiderable fuppreflion of
the excretions.
                        CIV.
  The fymptoms whi^h denote a great degree of debi-
lity, are,
  In the Animal  Functions :  I. The weaknefs of
the voluntary moiions; II. The irregularity of the vo-
luntary motions,  depending on their debility; III. The
weaknefs of  fenfation ; IV.  The weaknefs and irre-
gularity  of the intelleduai operations.
  In the Vital Functions ;  I. The weaknefs of the
pulfe ; II. The coldnefs or ihrinking of the extremi-
ties ; III. The tendency to a deliquiurn animi in an e-
red pofture;  IV. The weaknefs of refpiration.
  In the Natural  Functions : I.  The weaknefs of
the  ftomach, as  appearing in anorexia,  naufea,  arid
vomiting ; 11. Involuntary excretions, depending upon
                                                  a
  *  No part of medical  knowledge is fo ferviceable in the praftice
of phyfic as proouoitics.   It wonderfully affilU in the cure of all
difeafes, but more efpecially fevers, and other acute diforders.  The
>oung reader, therefore,  ou^ht to be particularly attentive to this
part uf the work.  Wl■•: the author advances is very different from
what has gone before.  We have here no hypothecs or fancies, no
iuppofitions unfupported by fails ; but, on the contrary,  truth?
deduced from a careful obfefvatu.n uf uatuiv, and airaii'ed in a dif-
ti..cl an- pes L>uiio.iJ .nu,inc 
               O F   P H  Y S  I C.             81

a  palfy of  the  fphinders; III.  Difficult deglutition,
depending  upon a palfy of  the mufcles of the fauces.
                         CV.
   Lafilly, The fymptoms denoting theputrefcent filate
of the fluids, are,
   I.  With  refped to the ftomach ; the loathing of an-
imal food,  naufea and vomiting, great thirft,  and a
defire of acids.
   II. With refped to the fluids ;   i. The blood drawn
out of the veins not coagulating as ufual ;  i. Hemorr-
hagy from different parts, without marks of increafed
impetus ; 3. Effufions under the fkin or  cuticle, form-
ing petechiae, maculae, and  vibices;  4. Effufions of a
yellow ferum under the cuticle.
   III. With refped to the ftate of the excretions ;  fe-
tid breath, frequent loofeand fetid ftobls, high-colour-
ed turbid urine,  fetid fweats,  and the fetor and livid
colour of bliftered places.
   IV. The cadaverous fmell of the whole body.
                       CVI.
   Thefe  feveral fymptoms  have  very often, each of
them fingly, a fliare in determining the prognoftic :
but more efpecially by their concurrence and combi-
nation with one another : particularly thofe of debili-
ty with thofe of putrefcency*.
                       CV1I.
   On the fubjed of the prognoftic, it is  proper to ob-
ferve, that many phyficians have been of opinion there
is fomething in  the nature of  fevers  which generally
determines them to be of a certain duration; and there-,
fore that their terminations, whether falutary or fatal,
   Vol. I.                L                 happen
  * It may not be amifs to explain this circumftance a  little more
fully.  Coldntfs of the extremities may alone be fufficient to induce
the practitioner to think the iffue of  the difeafe fatal ;  yet  if this
fymptom be combined with a weaknefs and irregularity  of the  inT
telltdtual opeiations,  and thefe two, accompanied with involuntary,
loofe, and foetid evacuations of ltool, and  urine, death may be prty.
flounced to be at no great diltance. 
82           PRAi  iitit
 happen at certain periods of the difeafe, rather than at
 others. Thefe periods are called the Critical Days ;
 carefully  marked by Hippocrates and other  ancient
 phyficians, as well as by many moderns of the greateft
 eminence in  pradice;  whilft at the  fame  time ma-
 ny other moderns, of no mconfideiable authority, de-
 ny their  taking place in the fevers of thefe northern
 regions which we inhabit.
                      CVIII.
   1 am of opinion that the dodrine of the ancients, and
 particularly that of Hippocrates, on this fubjed, was
 well founded ;  and  that it is applicable to the fevers
 of our climate.
                        CIX.
   I am of this opinion,  fir/1, Becaufe I obferve  that
 the  animal ceconomy, both  from its own conftitution,
 and from habits which are  eafily  produced in  it,  is
 readily fubjeded to periodical movements.  Secondly,
 Becaufe in the difeafes of the human  body, I obferve
 periodical movements to take place with great con-
 ftancy and exadnefs ;  as in the cafe of intermittent
 fevers, and many other  difeafes.
                        CX.
   Thefe confiderations  render it probable, that exact '
 periodical movements may  take place  in continued fe-
 vers ; and I think there is evidence of fuch  move-
 ments adually taking place.
                        CXI.
  The critical days, or thofe on which we  fuppofe the
 termination of continued fevers efpecially to happen,
 are, the third, fifth, feventh, ninth, eleventh, fourteenth,
feventeenth, and  twentieth.   We mark  none beyond
 this  laft ;  becaufe^ though  fevers are  fometimes pro-
 traded beyond this  period, it is, however, more ra »-
 ly,  fo that  there are not a fufficient number of ob-
 fervations to afcertain the courfe  of them ;  and fur-
 ther, becaufe it is probable that, in fevers long pro-
                                          tracted, 
O  F  P  H  Y S I  C.             83
traded, the movements become lefs exad and  regular,
and theiefo e lefs eaiily obfeived.
                       CXil.
  That the days now mentioned are the critical days,
feems to be proved by the particular fads which are
found  in the writings of  Hippocrates.  From thefe
fads, ascolleded from the feveral writings of that au-
thor by M.  De Haen, it appears, that of one hundred
and fixty-three inftances of the termination of fevers,
which happened  on one or other of the  firft twenty
days of the difeafe, there  are one hundred  and fevon,
or more than two thirds of the  whole number, which
happened on one  or other  of the  eight  civs above
mentioned ; that none  happened  on the fecond or
thirteenth day ; and upon  the eighth, tenth, twelfth,
fifteenth, fixteenth, eighteenth, and  nineteenth, there
are but  eighteen  inftances of termination,  or  one
ninth of the whole.
                      CXI1I.
  As the terminations  which happen on the feven
days laft mentioned, are, upon the whole, few ,  and,
upon any one of them, fewer than thofe  which hap-
pen  on any of our fuppofed critical days ;  fo there
are therefore nine  days  which may  be  called non-
critical ; while,  on the other hand, the many ter-
minations which happened on the feventh, fourteenth,
and  twentieth  days,  afford a proof  both of critical
days in general, and that thefe  are the chief of them.
Hereafter  I fliall  mention  an analogy that  renders
the power of the other critical days fu::iciently pro-
bable.
                       CXIV.
  It appears further, that as, of the terminations which
were final and falutary, not a tenth part happened on
the non-critical days ; and of the terminations which
were final and fatal, though the greater number hap-
pened on the cri.ical days, yef above a third  of them
                     JL 2               happened 
84            PRACTICE

happened  on the non-critical ;  fo it would  appear,
that the tendency of the animal  ceconomy is to  ob-
ferve the critical days, and that it is by the operation
of fome violent and irregular caufe  that the courfe of
things is fometimes turned to the non-critical.
                      cxv.
  What has been faid,  gives fufficient ground for pre-
fuming, that it  is the general tendency of the animal
ceconomy to determine the periodical  movements in
fevers to be chiefly on the critical days.   At the fame
time,  we muft acknowledge it to be a general fenden:
cy only;'and that in patricular cafes, many circumftan-
ces  may occur todifturb the regular courfe of it. Thus,
though the chief andmore remarkable exacerbations in
continued fevers  happen on the critical days, there are
truly  exacerbations happening every day ;  and thefe,
from certain caufes, may become confiderable and cri-
tical.  Further, though  intermittent fevers are certain-
ly very ftrongly determined to obferve a  tertian of
quartan period, we know there are certain circumftan-
ces  which prevent them from obferving thefe periods
exadlv., and which render them either anticipating or
poftponing fo much, that the days of paroxyfms come
to be  quite changed ;   and  it is aPowable to fuppofe,
that the like may happen with refped to the exacerba-
tions of continued fevors, fo as thereby  to d'diurb the
rry'ar ..,_,, >carance of critical divs.
  A particular inftance of this  occurs with refped to
the fixlh day of  feve--.  In the writn,^ of K'poo-
crates, there are n.nv  'o.ftances of r?rminations ru-r>-
peningon the fT'di day;  bur  it i  rot  therefore rec-
koned among the critical days ; for ofth<" tormmanons
Npoordiii:; on that day, the-" is rot one v.-bich proves
fina !y of a falutary kind ; the greater nurroer are IV
tal, and ali the reft a>-~ imperfect, and  fc-Uowed with
a relapfe.   Ail tbi ihows, that feme violent caufe had,
in thefe cafes, produced a deviation from the otdinary
                                            courfe 
                 OF  P 11  Y  S  I  C.               85

 courfe of nature; that the terminations on  the fixth
 d<iy  arc  nothing more  thaa  anticipations of the fe-
 venth,  and  therefore a  proof  of the  power of  this
 laft*.
                         CXVI.
   The dodrine  of  critical days has been much em-
 barraffed by fome diffonant  accounts of it,  which  ap-
 pear  in the writings imputed to Hippocratesf.    But
 this may be juftly accounted for from  thefe  writings
 being truly  the works  of different perfons, and from
 the moft  genuine of them  having fu fie red many cor-
 ruptions; fo that, in fhort, every thing which  is  in-
 confiftent with the fads above laid  down, may be afi-
 cribed to one  or other of thefe caufes.
                                                    This,
   * This idea of the general tendency of nature to preferve a regu-
 larity in the animal motions, is a molt ingenious explanation of the
 apparent irregularities in the termination of fevers.  It  is perhaps
 one of the belt defences of the  critical days that ever appeared,  be-
 caufe it explains, in  a  moft "fatisfa&ory  manner,  why the termina-
 tion on the fixth day fhould not be falutary.   The violence of the
 disturbing-caufe excites motions which nature has not the power of
 withstanding, and which are either the immediate caufes of death,
 or induce fuch morbid alfe&ions as prove ultimately fatal.

   f To enter into a  critical inquiry, whether the works  handed
 clown to us as the writings of Hippocrates are peally the productions
 of that great man, or compilations fiom various phyficians, would
 be foreign to the  delign of this work.  The ftyle of them  is,  if I
 may be  allowed the  expreflion, homogeneous ; the fame provincial
 dialect prevails through the whole  of them ;  and they are extremely
 remarkable, efpeciu'ly fuch of them as rtfpeft the  critical days,  for
 being rather a detail of obferved facts,  than  reafonings brought to
 fnpport a favourite hypothefis.  It is probable indeed that Hippo-
 cates, who has got the credit of the work, might have been indebt-
 ed to manv  of  his contemporaries for fome  of the materials that
 compofe them ; but the famenefs of the ftyle is a ftrong preemp-
 tive argument that they are the pioduMion of one perfon,  or at leaft
 or their hiving  been  reduced to their prefent  form by one and the
fame ha-d.  Dr.'Cullen's other fuppofition, of their having fu {feted
many, and,  he might have added, material corruptions  feems highly
probable. 
86            PRACTICE
                      CXVil.
   This, further, has efpecially difturbed the dodrmc
 of critical  days, that Hippocrates himfelf attempted,
 perhaps too haftily, to eftablifh general rules,  and to
 bring the dodrine to a general theory, diouvn from Py.
 thagorean opinions concerning the power ot numbers,
 It is this which feems to have produced the  idea of
 odd days, and of a quaternary and feptenary  period;
 dodrines which  appear fo  often in  the writings of
 Hippocrates.  Thefe, however,  are  inconfiftent with
 the fads above laid down; and indeed, as Afclepiades
 and Celfus  have obferved, are inconfiftent with one
 another.
                     CXVIII.
   Upon the whole, therefore, it is apprehended, that
 the critical days above afligned, are truly the  critical
 days of Hippocrates,  and may be confiftently explain^
 ed in the following manner.
                       CXIX.
   From the univerfality of tertian or quartan periods
 in intermitent fevers,  we cannot doubt of there being,
 in the  animal ceconomy, a tendency to obferve fuch
 periods*; and the critical days above mentioned are
 confiftent with this tendency of the  ceconomy, as all
 of them mark either tertian or quartan periods. Thefe
 periods, however,  are not promifcuoufly mixed,  but
 occupy  conftantly their feveral  portions in the pro-
 grefs of the difeafe ; fo that, from the beginning to the
eleventh day, a tertian period takes place,  and, from
 the eleventh  to the twentieth, and perhaps longer, a
 quartan period is as fteadily obferved.
                       cxx.
  What determines the periods to be changed about
the eleventh day,  we have not clearly perceived; but
the fad  is certain :  for there is no inftance of any ter-
mination on the thirteenth, that is, the tertian period
next following the eleventh ;  whereas, upon the four-
                                           teenth
 * The author might have added,or periods compounded of thefe t.\o. 
Uf   f H Y.SIC.           87
teenth, feventeenth, and twentieth, which mark quar-
tan periods, there are forty-three inftances of termina-
tions, and fix only on all the intermediate days  be-
tween thefe.
  This prevalence  of a quartan period It ares no room
for doubting that the twentieth, and not the twenty -
firft,  is the  critical day  marked  by  Hippocrates,
though the laft is mentioned as fuch in the common
edition of the Aphorifms,  taken from an erroneous
manufcript, which  Celfus alfo feems to have copied.
                      CXXI.
   A confiftency with the general tendency of the fyf-
tem, renders the feries of critical days we  have men-
tioned, probably the true one; and the only remain-
ing diificulty  in finding what  we have delivered to be
the fame with the genuine  dodrine of Hippocrates, is
the frequent mention of the fourth as a critical day.
   It is true there are  more inftances of  terminations
happening on this day, than on fome of thofe days we
have afferted  to be truly critical: but its inconfiftency
with the more general tendency, and fome  other con-
fiderations, lead us  to deny its being naturally a criti-
cal day ; and  to think, that the inftances of termina-
tions, which have really occurred on the fourth day,
are to be reckoned  among the other irregularities that
happen in this matter.
                      CXXII.
   I have thus endeavoured to fupport the dodiiiie of
critical days,  chiefly  upon the particular fads to be
found in the,  writings of Hippocrates : And although
1 might alfo produce many other teftimonies of both
ancient and modern times ; yet it muft be owned, that
fome of thefe  teftimonies may be fufpeded  to have a-
rifen rather from a veneration of Hippocrates, than
from accurate obfervation.
                     CXX1II.
  Wi:h refped to the  opinions of many moderns who
                                            deny 
 BS           PRACTICE

 deny the prevalence of critical days,  they are to be
 little regarded,  for the obfervation of the courfe of
 continued fevers is  known to be difficult and fallaci-
 ous; and therefore the regularity of that courfe may
 have often efcaped inattentive and  prejudiced obferv-
 ers.
                      CXX1V.
   Our own obfervations amount to this,  That fevers
 with moderate fymptoms, generally the cafes of the
 fynocha, frequently terminate in nine days, or fooner,
 and very  conftantly upon one or other of the critical
 days which fall within that period: but it is very rare,
 in this climate, that cafes of cither  the typhus or fy-
 nochus terminate before the eleventh day; and, when
 they do terminate on this day, it is  for the  moft part
 fatally.  When they are protraded beyond this time,
 I have very  conftantly found,  that their terminations
 were upon the fourteenth, feventeenth, or twentieth
 day.
   In fuch cafes, the falutary terminations are feldom
 attended with any confiderable evacuation.   A fweat-
 ing frequently appears, but is feldom confiderable ; and
 I have hardly ever obferved critical and decifive ter-
 minations attended with vomiting, evacuations by
 ftool, or remarkable changes in the urine.   The fo-
 lution of the difeafe  is  chiefly to  be  difcerned from
 fome return of fleep and appetite, the ceafing of deli-
 rium, and an abatement of the frequency of the pulfe.
 By  thefe fymptoms we can often mark a crifis of the
 difeafe : but it feldom happens fuddenly ami entirely;
 and it is moft commonly from fome  favourable fymp-
 toms occurring upon one critical day, that we can an-
 nounce a more entire folution upon the next following.
   Upon the whole, 1 am perfuaded, that, if obfervati-
 ons  fliall  be made with  attention,  and without pre-
judice, I ihall be allowed to conclude  with  the words
 of the learned and fagaciuus Gaubius,<c Fallor, ni fua
                                            confti- 
               OF  PHYSIC.           89

" conftiterit  Hippocrat: audc iotas,. Galeno fides,
" Nature virtus et ordo."



                  CHAP.   VI.

 OF THE METHOD OF CURE IN  FEVEPvS.

                 SECT.  I.

 OF THE CURE OF CONTINUED   FEVERS.

                    CXXV.
     AS it  is allowed, that, in every fever wThich has
      its full courfe, there is an effort of  nature of a
falutary tendency, it might be fuppofed that the cure
of fevers fhould be  left to the operations of nature, or
that our art fhould be only direded to fupport and re-
gulate thefe operations, and that we fhould form our in-
dications  accordingly.   This plan, however, I  can-
not adopt, becaufe the  operations of nature are  very
precarious, and not fo well underftood as to enable us
to regulate them properly.  It appears to me,  that
trufting to thefe operations has often given occafion to
a negligent and inert pradice ;  and there is reafon to
believe, that  an attention to the  operations of nature
may be often fuperfeded bv art.
                     CXXVI.
  The plan which  to me appears to be moft fuitable,
is that which  forms the indications of cure upon the
view  of obviating  the  tendency  to  death ; while,
at the fame time, the means of executing thefe indi-
cations are direded by a proper attention to the prox-
imate caufe of fevers.
  Upon this  plan, in confequence of what has been
laid down above on the fubjed of the prognoftic, we
  Vol. I.                 M                form 
 oo            PRACTICE

form three general indications in the cure of continued
 fevers ; and  the one or other of thefe is to be em-
 ployed  according  as the  circumftances of the fever
 (eii.) fhall dired.
   The firft therefore is,  To moderate  the violence of
 reaction.
   The fecond is, To  remove the caufes or obviate the ef-
fects  of d b'dity.  And,
   The  third  is, To  obviate or correct  the tendency of
 thefluias to putrefaction.
                    CXXVII.
   The firft indication may bo anfwered, that is, the
 violence,of readion may be moderated.
   i.  By all thofe means which diminifh the  adion of
 the heart and arteries,
   2.  By thofe means which take off the fpafm of the
 extreme veffels, which we fuppofe to be the  chief
 caufe of violent readion.
                    CXXVIIL
   The adion of the heart and arteries may  be dimi-
 nished,
   i.  By avoiding  or moderating  thofe irritations,
 which,  in one degree or other, are almoft conftantly
 applied  to the body.
   2.  By the ufe of certain fedative powers.
   3.  By diminilhing the tenfion and tone of the arte-
 rial fyftem.
                     CXX1X.
   The irritations fexxviii.  1.) almoft conftantly appli-
 ed, are the impreffions made upon our  fenfes ; theex-
 ercife of the  body and mind ; and the taking in of ali-
 ments.   The avoiding thefe as  much  as poffible,  or
 the moderating  their force, conftitute  what is rightly'
 called the  Antiphlogistic Regimon, proper to be
 employed in  almoft every  continued fever
                      CXXX.
   The condud of the regimen is to be direded by the
 following rules and considerations.
                                            1. Im- 
               OF'PII  YSIC.            91

   1. Irrpreffio■■■* on the external fcnfes, as being fti-
mulant to the fyftem, and a chief lupport of its adi-
v;ty, lhould be avoided rs much as poffible ; thofe e-
ipecially of more conftant application, thofe of a ftrong-
er kind, and thofe which give pain and uneafmefs.
   No impreftion is  to be more  carefully guarded a-
gamft than that of externa! heat ; while, at the fame
time, every other means of incieafmg the heat of the
body is to be ftiunned. Boththefe precautions are to be
obferved as foon as a hot ftage is fully formed, and to
be attended  to  during its continuance ;  excepting in
certain cafes, where a determination to fweating is ne-
ceffary, or whore the ftimulant effeds of heat may be
compenfated by circumftances which determine it to
produce a relaxation and revulfion.
   2. All motion of the body is  to be avoided, efpeci-
ally that which requires the exercife of its own muf-
cles; and that pofture of the body is to be chofen which
employs the feweft mufcles, and which  keeps none of
them long in a ftate of  contradion.  Speaking, as it
accelerates refpiration, is  particularly to be refrained
from.
   3. The exercife of the mind alfo is a ftimulus to the
body ; fo  that all impreflions which lead to thought,
and thofe efpecially which may excite emotion  or
pafli m, are to be carefully fhunned.
   With refped to avoiding impreflions of all kinds, an
exception  is  to be made  in the cafe of a  delirium com-
ing on,  when  the  prefenting of accuftomed objeds
may have the effed of interrupting and diverting the ir-
regular train of ideas then arifing in the mind.
   4. The prefence of  recent aliment in the ftomach
proves  always  a ftimulus  to the f\ftem, and ought
therefore to be as moderate as pofuole.   A  total ab-
ftinencc for fome time may be of fervice ; but as this
cannot be long continued with faftty, we muft avoid
the ftimulus of aliment, by  choofmg that kind which
                       M  2                  gives 
92             PRACTICE

gives the leaft*.   We fifppofe that alimentary matters
are more ftimulant according as they are more alka-
lefent; and this leads  to avoid all animal, and to ufe
vegetable food only.
  As our drink alfo may  prove ftimulant, fo all aro-
matic and fpiritous liquors are to be avoided; and, in
anfwering the prefent indication, all fermented liquors,
excepting thofe of the loweft quality, are to be abftain-
ed from-f-.
                        CXXXI.
  Befide thefe ftimulant powers more conftantly ap-
plied, there are  others which,  although occafionally
only, yet, as commonly accompanying fevers, mu.t be
attended to and removed^.
  One is, the fenfe  of thirft, which, as a  powerful fti-
mulus,  ought always,  in one way or other,  to be re-
moved §.
  Another ftimulus  frequently arifes from  crudities,
or corrupted humours, in the ftomach ; and  it is to be
removed by  vomiting, by dilution, or by the ufe of
acid-jj.
                                               . A third
    In addition to thefe directions it may be mentioned that, if the
patient have a defire for food, which is feldom the cafe,  he ought to
make very fparing and frequent meals.   Much food taken at'once,
proves a  greater ftimulus rl^n the fame quantity taken at feveral dif-
ferent  times ;  especially  if fufficient quantities of diluting muciiagi,
nous drink, fuch as lintfeed tea, barley-water, water-gruel, &c.  be
taken along with it.
  + Thin liquors are the beft in carcs of this kind :  of thefe we may
either  ufe water alone, or weak lintfeed tea, thin harlev-water, toad
*.)d  water, whey, currant-jelly diffolved in water, with  a variety of
fuch mucilaginous acefcent  drinks.  They ought  to  be taken in
fmall quantities, and often.
  t This paffage might have been more clearly expteffed thus : be-
fides the fiimubnt power? more conllantly applied,  others, only oc-
calionul'v accompanying Fevers,  muft be attended to and removed.
  §   The drinks mentioned in the former note are beft adipted to
this purpofe.
  j| The ve-etable  acids are the moil fuitable, efpecially the juices 
I
OF  PHYSIC.
93
  A third ftimulus often arifes from the preternatural
retention of  faxes in the int-eflines; tmd ought to be
removed by frequent laxative glyfters*.
  A fourth ftimulus  to be conftantly fufpecfed in fe-
vers, is a general acrimony of the fluids, as produced
by the increafe of motion and heat, joined with an in-
terruption of the excretions.  This acrimony*is  to be
obviated or removed by the trking  in of large quan-
tities of mild  antifeptic Jiquorsf.
                       CXXX1I.
  The avoiding of irritation in all thefe particulars,
(exxx, and exxxi.)  conftitutes the antiphlogiftic re-
gimen abfoiutely neceffary for moderating the violence
of reaction ; and, if I miftake not, is proper in almoft
every  circumftance of continued fevers ;  becaufe  the
propriety and fafety  of employing  ftimulants is often
uncertain; and becaufe feveral of thofe above menti-
tioned, befide their ftimulant powers, have other qua-
lities by which they may be hurtful.
  It appears to me, that the fuppofed utility of ftimu-
lants, in certain cafes of fever, has often  arifen from a
                                               miftake
of acid  fruits, as the juices of oranges, lemons, currants or .ipples,
diluted with  water.  In lone  cafes the  mineial  acids  h.:ve been
much extolled,  efpecially the  nitrous, when united with (pint o;
'.\me.   The fpiritus astheris nit rod of the laft London Pfiaruv.eo-
pocia is  ufed with fuccefsin thefe cafes.  It may be «iven r barley-
water, to the quantity of twenty or twerty-'v e dtops vithin the
hour.
  * The preference of clvfters to puigii.g tr< dicines'i-obv'ouv__
The adion even of the mofi gentle laxatives is alix iw attended with
f-jme degree of ftimulus, while clyneis,  efpeeiaUv  the  rr-.'.U  or,<.,
feldom produce that efTed. The beft clyftcr in »Wr c hOs,  U kdf
a putt of milk, with as much  water,  two ountes  of oil, and one
ounce of brown fugar, or,  what i.-> hetter than fugar, two ounces of
manna.
  f" The chief of thefe are the acid  fruit? diluted with w.-Oer ; to
which we may add the deco&ion of ma!t, of radix grnmhi>, (the
I'riticum repens of Linne.) infufions of f*ge, mint,  and other plajis
of mat natural order which Linne calls Spirautii*. 
94           PRACTICE
 miftake  in  having afcribed Ho their ftimul ont v.hat
 really dependedrupon their antifpafmodic power.
                    CXXXIII.
   A fecond  head of the means (exxviii  2.) for mo-
 derating the violence of reaction, comprehends certain
 fedative powers, which mav-be employed to dinrnifh
 the activity of the whole body, and particularly that
 of the fanguiferous  fyftem.
   The firft of thefe to  be mentioned is the application
 of cold.
   Heat is the chief fupport of the activity of the ani-
 mal fyftem ; which is therefore provided in itfelf with
 a power of generating he.it.  Bur, at the fame time, we
 obferve, that this would go toexcefs, were it not con-
 ftantly moderated by a cooler temperature in the fur-
 rounding atmofphere.   When, therefore, that  power
 of the fyftem generating heat is increafed, as is com-
 monly the cafe in fevers, it is neceffary not only to a?
 void all  means  ofincreafing it further,  but it feems
 proper alfo to apply air of a cooler temperature ; or at
 leaft to apply it  more entirely and freely, tjhan in  a
ftate of health.
   Some late experiments in the fmall-pox, and in con-
tinued fevers, fhow that the free admifnon of cool air
to the body is a  powerful  remedy in moderating the
violence  of reaction ; but what is the mode of its oper-
ation,  to what circumftances of fever  it is peculiarly
adapted,  or what limitations it requires, I fhall not ven-
ture  to determine, till more particularly inftructedby
further experience.
                    CXXXIV.
   A fecond fedative power which may be employed in
fevers, is that of certain medicines, known,  in the
writings  on the  Materia Medica,  under  the title of
Refrigerants.
   The chief of thefe are acids of all kinds, when fuf-
ficiently dilu'.e*:  ; and they  are,  in feveral refpeds, re-
                                            medies 
OF   PHYSIC.
95
medies adapted to continued fevers.  Thofe efpecially
in ufe are, the Vitriolic and Vegetable; and,on many
accounts, we prefer the latter*.
                       CXXXV.
   Another fet of refrigeraoits are,  the  Neutral Salts,
formed of  the  vitriolic,  nitrous or  vegetable acids ;
with alkalincs, either fixed or volatile.   All thefe  neu-
trYuS, while they are diffolving in water, generate cold ;
but as that cold ceafes  foon after thefolution is finifh-
ed, arid as the falts are  generally exhibited in a diffolv-
ed ftate, trieir  refrigerant power in  the animal body
does  not at all depend upon their power of generating
cold with water.  The Neutral chiefly employed as a
refrigerant, is  Nitre ; but all the others, compounded
as above  mentioned,  partake more or lefs  of the fame
quality f.
                       CXXXVI.
   Befide thefe neutrals,  fome metallic falts alfo  have
been employed as refrigerants  in fevers ; and particu-
larly  the Sugar of  Lead.  But the refrigerant powers
of this are  not  well  afcertained;  and its deleterious
qualities  are  too  well known to  admit of its being
freely ufed.
                                            CXXXVII.

   *  The vitiiolic acid is harfh to the tafte,  and frequently afts as an
aftringent ; it is therefore not always ir.adrniilii.de. The belt vegetable
acids for this purpofe, are as was faid above, the natural juices of
acid  fruits.  The  acid of tartar is the bell refrigerant we have :
there is an excellent formula of it in the  Swediih Pharmacopoeia,
under the title 1'ulvis refrigerans, which confitts chiefly of the tf-
fential fait of tartar and fugar.  The dofe of the acid of tartar,
prepated according to Scheele's prefcription, is -half a fcruple, or
fiftten «rains, in  the hour, largely diluted with a mucilaginous
liquor.
   f  Nitre has been long ufed  as a refrigerant.   In too large quan-
tities, however,  it has often done harm.   It may therefore  be ne-
ceffary to guard  the young practitioner againft giving nitre in a
Lrgei quantity than two drachms in the twenty-four hours,  nor in
doles of above te.i grains,  well  dilated with mucilaginous drinks. 
0 0
PRACTICE
                     CXXXVII.
  Under  the third general  head (cxxvm,  3.)  of
the means to be employed for moderating the violence
of reaction, are comprehended the feveral means of di-
minifhing the tehfim, tone, and  activity, of the  fm-
guiferous fyftem.   As the activity of this fyftem de-
pends, in a great meafure, upon  the  tone, and this a-
gain upon the tenfion of the veffels, given to them by
the quantity of fluids  they contain,  it is evident, that
the diminution cf  the quantity of thefe,  muft  dimi-
nifh  the activitv of the fanguiferous fyftem.
                    CXXXVliI.
  The quantity of fluid* contained in the fiaguiferous
fyftem, may be diminifhed moft conveniently by the
evacuations of blood-lettinc;-and  purging.
                     CXXXiX.
  Nothing is more evident, than that blood-letting is
one of the moft powerful means of diminiihing  the
activity of the whole body, efpecially of the fangui-
ferous fyftem ; and it muft therefore be the moft ef-
fectual means  of moderating the violence of reaction
in fevers.  Taking this as a fact, I omit inquiring into
its mode  of operation, and fliall only confider in what
circumftances of fevers it may  be moft propeily em-
ployed.
                       CXL.
  When the violence of reaction, and its  conftant at-
tendant,  a phlogiftic diathefis, are fufriciently manireft;
when thefe conltitute the principal part of the difeafe,
and  may be  expected  to continue  throughout the
whole of it, as in the cafe offynocha  r then blood-let-
ting  is the principal remedy,  and may be em ployed as
far as the fymptoms of the difeafe may feem to require,
and  the conftituti 01 of the patient  will  bear.   It is,
however,  to be attended to, thar a greater evacuation
than L neecolary, may 0*0. afi.m a flower recovery, may
                                            render 
O F  PHY SIC.             97
render the perfon more liable to a relapfe, or may bring
on other difeafes.
                       CXLI.
  In the'cafe offynocha, therefore, there is little doubt
about  the propriety of blood-letting : but there are
other fpecies of fever, as the fynochus? in which a vio-
lent reaction and phlogiftic diathefis appear, and pre-
vail during fome part of the  courfe  of the difeafe;
while, at the fame time, thefe  circumftances do not
conftitute the ptincipal part of the difeafe, nor are to
be expected  to continue  during the whole courfe of
it ; and it is well known, that, in many cafes, the ftate
of violent reaction is to be fucceeded, fooner or later,
by a ftate of debility, from the excefs of w7hich the dan-
ger of the difeafe is chiefly to arife.   It is, therefore,
neceffary, that, in many cafes, blood-letting fhould be
avoided ; and even although, during the inflammato-
ry ftate of the difeafe, it may be proper, it will be ne-
ceffary to take care that the evacuation be not fo large
as to increafe the ftate of debility which is to follow.
    *                  CXLII.
  From all this  it muft appear, that the employing
blood-letting, in certain fevers, requires  much dis-
cernment and fkill, and is tobegoverned by the con-
fideration of the following circumftances :
■   i. The nature of the prevailing epidemic.
  2. The nature of the remote caufe.
  3. Thefeafon and climate in which the difeafe occurs.
  4. The degree of phlogiftic diathefis prefent*.
  5. The period of the difeafe.
  6. The age, vigour,  and plethoric ftate of the pati-
ent.
  7. The  patient's  former difeafes  and  habits of
blood-letting.
  8. The appearance of the blood drawn out.
  Vol. I.               N                 9. The
* The phlogiftic diathefis is explained in art. 247. 
98              PRACTIC E
   9.  The  effects of the blood-letting that may have
been already practifed.
                     CXLIII.
   When, after the confideration of thefe circumftan-
ces, blood-letting is determined to be neceffary,  it
fhould be obfervdd, that it is more effectual, according
as the blood is more fuddenly drawn off, and as the
body u at the fame time more free from all irritation,
and confequently when in a pofture in which the few-
eft mufcles  are in action.                ' %
                       CXLIV.
   Another evacuation whereby the quantity of fluids
contained in the body can be confiderably diminifhed,
is that of Purging.
                     CXLV.
   If we confider the quantity of fluids conftantly pre-
fent in the cavity of the inteftines, and the quantity
which may be drawn from the innumerable excreto-
ries that open into this cavity,  it will be obvious, that
a  very great evacuation can  be made  by purging;
and, if this  be done by a ftimulus applied to the intef-
tines, without being at  the fame time communicated
to the reft of the  body, it  may, by emptying both the
cavity of the inteftines, and the arteries which furnifh
the excretions poured into it, induce a confiderable re-
laxation in  the whole fyftem ; and therefore, purging
feems to be a remedy fuited to moderate the violence
of reaction  in  fevers.
                     CXLVI.
   But it is to be obferved, that, as the fluid  drawn
from the excretories opening into the inteftines, is not
all drawn immediately from the arteries, as a part of
it  is drawn from the mucous follicles only ; and as what
is even m^re immediately drawn from the arteries, is
drawn off flowly ; fo the evacuation will not, in pro-
portion to its quantity, occafion fuch a fudden  deple-
tion of the red  veflels as blood-letting does ; and
                                         therefore 
O F   P II Y S I  C.
99
:  therefore cannot operate fo  powerfully in taking  off
'  the phlogiftic diathefis of the fyftem.
                       CXLVil.
    At the fame time, as this evacuation may induce a
i  confiderable degree  of  debility ; fo, in thofe cafes in
  which a dangerous ftate of debility is likely to occur,
  purging is to be employed  with  a great deal of cau-
  tion ; and  more efpecially as the due meafure of the c-
  vacuation is more  difficult to be  opplied  than in the
  cafe of blood-letting.
                      CXLV1II.
    As we fhall prefently have occafion to ebfjrve, that
  it is of great importance, in the cure of fevers, to  re-
  store the determination of the blood to the veffels on
  the furface of the body ; fo purging, as in  fome  mea-
  fure taking off that determination, feems to be an eva-
  cuation not well adapted to the cure of fevers.
                       CXLIX.
    If, notwithftanding then; doubts, (cxlvi,  cxlvii, and
  cxlviii.)  it fhall be afferted, that purging, eyen from
  the exhibition of purgatives, has often been ufeful in
  fevers ;  I would beg leave to maintain, that this  has
  not happened from aJarge evacuation; and, therefore,
  not by moderating the  violence of reacti  u, except-
  ing in the cafe of a more purely  inflammatory fe\er,
  or of exanthemata of an inflammatory nature.   In o-
  ther cafes of fever, I have feen a  large evacuation by
  purging,  of mifchievous  confecmence ; and if,  upon
  occafion,  a  more  moderate evacuation has appeared
  to be ufeful,  it is apprehended to have been only by
  rrking  off the irritation of retained  feces,  or by eva-
  cuating corrupted  humours which happened to be pre-
  fent in the inteftines ;  for  both of which purpufes,
  frequent laxatives may be properly employed*.
                           N  2                  CU
    * Purges ought to or very cautjoufly adtniniftered  ififevers ; and
  fuch only are to be ufed as operate with the lead irritation.  In fe-
  »tfrs attended with local inflammation, we may be undet no appre- 
100
PRACTICE
                          CL.
  Another fet of means (cxxvii. 2.) for moderating
the violence of reaction in fevers,  are thofe fuited to
take off the fpafm of the extreme veffels, which we be-
lieve to be the  irritation that chiefly fupports the re-
action.
  Though I have put here this indication of  taking
off the fpafm of the extreme veffels, as fubordinate to
the general indication of moderating the violence of
reaction ;  it  is  however to be  obferved here,  that as
fever univerfally confifts in an  increafed action of the
heart, either  in frequency or in force, which in either
cafe isfupportedby a fpafm of the extreme veffels, fothe
indication folr lemoving this is a very generaPone, and
applicable in almoftj every circumftance offerer,  or at
leaft with a few  exceptions,   to  be taken notice of
hereafter.
                         CLI.
  For taking off  the fpafm of the extreme veffels, the
means to be employed  are either interml or external.
                        CLII.
   The internal means  (cli.) are
   1. Thofe which determine too force of the circula-
tion to the extreme •veff-'L on the furface of the body,
and by v,ef!oring  the tone ?. .c! activity of thefe veffels,
in-/ overcc*oe the ftoaCn on their extremities.
   2. Th.:e medicines  which have the power  of tak-
                                                   ing
L< .Hon ofda-ger  oven from the brifker purges, ,. Glauber's fait,
given in the quantity of an ounce, or an ounc- .1..id an half; or three
or fo'ir o-inces of the ii (n!,im f.nnx,  with lulf an ounce of Glau-  » »
ber's fait, and a drachm or  two of tindure of jalar>;  but In fevers
where no topical  inflarrr ation appears, the punAs, if neceffary,
mult be of  the mildelt kind, fuch as  mama, cafLi, &c.  and they,
muft be given in fmaH and often repeated dofes.  h\ molt  fevers the
inteftines lav he infficieroly eva-ruated by taking half an  ounce of
manna, and? feruple of cream of tartar, every hour till it operates,
diluting plentifully at the fame time with barley-water.  The phof-
phorated fcd», lately introduced into praftice by the ingenious Dr.
Pearfon of London,  is well calculated for thefe cafes.   The dofc of
it it au ounce or ten drachms in basJey-watcr, or broth. 
OF  PHYSIC.
IOI
ing off fpafm in any part of the fyftem, and which arc
known under the title of Antispasmodics.
                     CLIII.
  Thofe remedies which  are fit to determine to the
furface of the body,, arc,
   i. Diluents.
   2. Neutrajl Salts.
   3. sudorifics.
   4. Emetics.
                      CLIV.
   Water enters, in a large proportion, into the  com-
pofition of all the animal  fluids, and a large quantity
of it is always diffufed through the whole of the com-
mon mafs.  Indeed, in  a found ftate, the fluidity  of
the whole mafs  depends  upon the quantity of  water
prefent in it.  Water, therefore, is the proper diluent
of our mafs of blood ; and other fluids are diluent on-
ly in proportion to the quantity of water they contain.
                       CLV.
   Water may be faid to be the vehicle  of the feveral
matters which oirTht to be excerned ; and in a healthv
ftate the fullnefs of the extreme veffels, and the  quan-
tity of excretions, are nearly in proportion to the quan-
tity of water prefent in the body.   In fever, however,
although the excretions are in fome meafure interrupt-
ed, they  conrinue in fuch quantity as to exhale the
more fluid paits of the blood ; and  while a portion  of
them is  at the fame time neceflarily retained  in thd
larger veffels, the fmaller and the extreme veflels, both
from the deficiency of nuid.  and their own contracted
ftate, are lefs filled, and therefore allowed to remain
in that condition.
                      CLVI.
   To remedy this contracted ftate, \>a thing is more ne-
ceflary  than a large fupply of water, or  watery  fluids,
taken in  by drinking or orhe.wif.^ ;  for as any  fuper-
iluous quantity of water i. forced on by thefeveraiex-
                                          cretoii^i 
 102             PRACTICE

 cretories, fuch a force applied, may be a means of di-
 lating the extreme veffels, and of overcoming the fpafm
 affecting their extremities.
                        CLVII.
   Accordingly the throwing in of a large quantity of
 watery fluids  has been, at all times,  a remedy much
 employed in fevers;  and in no inftance more remark-
 ably,  than by the  Spanifh and Italian phyficians,  in
 the ufe of what they call the Dicsta aquea.'
                       CLVIII.
   This  practice confifts in taking  away  every other
 kind of aliment and  drink, and  in giving in divided
 portions every day,  for feveral days  togecher, fix or
 eight pounds of plain water, generally cold, but fome-
 times warm.  All  this, however is to be  done only
 after the difeafe has continued for fome time, and, at
leaft, for a wreek*.
                         CLIX.
   A  fecond means  (cliii. 2.) of determining to the
furface of  the body,"  is  by the ufe of neutral  falts.
1 hefe, in a certain dofe taken inttf the ftomach, pro-
duce, foon after,  a  fenfe of heat  upon the  furface of
the body ; and, if the body be covered clofe and kept
                                                warm,
  * Simply as a  diluevt,  water is undoubtedly the  bed drink that
ea:» be ufed, buO, by adding a fmall quantity of niuciia^e to it. two
intentions are anfwered at  the fame time, viz. diluting and overcom-
inc.; the ?.crimony ; hence the propriety of barley-water, water-gruel,
lintfeed-tea, all made extiemely weak ; of very flight decoftions of
 malt, of bre.v.l cruils. or even the gelatinous parts of young animals,
as calf's feet, or the more folid hartfhorn  fliavin^s, &c.  Thefe ani.
 :v.aHuhfiances  muft however, be ukd in  great moderation, and on-
 ly  111 thole cafes  where th'e  patient re qui* s nouriihment.   When
thi? watery regimen is c^-ried to a great length, the patient turns
 anafarcous ; but this effeft may  be prevented by fome of the neu-
 tral falts, of which tlu. Kali acetatum »fthe London Pharmacopoe-
 ia is moft prefeiable, on account of its diuretic quality.  The dofe
of it may becurried as far  as half an ounce or fix drachms inthe day.
The fame intention  may alfo be anfweied by eating water-creffes,
rzdiiVs, if in feafon,  or a little of the outer rind of turnips; all of
which are diuretics. 
U if   f li  I S  I  c.
103
warm, a fweat is readily brought out.   The fame me-
dicines taken during the cold ftage of a fever, very of-
ten put an end to the cold ftage, and bring on the hot;
and they are alfo remarkable for ftopping the vomiting
which fo frequently attends the cold ftage  of  fevers.
All this fhows, that neutral  falts have a power of de-
termining the blood to the furface  of the body, and
may therefore be of ufe in taking off the fpafm which
in fevers fubfifts there.
                        CLX.
   The neutral moft commonlv employed in fevers, is
that formed of an alkali with the native acid of veget-
ablci*, but all the other neutrals have more or  lefs of
the fame virtue ; and perhaps fome of them, particular-
ly the ammoniacal falts, poffefs it in a ftronger  de-
greef.
                      CLXI.
   As cold water taken into the ftomach, often  fhows
the fame diaphoretic effects with the neutral falts, it is
probable that the effec): of the latter  depends  upon
their  refrigerant powers mentioned above,  (exxxiv.)
What is the  effeel:  of  the neutral falts, given  when
they  are forming and in a ftate of eftervefcence ? It is
probable that tms circumftance may increafe the  re-
frigerant power of thefe falts, and may introduce into
the body a quantity of fixed air; but for thefe purpo-
fes it  would feem proper to contrive that the whole of
                                                the
  * The following is the ufual dofe of it every three or four hours;
          R. Sal. Abfinth. 9i.
            Succ Limon. Jfs, vel. q. f. ad. faturatioaem ;
            Adde Aq, Fontanae |ifs.
            Syrup, commun. jii.
            M. f. hault.
  f The form and dofc of this is the fame with the foregoing, or.ly
ufuig the volatile alkali inllead.of the fixed.  The aqua ammonia
acetataof the London Pharmacopoeia is one of the ammoniasal falts,
and may be given in dofes of two drachms every four hours, diluted
with an ounce and a half uf water. 
 104             PRACTICE

 the  effervefcerxe fhould take place in the ftomach*.
                        CLXIL
   A third means   (chii. 3.)  of  determining t;o  the
 furface of the body, and taking oft" the fpafm fubfnj-
 ing there, is by the ufe of fudorific medicines, and of
 fweating.
                      CLXIII.
   The propriety of this remedy has been much difpu-
 ted; and lpecious arguments may be adduced both for
 and  againft this practice.
   In favour of the  practice it may be faid,
   1. That, in healthy perfons, in every cafe of increaf-
 ed action of the heart and arteries a fweating  takes
 place,  and  is feemingly the means of preventing the
 bad  effeefs of fuch increafed action.
   2. That, in' h» ers, -their moft ufual folution and
 termination is  by fpontaneous fweating.
   3. That, even when excited  by art, it has been
 found  manifeftly ufeful, at certain periods, and in cer-
 tain fpecies  of fever.
                       <CLXIV.
  Upon the other hand,  it may be urged  againft the
 practice of fweating,                -..
   1. That as in fevers a fpontaneoris  fweating does
 not immediately come on,  fo  there muft  be in thefe
 fome circumftances different from thofe in the ftate of
 health, and which may therefore render  it doubtful
whether the fweating can be fafely excited by art.
  2. That, in many cafes, the practice has been atten-
 ded  with bad confequences.   The means  commonly
employed have a tendency to produce an inflammato-
                                                 ry
  * It  is certainly extremely ufeful in fupprefiing vomitings in fe-
vers.  The method of  producing the effervefcencc in the ftomach
 is as follows : Let the patient take the acid firft, diluted with a fuf-
 ficicat quantity of water, and immediately after let him fwallow
 the alkali, alfo diluted. The proportion of the alkali to th;  acid
 muft be learned from chemiftry.  If the mild  fixed alkali is good,,
 it willfcturate about twelve times its weight of lemon juice.
/ 
              O F   P H Y  S I C.           105

ry diathefis ; which, if not taken off by the fweat fol-
lowing their  ufe, muft be increafed with much dan-
ger.  Thus, fweating employed to prevent the accef-
dions  of intermitting fevers, has often changed them
into a continued form, which is always dangerous.
   3.  The utility of the pradice is further doubtful,
becaufe fweating, when it happens, does not always
give a final determination as muft  be manifeft in the
cafe of intermittents, as well as  in many continued
fevers, which are fometimes in the beginning attend-
ed with fweatings that do not prove final; and, on the
contrary, whether fpontaneous, or excited by art, feem
often to aggravate the difeafe.
                      CLXV.
   From  thefe confiderations, it is extremely doubt-
ful if the practice of fweating can be admitted very
generally; but, at the fame time,  it is alfo doubtful,
if the failure of the practice, or the mifchiefs faid  to
have arifen/from it,  have not  been owing to  the im-
proper conduct  of the practitioner.
   With  refpect  to this laft, it is almoft agreed among
 phyficians,
   1. That fweating has been  generally  hurtful when
excited by ftimulant, heating, and  inflammatory me-
 dicines.
   2. That it has been hurtful when excited by much
external heat, and continued with  a great increafe  of
 the heat of the body.
   3. That it is always hurtful when  it does  not foon
 relieve, but rather increafes, the frequency and hard-
nefs of the pulfe, the anxiety and difficulty of breath-
ing, the  headach, and delirium.
   4. That it is always hurtful if it be urged when the
fweat is  not fluid, and when it is partial, ancf on the
fuperior  parts of the body only.
                      CLXVI.
   In thefe cafes, it  is probable, that either an inflam-
   Voi..  L                O                matory 
ic6            PRACTICE
matory diathefis is produced, which increafes the fpnfm
on  the extreme veffels; or that, from  other caufes,
the fpafm is too  much fixed to yield eafily to the in-
creafed action of the heart and arteries ;  and,  upon ei-
ther fuppofition, it muft1 be obvious,  that  urging the
fweat, as ready to produce  a hurtful determination to
fome of the internal parts, may be attended with very
great danger.
                     CLXVII.
   Though the doubts ftarted (clxiv. J are to be atten-
ded to ; and although the practices (clxv.) having been
found hurtful, are therefote to be  rejected; it ftill re-
mains true,
   i. That fweating has certainly been often  ufeful in
preventing  the acceffion of fevers, when the  times of
this have  been certainly forefeen, and a proper  con-
duct employed.
   2. That,  even  after fevers have in fome  meafure
come on, fweating, when  properly employed, either
at the very beginning of the difeafe,  or during its ap-
proach and gradual formation,  has often prevented
their further progrefs.
   3. That even  after pyrexiae  have continued  for
fome time,  fweating  has  been fuccefsfully employed
in curing them, as particularly in the cafe of rheuma-
tifm.
   4.t That certain fevers,  produced by a powerful fe-
dative contagion, have been  generally treated, fo far
as we yet know, moftfuccefsi'ully by fweating.
                       CLXVI1I.
   Thefe inftances (clxvii.) are in favour of fweating,
 but give no general rule ;  and it muft be left to  fur-
ther experience to determine how far any general rule
 can be eftablifhed in this  matter.   In the mean time,
 if the practice of fweating is  to be attempted, we can
 venture to lay down the following rules for the  con-
 duct of it.
1.  That 
OF    PHYSIC.
107
   i.  That it mould be excited without the ufe of fti-
mulant inflammatoi v medicines.
   2.  That it fhould be excited with as little external
heat, and with as little increafe of the heat of the bo-
dy, as poffible.
   3.  That, when  excited, it fhould be continued for
a due length of time, not lefs than twelve hours, and
fometimes for twenty-four or forty-eight hours •, al-
ways, however, providingthat it proceeds without the
circumftances mentioned (clxv, 3. 4.)
   4.  That for fome part of the time, and as long as
the perfon can eafily bear,  it  fhould be  carried on
without admitting of fleep*.
   5.  That it  fhould be  rendered univerfal over the
whole body ; and,  therefore, particularly, that care be
taken to bring the fweating to the lower extremities.
   6.  That the practice  fhould be rendered fafer by
moderate purging, excited at the fame  time.
   7.  That it fhould not be fuddenly checked by cold
any how applied'to the bod v.
                      CLXIX.
   When attention is to be given to thefe rules,  the
fweating may be excited, 1. By warm*bathing, or a
fomentation of the  lower extremities.  2.  By frequent
draughts of tepid liquors  chiefly water, rendered more
grateful by the addition of a light aromaticf, or more
powerful by that of a fmall quantity of wine.  3. By
giving  fome dofes of neutral falts^.   4.  Moft effectu-
                    O 2                        ally,
  # This direction is not always abfolutely neceflary.
  f The light aromatics here mentioned are fage,  mint, balm, Sec.
For the purpofe of fweating, white  wines anfwer belt, elpecially
the thin frefli wines; as alfo Rhenidi wines, particularly Hock.
They  muft be taken warm and  plentifully diluted.  Wine  whey is
alfo a very powerful fudorific, a* are alfo wheys made with vinegar,
cream of tartar, the juices of acid fruits, or with dalcoied fpirit of
nitre.
  $ Neutral falts may be given in the quantity of two fcruples or a
drachm : but the patient muft neveithclefs drink large quantities of 
108              PRACTICE

ally,  and perhaps moft fafely, by a large dofe of opiate,
joined with a portion of neutral falts, and of an eme-
tic*.
   In what cafes may cold water, thrown into the fto-
mach in large quantities, be employed to excite fweat-
ing?  See Celsus, Lib. III. chap, vii—ix.
                         CLXX.
f The  fourth  means  (cliii.'i.) of determining to  the
furface  of the body, and thereby taking off the fpafm   •
affecting the extreme veflels, is by the  ufe of emetics,  ■■•
                         CLXXI.
   Emetics, and particularly antimonial emetics, have
been employed in the cure of fevers pver fince the in-
troduction of chemical medicines : but, for along time,
they were employed by chemifts and  Ghemical prac-
titioners only;  and although of late the ufe of them has
                                                 become
warm water. The tartarus tartarifatus is the neutral moft frequently
ufed for producing fweats; its dofe is  generally  3i. but it may be
increafed to two drachms.
   * This is the well known Dover's powder, now called in the Lon-
don Pharmacopoeia,  pulvis ipecacuanhse compofitus.   It confiftsof
8 parts of  neutral fait,  one of opium, and one of ipecacuanha ; fo
that 10 grains of it are an ordinary dofe : But it has been given to
the quantity of a fcrupje without any bad confequences, and that,
dofe repeated every two or three hours, till the effeel; was produced.
In general,however,  dofesof 12 or 15  grains are  the moft ufual, and
are found by experience to be the beft.  The Dover's powder, v\hen
 j;iven in large quantities,  often naufeates and is reje&ed by vomit.
 In the Edinburgh  Pharmacopoeia, the Dover's powder confills of 9
 parts of neutral fait, one of opium, and one of ipecacuanha.  The
 dofe of this, therefore, will be nearly the fame as the dofc of the for-
 mer ; eleven grains of Edinburgh Dover's powder being equivalent
 *<> ten of the London.   In adminiifring this powder it may be nc
 reffary to obferve, that the patient ought to refrain from drinking
 for at leaft an hour after taking it, becaufe it naufeates more readily
vKmuch diluted in  the ftomach ; and if the naufea be fo great,as to
 produce  vo-niting, its efftds as a fudorific are confiderably diminifh-
 ed, when however,  a fweat is produced, thin diluting drinks may
 and ought to he plentifully given ; for,  in fuch cafes, it is evident
 from the effect,  that the medicine  has paffed  out of the ftomach,  •
 and that no materia; naufea can then be produced by  it. 
OF   PHYSIC.
109
become very general, their efficacy is ftill difputed, and
their manner of operating is not commonly explain-
ed*.
                      CLXXII.
  Vomiting is, in many refpects,  ufeful in  fevers; as
it evacuates the contents of the ftomach ;  as it emulp--
es the biliary and pancreatic ducts; as it evacuates the
contents of the duodenum, and perhaps of slfo a lar-
ger portion of the inteftines; as it agitates  the whole
of the abdominal vifcera,  expedes the  circulation in
them, and promotes their feveral fecretions; and, laft-
ly, as agitating alfo the vifcera of the  thorax,  it has
like effects there.   Air thefe feveral effects are, in ma-
ny cafes and circumftances of fever, procured with ad-
vantage ;  but  do  not properly  fall  under  our view
here, wfrere we are to  confider only  the  effect of vo-
r,'t:n,5 in determing to the furface of the body.
                     CLXXI1I.
   This effect we do not impute to the exercife of vo-
miting  in  agitating the whole frame ; but to the par-
ticular operation of emetics upon the mufcular fibres
of the ftomach, whereby they excite the action  of the
extreme arteries on the furface of the body, fo as  there-
by  effectual to determine the blood into thefe veflels,
remove  the atony,  and take off the fpafm affecting
them.
                                           CLXXIV.

  * All the antimonial emetics are violent in their  effefts,  and are
fometimes attended with difagreeable confequencej.  Emetic tar-
tar is found from experience to be the fafeft of them ;  bvit it iti^not
always of the fame ftrength, unlefs peculiar attention be paid toth-
making it.   The prefcription for it in the laft Edinburgh pl'.arma-
t opoeia is preferable to that in the London.  Some  Chemills think
that it would be better to nfe boiling water alone, and omit the al-
kaline fait, alledging that the alkali renders the precipitation vari-
a')!e in point of ftrength : But this opinion  is  erroneous.  I he
•ilkali is ufed in order to free the precipitate more completely from
any remains of the muriatic acid, making it thereby a milder pow-
der and a more perfect calx. 
no
PRACTICE
                    CLXX1V.
 .  That fuch is the power of emetics, will appear from
 the feveral confiderations mentioned above (xliv.) and
 therefore,  that  they are remedies well fuited to the
 cure of fevers.
                     CLXXV.
   Emetics, for that purp >ie, are adminiftered in two
 different ways:  that is, eitiier in fuch dofes as may exr
 cite full and repeated vomitings ;  or  in fuch dofes as
 may excite ficknefs and naufea only,  with little or no
 vomiting at all.
                     CLXXVI.
   Full vomiting is beft  fuited to the feveral purpofes
 mentioned clxxii. and is alfo well  fuited to determine
 to the furface of the body, fo as thereby to obviate the
 atony and  fpafm which lay the foundation of fever.
 Thus vomiting, excited a  little before the  expe&etj
 acceffion of the  paroxyfm of an intermittent, has been
 found to prevent the paroxyfm altogether.  And it
 has been obferved alfo, that, when contagion has been
 applied to a perfon, and firft difcovers its operation, a
 vomit given will prevent the fever, which was other-
 wife to have been expected.   See Linda/? Fevers and
 Infpeftion.
                    CLXXVII.
   Thefe are advantages to  be obtained by  exciting
 vomiting at the  firft approach of fevers, or of the pa-
 roxyfms of fevers ; and after  fevers  are formed, vomit-
 ing may alfo be employed, to take off, perhaps entire-
 ly, the atony and fpafm, or at leaft to moderate thefe,
 fothat the fever may proceed more gently and fafely.
                   CLXXVIII.
   It is  feldom,  however, that vomiting is  found to
produce a final  folution of fevers;  and, after they are
once formed, it  is commonly  neceffary to repeat the
vomiting feveral times ;  but  this  is attended with in-
convenience, and fometimes  with difad vantage.  The
                                          operation^ 
OF  PHYSIC.
in
operation of full vomiting commonly foon ceafes,  and
the exercife of vomiting  is often a debilitating pow-
er ; and therefore, when the vomiting does not remove
the atony and fpafm very entirely,  it may give occa-
fion to their recurring with  greater force.
                    CLXXIX.
  For thefe reafons, after fevers are fully formed, phy-
ficians have thought proper to employ emetics in nau-
feating dofes only.  Thefe are capable of exciting the
action of the extreme  veffels, and their  operation is
more permanent.  At the fame time, they often fhow
their power by  exciting fome degree of fweat, and
their operation is  rendered more fafe, by their  com-
monly producing fome evacuation by ftool.
                      CLXXX.
   Such are the  advantages to be procured  by naufe-
 ating dofi'S of emetics; and it only remains to men-
 tion, what are the medicines moft fit  to be employed
 in  that manner, what are the moft proper times for
 exhibiting, and  what is the beft manner of adminifter-
„ ing them.
                    GLXXXI.
   The emetics at  prefent chiefly in ufe, are, Ipecacu-
 anha and Antimony.
   The former may be employed for every purpofe  of
 emetics, particularly thofe mentioned  clxxii.  It may
 likewife be employed, either in  larger or fmaller dof-
 es, for determining to the furface of the body: but,
 even  in very fmail dofes, it fo readily excites vomit-
 ing, as to  be with difficulty employed for the purpofe
 of naufeating only ; and, however employed, there is
 reafon to believe, that its effects are lefs permanent, and
 lefs powerfully communicated from the ftomach  to the
 reft of the fyftem, than thofe of Antimony.
                    CLXXXII.
    This, therefore, is generally preferred ; and its pre-
 parations, feemingly  various, may all be referred to
                                              two 
 112            PRACTICE

 two heads:  the one, comprehending thole  in which
 the regulinepart is in a condition to be acted upon by
 acids ; and  therefore, on  meeting with acids  in the
 ftomach,  becomes active :  and the other comprehend-
 ing thofe preparations in which the reguline part is al-
 ready joined with an acid, rendering it active.
                    CLXXXIil.
   Of each kind there are great numbers, but not  dif-
 fering eflentially from one another.  It will be enough.
 for us to compare the Calx Antimonii Nitrata of the.
 Edinburgh  Difpenfatory with the Emetic Tartar of
 the fame.   The former, as I judge, is nearly the fame
 with  what is called James's Pov\der*.  Which of thefe
 is beft fuited to the cure of fevers, as above explained,
 feems doubtful; but it appears to me that,  although
 the former may have fame advantages from its flower
 operation, and  may thereby feem to be more certain-  J
 ly fudorific  and purgative, yet the  uncertainty of its  '
 dofe renders it  inconvenient, has often given occafion  i
 to the timid to  be  difappoi'nted, and to the bold to do  I
 mifchief.  On  the other hand, the dofe of the Emetic
 Tartar can be exactly afcertained ; and I think it may
 be exhibited in fuch a  manner as to produce all  the
 advantages of the other.
                    CLXXXIV.
  Whichfoever of thefe preparations be employed; I
judge the moft  proper time for exhibiting them, to be
 the time of acceflions ; or a little before,  when that
 can  be certainly known.  In continued fevers,  the
 exacerbations  are  not  always  very obfervable;  but
 there is reafon  to think, that  one commonly happens
 about noon, or foon after it, and another in the even-
                                              ing 5
  * The pulvis antimonialis of the London Pharmacopoeia is in-
 tended as a  fubftitute for, or imitation  of, James's powder.  The
 dofe of it is 7 or 8  grains.  It is by no means fo fure in its operati-
 ons as the emetic tartar ; yet, it has becfi much extolled  by feveral
 eminent modern pra&itioncr*. 
OF   PHYSIC.
ir3
ing;  and  that thefe,  therefore,  arc the moft  proper
times for exhibiting emetics.
                     CLXXXV.
  With refpect to the manner of adminiftration, that
of the Calx  Nitrata is fimple, as the whole of what is
judged  a  proper dofe is given at once,  and  no more
can properly be given till the  time of  the next ac-
ceflion*.
  The adminiftration of  the  Emetic Tartar is  differ-
ent.   It is to be given in fmall dofes,  not fufficientto
excite vomiting ; and  thefe dofes, after fhort intervals,
are to be repeated for feveral times, till ficknefs, nau-
fea, and  fome,  but not  much,   vomiting, come on.
The difference of this adminiftration muft depend up-
on the dofe, and the length of the intervals at  which
it is given.  If it be intended  that the medicine  fhould
certainly  operate  by ftool, the dofes are made  fmall,
and the  intervals long.  On the  contrary,  when vo-
miting is proper, or when much  purging ought to be
avoided, and therefore fome vomiting muft  be admit-
ed, the  dofes are made larger and the intervals  ftiort-
erf.
  Vol. I.                P              CLXXXVI.

  * The dofe is ten or twelve grains.  This calx, however, is very-
uncertain in  its operations,  fometimes adding  with great violence,
and fometimes fcarcely producing any perceptible effefts.
  f The dofe of the Antimonium tartarifatum fhould never exceed
three grains.  The beft method  of giving it  is,  to diflolve three
grains  in fix ounces of water ; and of this mixture give two table
fpoonsful: if no vomiting enfues within twenty minutes, repeat the
dofe, and continue to give a table fpoonful every ten minutes till the
vomiting  is excited, which  muft be encouraged by drinking plenti-
fully of chamomile tea, or a thin water gruel.   If the Emetic tar-
tar be intended for a fudorific, two table fpoonsful  of the following;
folution every two or three hours wiil*perhaps be move prooer thau
fmall dofes of the other.
            R. Antimonii tartarifati gr. ii.
              Aq. Cinnamon, ^ii.                   _
              -----fynt, Jvi.
              M.F. Julap. 
H4
PRACTICE
                   CL XXXVI.
  With refpect to both kinds of preparations, the re-
petition is to be made at the times of acceffion, but
not very often : for if the firft exhibitions, duly ma-
naged, have little effect, it is feldom that the after ex.
hibitions have much ; and it fometimes happens that
the repeated vomitings, and efpecially repeated purg-
ings, do harm by weakening the patient.
                   CLXXXV1I.
  The other fet of internal medicines, (clii, 2.) which
I fuppofe may be ufeful in taking off the fpafm of the
extreme veffels, are thofe named Antifpafmodic.  How
many of thefe may be  properly employed, I am uncer.
tain ; and their mode of operation is involved in  great
obfcurity.   It is certain  however,  that opium,  cam-
phor, murk, and perhaps fome others, have been em-
ployed in fevers  with  advantage ; but the circumftan-
ces in  which they are efpecially proper and fafe, I find
difficult tp afcertain ; and therefore cannot venture
here to lay down any general  doctrine concerning
them.
                   CLXXXVIII.
   The external means  (cli.) fuited to take off  the
fpafm  of the  extreme veffels, are  Blistering and
Warm Bathing.
                   CLXXX1X,
   What are the effects of Bliftering, fo frequently em-
ployed in fevers, is not ye: agreed upon among phy-
ficians ; and many drferent opinions have been main-
tained on this fubject, drawn not only from reafoning,
but alfo from prefumed experience.   I muft not, how-
ever, enter into controverfy ; butfnali deliver my own
opinion in a few words.
                      CXC.
   I am pcrfuaded, that the fmall quantity of cantha-
rides abforbing from a bliftering plafter, is not fuffici-
cnt to change the confidence of the mafs of blood:
                                               and 
OF  PHYSIC.
U5
and therefore that fuch a quantity can neither do good,
by  refolving phlogiftic lentor, if  it exifts ;  nor do
harm, by increafing the diffolutionof the blood arifing
from a putrid tendency in it.   I therefore neglect en-
tirely the effects of cantharides upon the fluids.
                      CXCI.
  The inflammation produced by the  application of
cantharides to the fkin, affords a certain proof of their
ftimulant power : but, in many perfons, the effect of
that ftimulus is not confiderable ;  in  many, it is not
communicated to the  whole fyftem, and, even  when
the effect does take place in the whole fyftem,  it feems
to be taken off,  very entirely,  by the effufion and eva-
cuation of ferum from the bliftered  part.  I  conclude,
therefore, that neither much good is to be expected,
nor much harm to be apprehended, from the ftimulant
power of bliftering ; and the certainty of this conclu-
fion is eftablifhed, by the great benefit arifing from
the proper  practice of bliftering in inflammatory dif-
eafes.
                      CXCII.
   Much has been imputed to the  evacuation occafi-
oned by bliftering : but it is never  fo confiderable as
to affect the whole fyftem ; and therefore can  neither,
by  fudden depletion, relax the  fanguiferous veffels,
nor, by any revulfion,  affect the general diftribution
of the fluids.
                     CXCIII.
  The evacaution, however,  is fo  confiderable as to
affect the neighbouring veflels ; and the manifeft uti-
lity of bliftering near the part affected, in inflammatory
difeafes, leads me to believe, that bliftering by deriv-
ing to the ikin, and producing an effufion, there  re-
laxes the fpafm  of the deeper  feated veffeis.   I appre-
hend it to  be  in this  manner  that the tumour of a
joint, from an eff avion into the cellular textur sounder
thehkin, takesoff the rheumatic pain affe&ingtfoafojoint.
                      P 2               CXC1V. 
tiG           PRACTICE
                     CXCIV.
  Analogous to this, it may be held, that the good ef-
fefts of bliftering in continued  fevers, arife  from its
relaxing  the fpafm of the  extreme veffels, by a com-
munication of  the bliftered part  with the reft of the
fkin; and this is illuftratcd by the  effed ofblifter.
ing in colic and dyfentery.
                     exev.
  It appears to me, that bliiicring may be employed
at any period of continued  fevers ; but that  it will be
of moft advantage in the advanced ftate of fuch fevers,
when, the readion  being weaker, all  ambiguity from
the ftimulant power of bliftering is removed, and when
it may beft concur with other circumftances tending
to a final folution of the fpafm.
                     CXCVi.
  From the view of this matter  given in exciii. and
exciv. it will appear, that the part of the body to which
blifters ought to be applied, is indifferent, excepting
upon the fufpicion of topical, affedion, when the blif-
tering ought to be made as near as poffible to the part
affected*
                    CXCVII.
  Whether Sinapisms, and other Rubefacients,
ad in a mmner analogous -to what we have fuppofed of
bliftering, may be  doubtful; but their effeds in rheu-
raatifm,  and  other inflammatory  difeafes, render it
0: oioable.
                    CXCVI1I.
  The other external means of taking off the fpafm of
the extreme veflels, is Warm Bathing.  This was fre-
quently,  and  in various circumftances, employed  by
the ancients ;  but till very lately has   been  negleded
by  nvdern phyficians.  As the heat  of the bath fti-
mulates the extreme veffels, and with the concurrence  :
of moifture, alfo relaxes, them it feems to be a fafe fti-  ■
rnuius well fuited  to take  offthe fpafm affecting them.  .
                                         CXCIX.  . 
OF  PHYSIC.
117
                      CXCIX.
   It  may be applied to the whole body bv immerfi-
 on; but this  is, in many refpeds, inconvenient ;  and
 whether fome of  the  inconveniences of  immerfion
 might not be avoided  by a vap air-bath  I have not
^learned from experience. I know, however, from much
 experience, that moft of the purpofes of warm-bathing
 can be obtained by a fomentation of the legs and feet,
 if properly adminiftered,  and continued for a  due
 length of time,  which ought not to be lefs than an
 hour,
                       CC.
   The marks of the good effeds of fuch fomentation,
 are, the patient's bearing it eafily, its relieving deliri-
 um, and inducing fleep.

   Having  now  confidered the feveral means  of fatif-
 fying the firft general indication in the cure » f fevers,
 I proceed to the fecond (exxvi.)  which is, To remove
 the caufe, or obviate the effects of debility.
                       ecu.
   Moft of the fedative powers inducing debility, ceafe
 to ad foon  after they have been firft applied ;  and,
 therefore, the removing them is not an obj.-ct of bur
 prefent indication.   There is only one which may be
 fuppofed to act for a lono time; and that is, the con-
 tagion applied :  but we know nothing of the nature
 of contagion that  can lead us to any meafures for re-
 moving or correding it.  We know only its effeds as
 a fedative povverinducing debility, or as a ferment in-
 ducing a tendency to putrefadion in the fluids.   The
 obviating the latter will be cmfidered under our third
 r neral indication, and the former alone is to  be  con-
 lidered here.
                       CCIII.
   The debility induced in fevers by contagion, or o-
 ther caufes, appears efpecially in the weaker energy of
                                              the 
 n8            PRACTICE

 the brain ; but in what this confifts or how it may be
 directly reftored, we do not well  know.  As nature,
 however, does, feemingly for this purpofe, excite the
 adion of the heart  and arteries, we afcribe the conti-
 nuance of debility to the weaker  readion of the fan-
 euiferous fyftem ;  fo  that the means to be employed
 for obviating debility, are immediately direded to fup.
 port and increafe the adion of the heart and arteries;
 and the remedies ufed are Tonics or Stimulants.
                       CCIV.
   In contagious difeafes, both  from the effeds  which
 appear, and from diffedions, it  is known, that the  tone
 of the heart and arteries  is confiderably diminiihed;
 and that tonic remedies,  therefore, are properly indi*
 cated.
   Thefe are to be confidered as of two kinds ; the firft
 being the power of cold, the fecond that of tonic me.
 dicines.
                      CCV.
   The power of cold,  as a tonic, I have mentioned a'
 bove(xo.)and it is employed, in fevers, in two ways;
■either as the cold matter is thrown into the ftomach,
 or as it is applied to the furface of the body.
                       CCV1.
   As  it has been fliewn above, that the tonic power
 «»f cold can be communicated from any one part to e-
 very othor part of the fyftem ;  fo it will readily be al-
 lowed, that the ftomach is a part as fit for this commu-
 nication as any other; and that cold drink, taken into
 the ftomach, may therefore prove  an ufeful tonic in
 leve.s.
                     CCVII.
   This the experience of all ages has confirmed : but,
 at  the fame time, it has been frequently obferved, that,
 in  certain circumftances,  cold drink, taken into  the
 ftomach,  has proved  very hurtful; and, therefore,
 that the ufe of cold drink in fevers requires tome li*
                                        notations. 
              OTTm'src.            119

mitations.  What thefe  limitations  fliould  be,  and
what are all the circumftances which may forbid the
ufe of cold drink, is difficult to determine;  but  it
feems clearly forbidden,  in all cafes where a phlogif-
tic diathefis prevails in the fyftem, and more efpecial-
ly when there are topical affedions of an inflamma-
tory nature.
                     CCVIII.
   The other methdd of employing cold as a tonic, is,
by appHing it to the furface of  the body.   The ap-
plication of cold air to the furface of the body, as a re-
frigerant power fit to moderate the violence of the re-
action, 1 have fpoken of above, (cxxxiii.) but probably
it may alfo be confidered  here as  a  tonic, and ufeful in
cafes of debility.
                      CCIX.
   Not only cool air, but cold water alfo,  may be ap-
plied to the furface of the body, as a refrigerant, and
perhaps as a tonic.  The ancients frequently applied
it with advantage, to particular parts, as a tonic; but
it is a* difcovery of modern times,  that in  the cafe  ot
putrid fevers, attended with much debility, the body
may be waihed all over with cold water.
                      CCX.
   This was firft pradifed at Breflaw in Silefia, as ap-
pears  from a  differtation, under the  title of Epidemia
verna qua; Wrat'tflaviam, anno 1737, affixit, to be found
in the appendix  to the Acla Nat. Curiof. Vol. X.  And
from other writers we find, that the p.adice has pall-
ed into fome of the neighbouring countries ; although
in this iil.md, fo far as I  know, we have hitherto had
no experience of it.
                      CCXI.
   The medicines which have been employed in fe-
vers, as tonics, are various.  If the Saccharum Satur-
nihas  been found ufeful,  it is, probably, as a tonic, ra-
ther than as a refrigerant; and the Ens Vene- is,  oro-
                                              ther 
120
P  R  A C T I C E
 ther preparations of iron which have been employed,
-can ad as tonics only.   The preparations of copper,
 from their effeds in cpilepfy, are prefumed to poffefs a
 tonic power ; but, whether their ufe in fevers be found-
 ed upon their tonic  or their  emetic powers, may be
 uncertain.   The ufe of arfenic and of alum, in inter-
 mittent  fevers, feems manifeftly to  depend upon their
 tonic power.   And, upon the  whole,  there  may oc-
 cur cafes of continued feve.s,  which may  be  cured by
 tonics taken from the foffile kingdom : but the ufe of
 thefe has been rare, as well as the effeds uncertain; and
phyficians have employed, more commonly, the vege-
table tonics.
                        CCXII.
   A great vaiiety of thefe has been employed 'in  the
cure of  intcrm it^nt  fevers;  but  how memy of them
may be  employed in continued fevers, cr  in what cir-
cumftances of thefe fevers, is not well afcertained; and
I fhall now  only confider the queftion with refped to
the moft celebraied of the tonics, the Peruvian Bark*;
                                               CCXIII.

   * When or how the inhabitants of Peru firft  difcovered the fe-
brifuge  powers of  this bark is involved in fable and uncertainty.
They appear, however, to have long known  its virtue, although we
have no pi oofs of revealing it tot lie Europeans before the middle of the
laft century. The Spaniards calls the tree which produces it PaL de
Calcnturas, or fv.ver tree.  Linne calls it Cinchona officinalis, in me-
mory of the Countefs de Cinchon, the Spanifh viceroy's Lady in
Peru, who was the  firft European that had  been cured  by  it.  It
was firft brought into Italy by a Jefuit about the year  1649, and
distributed through Europe by the fathers of that order; hence the
names Cortex and Pulvis Jcfuiticus, Pulvis  patrum.  By Cardinal
de Lugo's influence a cargo  of it was procured and  brought to
Rome foon after, whence it received the name of Pulvi6 Cardinalis
de Lugo.   As this  bark is a medicine of confiderable importance,
it may not be  improper to join a fhort dcfcription of the external
qualities of the belt  fort.  It is in concave pieces, fcarccly ever ex-
ceeding the fourth part of a cylinder cut longitudinally.   It breaks
fhort, and when broken evidently appears to be compofed of three
diftinft and feparate coats, viz. one outer thin coat,  that is fomc-
what rugged, often covered with mofs of different kinds,  and is of 
OF   PHYSIC.
121
                        CCXIII.
   This bark has been  commonly confidered as a fpe-
cific, or as a remedy of which the operation was not
underftood.   But it  is certainly allowable to enquire
into this matter; and I apprehend it may be explain-
ed.
                       CCXIV.
   To this purpofe it is  to be remarked, that as,  in ma-
rly cafes, the effeds of the bark are perceived foon af-
ter its being taken into the ftomach, and before it can
poflibly be conveyed to the  mafs of blood,  we may
conclude, that its effeds do not arife from its operat-
ing on  the fluids ;  and muft,  therefore,  depend upon
its operating on the nerves of the ftomach, and being
thereby communicated  to  the reft of the nervous fvf-
tern.   This operation feems  to be a tonic power,  the
bark being a remedy in many cafes of debility, parti-
cularly in gangrene :  and, as the recurrence of the pa-
roxyfms of intermittent fevers depends  upon a  recur-
rence of  atony,  (xxxv, and xxxvi.) fo probably the
   Vol. I.                  Q_                 bark,
a reddifh brown colour like cinnamon. The middle coat is confider-
ably thicker, of a clofer texture, and deeper colour than the firft, and
is lefs brittle but more refinous than any other part.  The third or
innermoft coat is woody and fibrous, and of a britifh red,  at leaft
conliderably brighter than any of the others.  From this defcripti-
on of  the bark, great care  muft be taken in powdering it, not to
leave much grofs powder, but to pals the whole of it through the
fieve, becaufe the moft refinous, andconfequcntly the moft effectual,
part of the bark is the longeft and moft difficult to powder.   Wither
refpe& to the two kinds of bark fo much talked of and noticed a few
years ago, it may be proper to obferve, that they feem to be the pro
du&ion of the fame tree. The Spaniards always fele&ed fuch piec-
es as thofe above defcribed out of the original packages, and rejected
the thin, pale, and quilled  fort, which the Englifh preferred.  It is
certain that both the red, pale, quilled, and a variety of gradation be-
tween them,  all occur in the fame eheft as originally imported ; and
it is extremely improbable, that the bark of different kinds  of trees
fhould be packed together.   13e this matter however as it may, ex-
perience gives the preference to what is called the red bark, and this
fort ought furely to be u:td. 
122            P  R  A L 1  1 L L

bark, by  its tonic power, prevents the recurrence of
thefe paroxyfms ; and this is greatly confirmed by ob-
ferving, that many other tonic medicines anfwer the
fame pur pole.
                     ccxv.
  If the operation of the bark may be thus explained,
from its poffeffing a tonic power, it is eafy to perceive
why it is  improper  when a  phlogiftic diathefis pre-
vails ; and,  from the fame view,  we can afcertain in
what cafes of ccnrnucd fever it  may  be admitted.
Thefe are either after confiderable rennffions have ap-
peared, when it may be employed to pr   ont the return
of exacerbations, on the fame  footing that it is ufed in
intermittent fevers ; or in  the  advanced ftate of fevers,
when all fufpicion of an inflammatory ftate is removed,
and a general deoi'ity prevails in the  fyftem ; and its
being then employed is fufficiently agreeable to the
prefent pradice.
                     ccxvi.
  With refped to the ufe of  the bark, it is proper to
add, that good effeds are to  be expeded from it, al-
moft only when given in fubftance and in large quan-
tity*.
                     CCXVII.
  Another fet of medicines to be employed for obvia-
ting debility and its effeds, are the direct ftimulants,
(cciii.)   Thefe, in fome meafure,  increafe the tone of
the moving fibres; but they are different from the to-
nics, as more directly exciting and increafing the ac-
t*>n of the heart and arteries.  This mode of their o-
                                           peration
  * The dofes of the bark can only be determined from the ftate of
the patient's fiomach and the violence of the difeafe : It is ufual to
give a drachm of the powder at a dofe, and repeat it every two or
three horns, according to the exigency of the cafe, or the ftate of
the  patient's bowels.  It frequently paffes off by ftool when given
too liberally ; this  mconvenjence is obviated bv giving a few drops
8 or 12, of kuidr.;ium, with each dofe.      ' 
                 OF   PHYSIC,            123

  peration renders the  ufe of them  ambiguous ;  and
x  when an inflammatory diathefis is prelent, as fo often
  happens in the beginning of fevers, the effeds of thefe
  ftimulants  may be  very  hurtful; but it  ftill remains
  probable, that, in the advanced ftate of fevers,  when
.  debility prevails, theymav be uft-ful.
                       CCXVIII.
    What are the ftimulants that may be moft properly
  employed, I  am uncertain, as  the ufe of them in  this
  age has been rare; but I am difpofed to believe that,
  of all kinds, wine is the beft.
                        CCXIX.
    Wine has the^advantage of be.o:o; grateful to the pa-
  late and  ftomach, and of having-its ftimulant parr.: fo
  much diluted, that it can  be  conveniently  givo, in
  fmall dofes ;  fo that it may be employed with fuffici-
  ent caution ; but it is of little fervice unlefs taken pret-
  Xy largely*.
                         CCXX.
    It may be fuppofed, and on good grounds, that wine
  has an operation analogous to that of opium  and fome
  other narcotic medicines.  It  may  indeed  be faid,
  that we can diftindly mark its ftimulant  power only,
  which renders its effeds in thephrenitic delirium ma-
  nifeftly hurtful, and, in the mild de'lrium, depending
  on debility, as remarkably ufeful.  But in all this, the
  analogy with opium is ftill obvious ;  and it  is proba-..
  ble,  that both  wine  and  opium are more  ufeful by
                           Q^ 2                   their
    * Wine is a valuable cordial, and is much fuperior to moft other
  ftimulants ; it raifes the pulfe, fupports the vis vitae, promotes dia-
  phorefis, and refills putrefaction.  With refpect to the  medical dif-
  ferences of  wines, it may fuffice to obferve, that the effects of full
  bodied wines are more lafting than thofe of the thinner.  Red wines
  are fubaftringent, and conk-qucntly pofftfs a tonic virtue, and , ,-e
  hence more proper in fevers of all kinds  where wine is at nil adrniffi-
  b e, than white wines are.  All fweet wines are nutricjveand in ge-
  neral more  ftimulating than others;' b-.rt they heat much, and are
  apt to turn four on the ftomach. 
124            PRACTICE

their fedative and antifpafmodic, than by their ftimu-
lant powers.
                     CCXXI.
  Thefe are the means of anfwering our fecond gene-
ral indication  (cxxvi, 2.) and I now proceed to the
third, which is, To obviate or to  correcl the tendency of
the fluids to putrefaction.
                     CCXXII.
  This may be done,
  1. By avoiding any new  application of putrid  or
putrefcent matter.
  2. By evacuating the  putrid or putrefcent matter
already  prefent in the body.
  3. By correding the putrid or putrefcent matter
remaining in the body.
  4. By {importing the tone of the veffels, and there-
by refitting further putrefadion, or obviating its efte&s.
                     CCXXIII.
  The further application of putrid or putrefcent mat-
ter may be avoided,
   1. By removing the patient from places filled with
corrupted air.
   2. By correding  the air from which he cannot be
removed.
   3.  By preventing  the accumulation of the pati-
ent's own effluvia, by a conftant ventilation, and by a
frequent change of bed-clothes and body-linen.
   4. By the careful and  fpeedy  removal  of all ex-
cremental matters from the patient's  chamber.
  5. By avoiding animal food, or correding it.
                     CCXXIV.
   The  putrid or putrefcent  matter,  already prefent
in the body, may be  evacuated partly  by evacuating
frequently the contents of the inteftines* ;  and more
                                         effedually

  * The evacuants to be ufed in thefe cafes are,  the milder purges,
fuch as manna, &c. Rhubarb and fenna may alfo be ufed ; but wc 
OF   PHYSIC.
125
effedually ftill,  by fupporting  the excretions of per-
fpication and urine, by the plentiful ufe of diluents*.
                          CCXXV.
   The putrid or  putrefcent matter, remaining in the
body, may be rendered  more mild  and  innocent by
the ufe of diluents ;  or  may be correded by the  ufe
of antifeptics.    Thefe  laft  are of many  and  various^
kinds ; but which  of them are  conveniently applica-
ble, or more particularly fuited to the cafe of fevers,
is not  well afcertained.   Thofe moft certainly appli-
cable and  ufeful,  are, acefcent aliments, acidsf of all
kinds, neutral faltsf  and fixed air§.         CCXXVI.
muft avoid the draftic purges, fuch as jalap,  fcammony,  aloes, and
fimilar refinous purges.  Calomel has been found very ufeful in thefe
cafes : It may be given to  the quantity of 8 or 10 grains, and three
ounces of the infufum fennae  with  half  an ounce of Glauber's fait
may be given, about 10 or  1 2hoursafter it, to accelerate it6 operatior,
   * The diluents neceflary in thefe cafes muft all be mixt with a little
port wine or claret. Warm  port wine and water is the beft diluent.
   f Whether all kinds of acids are to be ufed as antifeptics is fome-
•vhat doubt ful.  The  mineral acids, efpecially  the  vitriolic, have
been much recommended ; but the vegetable acids feem much more
efficacious.  As their mildnefs allows us to give them in very large
quantities, and as they  more eafily enter into a union with the ani-
mal fluids than the  foffile acids do, they feem  more fuitable anti-
feptics in thefe cafes.  Whether there is any difference between
the native vegetable acids and vinegar, with  refpect to their antifep-
tic qualities, was formerly  much difputed by practitioners.   Phy-
ficians, however, have now fettled  this queftion :  and are generally
of opinion, that, in cafes of  putrefcence arifing from fevers, the fer-
mented  acid :s moft  proper ; but, in cafes of putrefcence without
fever, they prefer the native  acid juices.
   £ The antifeptic power of the different neutral kits is extremely
various.  According to the reafoning in the  foregoing note,  thofe
conlifting of a vegetable acid bafe ought  to be preferred ; and indeed
experience confirms the opinion.   The fpiritus Mindercri would per-
haps be ufeful, if it could be prevented from palling too haftily off
by fweat and urine. In dofes of a  drachm every two hours, it  is Tef,
fubjrer to promote fweet and  urine,  than when given in the ufual
dofe of half an ounce.   Lemon juice, faturated  with volatile alkali,
has often  been fnccefsfully ufed  in  thefe cafes ;  efpecially when
they are taken either  in the  act of effervefcence,  or feparately, the
k.'ix' immediately after the  other.
   £ The antifeptic qualities of fixed  a'r are much doubted by fere- 
126             PRACTICE
                       CCXXVI.
    The progrefs of putrefaction  may be ccnfiderably
 retarded, and its effeds obviated,  by  fupportirg the
 tone of the veffels :  and  this  may be done by. tonic
 remedies; the chief of which are, Cold, and Peruvian
 Bark, both fufficientlv treated  of above,  (ccv. etfeq.)
                      CCXXVII.
    I have  now finifhed the confideration  of the three
 general indications to be formed in the cure of conti-
 nued  fevers;  and have mentioned moft of the reme-
 dies which have been, upon any occafion, employed
 in this bufinefs.   It was neceffary, in  the firft place,
 to confider thefe  indications and remedies feparately,
 and to explain the operation of the latter more gene-
 rally :  but, from what has been now delivered, com-
 pared  with what was faid above,  concerning the dif-
 ference of fevers, and the fignification of their feveral
 fymptoms in forming the prognoftic, I exped it will
 not be difficult to amgn the indication, and to felect
 and combine the feveral remedies mentioned, fo as to
 adapt  them to the feveral fpecies and ckcumftances of
 continued fevers.                              I think

 ral eminent phyficians. The giving it is frequently very difficult, and
 fometimes even impoffible. The author might haveadded feveral other
 antifeptics to the fhort lift he has given : What  he has mentioned,
 however, are fuch as are generally ufed, or approved of by practiti-
 oner s.   Camphcr is  a confiderable antifeptic, but it is of too
 heating a quality to be given in fuch  quantities as feem neceflary.
 The common dofe of it is from one  to  ten grains, and it is beft ex-
 hibited in the form of a bolus ; in which form it  may alfo be joined
 with fome other antifeptic, as
            R. Camphor, gr. viii.
              iSpt. Vini- gutt. x.
              Pulv. Rad. Contrayerv.  3u.
              Jivr. Sim pi. c. f.
              M. f. bol.
This dofe rmy be repeated every fix hours, or oftener, efpecially if
the pulfe be low or weak.   In ufing camphor the  practitioner ought
to remember that this medicine, when given in large quantities, fre-
quently  occafions  delirium.   Peculiar attention  muft therefore be
paid to that fymptom, end the dofes of camphor regulated with cau
Von. 
kj j.    iilxSIC.            127
I think it may be ufeful for my  Readers to have  the
   whole of the cure of Continued jKevers  brought
   under one View, as  in the following Table.

  IN THE CURE OF CONTINUED  FEVERS,
                 THE INDICATIONS  AIIE,
         I.  To  moderate the violence of reaction.
  Which may be done by,
     I.  Diminifhing the adtion of the heart and arteries, by
  A. Avoiding or moderating thofe irritations which are almoft
         conftantly applied to the body ;  as,
      a.  The impreflions made upon our fenfes, particularly,
        a Increafed heat, whether arifing from
        aa. External heat, or,
        cc. The accumulation of the heat  of the body.
      b. The exercife of the body,
      c. The exercife of the mind,
      d. The taking in of aliment,
      e. Particular irritations arifing from
         a. The  k-nfe of thirft,
         c Crudities, or corrupted humours, in the ftomaeh,
         h.  The preternatural retention of feces.
         b. A general  acrimony of the fluids.
   B. Employing certain fedative powers ;  as,
      a. Cold,
      b. Refrigerants ; the chief of which are,
         a. Acids of all kinds,
         c. Neutral falts,
         I.  Metallic felts.
    C. Diminifhing the tendon and tone of the arterial fyftem, by
      a. Blood-letting,
      b- Purging.
         2. Taking off the  fpafm of the extreme veffels, by
   A.  Internal  means; which are,
      a. Thofe remedies which  determine to the furface, as,
         a. Diluents,
         c.  Neutral falts,
         h. J-udorifics,
        d. Emetics.
      b. Thofe remedies named antifpafmodics.
   B. External  means; as,
      a. Bliftering,
      b. Warm bathing.
 II.  To  remove the cau/es, or obviate the fffeffis,  of debi-
                           lity, by
  i. Supporting and iacreafing the action of the heart and arteries, by
   A. Tonics, as,                                    a. Colo, 
128             PRACTICE
      a. Cold,
      b. Tonic medicines, which are either,
        a. Foffile, as,
        aa. Saccharum faturr.i, &c. or,
        c. Vegetable,  as,
        aa. Peruvian Bark.
   B. Stimulants, as,
      a.  Aromatics, &.-.
      b. Wine.
 III.  To  obviate  or  correel the tendency of the fluids U
                   putrrfaclion, by
     I. Avoiding the application of putrid or putrefcent matter, by
   A. Removing the patient from places filled with corrupted air.
   B. Correcting the air from which he cannot be removed.
   C. Avoiding  the accumulation of the  patient's own effluvia, by
      a. A conftant venilation,
      b. Frequently changing the bed-clothes and body-linen.
   D. Removing carefully and fpeedily all excremental matters.
   E. Avoiding animalfood, or correcting  it-
     2. Evacuating the putrid  or putrefcent  matter  already pre-
                  fent in the body, by
   A. Evacuating frequently the inteftines.
   B.  Supporting the excretions of perfpiration and urine, by
      a. Diluents,
      b. Neutral falts.
     3. Correcting the  putrid or putrefcent matter remaining in t'i-
      body, by
   A. Diluents,
   B. Antifeptics,
   C.  Fixed air.
    4. Refilling farther putrefaction, or  obviating its effects, by
Supporting the tone of the veffels, by Tonic remedies.
                   SECT.      II.

  Of  the CURE of INTERMITTENT FEVERS.

                         CCXXVIII.
***   It ftill remains to confider the cure  of intermittent
  fevers ; and,  with refped to thefe, we form  alfo three
  general indications.
                                                           1. 
OF   PHYSIC.
129
   i. In the time of intermifiion,  to prevent the recur-
rence of paroxyfms.
   2. In the time of paroxyfms, to  conducl thefe fo as to
obtain a final folution of the difeafe.
   3. To take off certain circumftances which might t)t e-
vent the fulfilling of the two fir ft indications.
                    CCXXIX.
   The firft indication may  be anfvvered in two ways:
   1. By increafing the adion of the heart and arteries
fome time before the period of acceffion, and fupport-
ing that increafed adion till the period of the acceffion
be over,  fo  as thereby to  prevent the recurrence of
the atony and fpafm of the  extreme veffels which give
occafion to the recurrence of paroxyfms.
   2. Without increafing the adion of the heart and
arteries, the recurrence of paroxyfms may be prevent-
ed, by fupporting the tone  of the veffels and thereby
preventing atony, and the confequent ipafm.
                    CCXXX.  ,
   For the purpofe mentioned in  ccxxix, i. the adion
of the heart and arteries may be increafed,
   1. By various ftimulant remedies, internally given,
or externally applied, and that without exciting fweat.
   2. By the fame remedies, ot others fo managed as
to excite fweating, and to fupport that fweating till the
period of acceffion be for fome time paft.
   3. By naufeating dofes of emetics, given about an
hour before the time of acceffion, thereby fupporting
and increafing the tone and adion of the extreme vef-
fels.
                   CCXXXI.            .,:.
   The tone  of the  extreme veffels may be fupfiorted
without increafing the adion of the heart and arteries
(ccxxix, 2.) by  various tonic medicines ; as,
   1. Aftringents alone.
   2. Bitters alone.
   3.  Aftringents and bitters conjoined.
  Vol. I.              R           4. Aftringents 
 130          PRACTICE

   4.  Aftringents and aromatics  conjoined.
   5.  Certain metallic tonics.
   6.  Opiates.
      Laftly, an impreffi.n of horr r.
   A  good deal of exercife, and as full a  diet as the
 condit.-m of the  mtientN apoetne  and di^.flion may
 allow of, will  be  roper during the time < f internum-
 on, and may be  confide-td as belonging to th;s iiead.
                   CCXXXil.
   Of a'l the tonic r;moiies  menioned (ccxxxi.) the
 moft cele orated,  and perhaps the moft certainly rff-c-
 tual, is the Pes ovian bark, the  tonic power of which
 we  have en.ieavoo ed to demonftrate aOove (ccxiv.)
 and have at the fa.ne time explained  its ufe in conti-
 nued fevers.
   The fame obfervation as made in ccxvi. is efpecially
 proper in the cufe of intermittents : and further, with
 refped to  thefe, the fallowing  obfervations  or rules
 are offered her2.
    1. That the bark may be employed with fafety at
 any .period of intermix cot fevers, providing  that, at
 the fame time, there be neither a phlogiftic diathefit
 prevailing in the fyftem, nor any confiderable  or fixed
 congeftion prefent in the abdominal vifcera.
    2. The proper time for exhibiting the  bark inin-
' termittcnt fevers, is diring the time of intermifiion  ;
 and  where intermiifions are to be expeded, it is to be
 abiiained f on in the time of paroxyfms.
    3. In remittents, though  no entire apyrexia oc-
 curs, the Bark  may be given  during  the  remifii-
 ons ; and it fhould be given, even though the remiflion
 be inconfiderable, if, from the known nature of the e-
 pidemic,  intermiifi'ms or  confiderable remifiions  are
 not to be foon expeded, and that great danger is ap-
 prehended from  repeated exacerbations.
    4. Li the cafe, cf genuine intermittents,  while a due
 quantity  of Bark is to bo employed, the exhibition <f
                                                  it 
OF   PHYSIC.
*3i
it ouoht to be brought as near to the time of acceffion
as the condition cf the patient's ftomacn will allow.
   5.  In general, in all cafes of inrermittems, it is not
fuiiicient that the recurrence of paroxyfms be flopped
for once by the ufe of the bark ; a relapfe is commonly
to be expeded, and fhould be  prevented by the exhi-
bition of the  bark, repeated at proper intervals*.
                         R 1                CCXXXIII.

   *  The quantity of bark to be given in the intermiffion mutt  be
as great  as the ftomach can poffibly  bear.  It is very common to
give twoounces during the inUrmifQon, in dofes ofrulf a drachm or
two  fcruples every hour,  efpecially  in quartans.   But it has been
found more fuccefsful in its operations,  when we begin  with fmall
dofes,  viz. 9i. in the commencement of the intermiffi'.ns. and in-
creafe the dofes to Ji. towards the end of it.  The baik fometimes
fits better on the ftomach by adding to it about an eighth or a fourth
of its weight of fome aromatic antifeptic.  Virginian fnake root an-
fwers tills intention very well. An ounce of red bark and two drachms
pf fnake  root taken during the intermifiion of* a tertian,  if the fto-
mach can bear it, or if no  diarrhoea comes on,  generally prevents
the next  paroxyfm.   In cafe of  diarrhoea being  produced by bark,
ten or twelve drops of laudanum  are to be given  three or four times
with each dole of the bark.   The fubilances generally joined  with
the bark in prefcription, feem calculated either to promote its effi-
cacy or reduce it to the intended form, without having regard to the
agreeablenefs of the composition. This however is a point of great
jconfequencc, as the tafte of  the bark, and the large quantity of it
neceffary for the cure, make the patient  frequently loath it before
its ufe ought to  be discontinued.  When made into an electuary or
bolus with fyrups, it flicks about the mouth or  fauces ; whence its
tafte remains a  long while ; but, when made into an electuary with
mucilages, it paffes down freely, fcarcely leaving  any tafte behind it.
The tafte of the bark is very effectually concealed by liquorice root
jn a  decoction, or by the extract in an eleftuary.  The extract of
logwood  alfo conceals the tarle of the bark,  and  an electuary made
with it, and a fuiiicient quantity of macilag?, is a very elegant form.
Decoctions, infufions, and tincture of the b.irk are much lefs effica.
cious than the fubftance.  The extract and the reiin are felaom em.
ployed in the cure ef intermittents, except when otVr forms wilj
not lit on the ftomach7  Th~ formula i;: tht  laft  London Pharmaco.
ptcia  is the  beft, being a compound of both the extract and refin  .
for the watery exir-i.it: is ilrong in bitternefs, but weak in aftringen'
ty» and the tefin is Ilrong in  aftringcncy,  but weak in bittcrnefs, an j 
!32
PRACTICE
                        CCXXXIII.
   Our fecond general indication for conducting  the
paroxyfms of intermittent  fevers, fo as to obtain a fi-
nal folution of the difeafe,  may be anfwered,
   i.  By  exhibiting emetics  during  the  time of  the
cold ftage, or at the  beginning  of the hot.
   2.  By opiates given during the time of the  hot ftage*.
                                               CCXXXIV,
both qualities are neceffary for curing intermittents.   About tenor
twelve grains of the extract are equivalent to half a drachm of pow-
der.   When aparo>yfm has been (lopped by the  bark, it is by no
means fafe to abandon the ufe of this medicine altogether, as a Te-
l-a.pf; is always to be apprehended.   The  dofes are gradually to be
diminiihed, and the intervals between the times of given them  are to
be increafed : After tertians, we  may diminifh the quantity daily
one  half, till we arrive at  two drachms ; and  thefe two  drachmi
ought to be  continued in dofes of two fcruples three a day for eight
days ; after which period, two fcruples ought to be given  night and
morning for.a week longer : after quaita.is, when the dofe is reduc-
ed to two drachms a day, it will be prudent to continue giving this
quantity daily for a fortnight, and half a drachm night and morning
for a fortnight longer.  In order the more effectually  to  prevent a
relapfe, great attention muft be paid to diet and regimen.   Patients
fcre generally extremely voracious after the cure of intermittents;
and  indeed they require confiderable nutrition to fupply  the wafte
occafioned by the fever.   Small quantities of food are to be taken
at once and  to be often repeated 5  and the  moft  nutritive, and at
the fame time eafily digeftable food, mi;if be chofen, as broths with
bailey and white flefh meat, roaft  lamb, veal, chickens, new laidegns
broilt-d  frefh hfh, &c.   Acrid, acefcent, and irritating  aliments, and
acids are to be carefully avoided.  The drink ought to be  in  mode-
rate  quantity, but lich and ftrong ;  as  mild aic, Fort wine and wa-
^er   With refpect  to the  regimen proper for convalefcents from
intermittents, it  may fuffice to obferve, that flccp may be indulged
in.   Exercife without fatigue is of great ufe, either by walking, by
riding on horfeback, or in a carriage, accurdir^ to the ftrength of the
patient.   But above all, cold mult be carefully avoided ; fo'r rothing
more effeaually produces a relapfe than an imprudent cxpofure to
cold  d;..:np air, or a neglect in keeping the body properly clothed.
The  practice of giving purges after the cure of intermittents is hi«h-
Jyblameable, and is frequently the  cafe of a reiapfe.   Should  Tof-
tivencfs be troublefomc, it may be  removed by very mild emollient
rJyilers.
   ::  Tine praftice, of giving vomits in the end of the cold ftage and 
OF   PHYSIC.
*33
                    cc::xx:v.
  The  circumftances which may efp-.cially  prevent
the fulfilling  of thofe two  indications, and therefore
give occafion to our third,  are,  a phlogiftic  diathefis
prevailing in the fyftem, and emgellious fixed in the
abdominal  vifce;a.   The  firft muft  be removed by
blood-letting and  the antiphlogiftic regimen • the fe-
cond, by vomiting and pu ging.
  Where thefemeafures are not immediately effectual,
I hold  it fafer to attempt the cure of the difeafe by
the means  pointed  out  in  general  in ccxxix. rather
than by thofe in article fecond of the fame paragraph.

             ..< .<<••<•« < •<••<<-<••<•<>$•>>•>•■>>. >.•>.»>-•>-}-.

                B   O   O   K   II.

         OF  INFLAMMATIONS,

                        OR

              PHLEGMASIA

                  CHAP.  I.

     OF INFLAMMATION  IN GENERAL,

                    SECT.  I
 OF THE PHENOMENA OF INFLAMMATION,

                     cexxxv.
        HEN any past upon the furface of the body h
         affected with unufual rednefs, heat, pain and
                                             tumour,
 an opiate after their operation, is old.  It is mentioned by ^vdev-
 ham, Bocihaave,  Van  Swieten,  and moll practical writers.  It
 mull not h( v.cver be indifcriminately ufed.  It is feldom aitendci
 wi;hany falutary effect,  except in vernal intermitttnts, and in the
 eaiiier period of the difeafe ; and it is conftantly attended v. ith dii-
 advantage w-hen thedikafe has been of long continuance,
w 
'54
PRACTICE
tumour, we name the d'foafe an Inftimmation or
Phlegmasia. Thefe f/mptoms of inflamma ion are ne-
ver coniiderable, without the whole fyftem being, at
the fame time, affected with pyrexia.
                   CCXXXVI.
  As the external, fo  like wife the internal parts may
be affected  with inflammation ; and we judge them to
be fo, when, together  with  pyrexia,  there  is  a  fixed
pain in any internal part, attended with fome inter-
ruption in  the exercoe of its functions,
                    ccxxxyu.
  We judge of the pretence of inflammation alfo from
the ftate of the blood drawn out of the veh s.  When
the blood, after cooling and concreting  lhows a por-
rion of the gluten feparated  frormthe reft of the mafs,
and lying on the furface of the craffamentum ; as fuch
ieparation happens in all cafes of more evident Phleg-
rnafia; fo,  in ambiguous cafes, we, from this appear-
ance, joined with other fymptoms, infer the prefence
o.'infhmmition. At the fame time, it muft be obferv-
ed, that as feveral circumftances in blood-letting,
may prevent this  feparation of gluten from taking
place in blood otherwife  difpofed to it; fo, from the
abfence of  foch  appe trance, we cannot always con-
clude againft the  prefence  of inflammation.
                  CC XXXVIII.
  I cannot eafily give any ^ther general hiftory of the
phenomena or" inflammation than what is contained
in :he three preceding  paragraphs ;  and the variati >ns
which moy tako place  in its circum (lances, will occur
to be ro >re  properly raV-n nonice of under the feveral
heads of roe particular j.enera and fpecies to be here-
after mentioned.  I proeeed, therefore, to enquire in-
to tae prjximato cau'e  of inilammatiqn in g'oioral.
SECT. 
0  Y" TP'H'Y SIC.           135
                SECT.   II.

OF  THE PROXIMATE CAUSE OF  INFLAM-
                    MATION.
                    CC XXXIX.
   The phenomena of inflammation   (ccxxxv.) all
concur in fhowing, that th  re is an increafed impetus
of the blood in the veffels of the part afTecle J ; and as,
at the fame time, the action of the heart is not a!-vavs
evidently increafed, there is reafon to prefume, that :he
increafed impetus of the blood in the particular part is
on ing efpecially to the increafed action of the veflels
of that part itfelf.
                      CCXL.
  The caufe of this increafed aclion in  the vefTtos of a
particular part is, therefore,  what  we  are to ioqi.oc
after, and to confider as the proximate caufe of  in-
flammation.
  In many cafes, we can mamfeftlv  perceive, that in-
flammation  arifes from  the application of ftimulant
fubilances to the part.  When the application of fuch
ftimulants, therefore, is evident, we feek for no other
caufe of inflammation : but as, in many cafes, fuch ap-
plication is neither evident, nor, with any  probability,
to be fuppofed, we muft, in  fuch cafes, feek for fome
other caufe of  the increafed  impetus  of the blood in
the velfels of the part.
                     CCXLI.
  Many phyficians have fuppofed, that an obftruction
of the extreme veffels, any how produced, may prove
a caufe of inflammation ; and particularly, that this
may arife from an  obftruclion  formed by a mattero
ftopping up  thefe veftels.  But many  difficulties  at-
tend thib doctrine*.                          1. The
  * This is the Boerhaavian doftrine which the author here refutes,
many objections might be made againft feveral parts of this refuta-
tion ; but to examine it minutely, is foreign to my purpofe, and
would tequiie more room than the  narrow limits of  thefe notes can
poffibiv allow. 
 t^G            PRACTICE

   i.  The opinion feems chiefly  to have arifen frorn
the appearance  of the blood defcribed in ccxxxvih
when the fjpporated gluten was considered as a prefer-  j
natural and morbid matter: but we now know very
certainly, that this  gluten is conftantly a conftituent
part of the human blood ; and that it is only a pecu-
liar feparation of the parts of the blood, that happens
in confequence  of  inflammation and fome other cir-
cumftances, which gives occafion  to  the appearance"  \
that was falfely confidered as a mark of a morbid len-
tur in the blood.
   ■2.  There are  no experiments directly in proof of a
preternatural lentor prevailing in the mafs of  blood;
nor is there any evidence of certain parts of the blood
occafionally acquiring a greater denfity  and force of  ^
cohefion than ordinary ; neither is there any proof of
the denfer,  or more coherent  parts, being prefent in
the mafs of blood in fuch greater proportion than ufu-
al, as to occafion a dangerous fpiilitude.   The  expe-
riments of Dr. Brown Langrifh on this fubject afford
no conclulion, having been made on certain parts of
the blood feparated from the reft, without attending
to the circumftances of blood-letting, which very much
alter the ftate of the feparation and concretion of the
blood drawn out of the veins.
   3.  The fuppofnion  of a preternatural lentor or vif*
cidity of the blood, is not well founded ; for it is pro^
bable, that nature has  fpecially  provided againft  a
ftate of the fluids, fo incompatible with the exercife of
the moft important fundions of the animal ceconomy
While ni- tion continues to prevent  a feparation of
parts,' and heat con innes to preferve the fluidity of
the more vifcid, thee fa ems to be always fo  large a
proportion of water prefent as to give a fufficient flu-
idity to the whole.   I mull own that this  is not abfo-
lutolv conclidive ; but I ftill repeat it, as givin^  a pro- %
Lability to the general argument.
                                             4. In 
OF  PHYSIC.
x37
   4. In the particular cafe of inflammation, there are
 feveral circumftances which render it probable that
 the blood is then more fluid than ufual.
   5. I prefume that no fuch general lentor, as Boer-
 haave and his difciples  have fuppofed, does ever take
 place; becaufe  if it did, it muft fhow more confider-
 able effects than commonly appear.
   6.  Befides the fuppofition of an obftructing lentor,
 phyficians have fuppofed, that an obftruclion may be
 formed by  an impermeable matter of another kind,
 and that fuch an obftruclion may alfo be the caufe of
 inflammation. This fuppofition is what is well known
 in the fchools under the title of an error loci ; but it is
 an opinion that I cannot find to be  at all  probable;
 for the motion of the blood in the  extreme  veflels  is
 fo weak and  flow,  as  readily to admit a retrograde
 courfe of it; and therefore, if a particle of blood fhould
 happen to enter a veflel whofe branches will not allow
 of its paflage, it will be moved backwards, till it meet
 with a veflel fit for tranfmitting it; and  the frequent
 ramifications and anaftomofes of the extreme arteries
 are very favourable to this.  I muft own indeed, that
 this argument is not abfolutely conclufive; becaufe I
 allow it  to be pretty certain, that an error loci; does
 actually upon occafion happen;  but, for the reafons
 I have given, it is probable that it feldom happens,
 and is therefore rarely the caufe of inflammation ; or if
 it be, that it is not merely  by the obftruclion that it
 produces; as, among other reafons, I conclude parti-
 cularly from the following argument,
  7.  Though an obftruclion fhould  be fuppofed  to
 take  place, it will not be fufficient  for producing the
 effects, and exhibiting the phenomena, that appear in
 inflammation.   The theory that has been common-
 ly employed on this occafion is by no means fatisfy-
ing; and, in fact, it appears, from many obfervations
and experiment:- that confiderable  obftructions may
  Vol. I.                S                    be 
i3S            PRACTICE

be formed,  and may fubfift, without produ«ng the
fymptoms of inflammation.
                    cqxLii.
  Obftruclion, therefore, from a matter ftopping up
the veflels, Gaub. Pathol. 249. 1. is n6t to be confi-
dered as the primary caufe of inflammation ; but, at
the fame time, it is fufficiently probable, that fome de-
gree of obftrudlion does take place in every cafe of in-
flammation-  The diftenfion,  pain,  rednefs and tu-
mour, attending inflammation, are to be explained
only by fuppofing, that the extremities of the arteries
do not readily tranfmit the unufual quantity of blood
impelled into them by the increafed action in the courfe
of thefe veffels.  Such an obftruclion may be fuppofed I
to happen in every cafe of an increafed impetus of the 1
blood ; but it  is probable, that, in the -cafe of inflam- 1
mation, there  is alfo a preternatural refiftance to the
iaee  paflage of the fluids.
                    CCXLIII.                   ,
  From the doctrine of fever, we are led to believe, '<
that an increafed action of the heart and arteries is not
fuppcrted for any length of time by any other means
than a fpafm affecting  the extreme veffels;  and that
the fame  fpafm  takes  place in  inflammation, feems
likely, becaufe that every confiderable inflammation
is introduced  by a  cold ftage, and is accompanied
with that  and other  circumftances of pyrexia.  It
feems alfo probable, that fomething analogous to this
occurs even in the cafe of thofe inflammations which
appear lefs confiderable and to be purely topical.
                    CCXLIV.
   From  all tins, the nature of inflammation may in
many  cafes be  explained in the following manner.
Some  caufes of inequality in the diftribution of the
blood may throw an unufual quantity of it upon par-
ticular veflels, to which it muft neceflarily prove a fti-
mirus.  But,  further,  it is probable,  that,  to relieve
                                               the 
OF  PHYSIC.
J39
the congeftion, the vis medicatrix natural increafes ftill
more the action of thefe veffels ; and which, as in all
other febrile difeafes, it effects by  the formation of a
fpafm on their extremities.
                     CCXLV.
   A fpafm of the extreme arteries,  fupporting  an in-
creafed action in the courfe of them, may therefore be
confidered as the proximate-caufe  of inflammation ;
at leaft,  in all cafes not arifing from direct ftimuli ap-
plied ; and even in this cafe the ftimuli may be fuppo-
fed to produce a fpafm of the extreme veffels.
                    CCXLVf.
   That, in inflammation, there is  the concurrence  of
a conftriclion of the extreme veflels, with an increafed
action in the other parts of them, feems probable, from
the confederation of Rheumatifm.  This  is a fpecies
of inflammation which  is often manifeftly produced,
either by cold applied to over-diftended veflels, or by
caufes of an increafed impetus, and over-diftenfion in
veflels previoufly conftricled.  Hence the difeafe efpe-
cially appears at  feafons liable to frequent and  c^onfi-
derable  viciflitudes of heat and cold.
   To this we may add, that the parts of the body moft
frequently affeded with inflammation, are  thofe ex-
pofed,  both to over-diftcnfion, from a change  in the
diftribution of the fluids, and, at the fame time,  to the
immediate aclion of cola\,  Hence^quinfis,  and pneu-
monic  inflammations,  are more  frequent than  any
others.
                    CCXLVII.
   That  a fpafm of the extreme veflels takes place in
inflammation,  is to be further prefumed from what  is
at the fame time the ftate of the whole arterial fyftein.
In every confiderable inflammation, though arifing in
one part only, an affection is communicated  to the
whole fyftem, in confequence  of  which  an inflam-
mation,  is readilv produced in other parts befide  that
                         S .                 firft 
143
PRACTICE
firft  affeded.  This general affedion is well  known
among phyficians, under the name of the Diathesis
Phlogisti ca.  It appears moft commonly in  perfons
of the moft rigid fibres ; is often manifeftly induced
by the tonic or aftringent powers of cold ; is increafed
by all tonic and ftimulant powers applied to the body;
is always attended with a hardnefs of the pulfe; and
is moft effectually taken off by the relaxing power of
blood-letting.  From  thefe  circumftances, it feems
probable, that the diathefis phlogiftica  confifts in an
increafed tone, or contractility, and perhaps in an in-
creafed contraction of the mufcular fibres of the whole
arterial fyftem.    Such a ftate of the fyftem feems of-
ten to arife, and fubfift for fome time, without  the ap-
parent inflammation of any particular part; but fuch
a ftate of the fyftem renders it likely, that a  fpafm may
at the fame time, readily arife in any of the extreme
veflels, and  a particular  inflammation  be  there pro-
duced.  It does, however, appear alfo, that the gene-
ral diathefis frequently arifes from inflammation begun
in a particular part.
                   CCXLVIII.
  I have thus endeavoured, in the cafe of  inflamma-
tion, to explain the ftate of the whole fyftem,  as well
as that of the part more  particularly affected.  The
latter I have confidered as when in its  firft formation;
but after it has fubfifted for fome  time, various changes
take place in the part affected; and  of thefe  I muft
now take notice.
               SECT.    III.
     Of //^Terminations of Inflammation.
                    CCXLIX.
  If an inflammation be cured while the ftate and tex-
ture of the part remain  entire, the difeafe is faid to be
terminated by Resolution.
                                            Thi; 
OF  PHYSIC
141
  This  happens  when  the  previous congeftion and
fpafm have been in a moderate degree, and the increaf-
ed impetus of the blood has been fufficient to over-
come the fpafm, to dilate the veffels, and to remove
the congeftion, fo that the part is reftored to its ordi-
nary and healthy ftate.
  A refolution takes place alfo when the increafed
impetus of the fluids has produced an increafed exha-
lation into the adjoining cellular texture, or an increaf-
ed excretion in fome neighbouring part, and has there-
by relaxed the fpafm, and relieved the congeftion,  in
the veffels of the part more particularly affected.
  Laftly, A refolution may take place, when the in-
creafed impetus of the  blood in the whole fyftem oc-
cafions an evacuation, which, though in a diftant part,
may prove fufficient to take off the phlogiftic diathefis
of the whole fyftem,  and thereby relieve the congefti-
on and fpafm of the particular  part affected by inflam-
mation.
                       CCL.
  The tumour which appears in inflammation may be
imputed in part to  the congeftion  of  fluids  in their
proper veffels; but is owing chiefly to an effufion of
matter into the adjoining cellular texture;  and,  ac-
cordingly, tumours  feldom appear but in parts adjoin-
ing to a lax cellular texture.   If, in this cafe, the mat-
ter effufed be only a larger quantity of the ordinary ex-
haling fluid, this, when the free circulation in the vef-
fels is reftored, will be readily abforbed, and the v  e
of the part will become the  fame as before.   Bu    f
the increafed impetus of the blood in an inflamed p: t,
dilate the exhalent veflels to fuch a degree, that \> :j
pour out an entire ferum, this will not be fo readily
reabforbed : and, from the  experiments  of  Sir John
Pringle, and efpecially from thofe of Mr. Gabcr, Mif-
celL Taurin. Vol. II. we learn, that the ferum, under
                                             flag- 
142
PRACTICE
ftagnation, may fuffer a particular change, by having
the gluten prefent in it changed into a white,  opaque,
moderately vifcid, mild liquor, which we name Pus.
When this change takes place in  the inflamed part,
as it is at the lame time  attended with an abatement
of the  rednefs, heat, and pain,  which before diftin-
guifhed the inflammation, fo the difeafe is faid  to be
terminated by Suppuration ; and an inflamed part,
containing a collection of pus, is called an Abscess.
                      CCLI.
   In inflammation, the tendency of it to fuppuration
may be difcovered, by the long continuance of the in-
flammation, without the fymptoms of refolution ;  by
fome remiflion of the pain of diftenfion ; by the pain
becoming of a throbbing kind, more diftindly con-
nected with the pulfation of the arteries ; by the pulfe
of the  arteries being fuller  and fofter ; and often by
the patient's being frequently affected with cold flii-
verings.  The period at which this takes place is not
detcrmmec1, but may fometimes fooner, fometimea.la-
ter.  When the tendency is determined, the time ne-
ceffary to a complete fuppuration is  different in dif-
ferent cafes.
   When pus is completely  formed,  the  pain in the
part entirely ceafes, and a weight is felt in it.   If the
collection be formed immediately under the fkin, the
tumour becomes pointed, the- part  becomes foft, and
the fluctuation of the fluid  within can commonly be
perceived; while, at the fame time,  for the moft part,
the rednefs of the  fkin  formerly  prevailing  is very
much gone.
                     CCLII.
   Ih abfeeffes, while the  pus is formed of one part of
the matter which had been  eftufed,  the  other and
thinner parts are reabforbed,  fo that,  in the  abfeefs,
when opened, a pus alcne appears.   Thus  pus, how-
                                             ever, 
              of  f~tty s i c.            143

ever, is not the converted gluten alone : for the con-
verfion of this being the effect of a particular fermen-
tation, which may  affect the  folid fubftance of the
part, and perhaps every folid of animal bodies ; fo it
moft readily,  and particularly, affects the cellular tex-
ture,  eroding much  of it, whicn thereby becomes a
part of. the pus.  It generally happens alfo, that fome
of the fmallerred veflels are eroded, and thereby fome
red blood often appears mixed with the pus in abfcef-
'fes.   Upon the whole, the internal furface of an ab-
feefs is to be confidered as an ulcerated part.
                     CCLIII.
  This account  of fuppuration  explains, why an ab-
feefs, when formed, may either fpread into the cellular
texture of the neighbouring parts ; or, by eroding the
incumbent teguments, be poured out upon the furface
of the body,  and produce an open ulcer.
                     CCLIV.
  We have here given the idea of an abfeefs as a col-
lection of matter following inflammation ;  but the
term has been applied to every collection of matter
effufed, and changed by llagnation in an enclofed ca-
vity.
   The matter of abfeeffes, and of the ulcers following
them, is various,  according to the nature  of what is
effufed, and  which may be,
   1.  A matter thinner than ferum.
   2.  An entire and pure ferum.
   3.  A quantity of red globules.
   4.  A matter furnifhed by  particular glands feated
in the part.
   5.  A mixture of  matters from different fources,
changed by peculiar fermentation.
   It is the fecond only which  affords a proper pus ;
the effufion whereof, whether in fuppurating parts or
ulcers, feems to  be the peculiar effect of an inflamma-
tory ftate of the veflels; and  for this rtafon it is, that,
                                            when 
144          PRACTICE
 when ulcers do not produce a proper pus, a circum-
 ftance always abfolutely  neceffary to their healing,
 we, in many cafes, bring the ulcers to a ftate of pro-
 per fuppuration, by the "application of ftimulants ex-
 citing inflammation^ fuch as balfams,  mercury, cop-
 per, &-c.
                      CCLV.
   When the matter effufed into the cellular texture
 of an inflamed part, is tainted with a putrid ferment,
 this produces, in the effufed matter, a ftate approach-
 ing more or lefs to that of putrefaction.   When this
 is in a moderate degree, and affects only the fluids ef-
 fufed, with the" fubftance of the cellular texture, the
 part is faid to be affected with Gangrene ; but if the
 putrefaction affect  alfo the veflels and mufcles  of the
 pait, the difeafe is faid to be a Sphacelus.
                     CCLVI.
   A gangrene,  and its confequences, may arife from a
 putrid ferment diffufed in the mafs of blood, and pour-
 ed out with the ferum effufed, which it operates upon
 more powerfully while the ferum is ftagnant, and re-
 tained  in the heat of the body:  but it may alfo arife
 from the peculiar nature of the  matter effufed  being
 difpofed  to putrefaction; as particularly feems to be
 the cafe of  the red  globules of the  blood effufed in a
 large quantity.   In  a third manner alfo, a gangrene
 feems  frequently to arife from the violent excitement
 of the inflammation deftroying the tone of the veffels;
whereby  the whole fluids ftagnate,  and run into pu-
 trefaction, which taking place in  any degree, deftroys
ftill  further the  tone of the  veffels, and fpreads the
gangrene.
                    CCLVII.
  In inflammation,  the tendency to gangrene may be
apprehended from an extreme violence of pain and
heat in the inflamed part, and from a great den-rec of
pvrexia attending the inflammation.
                                              The 
0  F  PHTS  I  G.
i45
   The actual coming on of gangrene may be perceiv-
ed, by the colour of the inflamed part changing from
a clear to a dark red; by blifters arifing upon the part;
by the part becoming foft,  flaccid, and infenfible ;
and by the ceafing of all pain while thefe appearances
take place.
   As the gangrene proceeds, the colour of the part be-
comes livid, and by degrees, quite black; the heat of
the part entirely ceafes; the  foftnefs and flaccidity ot
the part increafe ; it lofes its confiftence, exhales a ca-
daverous fmell, and  may then be confidered as affected
with fphacelus.
                    CCLVIII.
   Gangrene is thus a third manner in which inflam-
mation  terminates :  and the fchools have commonly
marked a fourth termination of inflammation ; which
is, by a  fcirrhus,  or an indolent hardnefs of the part
formerly affected with inflammation.  This, howe-
ver, is a rare occurrence, and does not feem to depend
fo much upon the nature of inflammation, as upon the
circumftances of the part affected,   It is in glandular
parts chiefly that fcirrhofity k obferved ; and it is pro-
bably owing to the parts readily admitting a ftagnation
of the fluids*  I have obferved, that inflammation fel-
dom induced fcirrhus;  but that this more commonly
arifes from other caufes ; and when inflammation fu-
pervenes, which  it is fooner or later apt to do, it does
not fo commonly increafe as change the fcirrhofity in-
to fome kind of abfeefs. From  thefe confiderations;,
it does not  feem neceflary  to take any further notice
of fcirrhus as a termination  of inflammation.
                      CCLIX.
  There are, however,  fome other terminations of
inflammation not commonly taken notice of,*butnow
to be mentioned.
  One is,  by the  effufion of a  portion of the entire
mafs of blood, either by means of rupture or of anaf-
  Vol. I.                 T                tomofis 
I4&             P R A  C T 1 <J  iL
tomofis into the adjoining cellular texture.  This hap.
pens efpecially in inflammations of the lungs, where
the effufed matter,  by  comprefling the veffels,  and
ftopping the circulation,  ocoalions a fatal futfocation ;
and this is perhaps the manner in which pueumoni:
inflammation moft commonly proves fatal.
                     CCLX.
  Another kind  of termination is, that of certain in-
flammations on the furface of the body, when there is
poured out under the cuticle a fluid, which being too
grofs to pafs through  its pores,  therefore feparates it
from the fkin, and raifes it up into the form of a vefi-
cle containing the  effufed  fluid ;  and  by which effu-
fion the previous inflammation is taken off.
                     CCLXI.
  Befide thefe already mentioned, I  believe there is
ftill another  manner in which  inflammation termi-
nates.   When the internal parts are affected  with  in-
flammation,  there feems to have been almoft always
upon their furface an exudation, which appears partly
as a vifcid concretion upon their furface,  and partly
as a thin ferous fluid effufed into the cavities in which
the inflamed vif:era are placed.  Though we  have be-
come acquainted with thefe appearances only, as very
conftantly accompanying thofe inflammations which
have proved fatal, it is  however probable,  that like
circumftances may have attended thofe  which were
terminated by refolution, and  mav have contributed
to that event.  It  is in  favour of this  fuppofition that
there are inftances of pneumonic inflammation termi-
nating in  a hydrothorax.
                                           SECT. 
OF  PHYSIC.
147
              SECT.     IV.

OF THE REMOTE CAUSES OF INFLAMMA-
                    TION.

                    CCLXII.
   The remote caufes of inflammation may be reduced
to five heads.
   1. The application of ftimulant fubftances; among
which are to be reckoned the action of fire, or burn-
ing.
   2.  External violence  operating mechanically in
wounding, bruifing, comprefling,or overftretching the
parts.
   3. Extraneous fubftances lodged in any part of the
body, irritating by their chemical acrimony or  me-
chanical form, or comprefling by their bulk or gravity.
   4. Cold, in a certain degree, not fufficient immedi-
ately to produce gangrene.
   5. An increafed impetus of the blood determined
to a particular part.
   It will  not be difficult to understand how thefe re-
mote caufes, fingly,  or in  concurrence, produce the
proximate caufe of inflammation.
                    CCLXIII.
   It does not appear, that, in different cafes of in-
flammation, there is any difference in the ftate of the
proximate caufe, except  in the  degree of it; and
though fome difference  of  inflammation may  arife
from the difference of the  remote caufes, yet this is not
neceffary to be taken notice of here; becaufe the dif-
ferent  appearances which  attend different inflamma-
tions may be referred, for  the moft part, to  the differr
encc of the part affecled, as will appear when we fhall
confider the feveral genera and fpecies marked in the
Nofology.  W hen I come to treat of thefe, I fliall find
                    ,   T 3                a more 
148
PRACTICE
a more proper occafion for taking notice of the differe
ent ftates of the proximate, or of the differences of the
remote  caufe, than by treating of them  in  general
here.

             ..«..<..<..<..<..<..< .<.<..<.■«£■$,>■■>■■>■■>■■>■■>■■>■■>■■>■>•*••

                   SECT.    V.

     OF THE CURE OF INFLAMMATION,

                      CCLXIV.
  The. indications of  cure  in  inflammation  are
different,  according as it may ftill be capable of refo-
lution, or may have taken a tendency to the feveral o-.
ther terminations above mentioned.  As the tendency
to thefe terminations is not  always immediately evi-
dent, it is always proper, upon the firft  appearance of
inflammation, to attempt the cure of it by refolution.
For this purpofe, the indications  of cure are,
   1.  To remove the remote caufes, when  they are e-
vident, and continue to operate.
   2.  To  take off the phlogiftic diathefis affecting ei-
ther the whole fyftem, or the particular part.
   3.  To take off the fpafm of the particular part, by
remedies applied either to the whole fyftem, or to the
part itfelf.
                      CCLXV.
   The  means of removing the remote caufes will rea-
dily occur, from confidering the particular  nature and
circumftances of the different kinds.  Acrid  matters
muft  be removed, or their action muft be  prevented,
by the application  of  correctors  or  demulcents*.
                                              Com-
  * If the matter caufing the inflammation be an  acid, then'tlie
application of an alkaline fubflance will be proper : If, on the con-
trary, the inflammation be produced by an alkali, then an acid mull
be applied.  In many cafes, however, the acrid fubilances caufing
Miflamuut.on are neither alkaline nor acid; and,  in furh. cafe , or 
OF    PHYSIC.
149
Comprefling and overftretching powers muft be taken
away; and, from their feveral circumftances, the means
of doing fo will be obvious.
                     CCLXVI.
   The means  of taking off the phlogiftic  diathefis of
the fyftem, are the fame with thofe for moderating the
violence ot reaction in fever, which are mentioned and
treated of from cxxvij to cxlix. and therefore need not
be repeated here.  I only obferve, that, in the ufe of  ,
thofe  remedies, there is lefs  occafion for  any referve
than in many cafes of fever;  and more particularly,
that topical bleedings*  are here particularly indicated
and proper.
                      CCLXVII.
   The means of taking off the fpafm of the particular
 part are nearly the fame as thofe mentioned above,
 for  taking off the fpafm of the extreme veflels in the
 cafe of fever, and which are treated of from cl. to cc.
 Only it  is obferved here,  that fome  of thefe are here
 efpecially indicated, and that fome of them are to be
 directed  more particularly to the part efpecially affect-
 ed :  the  management of which will be  more  properly
 confidered when  we fliall treat of particular inflam-
 mations§.
                                            CCLXVIII
 when we cannot fjnd a proper corrector, we mud ufe drmulcents,
 which by their obtuiiding qiulity,  (heath the  acrimony, or defend
 the parts to which they are  applied from being irritated or corrod-
 ed.

   *  The  advantages of topical Meedinga, in mod cafes of local In-
 flammation, aiv veiy great-  They in a v  be performed by flipping,
 or what is in many  cafes more preferable, by leeches.  Cupping
 ■a£\s fometimes as a  ftimulus, efpecially on parts that are tendinous
 or flefhy,  or where  tire the cellular fubftance  is thin, and thus fre-
 quently increafesthc inflammation which we would wifn to refolvc.
   §  The  refolution of an inflamed part is confide-ably afliilcd  hy
 the application of difcutients ; and in moft caftrs,   when the gene-
 ral fyltem  is not affected, thefe difcutients alone frequently fucceed
 in diffolving an incipient phlegmon.   Solutions  of  lead in vinegir
 aic the applications which  the bell modern practitioners generally 
*5°
PRACTICE
                         CCLXVIII.
  When  a tendency to fuppuration  (ccli.) is diftind-
 ly perceived, as wc fuppofe it to depend upon  the ef-
                                                        fufion
 approve.   Goulard's  extract was fuppofed by the vulgar  to be a
 new remedy ; and his panegyric oa it tended, in a confiderable de-
 gree, to render the ufe of lead njore univerfal  than it had bec.i be-
 fore his time.  There are however, many weighty objections againft
 the formula ufed by that gentleman ; the chief one is, that on ac-
 count of the different  ftrength of the vinegar  employed, and of the
 degree of heat ufed in the procefs, we can  never accurately afcer-
 tain the quantity of lead diffolvcd in the acid j and cmifequently the
 efficacy of this preparation muft be uncertain.   The Saccharum Sa-
 turni, which is always of the fame ihrength, is therefore preferable to
 Goulard's extract; and as vinegar is a powerful  difcutitnt itfelf, it
 has been ufual to add a quantity of vinegar to  the folution of the fu-
 gar of lead in diftilled  water.  The following proportions have been
 found in genei al to be the beft :
        R. Sacchar. Saturn. 31.
          Acet. Gallic, opt. ^iv.
          Aq. font, diftillatae Jxxsii.
          M.
 li  the application cf this  folution,  it is of great confequence that
 the parts affected fhould be continually moillened witfi it.   Poulti-
 ces made of fr^fli bread crumb, and as much of the above folution as
 i'' neceffary, are in general preferable to any other mode of applying
 it;  but  ft  fometini".? happens that the inflamed part is fo extremely
 Paii.f >I  rod tender, as not to bear the great weight of a poultice ;
 and in fuch cafes we muft have recourfe to pieces of foft linen, moift-
 critd with the folution.   Both  thefe applications, viz. poultices, or
 'vet p!ec^-,fs, muft always be applied cold, and be frequently renew*
 ed wh«?n they become  warm, hard, or ftiff. This is the moft  approv-
 ed method  of applying lead for the purpofe of refolving infiammati-
 rT; yt it frequently happens that practitioners meet with patients
 •.vhcif- }  repofieflions for a popular remedy are fo great that  there is
 no perfuading them from ufing  it.   The method of making Goul-
ard's extract and Vegeto-Mineral Water are therefore fubjoined :
       Take Litharge of ^iold one pound.
       French White-Wine Vinegnr a quart,
B°il them  in an earthen veaV!, on a  flow fire, for  an Jiour and an
half, conftantly  ftirring them with a wooden  fpatula, and, when
cold,  pour off the clear liquor, which muft be kept in well  flopped
glafs phials.  The Vegeto-Mineral water is made by adding a hun-
dred drops of the above extract to a quart of water,  and four tea-
fpoon fulls of French brandy. 
                OF   PHYSIC.             151

fufion of a  fluid  whic]i cannot be eafily reabfoibed,
fo it becomes neceflary that this fluid be converted in-
to pus, as the only natural means c.f obtaining its eva-
cuation : and as the effufion is, perhaps, feldom made
without fon.e rupture of the veflels,  to the healing of
which a  pus is abfolutely neceffiry ; fo, in the cafe of
a tendency  to fuppuration,  the indication of cure  al-
ways  is,  to promote the production of a perfcft pus as
quickly as poffible.
                       CXLXIX.
   For this purpofe, various remedies, fuppofed to pof-
 fefs a fpecific power, have been  propofed; I can per-
 ceive  no fuch power in any of them ;  and, in  my opi-
 nion, all that can be done is, to favour the fuppuration
 by fuch  applications  as may  fupport a proper heat in
 the part, as,  by fome tenacity, may confine the perfo-
 ration of the part, and as, by an emollient quality, may
 weaken  the  cohefion  of  the  teguments, and favour
 their  erofion*.
                                                      As,
   * Poultices of various kinds have been recommended for this pur-
 pofe.  It  is, however, of little confequence what their ingredients
 are, provided  they be emollient, and applied  warm.  The white
 bread pultice is in common ufe,  and anfwers in general very well;
 the addition of a little oil keeps it from becoming hard, and is at the
  fame time ferviceable as an  emollient.  A poultice of bruifed lint-
  feed  well boiled with milk and water is ftrongly'recommended by
  fome writers, and indeed not without reafon, on account of its  very
  great emollient quality.   As  heat is abfolutely  neceffary for the
  production of matter in tumours, it is of great confequence that the
  poultices  fliould not be fuffered to cool on the part, and that  they
  fliould be often renewed.   Mr. Bell  has given excellent directions
  for applying poultices, with the intention of promoting fuppurati-
  on.   Warm fomentations and poultices, fays that rational practiti-
  oner,  * are the means ufually employed for the application of heat
  • to an inflamed part; and, when thefe are regularly and frequently
  ' renewed, nothing, it is probable, can more effectually anfwer the
  ' purpofe.  But in the ordinary manner in which they are applied,
  ' and as the cataplafms are renewed only once, or, at moft, twice
  ' a day, they  mull always, it is imagined, do mere harm than good,
  ' For as foon as the degree  of heat, they at firft poffeffed, is difiipa-
  ' ted, the moifture kept up by them, with the confequent evapora-
  ' tion that enfues, muft always render the part much colder than if it 
t52           Practice

                       CCLXX.                .    .
  As, in the cafe of certain effufions, a fupuratioii 19
not only unavoidable, but definable, it may be fuppof-
ed, that moft of the means of refolution formerly men-
tioned fhould be avoided ; and accordingly our prac-
tice is commonly fo  directed.  But as we  obferve, on
the one hand, that a certain dergee of increafed impe-
tus, or of the original circumftances  of inflammation,
is requifite to  produce a  proper fuppuration ;  fo  it is
then efpecially neceffary  to avoid thofe means of refo-
lution that may diminilh  too much the force  of  the
circulation.   And as, on the other hand,  the impetus
of the blood, when  violent,  is found  to  prevent the
proper fuppuration;  fo, in fuch cafes, although a ten-
dency to fuppuration may have begun, it  may be pro-
per  to continue thofe means of refolution whieh  mo*
derate the force of the circulation.
  With refpect to the opening  of  abfeeffes, when
completely formed,  I refer to the  writings on furge-
ry*.
                                            CCLXXI.
'  had been merely wrapped up  in flannel, without the ufe of any
'  fuch application.'
  '  In order to receive all the advantage of filch remedies, the part
•  affected fhould be well fomented with flannels, preffed out of any
*  warm emollient decoction, applied as warm as the  patient can ea-*
*  fily bear them, continued at kail half an hour at once, and repeat-
•  ed four or five times a day.
  '  Immediately after the fomentation is over,  a  large emollient
*  pjuitice fhould iikewife be applied warm, and renewed  every fe-
«  cond or third hour at fartheft.  Of all the  forms recommended
.  for emollient cataplafms, a  common  bread and  milk  poultice,
*  with a due proportion of butter or oil, is perhaps the moft eligi-
«  ble; as it not only poffeffes all the advantages of the others, but
<  can at all times be more eafily procured ?......Treatife on Ulcers,
'  Edition of 1787, p. 67.
  *  For a particular account of knowing where abfeeffes are com*
pletely formed,  at what period they ougiit  to be opened, and the
manner of opening them, the rca.'ercau confult no  author prefera-
ble to Mr.  Beli. 
OF   PHYSIC,
l53
                      CCLXX!.
   When  an  inflammation  has  taken a tendency to
gangrene, that event is to be prevented by every poffi-
ble means;  and thefe muft be diftereiit, according to
tho nature of  the  feveral caufes occafioning that ten-
dency;, as may be underlhood from what  has been al-
ready  faid of ti.em.  After a gangrene  has, in fome
degree, taken place, it can be cured only by the fepa-
ration of  the dead from the ming parrs.  This3 in
certain circumftances, can be performed by thekmr-;
and always moft properly, when it can be fo done.
   In other caies, it can be done  by excitioj* a fuppu-
ratory inflammation <. n the verge of the living part^
whereby  its cohefion  with  the dead may be  every
where broken off, fo that the Jatter  may fall off  by
itfelf.   While this is doing, 7r is proper  co prevent the
fuithrr putrefaction of the pu.t, and its fpreading wid-
er.  For  this purpofe,  various  antifeptic applications
have been propofed :  But it appears to ine, that, while
the teguments are entire, thefe applications can hard-
ly have any effect; and, therefore, that the fundament-
al procedure muft be to fcarify the part fo as to reach
the living fubftance, and, by the wounds  made  there,
to" excite the fuppuration required.  By the fame in-
'cifions alfo,  we  give accefs to antifeptics, which may
 both prevent the  progrefs of the putrefaction in the
dead,  and excite  the inflammation nccefoary on the
 verge  of the living part-*.
   Vol.  I.               ,U       -        CCLXXII.
   * The author  mentioned  in the preceding note treats this fub*
jtct in his ufual rational manner, and with no lefs perfpicuity than
 judgment.   Contrary  to the opinion of all former writers on gan»
b'iene, he  di(approves of the fcarilications, and the fublcquent ap-
plication of antifeptics and ftimulants.  Mr. Bell's reafoning agai.O:
this practice is  to the following purport ; The degree of inflamma-
tion rcquifite, and indeed neceffary, for the feparation of the dead
parr.., id only very flight : and, when too violent, it fails to produce
the defired effect,  Scarifications, and the fubfequent application of
ftiimdants, which increafe the inflammation too much, uie then foi„-
hurtful.   Again,  in  fcts ifyiog,  tjiere 'a a coiifidei^jk rO'k v. 
154             PRACTICE
                         CCLXXII.
   When the gangrene proceeds from a lofs of tone;
and when  this, communicared  to  the neighbouring
parts,  prevents  that  inflammation  which,  as I have
faid,  is neceffary  to the  feparation  of  the dead part
from the living; it  will be proper to obviate  this lofs
of tone by  tonic medicines given internally -r  and, for
this purpofe,  the Peruvian bark has been found  to be
efpecially effectual.    That this medicine operates by
a  tonic power,  I  hi'VC endt-avoured to  prove ahove,
(ccxiv.)  and from what is faid in cexv. the limitations
to be obferved   in employing it may alfo be  learned.
When toe gangrene  arifes  from  the violence of in-
flammation,  the bark may not only  fail of proving a
remedy,  but may  do harm : and its power as a  tonic
is efpecially fuited to thofe cafes  of gangrene which
proceed from an original lofs of tone, as in the cafe of
palfy and oedema; or  to  thofe cafes of  inflammation
where  a lofs  of tone  takes  place, while the original in-
flammatory fymptoms are  removed*.
                                             CCLXXHI.
wounding large blood-veffels,, nerves, or tendons ;  befides the dif-
advantage of allowing the putrefcent fluids of the gangrene to enter
more  freely  the found parts,  by 'increafing the  furface of the
wound.  With refpect to the application of antifeptics,  it is juftly
remarked,  that although thefe medicines have the quality of pie-
ferving dead  animal fubftances from corruption,  they by no  means
produce  the fame effect on living animal fubftances.  But. the con-
cluding argument is of much greater weight, viz. that  in a long
courfe of cxteuUvc praitice, no advantage ever acciued from  fcariti-
catiou.  Thcic  objections againft promifcuous fcarilication were firft
propofed 1 y Mr. Btll  in  his treatife on ulcers, about twelve years
ago~;  and the novelty of the opinion excited the attention of almoft
rvery practitioner.   At prefent,  however, it is uhivcrfally adopted,
and would, of itfelf, independent of the many improvements Mr.
Bell has made in furgery,  perpetuate his juftly acquired fame.
   *•" The bark muft be given in thefe cafes in  large quantities ; and,
fti the pulfe i>, in general, very fmall, port wine mult be ufed along
with it.  UtOide the ufe of thefe remedies, a good nourifhing diet is
abfolutely rcqoiiite, with fuch a quantity of ftro:i<* ^enerous wine as
is fully fufficient to keep up the • ulfe, and i  Juce the nccefuuyy flight 
               OF   PHYSIC:          155

                    CCLXXIII.
    The other  terminations of  inflammation either do
 not admit of any treatment, except that of preventing
 ilicm  by the  means  of refolution; or they belong
 to a treatife of furgery, rather than to this place.
    Having thus, therefore, delivered the general doc-
 trine,  I proceed now to confider the particular gene-
 ra and fpecies of inflammation.
    It has been  hinted above (eclxiii.), that the  differ-
 ence  of inflammation arifes chiefly frooi the differ-
 ence of the part affecloji  : ]  have therefore arranged
 them, as they are cutaneous,   visceral, or arti-
 cular ;  and in this order they are now to be confi-
 rmed.



               CHAP.     II.

   OF  INFLAMMATION,  MORE STRICTLY
                 CUTANEOUS.

                    CCLXXIV.

     CUTANEOUS inflammations  are of two kinds,
      commonly  diftinguifhed  by  the names of
 Phlegmon and Erysipelas.
   Of the latter there are two cafes,  which ought to
 he diitinguifhed  by different appellations.   When
 the difeafe is an  affedion of  the {kin  alone,  and
 very little  of  the  whole fyftem,  or  when the af-
 fection of the  fyftem  is  only fymptomatical of the
 name of  Erythema;  but when the external  inflam-
 mation is an exanthema, and fymptomatical of an af-
 cxternal  inflammation, 1 fliall   give the'difeafe the
                    U 2                   feclion
 degree of inflammation.  When, indeed, the patient i: extremely
languid, and much reduced, the warm flimulating cordials, as cam-
phirc, conft&io cardiaca, fpiritus aromaticus volatilis. Sec. may be
ufed with advantage. 
150           hUCTIC F

fecTton of the  whole fyftem, I fhall then name the dif-
eafe Lrysipelas*.
                    CCLXXV.
  It is the erythema only that I am to confider here,
  For the diftinftion between Erythema and Phleg.
mon, I have formerly referred to the characters given
of them in our Nofology. See Synopf. Nofolog. Meth,
Vol. II. p. 5. gen. vii. fpec. 1. and 2.  But 1 think it
proper now  to deliver  the characters d  them more
l'uiiy and exocriy here, as follow;.
   0  Phh-gmon is an  inflammatory affedion  of the
Tin, with ■?,  fwcliing,  tiling  generally to  a more con-
iiderable eminence in the middle of it; of a bright
ied colour ;  both the  f.vellin< and colour being pret-
ty exaoriy circumfcribed ;  the whole  being attended
■vuth a pain of difleniion, ofren of a Hounding or throb-
oiogkind, nnd frequently ending in fupptnation.
  An Erythema, R<f', or St. Anthony's lire, is an in-
flammatory  a (Vetion or  the fkin, with hardly any evi-
denr fwolling; of a  mixed  and  not very bright red
colour, readily disappearing upon preffure, but quick-
)y returning again ; the rodnefs of no regular circum-
icripticn,  bur fprcading unequally and continuing ah
rr<-\\ conftantlv rofpread upon the neighbouring prat;
wirh a  pain like  to that from  l.uning ; pro-'ucirig.'
blo'lers, fometi-ucs of  a Imail, fomeirnes  of a 1 irge'r
lize ;  ao 1 alw.iys  ending in  a defquamation  of  the
fearff-fk in, fometimes in gangrene.
  This fubject I am not topioicente hcrr, r? nropcrly
.  c;LOg'ngto furgery, the bufinefsof v bich lamfel-
<.om to ei fcr upon in thii  work;  and fliall therefore
obferve only  ac neceffary here, thai :he dirTerencc of
*K.ie  appearances feems to depend on the different
:'*at of ihe inflammation.  J"  the  phlegmon,  the in-
f;«ironou;on  feenr< to alicel efpecially the veffels on the
'-v.e.roo' furface  of the fkin comrounicatiu ^ v. :• 0  rhc
                                                h\\
  * 7 »■ FrvfO <•',:;, U pa,:; :s,i .• ]v ds-firibcd iit article <fo6\ et f q. 
OF  P II V  S I C.
'57
ids fubja~ent cellular texture ;  whence  a more copi-
ous effufion,  and that of ferum convertible into pus,
fakes place.  In the erythema, the inflammation feems
to have its feat in the vtffels on the external furface of
the ikin, communicating  with  the rote mueofum,
which  does not admit of any effufion, but what  fepa-
ntes the cuticle, and gives  occafion to  the formation
of a blifter, while the fmaller fize of the veffels admits
only of the effufion of a thin fluid,  very'feldom con-
vertible into pus.
  Befidcs thefe differences  in  the  circumftances of
fhefo two kinds of  inflammation,  it is probable that
they alfo differ with refpect  to their caufes.    Erythe-
ma is the effeel: of all kinds of acrids .externally appli-
ed  to  the fkin ; and,  when arifing from an internal
caufe,  it  is from an acrimony, poured out on the fur-
t ice <  f the fkin under the cuticle.   In  the phlegmon
an acrimony is not commonly evident*,
                   CCLXXYL
   Thefe  differences  in  tho foot and caufes  of tlis
phlegmon and erythema being'admitted,  it will be
evident, that when an erythema affects any  roarnnl
3-trr, it can take place in thofe only whofe furfacesare
covered with an epithelioid,  or membrane  ar.aiagous
10 the  cuticle.
                   CCLXXVII.           •
  The fame difiinfti n between the feat and caufes of
the two difeafes will, as I  jud^e, r-.adily explain what,
has been delivered bv practical writers, with refpect
to the cure* of thefe different cutaneous inflammations.-
Hut I fhall nor, however, profecute  tlus  here,  for the
reafon given above (ecl:;av.) ; and, for  the fimerea.
I'-n, fhall not fav any thing of the variety of external
ioiiammation,  that  might  otherwife be  confidered
here |.
                                           chap.
  * The method oft im ing an cryf;p?V, is delivered in auiclts7cP.
et fe^uent.
  f The cure  of ery'hcr.ia is chit fly . Sifted by the antiphhjgi.Kc 
10$
PRACTICE
                C  H   A   P.    HI.

   OF OPHTHALMIA, OR INFLAMMATION
                   OF THE EYE.

                    CCLXXVIII.
      THE inflammation of the eye may be confidered as
       of two kinds : according as it  has its feat in the
 membranes of the ball of the eye, when I would name
 it Ophthalmia Mem bran arum ; or as ic has its feat
 In the feb'iceous glands placed in the tarfu>, or edges
 of the ejc-lids. in which cafe k may be termed Oph-
 thalmia Tarsi.
   Thefe two kinds are very frequently  combined to-
 per her, as the one may readily excite the other; but
 they are ftill to be cxtir.guifhed according; as one or
 the other may happen to be the primarj affection, and
 »r. operly as they often arife from  different caufes.
                    CL* L A-XLa..
   The mrfammarion cf the  membranes  of the eye, af-
 fe£l?  efp>edal'ly, and molt frequently, the adnata,  ap-
 pearing • o a mrgefcencs  of its velfet?; fa that the red
 Tei-ok \*li!cht are naturally there, become not only in-
 n-cafti in o,:*-f  but there appear many  more tho.tr did
 im a nTr"U'*a?' Irate,   This turgefcence of the vefltls  is
 jLtte*rd?\i wiib pain, efpecially upon the  motion of the
 !>■ II of the eye ; and this; like erery other irritation ap-
 p\i :d to the furface of the eye,  produces an ef&fion
 -f tears from the lachrymal  gland.
   This inflammation  oinmoolj, and  chiefly, aileds
                                                  the
 rr^merr  rilreaJy  fufEcieBtljr defcriLed.  Altliong'i; IdcedTrrjr, pwrg-
 I'T-j. mo rhxr general reme;.*ies for refuting; an* frrFjamrna<i!V>n> Trill, in
 mulr1  cal^s, crrre an' eryo ^,r,d, yet. as it fsadifeaf*- fTepu-enriv de-
 jtenJiirL-Towai peewKar aBrf."rioayr we fliall always  find jneat advan-
 rain: fin«m tit e.vtjeruri! ufe ».f coolliitnts  applied cold,. or mucilagi-
 nou* d:I'.i«aiit« tak^n iaternrrll?..  Tbe difeafe, Imwi'very is  f. l-'-jm
litjijfcTOiT';, and g*-rurally terminates favoir.aLLy. 
OF   PHYSIC.
59
the adnata fpread on the anterior  part of the bulb of
the eye ; but ufually fpreads alfo along the continua-
tion of that  membrane on the infide of the palpebral;
and, as that is extended on the tarfus palpebrarum,
the excrefories of the fehaceous glands opening theie
are alfo frequently affeded.  When the affection of
the adnata is confiderable, it is  frequently communi-
cated to the fubjacent  membranes of the eye, and  c-
ven to  the retina  itfelf, which thereby acquires to
great a fenfibility, that the flighteft impreilion of light
becomes painful.
                    CCLXXX.
   The  inflammation of the membranes of the eye io>
in diiforent  degrees, according  as the  adnata is,more
or h.ij affeded, or according as the inflammation is ci-
ther of the adnata alone, or of the fubjacent me ml iOio, s
alfo ;  and, upon thefe differences, different fpc. 'os have
been  eltablilhed, and  different appellations'  given to
them. -ButI fhall  not, however, profecute the confi-
deration of thefe, being of opinion, that all the cafes
of the Ophthalmia  membranarum differ only in de-
gree, and are to be cured by  remedies of  the fame
kind  more or lefs employed.
   The  remoLo caufej  of Ophthalmia are many and
various ;  as,
   i-  External violence,  by blows, contufions, and
wounds,  applied  to the eyes; and even very flight
impulfts applied, whilft the eye lids are open,  to the
ball of the eye itfelf, are fometimes fufficient for  the
purpofe.
   2.  Extraneous, bodies introduced under  the eye-
lids, either of an acrid quality, as  fmoke and other a-
crid vapours*, or of a bulk fufficient to impede the
                                               free

  * Hence Chemifts, when fo much efnployed in procefles where co-
pious noxious v;.iou:s arife, oiwot U> he extremely careful to avoid
i«c iv as ii.uch, as polfible. 
160            PRACTICE
 fiee motion of the eye lids upon the furface of the eye*
 ball.
   3. The  application of ftrong li-ht, or  even of a
 moderate light lone; continued.
   4. The application of much hear, and particularly
 of that with moifture.
   5. Much exercife of the eyes in viewing minute ob-
jects.                                     «
   6. Frequent intoxication.
   7. Irritation from o;oer and various difeafes of the
eyes.
   8.  An acrimony prevailing in the mafs  of  blood,
and  deposited in the febaceous glands on  the edges of
the eye-lids.
   9.  A  change  in the1 distribution of the  blood,
whereby either a more  than ufual  quantity of blood,
?md  with more thin ufual force, is impelled into the
veffols of the head,  or whereby the free return of the
venous blood from the veffels of  the head is inter-
rupted.
   10. A certain confcnt of tho  eyes with  the other
parts of the fyftem,  whereby from  a certain Itate  of
thefe parts,  either a fimultaneous, or aa alternating
affedion of the eyes, is produced.
                   CCLXXXL
  The proximate caufe of Ophthalmia is not different
from that of inflammation in general; and the  differ-
ent circumftances of Ophthalmia may be explained by
the difference of its remote caufes, and by the different
parts of the eye which it happens to affect.  This may
be underftood from what has been already faid ; and
I fliall now therefore proceed to confider the Cure.
                   CCLXXXIf.
  In  the cure of  Ophthalmia, the tirff attention will
be always due to  ihc removing of  the remote caufes,
and the various means neceliary for this purpofe wih
                                                be 
               O F  P H Y S  I C              161

be directed  by the confederation of thefe caufes enu-
merated above.
  The Ophthalmia membranarum requires the reme-
dies proper  for inflammation in general ; and, when
the deeper-feated membranes are  affected, and efpe-
cially  when a pyrexia is prefent, large general bleed-
ings may  be neceffary.  But this  is feidom the enfe ;
as the  Ophthalmia, for the moft part,  is an affecfion
purely local,  accompanied with little  or no pyrexia.
General bleedings,  therefore,  from the arm or foot,
have little effect upon it; and the cure is chiefly to be
obtained  by  topical  bleedings, that is, blood  drawn
from veffels  near the inflamed  part; and opening the
jugular vein or the temporal artery, may be confider-
ed as in fome meafure of this kind.   It is  commonly
fufficient to apply a number of leeches* round the eye;
and  it is perhaps better ftill  to draw blcod from  the
temples,  by  cupping and fcarifyingf.   In many ca-
fes, a  very effectual remedy  is,  that of fcaiifying the
internal furface  of the inferior eye-lid ; and more fo
ftill, is cutting the turgid veffels upon the adnata itfelfjl.
  Vol.  I.              X               CCLXXXIII.
  * Ten or twelve may be applied  at once, and,  when  many are
employed together,  they generally produce a better effeft,  than if
fewer be employed repeatedly :  That is, twelve at once are more
efficacious than three at a time repeated four times a day.
  f Cupping and fcarifying the temples  ought to  be  performed
with very great caution, becaufe of the numerous ramifications  of
confiderable branches of arteries in thofe places.
  J Thefe operations require great nicety.  For the particular me-
thod of performing them, the reader is referred to the writers  on
furgery.
  Much harm enfues from thefe operations when injudicioufly per-
formed  ; they ought therefore to be refrained from, except when a
very fkilful and expert furgeon can be procured.  Tljey are feldom
ferviceaLle, except they be repeated feveral times.  Cutting the vef-
fels of the adnata is perhaps the betl preventive of an opacity of the
Cornea  that we know ; and, wherever there is the leaft tendency to-
wards an opacity, the praftice fhould be put in execution.  The
operation ought to be repeated daily for two, thtec, or four week*,
or even  longer, if a cure is not accomplifhed fooner.^ 
162              PRACTICE

                    CCLXXX1II.
  Befides blood-lettin'g, purging, as a remedy fuited
to inflammation in general, has been confidered as pe-
culiarly adapted to inflammations in any of the parts
of the head,  and therefore to Ophthalmia ; and it is
fometimes  ufeful :  but, for  the reafons given before
with  refpect to general bleeding,  purging in the cafe
of Ophthalmia does not prove unjful in any degreein
proportion  to the evacuation excited.
                    CCLXXX1V.
   For relaxing the fpafm in  the part,  and  taking off
the determination of  the fluids to it,  bliftering near
the part has commonly been found ufeful*.
                     CCLXXXV.
   Electrical fparks taken from the eye will often fud-
denly difcufs the inflammation of the adnata;  but the
effect is feldom permanent, and even a frequent repe-
tition feldom gives an entire  cure.
                    CCLXXXVI.
   Ophthalmia,  as  an external inflammation,  admits
of topical applications.  All  thofe, however, that in-
creafe the heat and relax the veffels of the part, prove
commonly hurtful ; and the admiffion of cold air to
the eye, the proper application of cold water immedi-
ately to the ball of the eye, and the application of va-
rious  cooling  and  altringcnt medicines,  which at the
fame time do  not produce much irritation, prove ge-
                                                nerally
  * The  part where Lli'.'ers  are ufually applied in ophthalmia arc
behind the ear, or the n?.pe of the neck.   l'he blifters ought to be
kept open by the fubfequent application of  the mild bliftering oint-
ment, if they affume appearances of healin ;
   Setons in the neck are fometimes recommended ; but, where fpet-
dy relief is required, they are of little fervice, becaufe they feldom
begin to difcharge till the expiration of a few days; befules they arc
extremely troublefome to the patient ; and, if the phlogiftic diathe-
fis be confiderable, they fometimes become fo exceedingly inflamed
as to produce many difagreeable ciixumllances that might have beea
avoided. 
OF  PHYSIC.
163
neraliy ufeful: even  fpiritous liquor?, employed in mo-
derate quantitv,  have cften  been of iervice*.
                    CCLXXXVil.
   In the cure of Ophthalmia, much care is  requifite
to avoid all  irrita ion, particularly that  of light; and
the only fafe and certain means  of doing- this, is by
confining the patient to a very dark chamber.
                    CCJ.XXXV1II.
   Thefe are the remedies of the Ophthalmia membra-
narum ;  and  in the Ophthalmia tarfi, fo  far  as  it is
produced by the  Ophthalmia membranarum, the fame
remedies may be n-ceilary.   As,  however,  the Oph-
thalmia  tarfi may often  depend upon an acrimony de-
puted in the febaceous glands of the part, fo it  may
require various internal  remedies according to the na-
ture of the acrimony in  fault -? for  whnh I muft refer
to the confideration of  fcrophula,  fyphilis,  or other
difeafes with which this Ophthalmia may be connect-
ed ; and  when the nature of the acrimony is  not af-
certained, certain  remedies,  more generally  adapted
;o the evacuation of acrimony, fuch, for inftance, as
mercurv, may be employedf.
                        X  2           CCLXXXIX.
  * Afoluiion ofafcru pie of fugar of lead in four ounces of diltilled water
is a very effe&ual application ; fome authors recommend equal parts
of white vitriol  and fugar of lead diffolved in diltilled water.  Thefe
tollyria, as they are called, do infini e mifchief if they are two Ilrong.
  If, therefore, the pjtie.;t complain of the lcalt fmaiting on  their
application, it  will be ueeefT.'.rv to dihite  the:n with the additon of
moie dillilled water.  They ought to be  applied cold, and pledgets
moiliened with  them  o-ight f.o be frequently renewed  when they
^rov hot or dry.  Ah additional direction may be added, viz. that
the folution of faccharum faturni be aKvays made in dillilled water,
efpecially when  it is to be ufed as  a co'lyrium, becaufe the leaft im-
pregnation  of any mineral acid, however combined, decompofes the
fugar of lead.
  Cold poultices of rafped raw potatoes  or turnips are fometimes
very efficacious.  They  may be applied  in a fine rnufiin bag, and
ought to be renewed whenever they grow  warm.
  j- If the ophthalmia be veneral,  mercury is the only remedy, and
external applications have litt'e effeft.  If  fcrophula is the caufe, 
 164           PRACTICE

                    CCLXXXIX.
   In the Ophthalmia tarfi, it almoft conftantly hap-
 pens, that fome ulcerations are formed on the tarfus.
 Thefe  require the application of mercury or copper,
 either of which may by itfelf fometimes entirely cure
 the affection ; and thefe may even be ufeful when the
 difeafe depends upon a fault of the whole  fyftem.
                       ccxa
   Both in the Ophthalmia membranarum, and in the
 Ophthalmia tarfi, it is neceffary to obviate that gluing
 or flicking together of the eye-lids which commonly
 happens infleep ; and this may be done by infinuating
a little of any mild unctuous medicines, of fome tena-
 city, between the eye-lids before the  patient fhall go
 to fleep*.



                 CHAP.    IV.

         OF PHRENSY,  OR PHRENITIS.

                      CCXCI.
     THIS difeafe  is  an inflammation of the parrs con-
      tained in the  cavity of  the  cranium;  and may
affect either the membranes of the brain, or the fub-
ftance  of the  brain itfelf.  Nofologiits have appre-
hended, that thefe two cafes might be diftinguifliedby
different fymptoms,  and therefore by different appel-
                                             lations :

relief is often fpeedily procured by an application of the Coagulum
a luminis, or the ungoentum c.itrinum, now called ungueotum hy-
drargyri  nitratum in the London  Pharmacopoeia.   The unguen-
turn tutias has been ufed in many cafes with advantage, as has alfo
the unguentum ceruffas acetatre.  But thefe topical applications ne-
ver effefr. a permanent cure.
  * Hog's lard, frefh prelfed lintfeed-oil, or oil of almonds, anfwff
this intentio-i very well, or the unguehtum fpermatu ceti, of"*
London Pharmacopoeia. 
              0«F  PHYSIC.            165

lations: but this does not feern  to  be confirmed by
obfervaticn  and  diflection ; and  therefore  I fhall
treat of both cafes  under the title of Phrenfv, or Phre.
nitis.
                    CCXCII.'
  An idiopathic phrenfy is a rare occurrence, a fym-
pathic more frequent; and the afcertaining either the
one or the other is, upon many occafions, difficult.
Many  of the fymptoms  by which the difeafe  is moft
commonly judged  to be prefent have appeared when,
from certain confiderations, it was prefumed, and even
from diffedion it appeared, that there had been no in-
ternal inflammation ; and,  on the other hand,  direc-
tions  have fhown, that the brain had  been inflamed,
when few  of the peculiar fymptoms of phrenfy had be-
fore appeared*.
                    CCXCIII.
  The fymptoms by which  this  difeafe may be moft
certainly known are,  a vehement pyrexia, a  violent
deep-feated head-ach, a rednefs  and  turgefcence of
the face and eyes,  an impatience of light or noife, a
conftant watching  and a delirium impetuous and furi-
ous.  Some  nofologifts have thought thefe fymptoms
peculiar to an  inflammation of the  membranes, and
that the inflammation of  the fubftance  of the brain
was to be  diftinguifhed by fome degree of coma at-
tending it.  It was for this reafon that in the Nofolo-
gy I added the Typhomania to the character of Phre-
nitis ; but, upon farther reflection,  I find no proper
foundation for  this  ; and, if wr pals  from the charac-
ters above  delivered, there will be no means of fixing
the  variety that occurs.
  I am here, as in other analogous cafes, of opinion,
that the fymptoms above  mentioned of an acute in-
flammation,  always mark inflammations of membran-
                                              ous
  *  This fentence is very obfeure ; the Author meant to fay, that
the didgnoltic fvmnto.r.a of this difeafe are uncertain. 
  166             PRACTICE

  ous parts;  and that an inflammation  of the paronchy.
  ma or fubftance of vifcera, exhibits, at leaft common.
  ly, a more  chronic affection.
                       CCXCIV.
    The remote caufe of phrenfy, are all thofe which di-
  recllyftimulatethemer^Lran-s orfubitanceofthebrain-
  and particularly all thofe which incieafe the impetus
  of the  blood in  the veffels of the brain. Among thefe
  the expofurc of the naked head to the dire ft lays ot'
  a very warm fun, is a frequent caufe.  The paffions of
  the mind, and cortain poitons, are amongft the remote
  caufes of phrenfy; but in what  manner they operate
  is  not well underftood.
                        CCXCV^
    The cure of phrenfy is the fame with that of inflam-
 mation  in general;  but  in phrenfy  the niuit powerful
 remedies are to be immediately employed.   Large and
 repeated blood-letting is efpecially  neceffary; and the
 blood fhould be drawn from veffels  as  near  as poffible
 to  the  part affected.'  The  opening  of  ihe tempo-
 ral artery has been recommended, and with fomerea-
 ion : but the praftice is attended with  inconvenience;
 and I apprehend that opening  the  jugular veins may
 orove m,,re effectual; but, at the fame time, it will be
 generally proper to draw blood  from  the  temples by
 cupping and fcarifying\*.
          1            CCXCVI.
  It k  probable, that purging, as  it may operate by
 revulfion, may be of more  ufe than in fome other in-
 flammatory affections.
                                                 For
     Practitioners have  in general admitted  two kinds of phrenfy.
 »•*.  the idiopathic or true plnenfy, and the fymptomatic.  The for-
 mer is what the Author cefcrib.-s in the text ; and, and as he haso-
 mated to defcribe the latter, which in article  292, he acknowledge!
 to be the more frequent of the two, 1 (hall enumerate its fymptoms.
  1 he lymptomaiic phrenfy is Qontlantly pi ecerfed  by fo we very
acute iuflammatory fever.  Its approach may be fufpecled bv a fup-
preflion of the excretions, by colourlefs ftools, by a black, dry, and
rough tongue, by pale and watery urine, which fometimes has blade 
                O F   P  H Y  S I  C.              167

  For the fame purpofe of revulfion, warm pediluvia
are a remedy; but,  at the fame time fomewhat ambi-
guous.    The taking off the force of the  blood in the
veffels of the head  by  an  erect: pofture, is generally
ufe1 ul.
                       CCXCVII.                        :
   Shaving of the head is always proper and neceffary1
for the admiffion of other remedies.  Bliftering is com-T
monly ufeful in this difeafe, but chiefly when  applied
near the part affected*.
                                                CCXVIII.
or dark brown clouds floating in it, by a defire but inability to fleep,"
by picking the bed-clothes,  by the eves appearing  fierce, and  the ■
veffels of  the  albuginea becoming turged, and by a few drops of
blood diililling from the nofe.
  When moft of thefe fymptoms appear in inflammatory fevers, we
juftly apprehend an attack of the phrenfy, and ought to have  im-1
mediace recourfe to fuch remedies as will leiTen its violence, or alto- "*
gether prevent its accefs.  Latge  bleedings, if the pulfe permit*
null  be made on the lower extremities, emollient glyfters are to be
frequently injected, laxatives adminiftered,  fometimes applied to the
feet and.legs, cupping glafles applied  to the thighs, and the patient'
muft be foiced to  drink plentifully, for he is  feldom thirfty in thefe
cafes, although his tongue be parched.  Befide thefe general reme-
dies, peculiar attention muft be paid to the primary difeafe ; and the
treatment of the fymptomatic phrenfy will vary according to the na-
ture of the difeafe by which it is produced.
   No part of the praftice of phyfic requires more judgment and fe-
gacity in  the practitioner, than afcettaining  the proper mode of
treating the fymptomatic phrenfy in different fevers.  To enter ful-
ly into the fubjeft, would require more room than thefe notes allow.
 1 can only therefore recommend the youngprnftitioner to pay great
 attention  to it,  He will find raany ufeful practical directions'for the
 treatment of thefe cafes, in moft of the medical writers, both ancient
 and modern, efpecially Sydenham and Van Swieten.

   * It has been ufual to apply a large bliftering plaifter  over   the
 whole head, and fader it to remiin on for eight and forty  hours.
 This however, hinders the application of other very powerful re-
 medies. Shaving the head of a fr?r.tic patient is always a troublefome
 (..potation  ; but the very great  benefit arifing from it renders it abfo-
 lutely neceflary in all cafes ; and the phyfician ought therefore to ad-
 vife iton the firft fufpicion of an approaching phrenfy. 
!68            PRACTICE
                     CCXCVUI.
7  Every part of the  antiphlogiftic regimen  is here
neceffary,  and  particularly the admiffion of cold air.
Even cold  fubftances applied clofe to the head, have
been found fafe  and  highly ufeful; and the applica-
tion of fuch refrigerants as vinegar,  is certainly pro-
per*.
                      CCXCIX.
.   It appears to me certain, that opiates are hurtful in
every inflammatory ftate of the brain ; and it is to be
,)bferved,  that,  from  the  ambiguity mentioned  in
.oexcii.  the accounts  of practitioners,  with regard to
zhe juvantia and lasdentia in this  difeafe,  arc  of very
uncertain application.
-<••<•■<■•<<••< < <••«•<•<.}.► >•■>>•>■
OF THE QUINSY,  OR CYNANCHE.
5                 C   H   A  P.    V.
r
\
t
i                         CCC.
     THIS name is applied to every inflammation of the
      internal fauces; but thefe inflammations are dif-
ferent, according to the part of the fauces  which may
be affected, and according  to the nature of the in-
flammation.   In the Nofology, therefore, after giving
the character of the Cynanche as a genus, I have dii-
tingufhed five different fpecies, which muft here like-
wife be feparately confidered.
                                         SECT.

   * Many eminent practitioners have diffuaded the ufe of thefe re-
frigerant applications to the newly fhaven head ; the immediate re-
lief which the mere (having generally procures feems  to indicate the
propriety of the praftice : and experience  has not difcovered any
material disadvantages attending it, but on the contrary, much be-
nefit accruing fiom it. 
OF  PHYSIC.
169
               SECT.     I.

    OF THE CYNANCHE TONSILLARIS.

                      CCCI.
  This is an inflammation of the mucous membrane
of the fauces, afferftim; efpeci dly that congeries of mu-
cous follicles  which forms the tonfils, and fpreading
from thence  along the velum and uvula, fo as  fre-
quently to affect every part of the mucous membrane.
                      CCCII.
  The difeafe appears  by fome tumour, fometimes
confiderable, and by a rednefs of the parts; is attend-
ed with a painful  and  difficult  deglutition ; with a
pain fometimes mooting info the ear;  with  a trou-
blefome clamminefs of the mouth and throat; with a
frequent, but difficult  excretion of mucus;  and the
whole is accompanied with a pyrexia.
                     CCCIII.
  This fpecies of quinfy is never contagious.  It ter-
minates frequently by  refolution*, fometimes by fup.
puration, but hardly ever  by  gangrene ; although in
this difeafe fome floughy  fpots,  commonly fuppofed
to be forerunners of gangrene, fometimes  appear up-
on the fauces.
                      CCCIV.
  This difeafe is commonly occafioned by cold exter-
nally applied, particularly about  the neck.   It affects
efpecially the young and fam uine, and a difpofition
to it is often acquired by habit;  fo that, from every
confiderable application of cold to any part of the bo-
dy, this difeafe is readily induced.  It occurs efpecial-
ly in  fpring  and  autumn,  when viciflitudes of heat
and cold  frequently take  place.   The  inflammation
  Vol. I.                 Y                  and
  *  As the moft frequent termination of this difeafe is by refolu-
tion, this mode of cure muft  always be attempted, and will feldom
fail of proving fuccefsful. 
170
PRACTICE
 and tumour are commonly at firft moft coniiderable in
 one tonfil; and afterwards abating in that, increafe in
 the other.
                        cccv.
   In the cure of this inflammation, fome bleeding may
 be proper ; but large general bleedings will feldom be
 neceffary.  The opening of the ranular veins feems to
 be an infignif.cant remedy ;  and leeches let upon the
 external fauces are of more efficacy.
                       CCCVI.
   At the beginning of the difeafe,  full vomiting has
 been frequently found to be of great fervice*.
                       CCCVII.
   This  inflammation may be often relieved by mode-
 rate aftringents, and  particularly by acids applied to
 the  inflamed partsf.  In many cafes,  however,  no-
 thing has been found to give more relief than the va-
 pour of warm water received  into the fauces by a pro-
 per  apparatus.
                       CCCVIIL
   The other remedies of this difeafe  are rubefacient
 or bliftering medicines, applied externally to the neck;
 and, with  thefe,  the employment of antiphlogiftic
 purgatives^, as well as every part of the  antiphlogiftic
 regimen, excepting the application of cold.
                       CC31X.
   This  difeafe,  as we have faid, often terminates by
                                           refolution,
  *  The  formula of an emetic may be feen in the note at par. 185,
 laft word.
  \  Various have been the opinions of phyficians refpefting the kind
 of gargles  proper in thefe  cafes.  A pint of tinfture of rofes, with
 two drachms of honey, has often been found ferviceable.   The fol-
 lowing gargle is frequently ufed with fuccefs.  Boil  an ounce of
oak-bark,  bruifed in a qnart of water, till half is evaporated, and to,
the (trained liquor add an ounce of honey of rofes,  and a drachm of
allum.  Sage^tea, with honey, is in common ufe, and frequently an-
fwers every purpofe.
  X Glauber's  falts anfwer the end of purges in thefe cafes very
well, efpecially if the patient drinks copioufly during the operation. 
OF  PHYSIC.
171
refolution,   frequently  accompanied with  fweating ;
which is  therefore to be  prudently  favoured and en-
couraged*.
                         cccx.
   When  this difeafe fliall have taken  a tendency  to
fuppuration, nothing will  be  more ufeful, than the fre-
quent takmg into the fauces the fleams of warm wa-
tcr-j-.   When the abfeefs is attended with much fwell-
ing, if it  break not fpontaneoufly, it fhould be opened
by a lancet; and this does not  require much  caution,
as  even the  inflammatory ftate may be  relieved by
fome fcarification of the tonfils.   J have never had oc-
jCafion to fee any cafe requiring bronchotomy.
                        Y 2                 SECT.

  *  Dover's pswder is an excellent fudorific in thefe  cafes.  The
method of giving it has been defcribed in a former note, on par. 169,
1. 11, at the  word emetic.   Many other fudorifiVs however, are
£ound to anfwer tolerably well, as wine-whey, whey made with dul
cified fpirit of nitre, vinegar whey, fage tea, with feveral other drinks
of a fimilar kind.
  The following bolus is often very  efficacious, efpecially when the
patient drinks largely of fage or balm tea.
*              R. Camphor, gr. viii.
                 Opii pur. gr. i.
                 Tart. Vitriolat. 3i.
                 Tere in mortario marmorco ; et adde
                  Confeft. cardiac 3L vel. 9. f. utfiat  bolus.
Small dofes of tartar emetic taken in fuch quantities as to  produce a
flight naufea, without vomiting,  are alfo good fudoi ifics.   1 wo ta-
bie-fpOo«fuls of the  following julep may be  taken every half-hour
till the effeft be produced, drinking, at the fame time, plentifully
of fome warm diluent.
               R. Tartar. Emetic, gr. iii.
                  Aq. font. J vii.
                  Syr. Papavcris rubri. Ji.
                  M, f. Julap.
  f yery convenient apparatus  for this purpofe  are  made by moft
tin-workers.  Befide the fleam of warm water here recommended,
external applications to the throat and fides of the neck have a con-
fidirablecffeft in forwardV,^ the fuppuration, as warm  poultices
fomentations, £■.•. 
172            PRACTICE
               SECT.     II.

       OF THE CYNANCHE MALIGNA.

                     CCCXI.
   This is a contagious difeafe, feldom fporadic, and
commonly epidemic.  It attacks perfons of  all ages,
but more commonly thofe in a young and infant ftat«.
It attacks perfons of every conftitution when expofed
to the contagion,  but moft readily the weak and in-
firm.
                     CCCXII.
   This difeafe is ufually attended  with a confiderable
pyrexia;  and  the  fymptoms of the acceffion of this,
fuch as  frequent cold, fhiverings, ficknefs,  anxiety,
and vomiting, are  often the firft  appearances of the
difeafe.   About the fame time, a ftiffnefs is felt in the
neck,  with  fome  uneafinefs in the internal fauces,
and fome hoarfenefs of the voice.  The internal fauces,
when viewed, appear of a deep red colour,  with fome
tumour; but  this laft is feldom confiderable, and de-
glution is feldom difficult or painful.   Very foon a
number of white or afh  coloured  fpots appear  upon
the inflamed  parts.   Thefe fpots fpread and unite, co-
vering almoft the  whole fauces with  thick flcughs;
which falling  off, difcover ulcerations.   While  thefe
fymptoms  proceed  in the fauces,  they are general7
attended with a coryza,  which pours out a thin  acrid
and fetid  matter, excoriating the  noftrils and  lips.
There is often alfo,  efpecially  in  infants,  a frequent
purging ; and a thin acrid matter flows from the anus
excoriating this and the neighbouring pans.
                    cccxni
   With thefe  fymptoms, the pyrexia proceeds with a
fmall, frequent, and  irregular pulfe ; ar d  there occurs
a minifeft exact roa; ion every evening, and fome re-
miinon in the mornings.   A  great  debility  appears in
                                               the 
OF   PHYSIC.
173
•the animal functions;  and the fenforium is affected
with delirium, frequently with coma.
                    CCCX1V.
   On the fecond day, or fometimes later, efilorefceu-
ces appear upon the fkin, which are fometimes in finall
points  hardly eminent; but, for the moft part, in pat-
ches of red colour, fpreading  and uniting fo as to co-
ver the whole fkin.  They appear firft about the face
and neck, and in the courfe of fome days fpread by de-
grees to the lower extremities.  The fcarlet rednefs is
often confiderable on  the bancs and  extremities of
the fingers,  which feel  ftiff and fwelled.  This erupti-
on is often irregular, as to the time of its appearance,
as to its fteadinefs, and as to  the time of its duration.
It ufually continues four days, and goes off by fome '
defquamation of the cuticle ; but neither on its appear-
ance, nor on its defquamation, does it always produce
a remiflion of the pyrexia, or  of the other fymptoms.
                    CCC XV.
   The progrefs of the difeafe depends on the Itate of
the fauces and  of the pyrexia.  When the ulcers on
the fauces, by their livid and black colour, by the fe-
tor of the breath, and by many marks of acrimony in
the fluids, fhow a tendency to gangrene, this  takes
 place  to  a  confiderable degree; and,  the  fymptoms
of a  putrid fever conftantly  increafing, the patient
 dies, often on the third day,  fometimes later, but for
the moft part before the feventh.  The acrimony pour-
ed out from the difeafed fauces  muft neceffarily, in
part, pafs into the pharynx,  and there  fpread the in-
 fection into the cefophagus, and  fometimes  through
t;.e  whole of the alimentary canal,  propagating the
putrefaction, and often exhaulting  the patient by  a
frequent diarrhoea.
   the acrid matter poured out in the fauces being a-
gain abforbed, frequently occafions large fwellings of
the lymphatic glands a'oour rhe neck, and  fometimes
to ftich a decree as to occafion fuffocation.
            h                                    It 
«74
PRACTICE
    it is  feldom that the organs  of refpiration efcape
 entirely unhurt, and very often the inflammatory af-
 fection  is communicated to them.   From defections
 it appears, that, in the Cynanche maligna, the larynx
 an/trachea are often affected in the fame  manner as
 in the Cynanche trachealis; and it is probable, that,
 in confequence of that affection, the Cynanche maligna
 often  proves fatal by fuch a fudden fuffocation as hap-
 pens  in  the proper Cynanche^trachealis;  but there
 is reafon to fufpect, that upon this fubject diffectors
 have not  always diftinguifhed properly between the
 two difeafes.
                      CCCXVI.
   Thefe are the feveral fatal terminations of the Cyn-
 anche maligna; and they do not always take place.
 Sometimes the ulcers of the fauces are of a milder na-
 ture ;  and the fever is more, moderate,  as well as  of a
 lefs putrid kind.  And when, upon the appearance of
 the efflorefcence ^pn the fkin,  the fever fuffers a remif-
 fion;  when the efflorencence continues  for three or
 four days, till  it has fpread over the whole body,  and
 then ends by a defquamation,  giving a further remifli-
 on of the fever; this often entirely terminates, by gen-
 tle fu eats, on or before the feventh day; and the reft
 of the  difeafe terminates in a few days more, by an ex-
 cretion of floughs from the fauces ;  while fleep, appe-
 tite, and the other marks of health return.
   From  what is laid in this and the preceding para-
 graph, the prognoftics in this difeafe may be readily
 learned.
                    CCCXVII.
   In  the cure  of  this  difeafe, its feptic tendency is
 chiefly to be kept in view.  The debility, with which
ic  is attended, renders all evacuations by bleeding and
purging improper, except in a  few inftances where the
debility is lefs,  and  the inflammatory fymptoms more
confiderable. The fauces are to be preferved from the
                                             effects 
OF   PHYSIC.
l75
 effects of the acrid matter poured out upon them, and
 are therefore to be frequently wafhed out by antifcep-
 tic gargles* or injections;  and the feptic tendency of
 the whole fyftem fhould be guarded againft and cor-
 rected by internal antifeptics,  efpecially by the Peru-
 vian bark given in fubftance, from the beginning, and
 continued through the courfe of the difeafe §.   Eme-
                                                        tics
   * When the violence of the fymptoms is moderate, and the ul-
 ceration flight, fage tea, or tea made of rofe leaves, or both together
 may be fufficient.  A gargle made of a  pint of fage and rofe tea,
 three fpoonfuls  of vinegar, and one fpoonful  of honey, has been
 found as efficacious as any of the (harper antifceptics with the  mi-
 neral acids.  Dr. Fothergill's gargle is,
          §>.  Decoft. peftoral. J xii. cui inter coquendum. adde
              Rad. contrayerv. contus.  Jfs.
              Liquori colato admifce
              Acet. vin. alb. |ii.
              Tinft. myrrh. §i.
              Mel. opt. 3V1.
   But he  often ufed it with a drachm of the Mel. Egyptiacum dif-
 folved in two ounces of it.   •
   The MeJ. Egyptiacum is a very harfh  application, and ought to
 bccautioufly ufed.  If the floughs cad off fo (lowly as to require a
 powerful application,  it is better praftice to touch them  with Mel.
 Egyptiacum by means of  an armed probe, than to ufe gargles, in
 which it is an ingredient.  In this difeafe, drift attention muft be
 given to the ufe of gargles and injections for the throat, becaufe the
 cure feem6 to  depend in part on procuring a difcharge from the
 glands of the fauces which thefe gargles  induce, and alfo becaufe
 they are the only means of retarding the progrefs of the ulcers.
  § The quantity of bark given ought to be very confiderable, viz. as
 much as the ftomach and inteftines can pofiibly bear ; half a drachm
 or two fcruples every hour, with a glafsofgood port wine. A fcru-
 pie of confeftio cardiaca, joined with each dofe of the  bark, has a
 double effeft of making the bark lefs  naufeous, and of preventing,
 in fome meafure, a tendency to a diarrhoea, but opium is a fovereign
 remedy for removing this fymptom when it is aftually prefent.
  In adminiftering the bark, great care muft be taken to avoid a di-
 arrhoea, which is a very dangerous fymptom  in any period of the
difeafe, but efpecially after the third or fourth day, when the patient
is in a confiderable ftate of debi'ity.
  Children are more frequently attacked with  this  difeafe than a-
dults j and  it is fometimes extremely difficult to prevail  on them to 
 176              PRACTICE

tics,  both by vomiting and  naufeating, prove ufeful,
efpecially when employed early  in the difeafe.  When
any confiderable tumour occurs, bliftcrs applied exter-
nally will be of fervice, and,  in any  cafe, nay be fit
to moderate the internal  inflammation.*
                                                   8 E C T.

take a fufficient quantity of this neceffary'and valuable, though inu-
feous medicine.  In thefe cafes,  glytters with powdered  oark have
been ufed with very great fuccefs.  Two  drachms ot the fine pow-
der may be given in five or fix ounces of barley water, every three
or four hours,  to  very  young children, and half an  oun-e, or fix
drachms, to children of 8 or 10 years old, in three quaiters of a pint
of barley-water.   If the firft glyfter comes away too fpeedi'v, two
or three grains of opium may be added to the fubfequeut glyiiers.
  *  In addition to the method of eure here delivered,  it maybe
proper to obferve,  that, as the cure depends much on the removal
of every thing putrid from the  patient, it is abfolutely neceffarv to
have the room well ventilated, but not  with cold air.  The  reafon
for this precaution is, that the patient always complains of the leaft
admiffion of cold air, becoming fick and oppreffed, probably in con-
fequence of the fudden  difappearance of the efflorefcence which al-
ways accompanies the difeafe.   The linea,ought frequently to be
changed, the patient kept clean,  the mouth and throat frequently
waflied, and great ple/ity of liquid vegetable nutriment muft be gir-
en, with generous wine.
  A hemorrhage from the nofe, mouth, or ears, very frequently oc-
curs in the latter itages of a malignant fore throat.
  This dlfcharge is by no means critical,  but always a dangerous
fymptom, and  muft be  (topped with  the  utmoit  expedition. It is
the confequence of fome arterial branch being corroded by the mor-
tification.  If the hemorrhage withstands the  ufual means  of tents
dipt  in  vinegar, or a folution of alum,  &c.  recourfe muft be had
to opium and bark  ; and the port wine muft be given fparinglv.
  In the advanced llages, a diarrhoea frequently appears, efpecially
in children ; it proceeds from the putrid and acrid matter  of the ul-
cers being received into the inteftines.  It  can  only  be prevented,
or effectually removed,  by a careful attention to keep the mouth as
dean as pofGble. 
              OFPHYSIC             177


                  SECT.   III.

     OF THE CYNANCHE  TRACHEALIS.

                   CCCXVIII.
  This* name ^as been given  to  an inflammation of
the ghttis, 1 ryox, or upper part of the trachea, whe-
ther it affect the membranes of thefe parts, or the muf-
cles adjoining.   It may arife firft  in thefe parts, and
continue to fubfift in them alone; or it may come to
afiecft thefe parts from the Cynanctae tonfillaris or ma-
ligna fpreading into them.
                     CCCXIX
   In either way it has been a rare occurrence, and few
inftances of it have been marked and recorded by phy-
ficians.  It is to be known by a peculiar ringing found
of the voice, by  difficult refpiration,  with a fenie of
ftraitening about the larynx, and by a pyrexia attend-
ing it.
                  v    cccxx.
   From the nature of thefe fymptomi, and from  the
difTection of the bodies of perfons who had died of rhis
difeafe,  there is no doubt of its  being of an inflamma-
tory nature.  It does  not,  however, always run  the
courfe of inflammatory affections,  but frequently pi re-
duces fuch an obftruclion of the paffige of the air, as
fuflbcates, and thereby proves fuddenly fatal.
                      cccxxi.
   If we judge  rightly of the nature of this difeafe, it
will be obvious, that the cure of it require, the moft
pow rful remedies of inflammation, to  be employed
   Vol. I.                  Z                  upon
   * This difeafe has been fuppofed to be  new, and confined chu fly
to infasts. It is however, defcribed by many of both the  anc:c it
and modern writers.  Boerhaave defcribes it in his 801ft and 8o2d
Apho'rifin.  It is, indeed, uncommon in adults, and moft frequent
in infants. Ic. was never rightly underftood, however, till Dr. Home
the profefTor of Materia Medica in this Univertfiy, inveftigatcd its
nature, and pointed out the only effeftual method of cure. 
   178           PR A  C T I C E

   upon the very  firft appearance of  the fymptoms.—
   When a fuffocatiou is threatened,  whether any reme-
   dies can be  employed to prevent  it, we have not had
   experience to determine,
                        CCCXXIL
      The accounts which books have  hitherto  given us
   of inflammation of the larynx,  and  the parts  connect-
   ed with it, amount  to what we have now faid ; and the
   inftances recorded have almoft all of them happened?   K
   in adult perfoiis; but there  is- a peculiar  affedion q(■•  :
   this kind hapneuing  efpecially to infants, which till
   lately has been little taken notice of.    Dr.  Home is
   the firft who has given any diftinct account of it; but,
   fince he wrote,  feveral  other authors  have taken no-
   tice of i% (fee Michaelis De angina polypofiafive mem-
   branacea, Argentorati 1778); and have given  different
   opinions with regard to it.  Concerning this  diveriity
   of opinions  I (hull not at prefent inquire; but  fhall de-
   liver the hiftory and  cure of this difeafe, in  fo far as
   thefe have arifen from my own obfervation, from that
   of Dr.  Home, and of other fkilful perfons in this neigh-
   bourhood.
                          CCCXXIII.
      This difeafe feldom attacks infants  till  after  they
   have been weaned.   After this period, the  youngef
   they are, the more they are liable to it. The  frequen-'
   cy of it becomes lef> as  children become more advan-
   ced :  and there are no inftances  of  children above
   twelve years of age being affecled with it.   It attacks
1   children of the midland countries, as well as thofe who
   live near the lea,  It  does not appear to be contagious,
   and its attacks are frequently  repeated in the fame
   child.   It is often manifeftly the effeel: of cold applied
   to  the body;  and therefore appears  moft frequently
   in the winter and fpring feafons.  It  very commonly
   comes  on with'the ordinary  fymptoms  of a  catarrh;
                                                  but 
              O  F  P H  Y S  I  C.          179

but fometimes  the  peculiar fymptoms of the difeafe
fhow themfelves at the very nYft.
                    CCCXX1V.
  Thefe  peculiar 'fymptoms  are the following;  A
hoarfencfs, with fome  fhrillncfs and ringing found,
both in fpeaking and coughing,  as if the noife came
from a brazen tube. At the fame  time, there is a fenfe
of pain about the larynx, fome difficulty of refpirati-
on, with a whizzing found in infpirati :<n, as if the
paffage of the air were ftraifentd.  The cough which
attends it. is commonly dry ; and*,  if any  thing  be
fpit  up,  it is a matter  of pumlent  appearance, and
fometimes films refembiing portions of a membrane.
Together with thefe fymptoms,  there is a  frequency
of pulfe, a reftleflhefs,  and an uneafy fenfe of heat.
When the internal fauces are viewed, they are fome-
times without any appearance of inflammation: but
frequently a rednefs and even  fwelling,  appear ; and
fometimes in the froces  there is an appearance of mat-
ter like to that rejected by coughing.  With the fymp-
toms now defcribed, and particularly with great diffi-
culty of  breathing,  and a  fenfe  of ftrangling in the
fauces, the patient is fometimes fudJenly taken off.
                    CCCXXV.
   There have  been many diffedtions  made of in-
fants  who had died of this  ciifeaie ;  and  almoft
conftantly  there  has appeared a preternatural memr
brane lining the whole internal furface of the upper
[•art of the trachea, and extending in the fameomanner
downwards into fome of its  ramificati ns.   This pre-
ternatural  membrane may be eafily feparated, and
fometimes has been found feparated in part, from the
fubjacent proper membrane of the trachea.  This laft
is  commonly found entire,  that is, without  any  ap-
pearance oferofion  or  ulceration;  but it  frequently
lhows the yefti^es of inflammation, and is covered  by
a matter rcfsmblingpus. like to that rejected by cough- 
i8o           PRACTICE

ing;  and very often a matter of the fame kind is
found  in  the bronchia?, fometimes in  confiderable
quancitv.
                   CCCXXVI.
  Fr-ra the remote caufes ot  this difeafe;  from the
catarrhal fymptoms commonly attending it; from the
pyrex a. conftantly p efent with it ; fom the fame kind
of preternatural oerabrane being found in the trachea
when the cynanche maligna is communicated to it;
and, from the veitiges of inflammation on the trachea
difcovered  upon daTcction ;  we  muft conclude, that
the difeafe con lifts in an inflammatory affection of the
mucous membrane of the larynx and trachea, produc-
ing an exudation analogous to that found on the fur-
face of inflamed  vifcera,  and  appearing partly  in a
membranous cruft,  and partly in a  fluid refembling
pus.
                   CCCXXVII.
  Though  this  difeafe  manifeftly  confifts  in an in-
flammatory affection, it does not commonly end either
in fuppuration or gangrene,   The peculiar and trou-
blefome circumftances of the difeafe feems  to confift
in a  fpafm of the mufcles  of the glottis, which, by in-
due ng a furfocation, prevents the common confeqtan-
ces  of inflammation
                  CCCXXVUI.
  When this difeafe termina es in health, it is by a re-
folution of an inflammation, by  ceafing  of  ihe fpafm
of the glottis, by an expectoration of the matter exu-
ding from the trachea, r.nd  of the crufts formed fure;
and  frequently it  ends without any  expectoration, or
at leaft with fuch  only  as  attends  an ordinary cat-
tarrh.
                    CCCXXIX.
  When roe difeafe er ds 'a = al!v, it  is by a fuffocati-
on ; feemingi),  as  we ha.  e fail, depending upon a
fpafm affecting the glottis;  but fometimes,  probably,  i
                                       depending 
OF  PHYSIC.
181
depending.upon a quantity of matter filling the bron-
chiae.
                      CCCXXX.
   As  we fuppofe the difeafe to he an  inflammatory
affection, fo we attempt to cure it by tho ufual reme-
dies of inflammation,  and  which for the moft part I
have found  effectual.  Bleeding, both general and  to-
pical*, has often given immediate relief; and, by be-
ing repeated, has entirely  cured the difeafe.   Blifter-
ing alfo, near the part affected,  has b.en found ui'cful.
Upon the firft attack of the difeafe, vomiting, immedi-
ately after bleeding, feems to be of confiderable ufe,
and lomeiiovies fuddenly removes the difeafe.   In eve-
ry ftage of the difeafe, the antiphlogiftic regimen is
neceffary, and particularly the frequent ufe of laxative
glyfterof-   Though we fuppofe that a fpafm affecting
the glottis  ib often  fatal in  this difeafe, I  have  not
found antifpafmo^lic medicines to be of any ufe.

                                             SECT.

   * The top* "1 bleeding is beft performed by leeches.  Three or
four may ! ^ a .,;i.e.i at once on each fide of the trachea, or on the
 trachea 1 k f.   JSotwithltanding  this tecommendation  of  topical
bit-  ling, previous general  bleeding is abfolutely neceffary in every
coe, a;;d ought  i^rr to be omitted.   It frequently produces relief
e 'en while the i lo >d is flowing from the vein ; but, in thefe cafes,
it is iinpr.ioVnt 10  op  the evaluation, even on the total removal of
t\'.i. ivmptoms.  As much blood muft  be  drawn as the infant can
 beir to f>fe, uad leeches ought moreover to be applied, as above di-
 rected ; for it  frequently happens, that, when all the fymptoms fod-
 dtuly dildj'p.i, the difeafe returns in a lew hours with redoubled
 violence, aiid fpre^ily puto an end to the child's hie.
   f  Laxative gh Iters are to be carefully diftinguifhed from purg-
ing glvfters, wlii-h generally i;ritate too violently," and thus increafe
 the infl rnmatory diathefis.  It is of little confequence what the
 compofitions of glyfters be,  provided they contain fome Glauber's
or Epfom lab, 'indatefufficieutly large.   The common glyfter  with
milk and w-ucr, and a little Epfom fair, aufweiofufncicntly well. 
i32          PRACTICE
                SECT.    IV.

    OF THE CYNANCHE PHARYNG^A.

                  CCCXXX1.
  In  the  Cvnanche  tonfillaris, the inflammation of
the mucous  membrane often fpreads upon the pha-
rynx,  and  into the beginning of the cefophagus, and
tbereby renders deglutition more difficult and uneafy :
but fuch a cafe does not require to be diftinguilhcd zs
a different fpecies from the common Cynanche ton-
fillaris ; and  only  requires that blood-letting and o-
t'ror remedies fhould be employed with greater dili-
gence than in ordinary cafes.   We have never feen a-
liy cafe in which the inflammation began in the pha-
rynx, ornn which this part  alone was inflamed: but
practical writers have taken  notice  of fuch a  cafe;
and to them,  therefore, 1 muft refer, both for  the ap-
pearances  which diftinguiih it, and for the  method of
cure,


               SECT.    V.

     OF  THE CYNANCHE PAROTIDJEA.

                   CCCXXXII.
   This is a cifoafe known to the  vulgar, and among
them has  got a peculiar appellation, in every country
of Europe* ;  but has  been little taken notice of by
medical writers.  It is often epidemic, and manifeft-
ly contagious.  It comes on with  the ufual fymptoms
of pyrexia, which is foon after attended with a confi-
derable tumour of  the  external  fauces and neck.—
This  tumour appears firft a^ a glandular moveable tu-
                                             mour
  * It is ca! ed here, and in razuy parts';!  G-cat -Biitain, the
M,.irps. 
              OF  PHYSIC.  y        183

rnour at the corner of the  lower juv ; but the levell-
ing foon becomes uniformly difrofej, ever a great part
of the neck, fometimes on one  fide only,  but more
commonly  on both.   The fwelling continues to in-
creafe till the fourth day ; but from that period it de-
clines,and in a few days more p ifics off entirely.  As the
fwelling of the fauces recedes, fome tumour affects the
tefticles in  the male fex,  or the breads in the f male.
Thefe tumours are fometimes large,  hard, and fome-
what painful ;  but in  this climate are feldom  ei'her
very painful or of  long continuance.   The pyrexia
attending this difeafe is commonly  flight, and recedes
with the fwelling of the fauces ;  but fometimes, when
the fwelling of the tefticles  does nut fucceed  to that of
the fauces, or  when the other has  been  fuddcnlyre-
preffed, the pyrexia  becomes  more confiderable, is
often attended with  delirium,  and has fometimes
proved fatal.
                  CCCXXXIII.
   As this  difeafe  commonly runs its courfe without
either dangerous or troublefome fymptoms, fo it hard-
ly requires  any remedies.  An antiphlogiftic regimen
and avoiding cold, are all that will  be commonly ne-
ceflary.   But  when, upon the receding of the fwell-
ings of the tefticles in males,  or of the breads  in fe-
males, the pyrexia  comes  to be  confiderable,  and
threatens an affection of the  brain, it will be proper,
by warm fomentations, to  bring  back the  fwelling ;
and, by vomiting,  bleeding, or bliftering, to obviate
the confequences of its abfence.
CHAP. 
 184            PRACTICE

              C  H  A  P.     VI.

 Of PNEUMONIA,or PNEUMONIC INFLAMMATION.

                   CCCXXXIV.
     UNDER th-s  title  I  mean to comprehend the
      whole of the inflammations aff cting ehi-er the
 vifcera of the thorax, or the membrane lining ttie in-
 terior furface of that cavity : for neither do our ding-
 noftics ferve to afcertain exactly the feat of the difeafe;
 nor does the difference in  the feat of the difeafe exhi-
 bit any confide  ^ble variation in the ftate of the fyi'o-,
 toms, nor lead to anv deference in the method of cure
                   ccexxxv.
   Pneumonic inflammation, however various in  its
 feat, feems to me to be always known and  diftinguifh-
 ed by  the  following  fymptoms : pyrexia,  difficult *
 breathing, cough,  and pain in fome part uf the tho-
 rax.  But thefe fymptoms  are,  en different occafions>
 varioufly modified.
                   CCCXXXV I.
   The  difeafe almoft always comes on  with a cold
 ftage, and is accompanied  with other fymptoms of py-
 rexia ;  though, in a few inftances, the pulfe may nbt
 be more frequent, nor the heat of the body increafed
 bl^nd what is natural.   Sometimes  the pyrexia  is
 fr^m the beginning accompanied with the other fymp-
 toms ;  but frequently it is formed for fome hours be-
 fore the other fymptoms  become confiderable, and
 particularly'before the  pain be felt.   For the moft
 part, the pulfe is frequent*, full, ftrong, hard, and
NtiMftk'f; but in a few  inftances, efpecially  in the ad-
                                   ^       vanced
   * A frequent pulfe it when thue is a' great number of ftroketfui
 a given time.
   f A quick pulfe is when the fltoke itfelf is quick,  although the%
 number in a given time be not very great.
   It is therefore no tautology to mention both frequent and quick, <
 as they are really ditlot-cT., and may !>r both prefent at once ; but, it 
0F   PHYSIC.            185
vanced ftate of the difeafe, the pulfe.is weak and foft,
and at the fame time irregular.
                  CCCXXXVII.
  The difficulty of breathing is  always prefent,. and
jnoft  confiderable  in  infpiration ; both becaufe the
lungs  do  not eafily admit of a full  dilatation, and
becaufe the dilatation  aggravates the  pain attending
the difeafe.   The  difficulty of breathing is alfo greater
when the patient is in one pofture  of  his body father
than  another.  It is  generally greater when  he lies
upon the fide affected ;  but fometimes the  contrary
happens.   Very often the patient cannot lie ealy upofi
either fide, finding eafe only when lying on his back ;
and fometimes, he cannot breathe eafily, except when
infomewhat of an erect pofture.
                  CCCXXXVIII.
  A cough alwaf6 attends this difeafe ^ but,  in differ-
 ent cafes, is more or  lefs urgent and painful.  It is
fometimes dry, that is, without any expectoration, ef-
pecially in the beginning of the difeafe : but more
 commonly it is, even  from the  firft,  moift,  and  the
 matter fpit up various-both in confiftence and colour;
 and frequently it is ftreaked  with  blood *.
                   CCCXXX1X.
  The pain attending this difeafe, is, in different cafes,
felt in different parts of the thorax, but rfloft  frequent-
 ly in one fide.   It has  been faid to  affect the rig<frt
fide more  frequently  than the  left;  but  this is not
 certain ; while, on the other hand, it is certain that
the left has been  very often affeded.   The pain is felt
   Vol. I.                A  a  x              fome-
 tht pulfe be above an  hundred in a minute, the phyfician muft have
 a very nice fenfe of feeling to diftinguilh between a quick and a flow-
 beat.
  *  Young practitioners fhould not be  alarmed  at this fymptom ;
nor fhould they fuppofe it a dangerous one : it is, on the contrary,
a falutary fymptom, and ought not to be reftraineJ, either by too
 rigorous an adherence to the untiphloglllic regimen, or by the uf*
 of ftyptics and.other aihingetits. 
186             P R A C  T  I  C B

fometimes as if it were under the ftcrnum ; fometime*
in the back between the fhoulders ;  and, when in the:
fides, its place has been higher or  lower,  more for-
ward or  backward :  but the place of all  others moft
frequently affected, is  about the fixth  or fevenrh rib,.
near the middle of its  length, or  a  little more  for-*
ward.  The pain is often  fevere  and  pungent; but
fometimes more dull and obtufe, with alenfe of weight
rather than of pain.   It is moft efpecially fevere and
pungent when occurring  the place laft mentioned.
For the molt part it con amies fixed  in one place ; but
fometimes fhoots from the fide to the fcapula on one
hand, or to the fternum and  clavicle on the other.
                     CCCXL.
   The varying ftate of fymptoms now mentioned
does not always  afcertain pfecifely the feat of the dif- #
eafe.   To me it feems probable, that the difeafe is al-
ways feared, or at leait begins,  in fome  part of the
pleura ; taking that membrane  in its greateft extent,
as now commonly underftood ;  that is,  as covering
not only the internal furface of the  cavity of the tho-; *
rax, but alfo as forming the  mediaftinum, and as ex-
tended over the pericardium,  and over the  whole
furface of the lungs.
                  CCCXXIJ. .
  There is, therefore, little foundation fordrftinguiffr-
ing this dif ale by different apellations taken from the
part which may  be  fuppofed to  be chiefly affected.
The term loou'iiV, might with propriety be applied
to every cafe of the dileafe ;  and has  been very  im-
properly limited to that inflammation whkh begins
in, \x\ii chitfiy afftc^  the pie urn coflalis.  I  have no
doubt that fuch a cale does truly  occur : but, at the
fame  time,  I  apprehend v: to be a  rare  occurrence;
and that the difeafe much  more frequently  begins in,
and chiefly  affects, the pleura inverting the lungs, pro-"
                                             doc- 
              () F   P II Y S  I C.  '         187

 cueing ali the fyinproms fuppofed to belong to what
 has been called the Fkurilts vera.
                    CCCXL1I.
   Some phyficians have imagined, that *here is a cafe
 of pneumonic inflammation particularly entitled  to
 the apcllation of Pe> ipneumony ; and that is, the cafe
 of an inflammation beginning in the parenchyma or
 cellular texture of the lungs, and having its feat chief-
 lv there.   But it  feems to me  very  doubtful,  if any
 acute inflammation of the lungs, or any difeafe which
 has been called Peripneumcny, be of that  kind.   It
 feems probable,  that every a.cutc mil am nation begins
 in  membranous  parts; and,  in  every  diffection  of
 perfons dead of petipneumony, the external  mem-
 brane of the  lungs, or fome part  of the ple.ura,  has
 appeared to have been confiderably affected.
                    CcCXLIll,
   Aa inflammation of the pleura covering the  upper
 furface of the diaphragm, has been diftinguifhed  by
 the appellation of Paraphrenias, as fuppofed to  be at-
 tended with the  peculiar fymptoms of delirium, rifus
 fardonicus, and  other'convulfive motions: but it is
 certain,  that  an inflammation of  that portion of the
 pleura, and affecting alfo even the mufcular fubftance
 of the diaphragm, has often taken place without any
 of fliefe fymptoms ; and  1  have not met with  either
 diffecitions,  or any accounts of diffections, which fup-
 port the opinion, that an inflammation  of the  pleura
 covering the  diaphragm, is attended with delirium
 more commonly than any other pneumonic inflamma-
 tion.
                    CCCL1V
  With sefpect *o the feat of pneumonic inflammation,
I muft obfenve further, that, although it may arife and
fubfift chiefly in one part of the pleura only, it is how-
:vt frequently communicated toother  parts of the
                      A a 7           '' .'   A'tic. 
i88             P R A*C T  I C  E

fame,  and commonly communicates a morbid afliec-
tion through its whole extent.
                     CCCCLV.
   The remote  caufe of pneumonic inflammation, ij,
commonly, cold applied to the body, obftructio.g per-
fpiration, and determining  to the lungs ; whde  .t the
fame time the lungs themfelves are exoofed fo  ie ac-
tion of the cold.  Thefe circumftances o per at •efpe-
cially, when an inflammatory  dia hefit.  prevails in the
fyftem; and, confequcntlv,  upon perfons of the great-
eft vigour ;  in cold climates ;  in the winter  feafon;
and particularly in the fpring, when vicilHtudes of heat
and cold are frequent.  The difeafe, hov^er,  i.oay
arife in any feafon when fuch viciffitudes occur.
   Other remote caufes alfo may have  a fhaie in this
matter; fuch as, every means of ofeft-ucting, ftrairwr
ingf,  or otherwife injuring^, the pneumonic organs.
   Pneumonic inflammation may happen to perfons of
any age, but rarely to thofe under the age of puberty:
and moft commonly it affects perfons fomewhat ad-
vanced  in life, as thofe between forty-dive and  fixty
yearn;  thofe, two, efpecially of a robuft and lull habit.
   The pneumonic inflammation has been fometimes
fo much an epidemic,  as to occafion a  fufpicion of its
depending upon a Specific  contagion ; but I have not
met with any evidence in proof of this. See Morgag*-
ry de caufis et fedibus morbo um, epift..xxi. art. 26.
                     CCCXL/I.
   The pneumonic, like other iujbmmations, may  ter-
                                             minate,

  * Violent exertions, in fpeaking, finging, playing on wind inftru-
pnents, running up hill, or in fhort any exercife  that increafes the
aftion of the lungs.
  -j- Receiving noxious vapours into the lungs is fometimes the caufe
ef pneumoni* inflammation ; efpecial y to; 1 (.five or other acrid poi-
/onous vapours, as ihe fumes of aifenic, of fulphur, of the muriatic
acid, and fimilar  caullic  and deftructive exhalations.   Chemifts,
therefore, in making experiments,  orartifts >viio work on fubftance!
yielding fuch vapours, fbould be careful u avoid them. 
              OF   PHYSIC.           189

minate, by refolution, fuppuration, or gangrene4; but it
has alfo  a termination peculiar to itfelf, as has  been
hinted above,  (cclix.) and that is, when it is attended
witli an effufion of blood into the cellular texture of
the lungs,  which foon interrupting! the circulation of
the blood through this vifcus, produces a fatal fuffoca-
tion.   This, indeed, feems to  be the moft commoji
termination of pneumonic inflammation, when it ends
fatally ; for, upon the diffection of almoft every per-
fon dead of the difeafe, it has appeared that fuch an ef-
fufion had happened.
                   CCCXLV1I.
   From thefe  diflections alfo we learn, that pneumonic
inflammation c6mmonly produces an exudation from'
the internal furface of the pleura; which  appears
jpartly a> a foft vifcid cruft, often of a compact, mem-
branous form, covering every where the furface of the
pleura, and particulary thofe parts where the lungs
adhere To,  the pleura coftalis, or mediaftinum ;  and
this cruft feems always to be the cement of fuch ad-
hefions.
   The fame exudation fhows itfelf, alii>, by a quanti-
ty of aferous whitifh fluid, commonly founu in rheca- •
vity of the thorax ; and fome exudation or effufion is
ufually found  to have been made like wife into the ca-
vity of the pericardium.
                   CCCXLVIII.
   It feems probable, too, that a like effufion is fome-
times made into  the cavity  of the bronchia?: foi,Tn
fome perfons who have died after labouring under &
pneumonic  inflammation  for  a  few  days only, the
bronchke have been found  filled with  a confiderable
quantity of a ferous and thickifh fluid; which,  I think,
muft be  confidered rather as the effufion mentioned,
having had its thinn  r parts takdn off by refpiration,
than as a pus fo fuddenly foimcd in-the inflamed port,
                                       GCCXiX. 
19®
PR  ACTICE
                    CCCXL1X.
   It is, however, not improbable, that this effufion,a»
 well as that made into the  cavities of the thorax and
 pericardium,  may be a matter of the fame kind with
 that which, in other inflammations, is poured into the
 cellular textute of the parts inflated, and there con.  '
 verted in:o pus ; but, in  the thorax and pericardium,
 it does not always aflitme that appearance, becaufe the
 cruft covering the  furface prevents the abforption of
 the thinner part.  This abforption, however, may be
 compenfatcd in the bronchiae by the drying power of
 the air ; and therefore the effufion  into them may put
 on a more purulent  appearance.
   In many cafes of pneumonic  inflammation, when J
 the Sputa are very  copious, it is difficult to fuppofe ^
 that the whole of them proceed from the mucous fol-
 licles of the bronchiae.   It feems more probable that
 a great part of them may proceed  from the effufed fe-
 rous fluid we  have  been mentioning;  and this too
 will account for the  fputa being fo often of a purulent
 appearance.   Perhaps the fame  thing may  account
 for that purulent expectoration, as well as that puru-
 lent matter found in the bronchiae, which the learned' *
 Mr. de Haen  fays he had often obferved,  when there
 was no ulceration of the lungs: and this  explanation
 is at leaft more probable than Mr. de Ilaen's fuppofh
 tion of a pus formed in the circulating blood.
                     CGCL.
  To conclude this fubject, it would appear, th^t the
 effufion into the bronchiae which  we have mentioned,
 often occurs with the effufion of red  blood in.occaii-
 oning the fuflivcation, which fatally terminates pneumo-
 nic infl.:m:n.!tion ; that the effufion of ferum alone may
 have this effect; and that the ferum poured out in a
certain quantity, rather than any debility in thepow-
»-r» of expectoKttion,  is the caufe of that ceafing  of ex-
pectoration  whic* very conftantly precedes the fa- 
             Q F  PHYSIC.           tg't

tal event.   For, in many cafes, the expectoration has
ceafed, when no other fymptoms of debility  have ap-
peared, and when, upon diil'cctfon, the bronchiae h/.vcj
been found full of liquid matter.   Nay, it is even pro-
bable, that,  in fome cafes, fuch an effufion may take
place, without any  fymptoms of violent inflammation;
and, in other cafes,  the effufion  taking place, may
feem to remove the fymptoms of inflammation which
had appeared before,' and thus account for thofe un-
expected fatal terminations which have fometimes hap-
pened.  Poflibly this effufion  may account  alfo for
many of the phenomena of the Peripneumonia Notha.
                     CCCLI.
  Pneumonic inflammation feldom terminates by re-
folution,  without being attended with fome evident
evacuation.   An haemorrhagy from the nofe happen-
ing upon fome  of  the firft  days  of the difeafe,  has
fometimes put an end to it; and it is faid, that an e-
vacuation from the hemorrhoidal veins, a bilious eva-
cuation by ftoolj and  an  evacuation of mine with a co-
pious fediment, have feverally had the fame effeel;:
but fuch occurrences  have been rare and unufual.
  The evacuation moft frequently attending,  and
feeming to  have the greateft effect  in promoting refo-
lution, is an expectoration of a thick white or yellow-
iih matter, a little ftreaked with blood,  copious,  and
brought up without either much or violent coughing.
  Very frequently the refolution of this difeafe is attend-
ee with,andperhapsproducedby afweat,which is warm,
■flf.id, copious over the whole body, and attended with
an rbatement of the  frequency of the  pulfe, of the
Liiac )fthe body, and of  the other febrile fymptoms.
                    CCCLII.
  Yi  prognoftics in this difeafe are formed frbm ob-
fervi: ■.- the ftate of the principal fymptoms.
  /' \  .ent pyrexia is always dangerous.
  I i»f  danger,  however, is vchiefly denoted by the
                                        diMicultv 
lgi
PRACTICE
difficulty of breathing.  When the patient can lie on
one fide only; when  he  can lie on neither  fide,  but
upon his back only; vi hen he cannot breath  with to.
lerable eafe,  except the  trunk of his body be erect ;
when, even in this pofture, the breathing is very diffi-
cult, and attended with a turgefcence and flufhingof
the face, together with partial fweats about the head
and neck, and an irregular pulfe : thefe circumftance?
mark the difficulty of breathing in progreflive degrees,
and confequently,  in proportion, the danger of  the
difeafe.
  A frequent violent cough aggravating the pain, is
always the fymptom of an obftinate difeafe.
  As I apprehend  that  the difeafe-is hardly eveY re-
folved, without  fome expectoration; fo  a dry cough
muft be always an  unfavourable fymptom.
  As the expectoration formerly defcribed, marks that
the difeafe is proceeding  to a refolution ; fo an expec-
toration which has not the conditions there mention-
ed, muft denote  at leaft a doubtful ftate of the difeafe;
but  the marks taken from the  colour of the matter
are for the moft part fallacious.
  An acute pain,  very much interrupting infpiration*
is always the mark of a violent difeafe ; though not of
one more dangerous,  than an obtufe pain, attended
with very difficult refpiration.
   When the pains, which at firft had affected one fide
only, have afterwards fpread into the other; or when,
leaving the fide  firft affected,  they entirely  pafs into
the other: thefe are always marks  of an increafing,
and therefore, of a dangerous difeafe.
  A delirium coming on during a pneumonic inflam-
mation, is conftantly a fymptom denoting much dan-
ger.
                     CCCLIII.
  When the  termination of this  difeafe proves fatal, it
is on one or  other of the days of the firft week, from
                                               the 
OF  PHYSIC.
*93
the third to the  feventh.   This is the moft common
cafe ; but, in a few inftances, death has happened at a
later period  of the difeafe.
   When the difeafe is violent, but admitting of refo-
lution,  this alfo happens  frequently in the courfe  of
the firft week  ;  but,  in a more moderate ftate of the
difeafe,  the  refolution is often delayed to the  fecond
week.
   The difeafe, on fome of the days from the third  to
the feventh, generally fuffers a remiflion; which, how-
ever, may be often fallacious, as the difeafe does fome..
times* return again  with as much  violence as  before,
and  then with great danger.
   Sometimes the difeafe difappearson the fecond or third
day, while an  eryfipelas makesits appearance on fome
external part;  and if this continue fixed,  the pneumo-
nic inflammation does not recur.
                       CCCLIV.
   Pneumonia, like other inflammations,  often  ends in
fuppuration or gangrene*.
   Vol.  I.                B  b                CCCLV.

   * As tin's termination of Pneumonia is always fatal, it is highly
neceflary  that the phyfician fhould be able to know when a gan-
grene is to be fufpected, that he may take the proper means  for pre-
venting it : or, v.  hen it is abfolutely formed, that lie  may  fave his
reputation, by informing the patient's relations of the impending
danger, and the fatal confequences with which fuch a tetmination
is attended :  )  fhall therefore add fome of the more remarkable diag-
noses of an incipient gangrene in this difeafe. ' A purulent  fpit-
tin^,  ilreakcd with deep coloured blood, or with a blackifh matter ;
a fetid breath; a  rattling  in the throat ; a dejected  countenance ; a
dim eye; a languid quick pulfe ;  the blood drawn from a vein vokl
of the inflammatory emit; fetid green (tools in abundance ; urine of
a bright flame colour, or depofiting a  black fediment of a  fcaly ap-
pearance.  More fymptpms of this fatal termination are unneccfla-
iy ; for, if moft of thofe above mentioned be prefent, the phyfician
has no other duty to perform than \y.irn the friends of the patient
that death may be foon expected.  It  may be farther remarked,
that, when a gangrene is begun, the patient is coniiderably freed
from pain, and both  himfelf and his attendants have graet  hopes of
his recovLiing; a few hours, however, foon undeceives them, and 
194           PRACTICE
                      CCCLV.   .
   When a pneumonia,  with fypmtoms neither  very
 violent nor very flight,  has continued  for many days,
 it is to be feared it will  end  in  a fuppuroiior:.  This,
 however, is not to be determined precifeiy by the num-
 ber of days : for, not only after the fourth, but even af-
 ter the tenth day, there  have been examples of a pneu-
 monia ending by  a refolution; ana if the difeafe has
 fuffered fome intermifiion, and again recurred, there
 may be inftynces of a  refolution happening at a much
 later period from the beginning of the difeafe,  thaa
 that juft now mentioned.
                      CCCLVL
   But if a moderate difeafe, in fpite of proper remedies
 employed, be protracted to the fourteenth day with-
 out any confiderable remiflion, a fuppuration is pret-
 ty certainly to be  expected ; and it will be ftill more
 certain,  if no figns of refolution have appeared, or if
 an expectoration which  ha^d  appeared fhall have again
 ceafed, and the difficulty of breathing has  continued
 or increafed,  while the other  fymptoms have rather
 abated.
                      CCCLVII.
   That, in a pneumonia, the effufion is made, which
 may lay the foundation of a fuppuration, we conclude
 from the difficulty of  breathing becoming  greater
when the patient is in a  horizontal pofture*, or when
 he can jie more ealilv upon the  affected fide.
                   " CCCLVIII.
   That, in  fuch cafes, a fuppuration has actually be-
gun, may be concluded from the patient's being fre-
quently affected with  flight cold  fiiiverings, and with
                                             a fenfe
 raifes the leputation of-lhe phyfician.  who has  pronounced a true
 prognofis.  See fome other diagnoftics of gangiene in  the notes on
article 359.
  * In all pneumonic affections, the breathing isgenerajly more dif-
ficult when the patient lies in an horizontal pofture, it cannot there-
fore be admitted as a diagnoftic t f an efiufion. 
O 1   PHYSIC.
l9S
 a fenfe of cold fometimes in one and fometimes in an-
 other  part of the body.   We form the fame conclu-
 fiun alfo from the ftate of the pulfe, which is common-
 ly lefs frequent and fofter, but fometimes quicker and
 fuller, than before.
                      CCCLIX.
   That a fuppuration is already formed,  may be in-
 ferred from there being a confiderable remiflion*  of
 the pain which had been before fubfilted, while, along
 with this, the cough, and efpecialiy the dyfpncea,  con-
 tinue, and are rather augmented.   At the fame time,
 the frequency of the pulfe is rather increafedf; the
 feverifh ftate fuffeis confiderable exacerbations every
 evening, and by degrees a  hectic in all its circumftan-
 ces comes to be formed.
                      CCCLX.
   The termination  of Pneumonia by  gangrene,  is
 much  more rare than has been imagined ;  and when
 it does  occur, it is ufually joined with the termination
 by effufion (ccclxiv.) and  the iymptoms of the  one are
 hardly to be diftinguifhed  from thofe of the other.
                      CCCLXI.
  The cure of pneumonic inflammation, muft proceed
 upon the general plan (eclxiv.) but the importance of
 the part affected, and the danger  to  which it is ex-
 pofed, require  that the remedies be fully, as well as
 early, employed.
                       B  b 2              CCCLXII.
  * The voting phyfician mull be on his guard with refpect to this
 fymptom ; for it is' alfo a fymptom of an incipient, or an already
 formed gangrene ;  he ought therefore to be peculiarly attentive to
 the concomitant fymptoms which the author enumerates, viz. the
 continuance or augmentation of the difficulty of breathing and the
 cough, both of which  either totally diiappear,  or are eonfiderably
 leffened art the fupervention of gangrene.
  ■j\The increafed frequency of the pulfe is alfo a fymptom  of a
gangrene being formed, but, if that increafed frequency be attended
with fcbrile'exacerbations in the evenings, then  and then  only can
the phyfician be fure that the difeafe ha6 terminated in fuppuratioi.\
aii'i not in gangrene. 
i96          PRACTICE
                   CCCLXII.
  The remedy chiefly to be depended upon, is that
of bleeding at the arm ; which will be performed with
moft advantage in the arm of the fide moft  affected,
but may be done in either arm,  as may be moft con-
venient for the patient or the furgeon.  The quantity
drawn muft be fuited to the violence of  the difeafe,
and to the vigour of the patient; and generally ought
to be as  large as  this laft circumftance will allow.
The remiflion of  pain, and the relief of  refpiration,
during the flowing of the blood, may limit the quan-
tity to be then drawn ;  but if thefe fymptoms of relief
do not appear,  the bleeding fhould be continued till
the fymptoms of a beginning fyncope come  on.  It is
feldom that one bleeding, however large,  will prove a
cure of this difeafe ; and although the pain and diffi-
culty of breathing may be much relieved by the firft
bleeding,  thefe fymptoms commonly, and  after no
long interval, recur; often with as much violence as
before.  In the event of fuch recurrence, the bleeding
is to be repeated, even  in the  courfe of the  fame day,
and perhaps to the fame quantity as before.
  Sometimes the  fecond bleeding may be larger than
the firft.   There are perfons who, by their  conftitu-
tion, are ready to  faint even upon a fmall bleeding ;
and, in fuch perfons, this may prevent the drawing fo
much blood at firft as a pneumonic inflammation might
require ; but, as the fame perfons are frequently found
to bear after-bleedings better than the firft, this allows
the fecond and fubfequent bleedings to be larger, and
to fuch a  quantity as the fymptoms of the difeafe may
feem to demand.
                   CCCLXI1I.
  It is according to the ftate of the fymptoms, that
bleedings  are to be repeated ;  and they will be rnore
effectual when practifed in the courfe of the firft three
cJ.iV.s, than afterwards ; but they«are not to be omitted, 
               O  F   P II Y S  I C.             i9y

although four days of the difeafe  may .have already e-
lapfed.   If the phyfician  ihall not haye been called
in (boner ;  or if the bleedings piactifed duiing the firft
days fhall not have been large  enough, or  even al-
though thefe bleedings fha.ll  hove procured  fome re-
miflion ; yet, upon the recurrence of the urgent fymp-
toms,  the  bleeding fhould be repeated at any ptriod
of the difeafe, efpecially within the firft fortnight;  and
even afterwai'.S,  if a tendency to fuppuration  be  not
evident, or if, after a feem ing  folution, the difeafe
fhall have again returned.
                     CCCLXIV.
  With refpect to the quantity of blood which ought,
or which uirh  fafety may be taken away, no  general
rules can be delivered, as it muft  be very different, ac-
cording to the ftate of the  difeafe, and conftitution of
the patient*   In an adult  male of tokr.iblc ftrength,
a pound  of blood,  avoirdupois,  is a  full bleeding.
Any quantity above twenty  ounces,  is a large,   and
any quantity  below twelve  a fmall,  bleeding.   A
quantity of from four to five pounds, in the courfe of
two or  three days, is generally as "much  as fuch pa-
tients will  fafely bear ; but,  if the intervals  between
the bleedings and the whole of the time during which
ihe bleedings have been employed have  been lon-g,
the quantity taken upon the  \vh le may be greaterf.
                                               cce-
  f Bleedings produce the beft  effect when the blood is diawn off
as quickly as poffible in a  I.;r<»e full dream ;  an J, in order to prevent
fyncope,  the patient ought to be laid hoi izontal'y, or even with his
head lower than his trunk.
  With refpect to the quantity of blood to be drawn a" orcc,  or in
the whole courfe of the difeafe, no genera- dirtcti""is can begiven ;
it muft depend entirely on the circumftances  of the difeafe and of
the patient.  In general, it is ufual to continue the difcharge until
the patient can either breathe more freely, or feels a confiderable
abatement of the pain.  If, however, the pain does not abate whi.e
the blood continues to flow, but figns of fainting u ,>pear,  the blood
mull then be immediately flopped.
  If the pain and other fvinptums continue violent, or return  after 
 i9S            PRACTICE

                     CCCLXV.
   When a large quantity  of blood has' been  already
 taken from the arm, and when it is doubtful if more
 c;in with fafety be drawn in thot manner,  fome blood
 may ftill be taken  by cupping and fcarifying.  Such
 a meafure will be more particularly proper, when the
 continuance or recurrence of pain,  rather  than  the
 diificulty of breathing, becomes the urgent fymptom ;
 ■And then the cupping and fcarifying mould be made
 as near to the  pinned  part as con  conveniently be
 done.
                     CCCLXVI.
   An expectoration takes place fometimes very early
 in this difeafe : but if,  notwithstanding that,  the ur.
 gent fymptoms  fliould ftill continue, the expectoration
 muft not fuperfede the bleedings mentioned ; and du-
 ring the fit ft davs of the difeafe,  its foluthm is net to
 be trufted to the expectoration alone.   It is in a more
 advanced ftage  only, when the prpper  remedies have
 been before employed,  and when, the fymptoms have
 fuffered a confiderable remiflion,  that the  entire cure
 may be trufted  to a copious  and  free  expectoration,
                    CCCLXVII.
  During the  firft days of the  difeafe, I have  not
 found that bleeding  flops expectoration.  On  the
 contrary, I have often obferved bleeding promote it;
 and  it is  in a more advanced ftage of the difeafe only,
 when  the patient, by large evacuations  and the conti-
 nuance of the difeafe,  has been  already  exhaufted,
 rhat bleeding feems to flop expectoration.   It appears
to me, that even then bleeding does not flop  expecto-
                                              ration
the firft bleeding, it will then  be neceffary to have recourfe to the
operation ; and it muft be repeated frequently through the courfe of
the difeafe  ; avoidmg, however, fo large an evacuation  at once as
way induce fainting.  The  reafon of this precaution is evident.
viz. that,  while the motion of the heart is fufpended during faint-
ing, the blood ilagnates in the right fide of the heart, and  is after-
wards thrown v\ith greater impetuolity through the lungs. 
                 OF  PHYSIC.             199

  ration fo much by weakening the powers of expecto-
  ration, as by favouring the fe*rous effufion  into the
  bronchiae, (cccxlviii )  and thereby preventing it.
                      CCCLXVJII.
     While the  bleedings  xve have mentioned fhall be
  employed, it will be neceffary to employ alfo  every
  part  of the  antiphlogiftic regin^en, (cxxx—cxxxii.)
  and particularly  to prevent the irritation which might
  arife from any increafe of heat.  For this ptirpofe, it
  will be proper  to keep the patient out of bed^  while
  he can bear  it eafily ;  and when  he cannot, to cover
  him very lightly while he lies in bed.   The tempera-
  ture of his chamber ought not to exceed fixty degrees
* *of Farenheit's  thermometer ;  and whether it  may be
  at any time colder,  I am uncertain.
                       CCCLX1X.
     Mild and  diltfent drinks, moderately tepid, at leaft
  never cold, given by fmall portions at a time, ought
  to be adminiftered plentifully.   Thefe drinks may be
  impregnated with  vegetable acids*.   They may be
  properly accompanied alfo with nitre, or fome  other
  neutrals f; but thefe falts fhould be given feparately
   from the drinksf.
     It has been  alledged,  that both acids and nitre are
  ready to excite coughing, and  in fome perfons they
  certainly have  this effect; but,  except in perfons of a
  peculiar habit, I have not found their effects in excit-
  ing cough fo confiderable or troublefome as to prevent
  our feeking  the  advantages otherwife to be obtained
  from thefe medicines.
                                                CCC-
     * See the note  to par. 131, 1. 11.  on the word acids.
     t See the note, par. 160, laft word.
     t Thefe falts generally render the drink naufeous ;  and, as plen-
  tiful dilution is abfolutely neceffary in thefe cafes, fo far from ren-
  dering the patient's  common drink naufeous, by impregnating it
  with ill favoured medicines,  we ought, by every poffible means, to
  endeavour to make it as agreeable as we can, that he may  be the
  more eafily prevailed on to take it plentifully. 
2oo            PRACTICE
                       CCCLXX.
   Some practitioners  hr.ve doubted, if purgatives can
 be fafely employed in this difeafe ;  and indeed a fpon-
 taneous diarrhoea occurring in the beginning of the
 diftafe  has feldom proved ufeful :  but I have found
 the moderate ufe of cooling laxatives* generally  Wife,
 and have always found it ufeful to keep the belly o-
 pen by  frequent emolient glyfters.
         ~*         CCCLXXI.
   To excite full vomiting by emetics, I judge  to be a
 dangerous  practice in this difeafe : but I have found it
 ufeful to exhibit naufeating dofes j ami, in a fomewhat'
 advanced ftate of the difeafe, I ruive found fuch dofes
 prove the  beft means of promoting expcctoration§.
                      CCCLXXIL
   Fomentations and poultices .applied to the  ptined
 part have beon recommended, and may be  ufeful;
 but the application  of them  is  often inconvenient,
 and may be entirely  omitted  for the fake of the more
 effectual remedy, bliftering-)-.
.   Very early  in the difeafe, a blifter fhould be applied.
 as near the pained part as poffible.   But as, when the
                                                   irri-
  *  The cooling laxatives are,  falls, manna, &r. but, in thefe
 cafes, thrte or four ounces of infufum fenny?., with half an ounce of
 Glaubers fait may be yf.-:\n without danger.
  $  '1 he taitar  emetic is the medicine j!uiei:d!y employed for this
 purpofe.  The dofe of it in thefe cafes, mutt be very fmall, and
 well diluted,  as in the following formula :
          R. Antimon,  taitrifat, g<.  ii.
             Aq. font,  J viifs.
              Svr. papaveris rubr.  5 fs.
              M.
The dofe of this mixture  ought not to exceed 3 table fpoon-fuls,
 when given with  this intention.
  f  The appiic;.tio:i of a bli.Lr to the part affected oir lit to be trie
firlr  nrefcription  in all complaints of the thorax, except fo rue ir-
 maik\b!e  or urgent caufe forbid the practice, becaufe if is a r.'.oit
 crr^uous rt::.i.dy,  a;,d is  as ncefiary aj bleeJins.r. 
OF   PHYSIC.
2C I
 irritation of a blifter is  prefent,  it renders  bleeding
 lefs effectual ; fo the application of the blifter fliould
 be delayed till a bleeding fhall  have been employe J.
 If the difeafe be moderate, the blifter may be applied
^immediately after the firft bleeding; but if the difeafe
 be violent, and it  is prefumed that a fecond bleeding
 may be neceflary foon after the firft it  will then  b :
 proper to  delay  the  firft blifter till after the fecond
 bleeding,  when it may be fuppofed that any further
 bleeding may be poftponed till  the irritation arifing
 from the blifter fhall have ceafed. It may be frequent-
 ly neceffary  in this difeafe to repeat the bliftering :
 and, in that cafe the plafters fhould always be applied
 ibinewhere on the thorax*; for, when applied to more
 diftan- runts, they have little effect.  The keeping the
 bhft :ou parts open, and making what is called a per-
 petual blifter, has  much lefs effed than a freih blifter-
 inL -
                     CCCLXXIII.
    As this difeafe often terminates by an expectorati-
 on, fo,  various means of promoting  this have been
 propofed: but none of them appear to be very effect-
 ual ; and fome of them, being acrid ftimulant fubftan-
 ces, cannot be very fafe.
    The gums ufually  employed feem  too  heating:
 fquills feem to be  lefs fo;  but they are not very pow-
 erful, and  fometimes  inconvenient by  the conftant
 naufea they irtduce-j-.
    Vol. I.                C c                    The
   * They ought however, to be applied as near to the  pained parj
 as poffible.
   f All the liquid forms of fquills which we have in the (hops are
 naufeating.  Pills made of the dry powder, with any electuary or
 confeive, or honey, is the form in which fquills affedt the ilomach
 least. The dofe is 4 or 5 grains of the dry  powder ; 10 grains ge-
 nerally, if not  conftantly, produce vomitings.   To prevent the
 naufeating effect of fquills, the addition of fome gratctul aromatic
 is of material ufe.  The pilulse filiticae of the Edinburgh Pharmaco-
 peia is a good formula, except that the dofe of it  uiu.l be large, 11. 
202
P  R  A  C  T  I C  E
         The volatile alkali may be of fervice as an expecto-
       rant ; but it fhould be referved for an  advanced ftate
       of the difcale.
         Mucilaginous and oily dumulcents appear to be ufe-
       ful, by allaying that acrimony of the  mucus  which
       occafions  too  frequent coughing ; and which cough-
       ing prevents the itagnation and thickening of the mu-
       cus, and thereby its becoming mild.
         VThe receiving  inr.o  the lungs the fleams  of warm
     -  water impregnated with vinegar, has often proved ufe-
       ful in  promoting expectoration*.
  _      *tyt,  of all  other remedies, the moft powerful for
^^^|^is r^jmofe,  are antimonial medicines, given in nau-
       feating tfWfes^jis in clxxix.  Of thefe, however,  I have
       not found 4he kermes mineral more efficacious than
       emetic taitaijjfcr antimonial wine ; and the dofe  of the
       kermes  is much mo;e  uncertain that  that  of  the o-
       thers.
                           CCCLXXIV.
         Though a fpontaneous  fweating  often proves the
       crifis of this difeafe,  it  ought not to  be  excired by
       art, unlefs with much caution.   At leaft, 1 have not
       yet found it  either fo effectual or fafe, as fome writers
      have  alledged.   When,  after fome remiflion of the
                                                      fymp-
       order to take a fuiTicient qmnfity of the fquills, ten grains of it
      containing, only one grain of dry fquilh, fuppofing no fyrup to be
      uid in  making the mafs.  " One convenience,  indeed, attenJs this
      1 jimiila, viz. that  we can give imall dofes with more prccifion than
      if we ufed the powder alone.   The gum ammoniac \z an expecto-
      rant ; and therefore, when given along w iih the fquills in thefe pills,
      may render a lefs dofe of the fquills neceffary.  If the extract uf
      liquorice be omitted, the pioportion of the iquillstothe whole will
      be increafed.
          Some pracli'.ioners propofe the fleam of vinegar alone : but it
      proves in general too initating.  The fame  objection  may be made
      agninft ufi.i j the fleam of wine, which fome practitioners have recom-
      mended inlicad of tlie fleam of  vintgar.   Plain water is the belt, as
      the warm vapour only ads by ruling the internal furface  of the
      lungs. 
or  PHYSIC.
203
fymptoms, fpontaneous fweats  of a proper kind arife,
they may be encouraged ; but it ought to be without
much boat, and without ftimulant medicines.  If, how-
ever,  the fweats be partial  and clammy  only,  and a
great difficulty of breathing ftill remain, it will  be ve-
ry dangerous to encoutagc them.
                  CCCLXXV.
  Phyficians  have  differed  much in opini. n  with re-
gard to the ufe of oph.tes in pneumonic inflammation.
To me it appears.,  that,  in  the beginning of the dif-
eafe, and before bleeding and bliftering have produc-
ed fome  remiflion of the pain and  of the difiiculty of
breathing opiates have a very bad  effect,  by their in-
creafing the difficulty of breathing, and other inflam-
matory fymptoms.  But  in  a more advanced ftate of
the difeafe, when the difficulty  of breathing has abat-
ed, and when the urgent fymptom is a cough, proving
the chief caufe of the continuance of the pain and of
the want of fleep, opiates may be employed with great
advantage and fafety,  The interruption of the expec-
toration, which they feem to occafion, is  for a fhort
time only ; and they feem often to promote it, as they
occafion a ftagnation of what was by frequent cough-
ing diffipatcd inferifibly, and therefore  give  the ap-
pearance  of what phyficians have  called  Concocted
Matter.
<■<••<■ <••<•■< ■<<!»»•>•> >•>■►•> >■ >•>•>•
CHAP.    VII.
OF 1 HE PERIPNEUMONIA NOTHA, OR
      BASTARD PERIPNEUMONY.
A
              CCCLXXVI.
Dfeafe under  this name is mentioned in fome
medical Writings of the  fixteenth century; but
                 C c 2                     it 
204          PRACTICE

it is very doubtful if the name was then applied to the
fame difeafe to which we now apply it.  It appears to
me, that unlefs fome of the cafes defcribed under the
title of Catawhus  Suffocativus be fuppofed to have
been of the kind I am now to  treat of, there was no   i
dcfcription of this difeafe given before  that by Syden-   I
ham, under the title I  have employed here.            ]
                   CCCLXXVII.
   After Sydenham, Boerhaave  was the firft who in a
fyftem took notice of it as a diftinct  difeafe ; and he
has defcribed it  in his  aphorifms, although with fome   \
circumftances different from thofe in the dcfcription
of Sydenham.   Of late, Mr. Lieutaud has with great   j
confidence aiferted, that  Sydenham  and Boerhaave
had, under the fame title, defcribed different difeafes;   *
and that,  perhaps, neither of them had on thu fubject'   1
delivered  any thing but hypothefis.                   |
                  CCCLXXVUI.
   Notwithftanding this bold affertion,  I am  humbly .
of opinion, and the B^ion Van Swieten feems to have
been of the fame, that Sydenham and  Boerhaave did
defcribe under the  fame title*,  one and the  fame di:-
enfe.   Nay, I am further of opinion, that the difeafe
defcribed  by Mr. Lieutaud himfelf, is not effentially
different from that  defcribed by  both the other au-
thors.   Nor will the doubts of the very learned, but   ,
modeft Morgagni,  on  this fubject,  difturb us, if we   \
confider,  that while very few defcribers of difeafes ei-   \
ther have it in their power, or have been fufficiently   ;
attentive in diltinguifhing between the cfiential and ac-
cidental fymptoms of difeafe;  fo, in a difeafe which
may have not only different, but  a greater number of
fymptoms, in one perfon  than  it has in another, we
need not wonder th.it the descriptions of the fame dif-
eafe by different perfons fliould come out  in fome re-
fpects di'ferent.  I fhall, however, enter no further in-
to this controverfy; but endeavour  to defcribe the
                                            difeafe 
OF  PHYSIC.
205
 (difeafeas it has appeared to myfelf; and, as I  judge,
 in the effential iymptoms, much the fame as it has ap-
 peared to  all the other authors mentioned.
                  CCCLXXIX.
   This difeafe appears at the fame feafons  that other
 pneumonic and catanhal affections commonly do ; that
 is, in autumn and fpring.  Like thefe dif&iies,  alfo, it
 is  feemingly  occafioned by  fudden changes  of  the
v weather from heat to cold.  It appears, alio,  during
 the prevalence  of contagious catarrhs ;  and it  is fre-
 quently under the form of the Peripneumonia  Notha
 that thefe  catarrhs prove fatal  to elderly perfons.
   This  difeafe attacks moft commonly perfons fome-
 what advanced in life, efpecially thofe of a full  phleg-
 matic habit; thofe who have before been frequently
 liable to catarrhal affections; and thofe who have been
 much addicted  to the large ufe of fermented and fpi-
 ritous liquors.
   The difeafe commonly comes  on with  the fame
 fymptoms as other febrile difeafes ; that is, with alter-
 11a e chills and  heats;  and the fymptoms of pyrexia
 are fometimes fufticiently evident;  but in moft cafes
 thefe are very mod rate, and in fome hardly  at all ap-
 pear.   With  the firit attack-of the difeafe, a  001; h
 comes on; ufually accompanied with fome expectora-
 tion, and in many cafes, there is a frequent  throwing
 up of a confiderable quantity  of a vifcid  opaque mu-
 cus.  The cough often becomes frequent and violent;
 is fometimes accompanied whh a lending head-ach;
 and, as in  other cafes  of cough, a vomiting is fome-
 times excited  by it.   The face is fometioie. flufhed,
 and fome giddinefs or dro\\finefs cften attends thedif-
 cafj.  A difiiculty of  breathing,  whh  a fenfe of op-
 prcflion, or ftraitenin^ in the cheft, with fome obfcure
 pains there, and a feme of laftitude over the whole bc-
 i!y,  very conftantly a'.tend  this d fe.f..  The  blood
                                            drawn 
 ^c6           PRACTICE

 drawn in this diferfe. fhows a buffy furface, as in other
 inflammatory  aftoctions.
   The difeafe has often the appearance only of a more
 violent catarrh, and after the employment of fome re-
 medies is entirely relieved by a free and copious  ex-
 pectoration.   In  other cafes, however,  the feverifii
 and catarrhal  fymptoms  are at firft very moderate, and '
 even flight; but afcer a few days,  thefe fymptoms fud-
 denly become  confiderable, and put an end to the pa-
 tient's life when the indications of danger were before
 very little evident.
                    CCCLXXX.
   From  the different circumftances in which this dif-
 eafe appears, the pathology of it is difficult.   It is cer-
 tainly often no other at firft than a catarrhal affection,
 which, in elderly perfons, is  frequently attended with
 a large afflux  of mucus to the lungs ; and  it was on
 this footing that  Sydenham  confidered it as only  dif-
 fering in degree from his Febris Hyemalis.  A catarrh,
 however, is ftriciiy an affection of the mucous mem- ,
 brane and follicle; of the bronchiae alone : but it may
 readilv have, and frequently has, a degree of pneumo-
 nic inflammation joined  to it;  and in that cafe may
 prove  more propel ly  the peculiar difeafe we treat of
 r.ere.  lout, furthtr, as pneumonic inflammation very
 often produces an effufion of ferum into  the bronchia?
 (cccxlviii.) fo  this, in elderly perfons, may occur in
 confequence of a flight  decree  of inflammation ; and
 when it does happen, will give the exquifite and fatal
 *. t;fes of the peripneumonia notha.
                   CCCLXXXI.
   After this attempt to  eftablifh the pathology,  the
 n.ithod of cure in  the different circumftances of the
cifp ife will not be difficult.
   In cafe  the fever, catarrhal and pneumonic fymp-
t;ins, are  immediately confiderable, a  blood-letting
 •■.'ill  certainly   be proper and ne<"<.-i!\ry :  but,  where
                                              t\v:k 
of   p h  r s  i c
207
thefe fymptoms  are  moderate,  a  blood-letting   will
hardly  be  rcquifite ;  and,  when an eflufion is to be
feared, the repetition of blood-letting may prove ex-
tremely hurtful*.
   In all cafes,  the  remedies  chiefly  to be  depended
upon, are vomitingf  and bliftering^.   Full vomiting
may be  frequently  repeated, and  naufeating dofesjj
ought to be conftantly  employed.
   Purging may perhaps be ufeful  ; but as it is feldom
fo in pneumonic affections^ nothing  but  gentle  laxa-
thes are herenecefiarv§.
                                                        In

   *  The intention of bleeding in this difeafe is merely to facilitate
the circulation  through the lungs, and to relieve the cpunflion  in
the breafl, when this intention is therefore anfwered,  and when the
ll.ortnefs  of breath and opprefhon about the  bread  are removed*
there is no farther need of the lancet.   As this difeafe chiefly attacks
elderly perfons, and fuch as are of a phlegmatic habit, much harm
may  be done by repeated bleedings, which always increafe debility
and retard the cure.
   |  Vomiting in this difeafe has been thought by many practitioners
to be a doubtful remedy.   The action of vomiting always oppreffes
the brealt, and fometimes  even increafes the fymptoms of the dif-
eafe.
   |  This is the chief remedy ; and the blifters ought to be applied
as near the part affe£ted as poffible.
   ||  In feveral of  the former notes we have fully defcribed the me-
thod of giving the emetic  tartar in naufeatirg doles. Their  ptinci-
pal effect is to procure a perfpirah'on , and, when this effect i» pro-
duced, the patient muft drink largely of any di!ne»t or attenuating
liquor, as thin barley-water, with the addition of  the juice of fome
of the acid fruits, or infufions of fome of the gentle aromatics,  as
fage, balm, mint, &c.  or even a thin wine whey.
   §  Purging is furely hurtful in this difeafe, by inducing too great a
ftate of debility  ;  the inteftines, however,  are to be emptied in the
beginning of the difeafe, which  is belt done by a purging glyfter,
and kept open by the fubfequent  ufe of gentle laxatives, or by  re-
petitions of mild emollient glyfteis.  The  purging gly."er may  be
iv.i'<'.: ;'.s follows :
             R. Aq. foi.t. lb.  1.
                 Fob Scnn. sjfs.
                 C(u;ne leniter,  et colaturse adde,
                 Sal.  Calhart.  ama,  |i. 
 2o8            PRACTICE

   In oil th^  circumftances  of the difeafe,  the anii-
 phlogiftic regimen is proper : cold  is to beguaideda-
 gainft ;  but much external heat is to be as carefully
 avoided.
                   CCCLXXXII.
   If a«perfon fweats  eailly, and it can be brought ©ut
 by the ufe of  mild tepid liquors  only,  the practice
 may  in fuch  perfons be tried.   See Morgagni De
 Sed. et. Ca:f.  Epift. xiii.  Art. 4.
                 CCCLXXX11I.
   I might here, perhaps, give a feparate fection on the
 Carditis and Pericarditis, or the inflammation of the
 heart and Pericardium; but they  hardly  require a
 particular  confideration.   An acute inflammation of
 the pericardium is almoft always a parr  of the fame
 pneumonic affection  I have  been treating of;  and is
 not always diftin2;uilbed by  any different fymptoms;
 or, if it be, does  not require any different treatment.
 The fame  may be faid of an acute  inflammation  of
 the heart itfelf; and when it  happens that the one or
 other is difcovered by the fymptoms of palpitation or-
 fyncope, no more will be implied than that the reme-
 dies of pneumonic inflammation fliould be employed
 with greater diligence.
   From directions,  which fhew  the heart  and peri-
 cardii; ni affected with erofions,  ulcerations,  and ab-
 feeffes,  we difcover,  that thefe parts had been before
 affected with inflammation ; and that in  cafes  where
 no fymptoms of pneumonic inflammation had appear-
                                                ed :
               Mei. §;;.
               M. f. Enema.
The fubfequent glyfkrs ought to corififl of nothing more than fim-
ple bailey water, or milk and water.  The laxatives, if they are ufed,  t
 Cuiuld be very gentle and mild ; as cream of tartar, whey, manna,
tan.;u-inJs, &.c.  Hidi an ounce of manna diflolved in half a pint of
i-re am of  taitar whey, makes an agreeable opening mixtuie ; half a
tea-1 up: id of it may be taken three or four times a day, fo as pro- 1 ■,.
 tiae at leaft two or three ftools in the tvrtitv-four lieu:;.         1


                                                f 
              O F   P HT  SIC.           20$

 ed : it may therefore be alleged, that thofe inflamma-
 tions of the heart and pericardium fbould be confi-
 dered as difeafes independent of" the pneumonic. This
 indeed is juft: but the hiftory of fuch cafes proves,
 that thofe inflammations had been of a  chronic kind,
 and hardly difcovering themfelves  by any  peculiar
 fymptoms; or, if attended with fymptoms marking an
 affection of the heart, thefe were,  however, fuch as
 have been known frequently to arife from other caufes
 than  inflammation.   There  is  therefore, upon the
 whole, no room for our treating particularly of the in-
 flammation of  the heart or pericardium.



             CHAP.     VIII.

 OF  THE GASTRITIS,  OR INFLAMMATION
              OF  THE STOMACH.

                  CCCLXXXIV.
     AMONG the inflammations of the abdominal re-
      gion, I have given a place  in our Nofology to
 the Peritonitis; comprehending under that title, not
 only  the inflammations affecting the peritonaeum lin-
 ing the cavity  of the abdomen,  but alfo thofe affecting
 the extenfions  of this membrane in the omentum and
 mefentery.  It is not, however, propofed  to treat of
 them here, becaufe it  is very difficult to fay by what
 fymptoms they are always to be known  ;  and farther
 becaufe, when  known, they do  not require any reme-
 dies befide thofe of inflammation in general.  I pro-
 ceed, therefore, to treat of thofe inflammations which,
 affecting vifcera of peculiar functions, both give occa-
fion to peculiar fymptoms, and require fome peculia-
rities in the method of cure : and I fhall begin with the
inflammation of the ftomach.
  Vol.  I.            D d          CCCLXXXV. 
210           PRACTICE
                  CCCLXXXVI.
   The inflammation of the ftomach is of two kinds,
Phlegm-mic, or Erythematic*.  The firft may be fat*
ed in what is called the Nervous Coat of the ftomach,
or in t!"e peritonaeum inverting it.   The  fecond is al-
ways featoi in  the villous coat and cellular texture
immediately fubjacent.
                 CCCLXXXVI.
   The phlegmonic inflammation of the ftomach, or
what has been commonly treated of under the title of
Gaftritis, i- known by an acute pain in  fome part of
the region of the ftomach, attended with  pyrexia,-
with frequent vomiting, efpecially upon occafion of any
thing being taken downMnto the ftomach,and frequent-
ly with hickup.   The  pulfe is commonly fmall and
hard;  and there is a greater lofs of ftrength insall the
functions of the body,  than in the cafe of almoft any
other inflammation.
                CCCLXXXVII.
   This  inflammation  may be  produced by  various
caufes; as, by external contufion ; by acrids of various
kinds taken into  the  ftomach ; frequently  by  very
cold diink taken into it while the body is very warm;
and fometimes  by over-diftenfion,  from the  having
taken in a large quantity of food of difficult digeftion.
All thefe may be  confidered as external caufes; but
the difeafe fometimes  arifes alfo from internal caufes
not fo well underftood.  It may arife from inflamma-
tions of the neighbouring parts-communicated to the
ftomach, and is then to be confidered as  a fymptoma-
tic affection only.  It may arife alfo from various acri-
monies gervrated within the body,  either in the fto-
mach itfelf, or in other parts,  and poured into the ca-
vity of the ftomach.  Thefe are caufes more diredly
                                           applied
  * T:d3 is a new term ; but whoever confiders  what is faid in
274 will, I expect, perceive the propriety, and even the iieceffity.
of it.                                           ;
• 
               O F   P H Y S I C.           211

  applied to the ftomach ; but there are perhaps  others
i  originating elfewhere, and affecting the ftomach only
  fympathetically.   Such may be fuppofed to have act-
  ed in the cafe of putrid  fevers and exantheraatic py-
  rexiae ; in which, upon diflection, it has been difco-
  vered that the ftomach had been affected with inflam-
  mation.
                  CCCLXXXVIII.
    From the fenfibility of the ftomach, and its commu*
  nication with the reft of ^e fyftem, it will be obvious,
  that the inflammation of this organ, by  whatever
  caufes produced, may be atttended with fatal  confe-
  quences;  In particular, by the great debility  which
  fuch an inflammation fuddenly produces, it may  quick-
  ly prove fatal, without running the common courfe of
  inflammations.
    When it lafts long enough to follow the ordinary
  courfe of other inflammations,  it may terminate by
  refolution, gangrene, or fuppuration.   The fcirrhofi-
  ties which are often difeovered affecting the ftomach,
  are feldom known to be the confequences of inflam-
  mation. •
                   CCCLXXXIX.
    The tendency of this difeafe to admit of refolution,
  may be known by its having arifen from no violent
  caufe; by the moderate ftate of the fymptoms;  and
  by  a gradual#remiffion  of thefe, efpecially in  confe-
  quence of remedies employed in the courfe of the  firft,
  or at fartheft the fecond week of the difeafe.
                      CCCXC.
    The tendency to fuppuration may be known by
  the fymptoms continuing, in a moderate degree, for
  more than one or two weeks ; and likevvife by  a con-
  fiderable remiflion of the pain, while a fenfe of weight
  and an anxiety ftill remain.
    When an abfeefs  has been formed, the frequency
  of the pulfe  is at firft abated ; but foon after, ic is a-
| Jfcf                 P d 2                   gain. 
212
PRACTICE
gain increased,  with frequent  cold fiiiverings, and
with marked exacerbations in the afternoon and even-
ing, followed by night-fweatings, and  other fymp-
toms of hectic  fever.  Thefe at length prove fatal.
unlefs the abfeefs open into the cavity of the ftomac^'
the pus be evacuated by vomiting, and the ulcer foon
heal.               CCCXCI.
   The tendency to gangrene may be  fufpectcd from
the violence of the fymptoms not yielding to the re-
medies employed during tlge firft days of the difeafe:
and that a gangrene has already begun, may be known
from the fudden remiflion of the pain, while the fre-
quency of the pulfe continues, and at the fame time
becomes weaker, accompanied with other marks * of
an increafing debility jn the whole fyftem.
                    CCCXCII.
   From the diffection of dead bodies it appears, that
the ftomach very often has been affected with inflam-
mation, when the characteriftic fymptoms of it (ccc-
lxxxvi.) had not appeared ;  and therefore it is very
difficult to lay down anv general rules for the cure of
this difeafe.          CCCXCIII.
   It is only in the cafe of phlegmonic inflammation,
characterifed in  ccclxxxvi.  that we  can advife  the
cure or refolution  to be attempted by large and  re-
peated bleedings employed early in the difeafe : and
we are not to  be deterred  from thefe by the fmallnefs
of the pulfe ; for, after bleeding, it commonly be-
comes fuller and fofter.  After bleeding, a blifter ought
to be applied to  the  region  of the ftomach; and  the
cure will be aflifted by fomentations of the whole1 ab-
domen, as well  as by frequent emollient and laxative
glyfters.               CCCXCIV.
   In this difeafe, the irritability of the ftomach vill
not admit of any medicines being thrown into it; and
if any internal medicines can be fuppofed neceflary,
                                             the
  * A delirium is one of the molt general concomitants of the
creafing debility of  the fyftem, and may be confidered as a di
noflic.
iey
I 
OF   PHYSIC.
213
they muft  be exhibited in glyfters.  The giving of
drink may be tried ; but it  ought to be of the very
mildeft kind, and in very fmall quantities at a time*.
                    cccxcv.
  Opiates,  in whatever  manner exhibited,  are very
hurtful during the firft days of the difeafe ;  but when
its violence fhall have abated, and when the  violence
of the pain and vomiting recur at intervals only, opi-
ates given  in  glyfters  may be  cautioafly tried, and
fometimes have been employed with advantage.
                    CCCXCVI.
  A tendency to fuppuration, in this difeafe, is to be
obviated by the means juft  now  propofed.   After  a
certain duration of the difeafe, it cannot be prevented
by  any means whatever; and when actually begun,
muft be  left to nature : the bufinefs of the phyfician
being only to avoid  all irritation.
                   CCCXCV1I.
   A tendency to gangrene can be  obviated in no other
way than by the means fuggefted cccxciii. employed
early in  the difeafe ; and, when  it does actually fu-
pervene, admits of no remedy.
                   CCCXCVIII.
   Erythematic  inflammations  of the  ftomach,  are
more frequent than thofe of the phlegmonic kind. It
appears, at leaft, from diffections, that the ftomach
has often been affected with inflammation,  when nei-
ther pain nor pyrexia had before given any notice of
it; and fuch inflammation I apprehend to have  been
chiefly of the erythematic kind.   This fpecies of in-
flammation alfo, is efpecially to be expected from acri-
mony  of any kind thrown into  the  ftomach ;  and
would certainly occur more frequently from fuch a
caufe, were not the interior furface of this organ com-
monly defended by  mucus exuding in large  quantity
                                             from
  * Chicken-broth is extremely mild ; it may  be taken in fmall
quantities, with about eight or ten grains of nitre in every pint of it.
Ljntfecd tea is alfo a very mild driak ;  and, if the inflammation  be
owing to the prefence of any acrid matter irritating the ftomach, it
is of great fervice by it« fheathing <;i:ality. 
114
PRACTICE
from the numerous follicles placed immediately under
the villous coat.   Upon many  occafions, however,
the exudation of mucus is  prevented,  or the liquid
poured out is of a lefs vifcid kind, fo as to be lefs fit- ♦
ted to defend the fubjacent nerves;  and it is in fuch
cafes that  matters even of moderate acrimony, may
produce an erythematic affection of the ftomach.
                   CCCXCIX.
  From what has been faid,  it  muft appear  that an
erythematic inflammation  of the ftomach may fre-
quently occur; but will not always difcover  itfelf, as
it fometimes takes place without pyrexia, pain, or vo-
miting.               CCCC.
  There are cafes, however, in which it mav be dif-
covered.  The affection of  the ftomach fometimes
fpreads into the cefophagus, and appears  in the pha-
rynx,  as well as on the whole internal furface of the
mouth.  When, therefore, an erythematic inflamma-
tion affects the mouth  and fauces,  and when at the
fame time there fhall be in  the ftomach  an  unufual
fenfibility to allacrids, with a frequent vomiting, there
can be little doubt of the ftomach being affected with *
the fame  inflammation that has appeared in the fau-
ces.  Even when no inflammation appears in the fau-
ces, yet if fome degree  of pain be felt in the ftomach,
if there be a want of appetite, an anxiety, frequent
vomiting,  an unufual fenfibility with "refpect to acrids,
fome thirft, and frequency of pulfe, there will then be
room to fufpect an  erythematic inflammation of the
ftomach ; and we have known fuch fymptoms, after
fome time, difcover their caufe more  clearly by the
appearance of the inflammation in the fauces or mouth.
   Erythematic  inflammation  is often  difpofed to
fpread from one place toanother on the fame furface;
anrj, in doing fo, to leave the place it had firft occu-
pied.   Thus, fuch an  inflammation has been known
to fpread fucceflively along the  whole courfe of the *
                                        limentarjL 
OF   PHYSIC.
2'5
limentary canal, occafioning in the inteftines diarrhoea,
and in the ftomach vomitings ; the diarrhoea ceafing
when the vomitings came on, or the vomitings upon
the coming on of the diarrhoea.
                      CCCCI.
  When an erythematic inflammation of the ftomach
 fliall be  difcovered, it is to be treated differently, ac-
 cording to the difference of its caufes and fymptoms.
  WheH it is owing to acrid  matters  taken in by the
 mouth, and when thefe may  be  fuppofed  ftill prefent
 in the ftomach, they are to be wafhed out by  throwing
 in a  large quantity of warm and  mild liquids, and by
 exciting vomiting.  At  the  fame time, if the nature
 of the acrimony and its proper corrector be known,
 this  fhould be thrown in ; or if a fpccific  corrector be
 not  known, fome general demelcents fhould* be em-
 ployed.
                      CCCCII.
   Thefe meafurcs, however,  are more fuited to pre-
 vent the inflammation, than to cure it after it has tak-
 en place.  When  this laft may be fuppofed to be the
 cafe, if it be attended with a  fenfe  of heat, with pain
 and  pyrexia, according to the degree of  thefe fymp-
 toms the meafures propofed in cccxciii. are to be*nore
 or lefs employed.
                     CCCCIII.
   When an erythematic inflammation of the ftomach
 has  arifen from internal caufes, if pain and pyrexia ac-
 company the difeafe, fome bleeding, in perfons not o-
 therwifc weakened, may be employed : but,  as the af-
 fection often arifes in putrid difeafes, and in convalef-
 cents from fever; foin thefe cafes, bleeding is inadmiffi-
 ble; allthat can be done being to avoid irritation, andto
 throw into the ftomach what quantity of acids,  and
 of afcefcent aliments, it fhall be found to bear.
   In fome conditions of the body in which this difeafe
 arifes, the Peruvian bark and bitters may feem to be
                                               in 
2 11'
PRACTICE
 indicated ; but an  erythematic  ftate of the ftomach
 does not commonly allow of them.



               C   II   A   P.     IX.

   OF  THE ENTERITIS, OR INFLAMMATION
              OF THE INTESTINES.

                      CCCCIV.
     THE inflammation of the inteftines, like that of
       the ftomach, may be either phlegmonic, or ery-
 thematic : but, on the fubject of the latter, I have no-
 thing to add to what has been faid in the laft chapter;
 and ihalljhere therefore treat of the phlegmonic inflam*
 mation only.
                      CCCCVI.
   This* inflammation  may  be known to be prefent,
 by a fixed pain of the abdomen, attended with pyrex-
 ia, coftivenefs, and vomiting.  Practical writers  men-
 tion the pain in this cafe as felt  in different parts of
 the abdomen, according to the  different  feat of the
 inflammation ; and fo, indeed, it fometimes happens;
 but very often the pain fpreads over the whole belly,
 and is felt  more efpecially about the navel.
                    CCCCVII.
   The Enteritis and Gaftritis arife from like caufes;
 but the former more readily than the latter, proceeds
from  cold applied to  the lower extremities, for to
 the belly itfelf.  The enteritis has likewife its own pe-
 culiar  caufes, as fupervening upon  the fpafmodic cho-
 lie, incarcerated hernia, and volvulus.
                    CCCCVIII.
   Innr-onmations of the inteftines have the  fame ter-
minations as thofe of the ftomach; and, in both cafes,
                                              the
  * Th? article.-: were thus numbered in the  laft edition, 
OF   PHYSIC.
i\7
the  feveral  tendencies  are to be difcovered  by the
fame fymptoms (ccclxxxix.—cccxci).
                        CCCCIX.
   The cure of the  interitis is, in general, the fame
with that of the gaftritis ; (cccxciii.  and feq.)  but iA
the  interitis,  there is commonly  more accefs  to  the
introduction of liquids, of acids, acefcent,  and  other
cooling remedies, and even of laxatives*.   As, howe-
   Vol.  I.                 E  e                       ver,

   *  In this uifeafe, we ought to be extremely cautious in the admi-
niftration either of the medicines or diluents.   The leafon  is evi-
dent from the following confiderations.  In every cafe of inflamma-
tion  of a canal,  the bore of that canal is diminifhed,  and frequent-
ly quite fhut. A quantity of any kind of ingefta being forced a«ainft
thiRobftruftion, mult tieceffarily increafe the irritation, and confe-
quently aggravate  all the fymptoms.   'I he fame reafon may be given
for the caution neceffary in  prefcribing laxatives, which always ir-
ritate ; for their action generally depends upon the irritation they
produce.  Large bleedings,  emollient glyllers frequently repeated,
fomentations, the  warm bath,  and fmall anodyne glyfters occafional-
ly injected, are the moft effectual remedies in the firft flage  of this
violent difeafe.  When  the  pain  remits,  and  the  violence  of the
fymptoms abates,  mild di'uents may then  be admitted, as chicken-
broth, thin lintfeed-tea,  &c.  and, if fuch liquors be retained with-
out  aggravating the fymptoms, we  may  then venture to give an
ounce of manna every three or four hours, till it procures a paffage.
   The internal ufe of opium  has been  extolled by feveral practi-
tioners in thefe cafes ; but experience  fhews that it generally does
liarm in every cafe of inflammation,  efpecially in the early ftages of
 it.
   The anodyne glyflcr  io the fafeft  method of ufmg opium ; but
glyfters of this kind arc  faid'to obit met :  This objection is, how-
ever, ill founded ;  for,  by diminifhing the irritation, thevevident-
 ly tend to refolve  the infkimmation.   The following formula of an,
anodyne glyltcr is  generally ufed :
                   ty.  Deco&.hoid. |ir.
                      Opii puri gr. iv.
                      M.
 Tn thefe glyfiers,  particular care muft be tt'/.cn to avoid every thing
tlr.t  1ms the  leafl tendency to iiritate.  If a  gangrene be  fuimed
before the phyfician be  ealleJ m.  is too fiequeiuiv the cafe,  the.!*
all remedy's are in va;:is 
2l8
PRACTICE
yer, a vomiting fo frequently attends this difeafe, care
muft be taken not to excite that vomiting  by either
the quantity or the quality of any thing thrown into
the itomach.
   The fame obfervation, with refpect to the ufe of o-
piates, is to be made here as in the cafe of gaftritis.
                      ccccx.
   Under the title of Enteritis, it has been ufual with
practical writers  to treat of the remedies proper for
the cholicf, and its higher degree named Ileus: but,
although it be true that the enteritis  and  cholic  do
frequently accompany each other, I ftill hold them to
be diftinct  difeafes, to  be often occurring feparately,
and accordingly to require and admit of different re-
medies.  I Ihall therefore delay fpeaking of the reme-
dies proper for the cholic, till I Ihall come to treat of
this difeafe in its proper place.
                    CCCCXI.
   What might be mentioned  with refpect to the fup-
puration or gangrene occurring in the enteritis,  may
be fufficiently underftood from what has been faid on
the fame fubject  with refpect to the gaftritis.
               CHAP.    X.

OF THE HEPATITIS, OR  INFLAMMATION
                OF THE LIVER.

                    CCCCXII.
    THE  inflammation of the  liver feems to be of
     two kinds; the one acute,  the other chronic.
                   CCCCXIII.
  The acute is attended with  pungent pain; confi*
                                            dera-
             f See par. 435. 
OF   PHYSIC;
219
derablc pyrexia ;  a frequent, ftrong, and hard pulfe ;
arid high-coloured urine.
                   CCCCXIV.
  The chronic hepatitis very often  does not  exhibit
any of thefe fymptoms; and it is only difcovered  to
have have happened, by our finding in the liver, upon
diffection, large abfeeffes, which are prefumed to be
the effect of fome degree of previous  inflammation*
As this chronic inflammation is feldom to be certainly
known, and therefore does not lead to any determin-
ed practice,  we omit treating of it here, and fhall on-
ly treat of what relates to the acute fpecies of the he-
patitis*.
                   CCCCXV.
  The aeute hepatitis  may  be known by a pain more
or lefs acute in the right hypochondrium, increafed
by prefhng upon  the part.   The  pain is very often in
fuch a part of the fide as to make it  appear like that
of a pleurify ;  and frequently, like that too, is increaf-
ed on refpiration.  The  difeafe is, in fome inftances,
alfo attended with a cough, which is commonly dry,
but fometimes  humid; and when the  pain thus re-
fembles that of a  pleurify,   the  patient  cannot lye
ealily except upon the fide affected.
  In every kind of acute hepatitis,  the pain is often
extended to the clavicle, and to the top of the fhoul-
der.   The difeafe is attended fometimes with hickup,
and fometimes with vomiting.   Many practical writ-
ers have mentioned the jaundice, or a  yellow colour
of the {kin and eyes,  as  a very conftant fymptom  of
of the hepatitis j  but experience has fhown,  that  it
may often occur without any fuch fymptom f.
                    E e 2                 CCCC-
  * It is doubtful whether this chronic hepatitis ever exilts.
  f This fymptom generally appears, however, after the dihafc
has continued for  three or four days ;  perhaps, indeed,  it  might
have been prefent in the beginning, for it is  frequently fo flight as
to efcape obfervation. 
223
PRACTICE
                   CCCCXVT.
   The remote caufes of hepatitis are not always to be
difcerned, and many have been affigned on a very un-
certain foundation.  The following feem to be fre-
quently evident,   i.  External violence from contu.
fions or falls, and efpecially thofe which have occafion-
ed a fracture of the cranium.  2. Certain paffions of
the mind.   3. Violent fummer-heats.   4.  Violent
exercife.   5. Intermittent and remittent fevers.   6,
Cold  applied  externally and internally;  and-there-
fore,  in  many cafes the fame  caufes which produce
pneumonic inflammation,  produce hepatitis ;  and
whence alfo the two difeafes are fometimes joined to-
gether.   7. Various folid concretions or collections of
liquid matter, in the fubftance of the liver, produced
by unknown caufes.  Laftly,  The acute is often in-
duced by a chronic inflammation  of this vifcus.
                   CCCCXV1I.
   It has  been fuppofed, that the  hepatitis may be an
affection  either of the extremities of the hepatic ar-
tery, or of thofe of the vena potarum ;  but of the laft
fuppofiticn there is neither evidence nor probability.
                  CCCCXVIII.
   It feems prpbable, that  the acute hepatitis is always
an affection ojf the external membrane of the liver, and
that the parenchymatic is of the  chronic kind.  The
acute difeafe may be feated either on the convex or
on the concave furface of the liver.  In the former
cafe, a more pungent pain and hickup may be pro-
duced, and the refpiration is more conliderably affect-
ed.  In the latter, there occurs lefs pain ; and a vo-
miting is produced, commonly by fome inflammation
communicated to the ftomach.  The inflammation of
the concave furfcee of the liver, may be readily com-
municated to the gall-bladder and biliary ducts ;  and
this perhaps is "the only cafe of idiopathic hepatitis at-
tended with jaundice.
                                           cccc- 
OF   PHYSIC.
221
                     CCCCXIX.
   The hepatitis,  like other inflammations,  may end
 by refolution, fuppuration, or gangrene ; and the ten-
 dency to the  one or the other  of thefe events, may
 be known from what has been delivered above.
                     CCCCXX.
   The refolution of hepatitis is often the confequence
 of, or is attended with, evacuations of different kinds.
 A  hemorrhagy,  fometimes  from the* right noftril,
 and fometimes from the hemonhoitlal veffels, gives a
 folution of the difeafe.  Sometimes a bilious dianhoea
 contributes to the fame event; and therefolution of the
 hepatitis, as of other inflammations, is  attended with
 iweating, and with an evacuation of urine depoming
 a copious fediment.   Can this difeafe be  refolved by
 expectoration?   It would feem  to be fometimes cur-
 ed by an eryfipclas appearing in  fome external part.
                    CCCCXXI,
   When  this difeafe has ended in fuppuration, the
 pus collected may be difcharged by the biliary ducts;
 or, if the fuppuratcd part does not any where adhere
 clofely to the  neighbouring parts, the pus may be dif-
 charged  into the  cavity of the abdomen : but if, du-
 ring the firit ftate of inilammation, the affected part of
 the liver fhall have formed a clofe adhefion to iome of
 the neighbouring parts, the difcharge of the pus af-
 ter fuppuration may  be various,  according to the dif-
 ferent feat of the  abfeefs.  When feated on the con-
 vex part of the liver, if the adhefion be  to the perito-
 naeum  lining  the common teguments,  the pus may
 make its way through thefe, and be difcharged out-
 wardly :  or, if the adhefion  ihould  have been to the
 diaphragm, the pus may  penetrate through this, and
                                              into
  * And the left alfo.  ft was a fancy of Galen's that inflammato-
ry fevers were only refedved by fuch hemorrhage trcm therig!;l nol-
tiil, and refolved  an inflammatory of the liver ; but a dUch-i£*
from the left,  an  inflammation of the fpleen. 
222
PRACTICE
into the cavity of the thorax, or of the lungs ; and
through the latter may  be difcharged by coughing.
When the abfeefs of the liver is feated on its 'concave
part, then, in confequence of adhefions, the pus may
be difcharged into the ftomach or the inteftines ; and into
thefe laft, either directly, or  by the  intervention of
the biliary ducts.
                   CCCCXXII.
  The prognoftics  in this difeafe are eftablifhed upon
the general principles  relating to inflammation, upon
the particular circumftances of the liver, and upon the
particular ftate of its inflammation.
  The cure of this difeafe muft proceed upon the ge-
neral plan ; by bleeding,  more or lefs, according to
the urgency of pain and pyrexia ; by the application
of blilteis;  by fomentations, of the external parts in
the ufual manner, and of the internal parts by fre-
quent emollient glyfters; by frequently opening the
belly by means of gentle laxatives,  and by diluent
and refrigerant remedies.
                  CCCCXXIII.
  Although, in many  cafes, the chronic hepatitis does
not clearly difcover itfelf; yet, upon many  occafions,
it may perhaps  be difcovered^  or at  leaft  fufpected,
from thofe caufes which might affect the liver (ccexvi.)
havingbeen  applied; from fomefulnefsand fometenfe-
nefs of weight in the right hypoGhondrium; from fbme
mooting pains at times felt in that region; from fome
uneaflnefs or pain felt  upon preffure in  that part; from
fome uncafinefs from lying upon the left fide; and  laft-
ly, from fome degree of pyrexia, combined with more
or fewer of thefe fymptoms.
  When from fome of thefe circumftances a chronic
inflammation is to  be fufpected,  it is to be treated bv
the fame remedies  as in the laft  paragraph, employed
more or lefs, as  the degree of the feveral fymptoms
fhall more diitinctly indicate.
                                     CCCCXXIV. 
OF  PHYSIC.
22S
                   CCCCXXIV.
 ^ When from either kind of inflammation a fuppura-
tion of the liver has been formed,  and the  abfeefs
points outwardly, the part muft be opened, the puse-
vacuated, and the ulcer healed according to the ordi-
nary rules for cleanfing and healing fuch abfeeffes and
ulcers.
                  CCCCXXV.
  I might here confider the Splenitis, or inflammation
of the fpleen; but it does not feem neceffary, becaufe
the difeafe very feldom occurs.  When it does, it
may be readily known by the character given in our
Nofology ; and its various termination, as well as the
practice  which it requires, may be  underftood  from
what has been already faid with refpect to the inflam-
mations  of the other abdominal vifcera.
              CHAP.     IX.

OF THE NEPHRITIS,  OR THE  INFLAMMA-
          TION OF THE KIDNEYS.

                   CCCCXXVI.
    THIS difeafe, like other internal inflammations, is
     always  attended with pyrexia ; and is efpecial-
ly known from the region  of the kidney being affected
by pain, commonly  obtufe, fometimes pungent.  This
pain is not increafed by the  motion  of the trunk of
the body, fb much as a pain of the rheumatic kind af-
fecting the fame region.  The pain   of the nephritis
may be often diftinguifhed by its fhooting along the
courfe of the ureter ; and is frequently  attended  with
a drawing up of the tefticle, and with a numbnefs of
the limb on the fide  affected ; although, indeed, thefe
                                       fymptoms 
224
PRACTICE
   fymptoms moft commonly accompany the inflammaT
   tion arifing from a calculus in the kidney or in the ure-
   ter.   The nephritis is almoft conftantly attended with
   frequent vomiting, and alfo with coftivenefs and chq-
v   lie pains.  Ufually  the ftate of the urine is changed ;
   it is moft commonly of a deep red colour,  is voided
   frequently and in fmall quantity at a time.   In more
   violent cafes, the urine is fometimes colourlefs.
                     CCCCXXVII.
     The remote caufes of  this difeafe may be varioufr:
   as, external  contufion ; violent or long-continued rid-
   ing ; (trains of the mufcles of the back incumbent on
   the kidneys; various acrids in the courfe of the circula-
   tion conveyed to the kidneys; and perhaps fome other
   internal caufes not yet well known. The moft frequent
   is that of calculous  matter obstructing the tubul; uri-
   niferi, or  calculi formed  in the pelvis of the kidneys^
   and either flicking there, or fallen into the ureter.
                      CCCCXX/III.                .;'
     The'various event of this difeafe may be underftood
   from what«i*as been delivered  on the fubject of other
   inflammations.
                      CCCCXXIX.
     Writers, in treating of the cure of nephritis, have
   commonly at the fame time treated of the cure of the
   Calculus Renalis: but, though this may often produce
   nephritis, it  is to be confidered as a diftinct and fepa-
   rate difeafe;  and what I have to offer  as  to the mode
   of creating it,  muft be  referved to its  proper place.
   Here i fhall treat only of the cure of the Nephritis
   Vera or  Idiopathica.
                      CCCCXXX.
     The cure  of this proceeds upon the general plan, by
   bleeding, external  fomentation, frequent  emollient
   glyfters, antiphlogiftic  purgatives,  and the free ufe of
   mild  and demulcent liquids*.  The  application of
                                               b lifters
     * Thifc h:ve a!! beea enumerated in fome cf the preceding n.'.cs. . 
OF   PHYSIC
225
blifters is hardly  admiiBblej or,  at leaft,  will require
great care, to avoid any confide! nolo abforption of the
cantharides*.

   Vol.  I.                 F f             CCCCXXXI.

   * This is a very neceflary caution.   BHtters generally affect the
urinary organs and veffels, occafioning much irritation,  and cor.fc-
quently increafing the inflammation.   As the author is rather fhort
in his directions for the cure of this very troublefome inflammation,
it nriy be propei to add fome particular directions forregulatiug our
praftice in thefe cafes.
   An ulcer in the kidneys is extremely difficult to heal;  we on<>ht
therefore  always to  attempt the cure of nephritis by  refolution.
The general remedies for anfvvering this  intention  have been  fre-
quently enumerated,  efpeciallyin the  notes on Art. 1  ?^,  131.---
The paiticular remedies more peculiarly adapted to this  difeafe are
demulcent drinks of  the  foftell natuie, and fuch as  are leaft apt
to irritate the parts ; as  lintfeed-tea,  decoction of marftimaiLr.vj,
&c.  Nitre has  been recommended among the  general antiphlo'dftic
remedies ; but,  in nephritis its  ufe is  doubtful, on  account of it»
palling quickly by  the kidgeys, and irritating them.
   A difficulty of making water is one of the fymptoms of this dif-
eafe, and  fome practitioners  recommend  heating diuretics.  This
practice, however, is extremely hurtful, and  ought  to Jj^jcarefuliy
avoided, becaufe thefe warm medicines, as tuipentiues, balfams, Sec.
alway3 increafe the irritation, efpecially in the urinary  pafTa^es.
   As the colon preffes immediately on the kidneys, efpecialiv on
the right one, we fhould be  particularly careful to keep it empty,
whicb is belt done by  glyfters.   Befide the ufe of glyfters in evacu-
ating the contents  of  the  colon,  they  act as  a fomentation to the
inflamed part ;  we ought theicfore, in thefe cafe?, to  prescribe them
larger than ufual, and repeat  them often.   They ought to be ex-
tremely emollient, and void of every ingredient that  is  any way Ui-
mulating.   A quart of thin barley-water or lintfeed-tea anlwersthe
purpofe as completely  as any of the more compound emollient gly Iters
of the Pharmacopoeias.   With refpect to diet and legimeu,  we nuy
obferve th.it lenient nourifhment is highly ptoper ; for every thing
acrid naturally forces itf.1: off by  the urine,  and confequently in-
eicafe;the irritation.   A total abftinence from food is by no means,
advifable,  becaufe, from  abltinence, little urine  is fecreted, and
the fmaller'the quantity fecreted  it is generally the  more acriJ, and
confequently noxious.   Tie patient ouy.hr. to be made to Ik  up -,'s
much as poffible.   \V>rm  foft beds, which are always  improper in
all inflammatory difeafes, are peculiaily hurtful in nephiitis, efpeci-
ally if the patient lies on lib back ; for in :Lis pafition the  ki'Jt;-/; 
 126             PRACTICE

                     CCCCXXXI.
  The Cyftitis, or inflammation of the bladder, is fel-
dom a  primary difeafe ;  and  therefore is not to be
treated of here.   The treatment of it, fo far as necef-
farv to be explained, may be  readily underftood  from
what has been alreadv delivered.
                     CCCCXXXII.
   Of the  vifceral inflammations, there remains  to be
confidered the inflammation of the Uterus ; but 1 o-
mit it here, becaufe the confideration of it cannot be
feparated from that of the difeafes of child-bearing wo-
 men.

               .<..<..<..<•<•■<••<• <<..<.<,$, %t>>. >..>..>..>..>..>..>.>.>«

               CHAP.     XII.

             OF  THE RHEUMATISM.

                    CCCCXXXIII.
      OF this difeafe  there  are two fpecies, the one nam-
       ed the  Acute, the other the Chronic rheuma-
 tifm.
                    ACCCXXXIV.
   It is the acute Rheumatifm which efpecially belongs
 to this  place,  as from its caufes, fymptoms, and me-
 thods of cure, it will appear to be a fpecies of phleg-
 mafia or inflammation.
                                         CCCCXXXV.
 are kept very warm, and are at the fame time preffed by the fuper-
 incumbent weight of the abdominal vifcera, all which will contribute
 to increafe the inflammation.  Although lying much in bed  bedif-
 app:oved, the patient ought by no means to be overfatigue^ with
 fitting too long.  The room fhould be moderately  cool, and the
 bed fpringy, but not foft.   In addition to what was faid above re-
 fpecting blifters in this difeafe,  it may be neceffary to obferve, that
 other veficauts befides cantharides maybe ufed, fuch as muftard poul-
 tices, commonly called finapifms, a poultice of frefh leaves  of the
 ranunculus acris, and other  acrid plant?. 
OF  PHYSIC.
227
                  CCCCXXXV.
   This difeafe is frequent  in cold, and more uncom-
 mon in warm climates.  It appears moft frequently
 in autumn and fpring, lefs frequently in winter when
 the  cold  is confiderable and conftant,  and very fel-
 dom during the heat offummer.  It may occur, how-
 ever, at any feafon, if viciflitudes of heat and cold be
 for the time frequent.
                  CCCCXXXVI.
   The acute  rheumatifm generally arifes from the ap-
 plication of cold to the body when any way unufualiy
 warm;  or when one part of the body  is  expofed  to
 cold whilft the  other parts are kept warm; or, laftly,
 \vhen the application of the cold is long continued, as
 it is  when wet or moift clothes are applied to any part
, of the body.
                  ccccxxxvir,
   Thefe caufes may affect: perfons of all ages ; but the
 rheumatifm feldom appears in either very young or eU
 derly perfons,  and moft commonly occurs  from the
 age  of puberty to that of thirty-five years*.
                 ccccxxxvni.
   Thefe caufes (ccccxxxvi.) may alfo affect perfons of
 any conftitution; but they moft commonl) affect thofe
 ofafanguine temperament.
                 ccccxxxix.
   This difeafe is particularly  diftinguifhed by piins
 affecting  the joints, for  the moft, part the joints alone,
 but fometimes  affeding  alfo the mufcular parts.  Ve-
 ry often the  puns fhoot along the courfe of the  muf-
 cles, from one joint to another, and are always much
 increafed by the adion of the mufcles belonging to the
 joint or joints affected.
 J                  CCCCXL.
   The lamer joints are  moft ftequentlv affected ; fuch
  ' '                F f 2          '            *s
   *  There are  many inllances, howeve-, of rheumatifm extrenuly
 ieci'.te in old people. 
22S           PRACTICE

the hip-joint, and knees of the lower, and the moul-
ders  and elbows of  the upper, extremities.  The an-
kles  and wrifts are  alfo frequently affeaed ; but the
fmaller  joints,  fuch as thofe of the toes or fingers,
f-ldom fuffer.
                   CCCCXLI.
  This  difeafe although confined to one  part of the
body only,  yet very often affects many parts of it;
and then it comes on  with a cold ftage, which is im-
mediately fuccecded by the other fymptoms of pyrex-
ia, and particularly  by a frequent, full, and hard pulfe*",
Sometimes the pyrexia is formed before any pniosare
perceived ; but more  commonly pains are felt in par-
ticular parts, before any fymptoms of pyrexia appeal;
                   CCCCXLII.
  When no pyrexia is prefent, the pain is  fometimes,
confined to one joint only j but,  when any confiden-
ble pyrexia is prefent, although the p.nin may be chiefly
in one joint, yet it feldom happens but that the pains
affect feveral joints  often at the  very fame time, but
tor the  moft part (hifting  their  place, and,  having a-
bated in one joint,  become more violent in another.
They ■ do not  commonly remain long in  the  fame
joint, but frequently  fhift from  one  to another, and
fometimes return to joints formerly affeded; and in
this  manner the difeafe often  continues  for a long
time.
                   CCCCXLIII,
   Tho  pyrexia attending this diftafe has an exacer-
bation every evening, and is moft confiderable during
the night, when the pains alfo become  more violent;
and  it  is at the fame time that the pains fhift their
place from one joint to another,  The pains feem to
be alfo increafed during the night, by the body  being
covered more clofelv, and kept warmer.
                  "CCCCXLIV.
  A  joint,  after h:i\in:; been for fome time affected H
                                             with, 
             O F   P H Y  S I C.            220
                         i
with pain, commonly becomes affeded alfo with fome
rednefs and fwelling, which is painful to the touch.
It feldom happens, that a fwelling coming on does not
alleviate the pain of the joint; but  the  fwelling does
always take off the pain entirely, nor fecure the  joint
againft a return of it.
                   CCCCXLV.
  This difeafe is commonly attended with fome fweat-
ing, which occurs early in the courfe of the difeafe;
but it is fjldom free or copious, and feldom either re-
lieves the pains or proves critical.
                  CCCCXLVI.
  In the  courfe of this difeafe the  urine h  high co-
loured, and in the beginning  without fediment; but
as the difeafe advance^, and the pyrexia has more con-
fiderable remiiUons,  the  urine depoiites a lateritious
fediment. This, however, does not prove  noitely cri-
tical; for the difeafe often continues long after fuch
a fediment has appeared in the urine.
                  CCCCXLVII.
  When blood is drawn in this difeafe it always ex-
hibits the appearance mentioned ccxjxvii.
                 CCCCXLVIII.
  The acute rheumatifm, though  it has  fo lmuh of
the nature of the  other phlegmafite,  differs  from all
thofe hitherto mentioned, in this, that it is not apt to
terminate in fuppuration.   This almoft never happens
 in  rheumatifm : but th *  difeafe fometimes  produces
ei'bfioRS of a tranfparent gelatinous fluid into the fheaths
of the tendons.   If wc may be allowed to fuppofe that
fuch effufions  are frequent, it  muft alio happen, that
the effufed fluid is commonly  reabforbed ;  for it has
feldom happened, and never indeed to my obfervati-
on, that confiderable or permanent tumours, h.ve been
pro J need, or fuch as require to be opened, and to have
tie contained fluid evacuated.   Such tumours, howe-
\crf- have occurred to others, znd the opening  m;vue 
233
PRACTIC  E
 in them has  produced  ulcers difficult to heal.  Vide !
 Storck. Ann. Med. II.
             0    CCCCXLIX.
  With the circumftances mentioned from ccccxxxix.
 to ccccxlviii.  the difeafe often continues for feveral
 weeks.  It feldom, however, prove fatal ; and it rare-
 ly happens that the pyrexia  continues to be confidera-
 ble  for  more than two or three weeks.  While the
 pyrexia abates in its violence, if the pains of the joint!
 continue, they are lefs  violent, more limited  in  their
 place, being confined commonly to one or a few joints
 only, and are lefs ready  to change their plaee.
                     CCCCL.
   When the pyrexia attending rheumatifm has entire-
 ly ceafed; when the fwelling,  and particularly the
 rednefs  of the joints, are entirely  gone ; but when
 pains ftill continue to affed  certain joints, which re-
 main ftiff,  which feel uneafy upon  motion,  or upon
 changes of weather, the difeafe is  named the Chro-
 nic  Rheumatifm, as  it very often continues for a  long
 time.  As the chronic is commonly the fequel of the
 acute  rheumatifm, I think  it proper to treat of tho
 former alfo in this place.
                    CCCCLI.
   The limits between the acute and chronic rheuma-
 tifm are  not always exadly marked.
   When the pains are ftill ready to fhift their place;
 when  they are efpecially fevere in the night time;
 when, at the fame time, they are attended with fome
 degree of pyrexia, and with  fome fwelling, and efpe-
 cially with fome rednefs of the joints ;  the difeale is
 to be confidered as ftill partaking the nature of thea-
 cute rheumatifm.
  But, when there is no degree of pyrexia remaining;
when the pained joints are without rednefs; when  they
are cold and ftiff;  when they cannot eafily be made  j
to fweat;  or when, while a free and warm  fwe*]t is
                                          brought j 
O F   P<H Y S  I  C.
231
brought out on the reft of the body, it is only clam-
my and cold on the pained joints; and when, ef^ci-
ally,  the pains of thefe joints are increafed by  cold,
and relieved by heat applied to them ;  the cafe is to
be confidered as that of a purely chronic rheumatifm.
                     CCCCLII.
  The chronic rheumatifm may affed different joints;
but is efpecially ready to affed thofe joints which  are
furrounded with  many mufcles,  and  thofe of which
the mufcles are employed in the moft  conftant and
vigorous exertions.  Such is the cafe of the vertebrae
of the loins,  the affedion of which is named Lumba-
go; or that of the hip-joint, when the difeafe is nam-
ed Ifchias, or Sciatica.
                     CCCCL1II.
   Violent ftrains and fpafms occurring on fuddcn and
fomewhat violent exertions, bring on rheumatic  af-
fedions, which at  firft partake of the acute, but very
foon change into the nature of the chronic rheumatifm.
                     CCCCL1V.
   I have thus delivered the. hiftory of  rheumatifm ;
and fuppofe, that, from what  has  been faid,  the  re-
mote caufes, the diagnofis, and prognofis of the difeafe,
may  be underftood.   The diftindion of the rheuma-
tic pains from thofe refembling them, which occur in
the fyphilis  and fcurvy, will  be obvious, either from
the feat of thofe pains, or from the concomitant fymp-
toms peculiar  to  thefe difeafes *.   The diftindion of
                                               rheu-
  * To diflinguifh the chronic rheumatifm from venereal or Icorbu-
tic pains, is, however, in fome cafes, extremely difficult, and often
requires the utmoit fagacity  of the practitioner.  A due-attention
to the caufes of rheumatifm, recited in the foregoing articles,
and a  ftrift examination whether the patient has been fubjeftcd to
thefe caufes, will fometimes determine the difeafe : but it often hap-
pens,  that the fame caufes v/hich produce rheum: tifn, alfo  exacer-
bate venereal and fcorbutic pains.  No general rules can be delivered
on this fubjeft ; and the practitioner mud truit to his own I-o^ity
fqr Ji.xiuuu in this uakult ci.-tiofis. 
 232            PRACTICE               1

 rheumatism from gout will be more fully underftood
 from who: :s to be delivered in the following chapter.
                    CCCCLV.
   With refpeft to the proximate caufe of rheumatifra,
 there have been various  opinions.  It  has been im-
 puted to a peculiar acrimony ;  of which, however, in
 ordinary cafes, I can find no evidence;  and from the
 confideration of the remote caufes, the fymptoms, and
 cure of the difeafe,  I think the fuppofition very im-
 probable.
   The caufe of  an  Ifchias Nervofa a digued  by Co-
 tunnius, appears to me hypothetical, and is notfup*
 ported by cither the phenomena  or method of cure.
 That, however, a difeafe  of a  iheumatic nature may
 be occafioned by an  acrid matter applied ro the nerve>,
 is evident from the toothach, a rheumatic affediongt-
 nerally arifing from  a carious tooth.
   That pains refertibling thofe of rheumatifm may a-
 rife from deep-feated fuppuvatioi\s, we know from fome
 cafes depending on  fuch a caufe, and which, in their
 fymptoms, referable  the lumbago or ifchias. I believe,
 however, that by a  proper attention, thefe cafes de-
 pending on  fuppuration, may be  commonly  diltin-
 guifhe&&coi the  genuine cafes of lumbago ;md ifchi-
 as ; anavrrom what is faid in ccccxlviii.  I judge it to
 be at leaft improbable, that a genuine lumbago or if-
 chias does ever end  in fuppuration.
                   CCCCLVI.
 ' The proximate caufe of rheumatifm  has been by
many fuppofed to be a lentor of the fluids obftructi:ihr
 the veflels of the part; but the fame confideration us
in ccxli.  i, 2, 3, 4, and 5, will  apply equally  here
for rejeding the fuppofition of a lentor.
                   CCCCLVII.
 While I cannot, therefore,find cither evidence or rea-
fonforfuppofingthat the rheumatifm depends upon .my
change in tlie ftate of tlie fluids, I muft conclude, tint
the proximate  caufe of acute rheumatifm, h common- 
              O  F  P H Y  S I C.           233

ly the fame with that of other inflammations not de-
pending upon a dired  ftbuulus.
                  CCCCLViil.
  In the cafe of rhtu natiim, 1 fuppofe, that the moft
common re note cauic of L, that is  ^.,lu applied, ooe-
rates efpecially on the veiitls <-i joitiii, ;;o:n  ti.'-fe
being lefs  cowred by a cedular texture than thofe of
the intermediate parts  eft he limbs.  I tupi^fe fur-
ther, that  the application of cold produces a c  m.ric-
tion of the extreme veffels on the iu.hue, and at the
fame time an increafe  of tone or ph. .,;lh.c oi.:thtfis
in  the courfe of them, fiom uhich arife b on increaf-
ed impetus of the blood, an :, at the i.ne true, a  e-  *
fifiance to  the  free paffa>/e ot it. and c nf ^iKitly in-
flammation and pain.  Forth r,  1 i.n p t<:,  that the
refiftance formed excites cut- vis muhcaaix to a further
increafe of the impetus of the bf; >d ; and, to fupport
this, a cold ftage arifes, a fpafm  is fo.med, and  a py-
rexia and phlogiftic diathefis are produced in the whole
fyftem.
                    CCCCLIX.
  According to this  explanation, the caufe of  acute
rheumatifm  appears  to be exadly analogous to that
of the inflammations depending on an increafed  afflux
of blood to a part while it is expofed to theaction of
coi.i.
  But there feems to be alfo, in the cafe of rheuma-
tifm, a peculiar affedion of the fibres of the mufcle6.
  Thefe fibres feem to  be under  fome degree of rigid-
ity, and therefore lefs  eafily admit  of motion ; and
are  pained upon the  exertions of it.
  It is alfo an aftcdion of thefe fibres which gives an
opportunity to the propagation of pains from one joint
t) another, along the courfe of the mufcles, and which
pains are more feverely felt in the extremities of the
  Vol. I.            G  g                    mu- 
234           PRACTICE
mufcles terminating in the  joints,  becaufe,  beyond
thefe, the ' fcillations  are not propagated.
   This affedion of the mufcular fibres attending rheu-
matifm, feems to  explain why [trains and fpafms pro.
duce  rheumatic  affldtons ; and, upon the  vvh !c,
fhow;, that, with  an imh:noia:o y affedion of the fan-
guifer >us fyftem,  there is alfo in rheumatifm a peculiar
affedion of the mofcular fibres, which has a confider-
able fhare  in  producing the phenomena of the dif-
eafe.
                     CCCCLX.
   Having  thus given my opinion of the proximate
caufe of rheumatifm,  I proceed to treat  of the cure.
                   CCCCLXI.
   Whatever difficulty may  occur with refped to the
explanation given (cccclvib. and cccclix) this remains
certain, that in acute  rheumatifm, at leaft in  all thofe
cafes  which do not arife from dired ftimuli, there is
an inflammatory  affedion of the parts,  and a phlogi-
ftic diathefis in the whole fyftem ; and upon thefe is
founded the method of cure, which frequent experi-
ence has approved of.
                   CCCCLXII
   The cure therefore requires, in the firft place, an
antiphlogiftic  regimen, and  particularly a total abfti-
nence from animal food, and from  all  fermented or
fpirituous  liquors ; fubftituting  a vegetable or milk
diet, and the plentiful ufe of bland  diluent drinks.
                   CCCCLXIII.
   Upon the fame principle,  (ccccl ) at leaft with per-
haps the fame  exception as above, blood-letting is the
chief remedy of acute  rheumatifm.   The blood ought
to be  drawn in large  quantity ;  and the bleeding is
to be  repeated in  proportion to the frequency, fulnefs,
and hardnefs of the pulfe, and to the viohnce  of the
pain.   For the moft part, large and  repeated  bleed-
ings, during the firft days of the  difeafe, feem  to be 
OF  PHYSIC.
235
neceflary, and accordingly have been very much em-
ployed :  but to  this fome bounds are to be Lt ; for
very profufe bleedings  occafion a  flow recovery, and,
if not  abfolutely eftedual, are  ready to  produce  a
chronic rheumatifm.
                    CCCCLX1V.
   To avoid that debility of the fvftem, which general
bleedings are ready to occa-ion, the urgent fymptom
of pain may be ofi en  relieved by  topical bleedings;
and efpecially when  any  fwelling  and  rednefs have
come upon a joint, the pain of it may be very certain-
ly relieved by  fuch bleedings ; hut, ars the continuance
of the difeafe  feems to depend more upon the phlogi-
ftic diathefis of the whole fyftem, than upon the af-
fedion of particular  parts,  fo topical  bleedings will
not always fupply the  place of the general bleedings
propofed above*.
                    CCCCLXV.
   To take off the phlogiftic diathefis prevailing in this
difeafe, purging may be ufeful, if  procured by medi-
                                                  cines
   *  Thefe topical bleedings,  however, have, by repeated experience
been f mnd of eilcntial advantage, efpecially //hen the partial inflam-
mation has been very violent.  l'hey are beft performed by leeches,
many of which ought to be applied all over the inflamed part.  Cup-
ping lias been King the favourite practice of many phyficians,  but it
generally irritates more than  the leeches :  yet  in cafes that require
immediate relief,  it is  preferable to  them. The Glauber,  or Ep-
fum falts, are the moft convenient purges in all cafes of acute rheu-
matifm.  Either of them  may be given feparately, 01 joined with
tjie infufum fennae,  as in the following formula :
             j^,. Infus.  Senna? ^iii.
                Sa;. Glauber,  %Cs.
                Tinct. Jalap. 3i.
                Tindt. Aromat. jfs,
                M. f. haull.
The morefuddenly purges operate in acute rhcumr.tifms, the more
efficacious are they generally found ;  and as large diluting warm thin
liquors c nl'.dirably accelerate the operation  of all purges, fuch
pradice  is never  to be neglected in thefe cafes.  Cream of tartar
whey, mixed with twice its quantity of warm water, is a very pro-
per drink to aflilt the operation of purges. 
 236             PRACTICE

 cines which do not ftimulate the whole fyftem, fuch ai
 neutral fairs, and which have, in fome meafure, a refri-
 gerant  power.   Purging, however, is not fo power-
 ful as  bleeding,  in removing phlogiftic  diathefis;
 and, when the difeafe has become general and violent,
 frequent ftools are inconvenient, and even hurtful, by
 the motion and pain which they occafion.
                    CCCCLXVI.
    In acute rheumatifm, applications  to the  painful
 parts are of little fervice.   Fomentations, in  the be-
 ginn'ng of the difeafe,  rather aggravate  than relieve
 the pai-is.  The rubefacients and camphire are more ef-
 fedual in relieving the rn ins ; but generally they only
 fhift the pun from one part into another,and do little to
 wards "he cure of the general affedion. Blittering.applir
 ed to the paino I parr, may alfo be very effectual in remo-
 ving the pain fro on it : but will be of little ufe, except
 where the pains  are much confined  to one part.
                   CCCCLXVIL
   The  feveral remedies mentioned from  ccccli,  to
 cccclv.  moderate the violence of the difeafe,  and fome-
 times  remove it enthely;  but they fometimes fail in
 this, and leave the cure imperfed.   The attempting
 a cure by large  and  repeated bleedings, is attended
 with many inconveni-.mes, (fee cxl.) turd the moft  ef.
 fedualand  fafe method  ■■■fearing this  difeafe,  is, after
 fome general  bke^ing*  f r taking off, or at leaft dimi-
 nifhing, the phlogiftic diath-.lis, to employ  fweating,
 conducted by tiae rules laic doum clxviii, and clxix*.
                  CCCCLXVJII.
   Opiates, except where 'hey are direded to procu."
                                               fwe;f,
  *  Sweating is moft effectual  in this difeafe, when produced by
Dover's powder.   The dofe of it is 12 or 15 grains, repeated at h-
terva.'s, of two or three hour.-,,  till a fweat  be produced. Diluent
driuksaretobeufedwitb.it;  and  it may be neceffary to obferve,
that they ought to bf fuch as are bland,  and by no nu<.r,s itimulat-
ing; viz.  barley-water, lintlecd-tea,- thin water-gruel,  &c. 
                OF   PHYSIC.           237

  fweat, always prove hurtful in every ftage of this dif-
  PTlr
                     CCCCLXIX.
    The  peruvian bark hns been fuppofd a re~cdv in
  fome ca'es of this  difeafe;  but v/e 'have feldom  found
  it ufeful, and in fome cafes hurtful.   It appears to me
  to be fit in thofe cafes  only,  in  which  the phlogiftic
  diathefis is already  much abated, and where, at thefime
  time, the  exacerbations of the difeafe are maniUftiy
  periodical, with confiderable remifiions interpofedf.
                      CCCCLXX.
     Calomel, and fome other  preparations of mercury,
  have been recommended  in  the  acute rheumatifm;
  but I believe they  are ufeful only in caf^s of the chro-
  nic kind, or at leaft in cafes approaching to the  nature
  of thefe.
                       cccclxxi.
     Having now treated fully of  the cure of  the acute
  rheujmatifm, I proceed to treat of the cure •if the chro-
  nic, which is fo frequently a fequel of the former.
                      CCCCLXXII.
     The phenomena of the.purely chronic rheumatifrs,
                                             m-ntioned

    * Notwithftanding this caution, many practitioners  ufe opines
^ efpecially when joined with  camphor,  to pro ure .weat9 in acute
  rheumatifm.  This compound 11 .-vtr fails to increafe the pfbgillic
  diathefis, and conftquentiy muft be huitful.   In the chrcne rheu-
  matifm, indeed, camphor and opium together form a valuable medi-
  cine.  The dofe is the  following bolus :
               Ijj  Camphor, gr. vi.
                 Sp.  Vini,  gutt. ::.
                 Opii gr. i.
                  Tart Vitriol gr. xv.
                 Syr. q. f. M.7. bolus.
    T  B'tk is  a'.v.p'g an ambiguous  renu \y  in  rheun t.fm,  ana
  on its firft introduction into practice it was thought to occafion or
  induce the difeafe.  Wherever an itifhmm tory diathe'is prevails the
  Peruvian bark is always an improper medicine, .and it has been found
  by experience to be maniftilly hurtful in the beginning, or inflatn-
  nalory ilate of the rheumatii.n. 
= 38             P  R  A C T I C E

mentioned in ccccxxxix, and ccccxl. load me to eon.
cluee, that its proximate caufe is an atony, both of the
blood- .eTels and of the mufcular fibres of the part af-
fected, together with a degree of rigidity and contrac-
tion in the latter,  fuch as  frequently attends them in.
a ftate of atony.
                   CCCCLXXIIi.
   Upon this view of the proximate caufe, the senc-
rai indication of cure mult be, to reftore the activity
and vigour of the vital  principle in the part; and the
remedies for this  difeafe,  which experience has  ap-
proved of, are chiefly fuch as are manifeftly fuited 60
the indication propofed.
                    CCCCLXXIV.
   Thefe remedies are either external or internal.
   The  external  are, the fupporting the heat of  the
part, by keeping it conftantly covered with flannel;
the increafing the  heat  of  the  part by external heat,
applied cither in a  dry or  in a humid form; the dili-
gent ufe of the flefh-hrufh,  or other means of friction';
the application of electricity in  fparks or fhocks; the
application of cold* water by affufion or immerfionj
the application of efTential oils of the moft warm and
penetrating kind ;  the application of fait brine ; and,
ia:tiy, the  employment  of exercife, either of the part
itieTTo far as it can eafily bear it, or of the whole bo-
dy by rid in a or other mode of geftation.
                   CCCCLXXV.
   The internal  remedies are,  1. Large dofes of eflen*
tial oil drawn from refinous fubftances, fuch as turpen-
tinef ;  2.  Subftanccs containing fuch  oils, as guai-
                                               ac*;

  * This^ when compared with article 458 and other-, feems to be
e typographical error, and the author meant warm.   Practice aiiords
many inftances of chrjnic rheumatifm being  occafioned  by  cold
Lathing.                             b
  ■\ Terpentine is an extremely heating oil, as indeed are all tire
(fa. no J oils; its ufe therefoie requires the greateft  caution.  T!;c 
OF   PHYSIC.
239
ac* ; 3.  Volatile  alkaline falts :  4, Thefe,  or  other
medieines directed to procure fweat, (clxix.) and, laft-
ly,  Calomelf,  or  other preparation of mereury,  in
fm ill dofes, continued for fome time.
                     CCCCLXXVI.
   Thefe (cccclxiii, cccclxiv.) are the remedies fuccefs-
fully employed in  the  purely  chronic rheumatifm ;
and there are ftill others recommended,  as bleedings
general and topical, burning, bliftering, and iftues: but
thefe appear  to  me to be chiefly, perhaps only, ufeful
when the difeafe ftill partakes of  the nature of acute
rheumatifm |.
                                              C  H A  P.

dofe isftom 8 to 15 drops on  a piece of fugar.   Venice turpentine
may be more conveniently given in thefoim of an emtilfion, by <!ii*
folving it  in water by means of yolks of eg os-   Two  fcruple* of
turpentine is the ordinary dofe ; and when given in this liquid and
diluted ftate, is much preferable to the oil.
   *  The officinal preparations o: guaiacum, are an extract of the
wood, a folution of the gum  in rectified fpirit,  another in  volatile
a kali, and an empyreumatical oil.  The gum may be given in the
quantity of 15 or 20  grains for a dofe, either in a b >Ius, or made
into an emulfion with yolk of egg ana an  ounce or two of water :
In larger quantities is  is too purgative.   The volatile el.xir of the
Edinburgh Pharmacopoeia is an excellent f>rm, as the vol.itive fpirit
promotes the medicinal virtue of  the guaiacum    The dofe of it is
from a drachm to half an ounce, morning and evening, in any conve-
nient vehicle ; a tea-cupful of milk is the beft, as it (heaths in lo.ue
meafure  the pungency  of the medicine.  Guaiacum is  very conve-
nientlyjoined with rubatb and magnefia,  when we find that fuch a
dofe of it,  as is  neceffary for procuring a fufficient opening, would
be too heating.   A formula of this kind is defcribed in the note on
article 559.
  f  Calomel, perhaps, has only been ferviceable in ventre:.! caf:  .
  f  The diet in  the cure of chronic rheumatifm  ought  to be gi-ne-
rous and full.  In many cafes, efpecially among  people in p.ior cir-
cumllances, good living, with two or three glaffes of fherry in the
day,  has cured the  difeafe  without any medicines.  One material
circumftance ought not to be omitted  : viz.  that the cure is much
imped «1  by coftivenef* : if, therefore, the guaiacum does not procure
ovo motions in the day. it will be neceflary to give alon:» wit.i it
leu.e warm hxative. The tinftura facra is a proper medicine m tneie 
240
PRACTICE
              C  H  A  P.    XIII.

  OF THE TOOTHACH,  OR ODONTAGIA.

                  CCCCLXXVII.
I HAVE formerly confidered this difeafe as a fpecies
   of Rheumatifm to be  treated upon the fame princi-
ples as thofe delivered in the preceding chapter; but
now,  from  more attentive confideration, I ana led to
confider the toothach as  a diftinct difeafe.  Whilft the
moil of what  has been  delivered .in the laft chapter
proceeds upon the fuppofition that the rheumatifm de-
pends upon  a certain ftate of  the  blood-veffels and of
the motion of the blood in them, without this being
produced by the irritation of any  acrid  matter appli-
ed : 1 judge, that in the toothach, though there are of-
ten the fame  circu'aitances in the  ftate of the blood-
veffels as in the cafes of rheumatifm, thefe chcum-
ftances in toothach  always arife from  the  application
of an  acrid matter to the nerves of the teeth.
                    CCCCLVIII.
  This difeafe is often no other than a pain felt in a
Particular tooth, without any inflammatory affectionbe-
iflflffeit the fame time communicated to the neighbouring
parts.   This,  however,  is rarely the cafe ;  and for the
moft part, together  \; ith the pain of the tooth  there
is fome degree of pain and  of inflammatory affection
communicated to the neighbouring parts, fometimes
to the whole of thofe on the  fame  fide  of the head
with the affected tooth
                  CCCCLXXIX.
  This inflammatory affection feems to me to be al-
ways  an  affection of mufcles, and of the membranous
                                              parti

cafes :  its rlofe is from one to two ounces : As is alfo the elixir fa-
crum of the Edinburgh  College Pharmacopoeia, its dofe may tc
from a drachm to half an uilu-, as occafion may require. 
OF  PHYSIC.
241
parts connected without any tendency to fuppuration •
and fuch an affection, as is excited by cold in  fimilar
parts elfewhere.   It is from thefe circumftances that
1 conclude the affection to be of the rheumatic kind
                 CCCCLXXX.
  It is poffible that the mufcles and membranes of the
jaw may be affected  by the fame caufes which pro-
duce the rheumatifm in other parts ;  and it is alfo pof-
fible,  that a rheumatic diathefis at firft produced by
irritation,  may fubfift  in the mufcles and membranes
of the jaw, fo that the  inflammatory affection may be
renewed by certain caufes without any new applica-
tion of  acrid matter : but I am perfuaded that either
of thefe occurrences are very rare, and I have never
been able to afcertain any cafes of toothach to be of
thefe kinds.  I confider it, therefore, as highly proba-
ble  that  this rheumatic affection of the jaws which we
name  toothach, is always dependent upon fome im-
mediate  application of  acrid matter  to the nerves of
the teeth.
                 CCCCLXXXI.
  It is however to be  obferved, that this application
of acrid  matter does not always excite  a pain in the
tooth  itfelf, or an inflammatory affection of the neigh-
bouring  parts ; but that it very often  operates by pro-
ducing a diathefis only ; fo that cold applied to the
neighbouring parts  does excite both  a pain in the
tooth, and an inflammatory affection of the neighbour-
ing parts which did not appear before.
  There  feem to  be alfo certain ftates of the  body,
which operate upon the fame diathefis,  fo as  to pro-
duce toothach.  Such feems to be the cafe of preg-
nant women, who are more liable to  toothach than
other  women.   There are probably alfo fome cafes of
increafed irritability which render perfons more fub-
ject to toothach.  Thus women  are more  liable to
  Vol.  I.              H h                   the 
242           PRACTICE

the difeafe than men, and particularly women liable to
hyfteric affections.
                  CCCCLXXXII.
   The  acrid  matter producing  this difeafe feems to
be  generated firft  in the  hard fubftances of  the
teeth ; and as  it often  appears firft upon the external
furface of thefe, it might be fufpected to arife from the
application of external matters  to the teeth:  but as
the production of this acrimony is often begun in the
internal cavity of the teeth, where the operation of
external  matters  cannot be fufpected, and as even
when it begins upon  the external parts of  the teeth,
the operation of the caufe is at  firft in a fmall portion
of the teeth only,  that it is difficult to fuppofe that
any matter externally applied could act in fuch a parti-
at manner ; fo it  is prefumed that the acrid matter oc--
cafioning the toothach is produced by fome vice ori-
ginating in the fubftance of the tooth itfelf.  When
it begins upon the external furface, it is on the ena-
mel ; but upon the  internal furface, it muft  be in the
bony part.   From what  caufes  it arifes in  either of
 thefe fubftances, I do not at all know ; but I fufpect that
 it often arifes from fome more general fault in the flu-
 ids of the body.   The frequent ufe of mercury, efpe-
 cially when thrown much upon the mouth, and the
 ftate of the fluids in fcurvy, feem both to give a difpo-
 fition to  a  caries in the teeth;  and it is poffible that
 fome other acrimonious ftates of the fluids  may have
 the fame effect.
                  CCCCLXXXIII.
    A caries in fome part of  the teeth, whether arifing
 upon their internal furface or upon  their external,
 proceeding fo far as to reach the nerves in the cavity
 of the teeth is pretty manifeftly the caufe of toothach,
 an 1  of the firft attacks of it: but when the cavity of
 the teeth has been opened,  fo that the external air or
 other matters can reach the cavity, thefe are often the
                                            exciting 
OF   PHYSIC.
243
exciting caufes of toothach, and ferve to prove in ge-
neral, that acrid matters applied to the nerves occafion
the difeafe.
                  CCCCLXXXIV.
  What is the  nature of  the matter produced in the
caries of the teeth,  I do not underftand,  nor have I
found any proper corrector of it; but I prefume it to
be of the putrid kind, as it often taints the breath with
a fetid odour.
                  CCCCLXXXV.
  In the cure of  this difeafe, a  long experience has
fhown, that the extraction of the carious tooth proves
the moft effectual, and  very  often the only effectual,
remedy of the difeafe.   But  as in fome cafes this ex-
traction is not  proper, and as in many cafes it is ob-
ftinately avoided,  other means of curing the difeafe,
or at  leaft of relieving the pain, have been fought for
and much practifed.
                 CCCCLXXXVI.
  Among  thefe remedies, thofe  are likely  to be the
moft effectual which entirely deftroy the affected nerve,
or at  leaft fo much of it as is expofed to the action of
the acrid matter  in the tooth.  When an opening  is
made into the cavity of the tooth, the nerve of it may
be  deftroyed moft certainly by  the  actual cautery ;
and may it alfo poffibly be done by the application of
potential cauftics, either of  the alkaline or acid kind.
               CCCCLXXXVIL
  When thefe remedies cannot be rendered effectual,
relief may often be  obtained by  diminiihing the fen-
fibility of the nerve affected, by the application of o-
piura, or of the more acrid aromatic oils*, and direct-
ly to the nerve in the tooth.  It appears alfo, that the
                                            fen fib i-
  * The Oleum Origani is  the oil generally ufed for this purpofe.
Great care muft be taken in ufing either thefe acrid eflential oils, or
the vitriolic or other mineral acids, that no pait of them touch the
gums. 
«44
PRACTICE
 fenfibility of the affected nerve may often be for fome
 time diminifhed by the external application of opium
 to the extremities of thofe nerves in the fkin,  which
 are branches of the  fame fifth pair  of nerves with
 thofe of the teeth.
                CCCCLXXXVIII.
   When the difeafe confifts entirely in a  pain  of the
 nerve of the tooth, without any confiderable affection
 communicated to the  neighbouring parts, the reme-
 dies already mentioned are thofe efpecially to be em-
 ployed ; but when the difeafe confifts very much in an
 inflammatory affection of the mufcles and membranes
 of the jaw,  and when  at the fame time there is little
 or no accefs for the abovementioned remedies to  the
 affected nerve,  other meafures are to be employed for
 relieving the difeafe.
                 CCCCLXXXIX.
   If the difeafe be attended with any general phlogif-
 tic diathefis of the fyftem, or with any coniiderable
 degree of pyrexia, a general bleeding may be  ufeful
 in relieving the difeafe;  but thefe  circumftances  oc-
 cur very rarely, and the  difeafe is for the moft part
 a purely topical affection ; in which, as I obferved be-
 fore, a general bleeding is of very little fervice.  As
 this difeafe, however, is a  topical inflammation, it
 might be fuppofed that topical bleedings would be ve-
 ry ufeful, and fometimes they are fo ; but it is feldom
 that their effects are  either  confiderable or perma-
 nent.   The reafons of this I take to be that the dif-
 eafe does not confift in an affection of the blood-veffels
 alone, as in the ordinary cafes of rheumatifm; but in
 a peculiar affection of  the  fibres both of the mufcles
 and of the veffels of the part induced  by irritation.
The inefficacy of topical bleedings is with me a proof
of the difeafe being of the latter kind.
                   ccccxc.
  The remedies therefore neceffary to give relief in
                                              this 
OF  PHYSIC.
245
this difeafe, are thofe which take off the fpafm of the
veffels,  and efpecially of the  mufcles and membranes
affected.   Such as bliftering, brought  as near to the
part affected as can be conveniently done*; and fuch
are alfo increafed excretions excited in the neighbour-
ing parts, as of  the faliva and mucus of the mouth
by the ufe of acrid mafticatories§.   It is  often fuffici-
ent to excite a ftrong  fenfation in the neighbouring
parts;  as by eau  de luce, fpirit of lavender,  or hun^
gary water fnuffed up the noftrils; or by the vitriolic
aether property  applied to the cheek.   It is upon the
fame footing ilia*; I fuppofe brandy or other ardent
fpirit held in the mouth  is often of fervice.
                      CCCCXC1.
   There  are cafes  of toothach in which it does  not
appear that the difeafe arifes from an  acrid matter im-
mediately  applied to  the nerve of  a  tooth ; but from
                                                     the

   * Blifters are applied moft fuccefsfully behind  the ears, fuch ap-
plications however, are always troublefome ; and their effefts are
often doubtful, other milder ftimul.uits frequently anfwer all the in-
tention of blifters,  and by  many practitioners arc  thought  to be
equally efficacious.  The applications generally ufedare camphorated
fpirit, or volatile alkali.   This laft, either alone,  or mixed with an
equal quantity of oil of almonds, rubbed on the jaw, the part being
kept warm by a piece of flannel, has often been found extremely
ufeful.  Warmth, any how produced on the part, always gives re-
lief; while, on the contrary, cold always exafperatesthe fymptoms :
hence the propriety of covering the ja»vs with flannel, and avoiding
a cold ftream of air.
   § Thefe  are horfe-radifh, fcurvy-grafs, the greater celandine,
with fome others; but the radix pyrethri is the bed.   In fome Phar-
macopoeia, but I do not recoiled which, there is a  formula, called
Trochifci Sialagogi, to the beft of my remembrance, as followi:
           R. Pulv. Rad. Pyrethri, £i.
              Gum. Maltich. gfs.
              01. Caryophyll. aromat.
              01. Mar] >ranse  a a 51.
              Cen*- Alb. g. f. ut! f. Trochifci.
One of thefe held in  the mouth, or chewed, promotes a copious
difcharge of fvlivi,  by warming and Simulating the fa.ivan- ^ands. 
246          PRACTICE
the external application of cold, or fome other caufei
immediately applied to the mufcles and membranes of
the jaw;  and which therefore feem to require fome
remedies different from thefe abovementioned.   But
in fuch cafes, it is to be fufpected, that the effects of
cold or of other  fuch caufes are owing to  a  diathefis
produced by an  acrid  matter applied to the nerve of
a tooth, and continuing in fome meafure to act there;
and we have accordingly often found, that the action
of thofe external caufes were  to be obviated only by
the extraction  of the tooth from which the diathefis
had arife n.
              CHAP.    XIV,

                OF  THE GOUT,

                   CCCCXCII.
     THE Gout, not only as it occurs in different per-
      fons, but even as it occurs in the fame perfon at
different times, is a difeafe of fuch various appearance,
that it is difficult to render the hiftory of  it complete
and exact, or to give a character of it that will uni-
verfaliy apply. However, I fhall endeavour to defcribe
the difeafe as it moft commonly appears, and to mark
the varieties of it as well as I  can.   From fuch a hif-
tory I expect that a general character may be given ;
and fuch I think is  the following, as given in the laft
edition  of our Nofology :
          GEN.   XXIII.   PODAGRA.
  Morbus hasreditarius, oriens fine caufa externa evi-
dente, fed praseunte plerumque  ventriculi affectione
mfohta; pyrexia; dolor ad articulum et plerumque
                                             pedis 
u f   p  n*Y s  i c.
247
pedis pollici,certe pedum et rnanuum juncturis, potif-
fimum infeftus;  per intervalla revertens, et feepc cum
ventriculiet  internarum partium affectionibus  alter-
nans.
                    ccccxcm.
   The Gout is generally a hereditary difeafe: but fome
perfons, without hereditary difpofition, feem to acquire
it; and, in fome a hereditary difpofition may be coun-
teracted by various  caufes.   Thefe circumftances may
feem to give  exceptions to  our general  pofition;  but
the facts directly fupporting it are very  numerous.
                      ccccxciv.
   This difeafe attacks  efpecially the male fex: but it
 fometimes, though more rarely,  attacks  alfo the fe-
 male*.  The females liable to it are thofe of the more
                                                   robuft

   * Hippocrates fays, that  women feldom have the gout, and ne-
 ver before the difappearance of the  catemenia.  In his  time and
 country, perhaps, the ladies were more temperate than they  were
  in other ages and in other places.  We find the gout a familiar dif-
  eafe among the Roman  ladies ; which, Seneca, in his ninety-fiith
( epiltle jultly afcribes to the  luxurious living and debaucheries, in
 which they indulged without controul.
   As the whole of that epiftle is an  excellent account of the dire-
  ful effects of  high living and debauchery, it may not be unaccepta-
  ble to the young praftitioner, who, perhaps, might otherwife be
  unacquainted with fo juft a defciiption of luxurious living, and its
  concomitant evils.  Independent of its containing a minute relation
  of Roman cuftoms, which makes it a valuable morfel for antiqua-
  ries, it may be read with peculiar advantage by the young phyfi-
  cian.
    As an apology for giving it in the original, I fhall fay  of Seneca
  what au elegant Englilh writer fays of Cicero ;  that any translation
  of his nervous language, is like the faint glimmerings of a taper
  compared with the blazing light of the meridian fun.
    Medicina  quandam paucarum  fuit fcientia herbarum, quibus
  fiftcretur fanguis fluens, vulncra coierent paulatim.  Deinde in banc
  pervenit tarn multiplicem vaiietatem.  Nee mirum tft:  tunc illam
  minus  negotii habuiffe, firmis adhuc, folidifque corporibus,  et fa-
  cilicibo,  nee per artem voluptatemque corrupto.  Qui  poftquam
  cccpit, non ad tolendum, fed ad irritandam, famern quaeri,  et in-
  vents funt multa» conditurir, quibus auviditas excitareter: qua dc- 
248             PRACTICE

robuft and full habits;  and  it very often  happens to
fuch long before the  menitrual evacuation  has ceaied.
          6                     "'                          I

fiderantibus alimenta erant, onera funt plenis.  Inde pallor, et ner-
vorum vino madentium tremor, et miferabilior ex cruditatibus quam
ex fame macies.  Inde incerti labantium pedes,  et Iemper qualis in
ipfa ebrietate titubatio.   Inde in totam cutem humor admifliis, dif.
tcntus venter, dum male afluefcit plus capcre, quampoterat.   Inde
fuffufio luriUae bilis,  et decolar vultus,  tabefque in fe putrelcentium,
tt retorti  digiti articulis obrigefcentibus, neivoruni line fenfujacen-
tium,  torpor aut palpitatio  fine intermiffione vibrantium.  Quid
capitis vergines dicam ?   Quid  oculorum auriumque tormenta, ct
cerebri aelhiantis verminationes,  etomni per qua;  exoneramur inter-
nis ulceribus aljjt&a ? Jnnumerabilia praeterea febrium genera, aliarum
impetufubeuntrum, aliarum tenui pelte repentium, aliarum cumhor-
rore et multa  mtmbroruni quaffatione venicntium ? Quid alios re-
ferum innumerabilos morbos, fupplicia luxuriae ?  Immunes erantab
illis ma.Iis qui noiidum fc deliciis  folverant, qui fibi imperabant,  fibi
miniftrabant.   Corpora opera ac vero labore durabant, autcurfude-
fatigati, aut venatu, aut  tellure verfata.   Excipiebat illor cibu»qui
nifi efurientibus placere non  poterat.  Itaque  nihil opus erat tarn
magna medicorum fupellectile, nee tot ferramentis atque pyxidibus.
Simplex erat ex fimplice caufa valetudo.   Multos morbox multa fer-
cula feceiunt.   Vide quantum rerum. perunam gulam  tranfiturarura
permifceat luxuria,  terrarum marifque vailatvix.   Necefie eiiitaquc
inter  fe tarn diverfa diflideant,  et haulla mali digeiantur, uliis olio
nitentibus.  Nee mirum,  quodinconftans variufque ex d.lcordi cibo
morbus eft, et  ilia ex coutrariis naturae paribus in eudem compulfa
redundant.  Inde tarn nullo aegrotamus genere quam vivimus.  Max-
imus ille medicorum, et hujus fcientiae conditor,  feminij nee capil-
los dufluere dixit,  nee pedes laborare.  Atqui  hae jam  et capillis
deftituuntur, et pedibus  aegras funt.  Non  mutata feminarum  ri-
tura,  fed vita eft.   Nam cum virorum licentiam asqua vtrint, corpo-
rum quoqe virilium vitia ajquaverunt, Non minus per vigilant, non mi-
nus potant, etoleoet mero viros  provocant. ./Equeinvitisingefta vif-
ceribus per os reddunt, et vinum omne vomitu  remetiuntur ; aeque
nivein  rodunt, folatium ftomachi asltuantis.   Libidi.ii vero nee n.a-
ribusquidem cedunt,  pati nata? Dii illasdcaeque male perdant:  adeo
perverfum  commentae genus impudicitTaS  viros  ineuut.   Quid ergo
mirandum elt, maximum medicorum ac naturaeperitiflimum, inmen-
dacio  prehendi, cam tot femina.'podagricae calvaeque fmt.  Benefi*
cium  lexus lui  vitiis perdiderunt; et quia feminani excrunt, damna-
tae funt morbis virilibus.   Antiqui medici nefciebant dare cibum he-
pius,  et vino fulciri venas  cadentea;  nefciebant fanieui cmittere,  et
tiiutiuam segrotatioucm bainco fudoribufque iaxare ; nefciebant cru- 
OF   PHYSIC.
249
I have found  it occurring  in  feveral females, wfiofe
menitrual evacuations were more abundant than ufual.
                      CCCCXCV.
   This difeafe feldom attacks eunuchs,  and when it
does, they feem to be thofe who happfc to be of a  ro-
buft  habit, to lead  an  indolent life,  and  live very
full.
                     CCCCXCVI.              >_
   The gout attacks efpecially men of robuft and large
bodies, men of large heads, of full and corpulent  ha-
 bits, and men whofe ikin is  covered  with  a thicker
rete muccfum,  which gives a coarfer furface. j
                      CCCCXCVII.
   If, with the ancients, we might afcertain, by certain
 terms, the temperaments of men, I  would  fay,  that
 the gout attacks efpecially men  of  a choleric-fanguine
   Vol. I.                   I i                    tem-

 rum vinculo, brachiorumque,  latentem vim, et in medio fedentem,
 adextrema revocare.  Non erat necefle circumfpicere multa auxili-
 orum genera cum eflent periculorum pauciflima.  Nunc autem quam
 longe procefferunt mala veletudinis ? Has ufuras voluptatum pendi-
 mus, ultra modum fafque concupitarum.   Innumerabiies effe mor-
 bos miraris ? Coquos numera.   Ceflat omne (tudium :  et liberalia,
 profelfi, fine ulla frequentia, defertii angulis praelident.   In rhtto-
 ruin ac phiiofophorum fcholis folitudo eft.  At quam celebres cnli-
 nx funt? Quanta nepotum focos juventus premit ? Tranfco puero-
 rum infelicium greges ; quos poft tranfacta convivia  aliae cubiculi
 contumeliae expectant.  Tranfeo agmina exoletorum per nationts co-
 lorefque defcripta ; et eadem omnibus levitas fit, eadem prima? men-
 fura languinis, eadem  fpecies capillorum, ne quis cui  " redtioriit
 " coma, crifpulis mifcatur.   Tranfeo  piltorum  turbam, tranfeo
 " mitiiliratorum, per quos figno dato ad inferendam coenam difcurri-
 " tur. Dii boni  quantum hominum unus venter exercet! Qiud tu
 " illos boletos, voluptarium venenum, nihil oculti operisjudicasfa-
 '* cere, etiamfi prselentanei non furant ? Quid tu  illam asftivam ni«
 " vem non putas callum jeci noribus obducere ? Quid ilia oftrea, in-
 " ertiflimam carncm, coenofaginatam,  nihil exiftimaslimefae gravi-
 '^ tatis inferred  Quid  illud fociorum garum,  pretiofam pilciuni fa-
 " nicm, non c red is urere fal fa tabe praecordia ? Qiid iila purulenta,
 " et quae fantum non ab ipfo vifceiibus extingui ? Quam fcedi atque
 " pellilcntes ructus funt,  quantum faltidium  fui,  cxbalantibus  cra-
 " pulain yeterem i" 
PRACTI  C E
 terrperamcnt,  and that it very  feldom attacks the
 purely fanguine or melancholic.  It is, however, very
 difficult to treat this matter with due preciiion.

                   CCCCXCVIII
   The gout fetdom attacks perfons employed in con-
 ftant  bodily  labour,  or perfons who live much upon
 vegetable aliment.  It is  alfo faid to be lefs frequent
 among thofe people who make no ufe of wine  or o-
 ther fermented liquors.
                   CCCCXCIX.
   The gout does not  commonly attack men, till after
 the age of five  and thirty; and generally not till a
 ftill later period.  There  are  indeed inftances of the
 gout occurring more early ; but thefe are few in com-
 parifon of the  numbers which agree with  what we
 have given as the general  rule.  When the difeafe
 does appear early in life,  it feems to be in thofe in
 whom the hereditary  difpofition is very ftrong, and to
 whom the remote caufes to be  hereafter mentioned
 have been applied in a confiderable degree.
                       D.
   As the gout is a hereditary difeafe, and affects efpe-
 cially men of a particular habit, its remote caufes may
 be confidered as predifponent and occafional.
                       DI.
   The predifponent caufe, fo far as expreffed by ex-
 ternal appearances or by the general temperament, we
 have already  marked ; and phyficians have been very
 confident in afligning  the occafional caufes : but, in a
 dueafe depending fo much upon a predifpofition, the
 afligning occafional caufes  muft be uncertain; as
 in the predifpofed,  the  occafional caufes may not al-
 ways appear, and in perfons not predifpofed, they may
 appear without effect.   This  uncertainty muft parti-
cularly affect the cafe  of the gout;  but I fhall  offer
what appears to me moft probable on the fubject. 
OF  PHYSIC.
251
                         DII.
  The occafional  caufes of the gout  feem to be of
t\vo kinds.   Firft,  thofe which induce  a plethoric
ftate of the body.   Secondly, thofe which, in pletho-
ric  habits, induce a ftate of debility.
                          Dili.
  Of the firft kind are a fedentary indolent manner of
life, a full diet of animal food,  and the  large ufe of
wine or  of other fermented liquors.   Thefe circum-
ftances commonly  precede  the difeafe ;  and if there
fhould be any doubt of their power of producing it,
the fact, however, will be rendered fufficiently proba-
ble by what has been obferved in ccccxcviii.
                         DIV.
  Of the fecond kind of occafional caufes which  in-
duce  debility are, excefs in  venery* ;  intemperance
in the ufe of intoxicating liquors § ;  indigeftion, pro-
duced either by the quantity or  quality of aliments f ;
much  application to ftudy or bufinefs J ; night-watch-
                         I i  2                   ing ||;
  * Why excefs of venery fliould be caufe of gout, has much en-.
gaged the  attention of medical writers, and various reafons have
been given why it fliould produce fuch an effeel.   There is not the
leaft doubt of the fact,  though fome authors have ventured to deny
it, and  have excluded the excefs of venery from being a caufe of
gout.   It produces  gout not primarily,  but fecondarily, if 1 may
be allowed the expreflion, by inducing a general ftate of debility,
and by weakening the power of digeltion,*both of which circum-
ftances are caufes of the gout.
  § By intemperate drinking the action of the ftomach and bpwels
becomes extremely feeble and languid, if it be not wholly deftroyed ;
hence continual indigeftions, to which the origin of the gout is at-
tributed.
  f Both the quantity and the quality of the aliments may produce
indigeftion ;  and hence the indulging in too great a quantity of ali-
ment, as well as in that which is of an indigeitiblc nature, are lecon-
dary caufes of the gout: viz. caufes which induce a ftate of debi-
lity.                                        .  .
  % Much application to ftudy may doubtlefs induce indigeftion, and
thus increafe the general ftate of delibity : it is not, however, by
intenfe,  or deep thinking merely, that  men grow pale amid their
books, but by the fedent.- v life which men generally lead, and th* 
252
PRACTICE
ing || ; exceffive evacuations ^f ;  the ceafing of ufual
labour*;  the fudden"change /rom a very  full to a
very fpare diet § ;  the  large  ufe of  acids  and  ace-
fcents f ;  and,  laftly,  cold X  applied to the  lower
 extremities.
                          DV.
   The firft (diii.) feem  to act by increafing the pre-
difpofition.   The laft (div.) are commonly the excit-
ing caufes, both of the firfl attacks, and of the repeti-
tions of the difeafe.
                        DVI.
   It is an  inflammatory affection of fome of the joints,
which efpecially conftitutes what  we call a paroxyfm
of the  gout.   This  fometimes  comes on  fuddenly
without any  warning, but is is generally preceded by
feveral fymptoms; fuch as the  ceafing of  a fweating
which the feet had been commonly affected with  be-
fore ; an unufual coldnefs of the feet and legs; a  fre-
quent numbnefs, alternating with a fenfe of prickling
along the whole  of the lower extremities  ;  frequent
cramps of the mufcles of the  legs ;  and an  unufual
turgefcence  of the veins.
                                                 DVII,
untimelylucubrationsin which they inconfideratelyindulge. Much ap-
plication to bufinefs can only be an occafional caufe of the gout, when
the bufinefs requires a fedentary and inactive life ; but as moll bufinefs
requires activity, attention to bufinefs is  feldom the cairfe of gout.
   |j  The want of fleep i's always a  caufe of indigeftion, and in-
creafes debility more perhaps, when earned to excefiT, than any other
 of the circu.nftances mentioned by the author.
   f  Tint large evacuations induce,debility is fufliciently evide.it.
      Nothing more  effcitu ally promotes digeflion than proper exer-
 cife  ; the leaving off accu!!omcd labour muft therefore neceflarily
 induce indigeftion and conf quent debility.
   §   Why this  induces debility is evident. See note on article 549,
   +  That  acids, by impairing the digeftive powers of the ftomach,
 .nay produce debility, is what  every practitioner allows.
   I  How  cold thus applied,  can produce a ftate of debility, is not
 very evident.   It is, however, one of the occafional caufes of gout,
 »j expeiience fufficiently teiiines. 
OF  PHYSIC.
2S3
                   .   DV1I.
  While thefe fymptoms take place  in the lower ex-
tremities, the whole body is affected with fome degree
of torpor and languor,  and the functions  of the fto-
mach in particular are more or lefs  difturbed.  The
appetite is diminifhed,  and flatulency, or other fymp-
toms of indigeftion, are felt.   Thefe fymptoms,  and
thofe of dvi.  take place for feveral  "days,  fometimes
for  a week or two, before a paroxyfm comes on : but
commonly,  upon the  day immediately preceding it,
the appetite becomes greater than ufual.
                      DVIII.
  The circumftances of paroxyfms are the following.
They  come on moft commonly in the fpring,  and
fooner or later according as the vernal heat fucceeds
 fooner or later to the winter's cold ;  and perhaps foon-
 er  or later alfo according  as the body may happen  to
be  more or lefs  expofed  to  viciffitudcs of  heat and
 cold,
                        DIX.
    The attacks are fometimes felt firft in the evening,
 but more commonly about two or three o'clock of the
 morning.   The paroxyfm begins with a pain affecting
 one foot, moft commonly in the ball or firft joint  of
 the great toe, but fometimes in other parts of the foot.
 With the coming on of this pain, there is commonly
 more  or lefs of cold fhivciing, which, as the  pain in-
 creafes, gradually ceafes,  and is fucceeded by a hot
 ftage  of pyrexia, which continues  for the  fame time
 with the pain itfelf.   From the firft attack,  the pain
 becomes by degrees more violent,  and  continues  in
 this ftate with great reftleffnefs of the whole body, till
 next  midnight, after which it gradually remits; and,
 after  it has continued for twenty-four hours from the
 firft attack, it commonly  ceafes very entirely, and with
 the coming on of a gentle fweat, allows the patient to
 fall aileep.   The patient, upon coming out of this fleep 
254
PRACTICE
in the morning, finds the pained part affected with
fome rednefs and fwelling, which, after having coiir
tinued for fome days, gradually abate.
                      DX.
   When  a paroxyfm  has thus come on, although the
violent pain after twenty-four hours be confiderably
abated, the patient is  not  entirely relieved from it.
For fome  days he has  every evening a return of more
confiderable pain and pyrexia, and which continue with
more or lefs violence till morning.  After continuing in
this manner for feveral  days, the difeafe fometimes
goes entirely off, not to return till after a long interval.
                      DXI.
   When the difeafe, after  having thus remained for
fome time in  a  joint; ceafes very entirely, it general-
ly leaves the  perfon in very perfect health,  enjoying
greater eafe and alacrity in the functions of both body
and mind, than he had for a long time before experi-
enced.
                      DXII.
   At the  beginning  of the difeafe, the returns of h
are fometimes only once in  three or four years:  but,
after fome time, the intervals become fhorter, and the
attacks become annual; afterwards they come twice
each year, and at length recur feveral times during the
whole courfe of autumn, winter,  and  fpring ;  and as
it  happens that, when the  firs are frequent, the pa-
roxyfms become alfo longer, fo, in the  advanced ftate
of the difeafe,  the  patient is hardly ever tolerably free
from it, except perhaps for two or  three months in
fummer.
                     DXIII.
   The progrefs of the difeafe is  alfo marked by the
parts which it affects.  At  firft, it commonly affects,
one foot  only ; afterwards every paroxyfm  affects,
both feet,  the one after the other; and, as the difeafe
continues to recur, it not  only affects both feet at
                                             once, 
O  F  P WT  S I C.
255
once, but after having ceafed  in  the foot which was
fecondly attacked, returns again into the foot firft af-
fected,  and perhaps a fecond time alfo into the other.
Its changes of place are not only from one foot to the
other,  but alfo from the feet into other joints, ef-
pecially thofe of the upper and lower extremities;  fo
that there is hardly  a joint of the body that is  not,
on one occafion or other, affected.  It fometimes af-
fects two different joints at the fame time ; but more
commonly it is fevere in a fingle joint only, and paff-
es fucceffively from one joint to another ; fo that the
patient's affliction is often protracted for a long time.
                     DXIV.
  When the difeafe has often returned, and the pa-
roxyfms have  become very  frequent, the  pains are
commonly lefs  violent than they were at firft ; but
the patient is  more affected  with  ficknefs, and the
other fymptoms of the atonic gout, which fhall be
hereafter mentioned.
                    '  DXV.
  After the  firft paroxyfms of the difeafe, the joints
which have been affected are entirely reftored to their
former fupplenefs and ftrength : but after the difeafe
has recurred very often, the joints affected do neither
fo fuddenly nor fo entirely recover their former ftate,
but continue weak and ftiff; and thefe effects at length
proceed to  fuch a degree, that the joints lofe their mo-
tion altogether.
                     DXVI.
  In many perfons, but not in all, after the difeafe
has frequently recurred, concretions of a chalky na-
ture are formed upon the outfide of the joints, and ii.r
the moft  part immediately under  the fkin.  The
matter feems  to be depofited at firft in  a fluid form,
but afterwards becomes dry and  firm.   In their dry
flate, thefe concretions are a friable earthy fubftance,
very entirely foluble in acids.  After they have been
                                            fo.m- 
256
PRACTICE
formed, they c. ntribute,  with other  circumftancci,
to deftroy the n;o:ion of the joint.
                     DXVII.       \
   In moft perfons who  have laboured under the gouf
for many years a nephritic  affection conies on, and
difcovers itfelf by all the fymptoms which  ufually at-
tend calculous concretions in the kidneys, and which
we fhall have  occafion to defcribe  in another place.
All that is neceffary to be obferved  here is, that  the
nephritic affection alternates  with paroxyfms of  the
gout, and  that the two affections, the nephritic and
the gouty, arc hardly  ever prefent at the fame time.
This alfo may be obferved, that children of gouty or
nephritic parents, commonly inherit one or  other of
thefe difeafes ; but whichever  may have  been  the
principal difeale of the parent, fome of the children
have the one, and fome the other.   In fome of them,
the nephritic affection  occurs alone, without any gout
fupervening ;  and this happens to be frequently  the
cafe of  the female offspring of gouty parents.
                     DXVIII.
    In  the  whole of  the hiftory  already  given I
hav"ev4e^?'ibed the moft common form of the difeafe;
and which therefore, however diverlified in the man-
ner I  have  faid,  may  be ftill called the regular ftate
of the gout.   Upon occafion, however, the difeafe af-
fumes different appearances* ;  but,  as I fuppofe the
difeafe  to depend always  upon a  certain diathefis or
difpofition of the fyftem;  fo every appearance which
we can perceive to depend upon that fame difpofiti-
on, I fhall confider as a fymptom and cafe of the gout.
                                                The
 * Thefe different appearances which the grut affumes, are extreme-
ly unlike  the regular gout above  defcribed; 'he young practitioner
ought therefore to pay peculiar attention to them,  that when he ob-
ferves them in patients, he may  not think them fymptoms of other
 difeales, or even miilake them for primary difeafes.  En ore of this
kind are  frequently committed by ignorant practitioners, to  their
own difcredit and tiie danger „f their patient's life. 
OfPHYSlC.
*57
The principal circumftance in what we term the Re-
gular gout, is the .inflammatory affedion of the joints;
and, whatever fymptoms we can perceive  to be con-
nected with, or to depend upon, the difpofition which
produces that inflammatory affection, but without its
taking place, or  Being prefent at the fame time,  we
name the Irregular Gout.
                     DXIX.
  Of fuch irregular  gout  there are three different
ftates, which I name  the atonic, the retrocedent, and
the mifplaced gout.
                     DXX.
  The atonic ftate is  when the gouty diathefis pre-
vails in the fyftem, but, from certain caufes, does not
produce the inflammatory affection of the joints.  In
this cafe,  the morbid fymptoms which  appear are
chiefly affections of   the  ftomach;  fuch as lofs of
appetite, indigeftion, and its various circumftances of
ficknefs, naufea,  vomiting,  flatulency, acrid eructati-
ons, and  pains in the  region of the ftomach.  Thefe
fymptoms  are  frequently  accompanied  with pains
and cramps in feveral  parts of the trunk, and the
upper extremities of  the body,  which  are reliev-
ed  by the difcharge of wind  from  the ftomach.
Together  with  thefe  affections  of  the  ftomach,
there commonly occurs a  coftivenefs;  but fome-
times a loofenefs with cholic  pains.   Thefe affect-
ions of the alimentary canal are often attended with
all  the  fymptoms of hypochondriafis;  as  dejecti-
on of mind, a conftant and  anxious attention to the
flighteft feelings, an imaginary aggravation  of thefe,
and an apprehenfion of danger from them.'
  In the fame atonic  gout,  the vifcera of the thorax
alfo are fometimes affected, and palpitations, faint-
ings, ani afthma, occur.
  In the head alfo occur, headachs, giddinefs, apo-
plectic and paralytic affections.
  Vol. I.           K  k                 DXXI. 
258             PRACTICE

                      DXXI.
   When the feveral  fymptoms nowjnentioned occur
in habits having the marks of  a gouty difpofition,
this may be fufpected to have laid the foundations
of them ; and efpecially when either, in fuch habits,
a manifeft tendency to the inflammatory affection has
 formerly  appeared ; or when the fymptoms mentioned
are intermixed with, and are not relieved by,  fome
degree  of the inflammatory gout.  In fuch cafes there
can be  no doubt of confideiing the whole as a ftate of
the gout.
                     DXXI I.
   Another  ftate of  the difeafe I name the rettocedent
gout.   This occurs  when an inflammatory ftate of
the  joints has,  in the ufual manner, come on, but
which,  without arifing to the ordinary degree of pain
and inflammation, or, at  leaft, without thefe continu-
ing for  the ufual time,  and receding gradually in the
ufual manner, they fuddeniy and entirely ceafe, while
fome internal part becomes affected.   The internal
part moft commonly affected is the ftomach, which is
then affected with anxiety, ficknefs, vomiting, or vio-
lent pain ;  but fometimes the  interrial part is the
heart, which gives occafion to a fyncope; fometimes
it is the lungs which are affected with  afthma; and
fometimes it is the head, giving occafion to apoplexy
or palfy.  In  all thefe cafes, there can be  no doubt
of the fymptoms being all a part of the fame difeafe,
however different the affection may feem to be in the
parts which it attacks.
                    DXXIII.
   The  third ftate  of irregular gout, which we name
the mi/placed,  is when the gouty diathefis, inftead of
producing the inflammatory affection  of the joints,
produces an inflammatory affection of fome internal
part, and  which appears from the fame fymptoms that 
OF  PHYSIC.
259
 attend  the inflammation  of thofe parts arifing from
 ether caufes.
   Whether the gouty diathefis does ever produce fuch
 inflammation of the internal parts, without  having
 firft produced it in the joints, or if the inflammation
 of the internal part  be always a tranflation from the
 joints previouily aflfedsd, 1 dare not determine ; but,
 even fuppofing  the latter to be always the cafe, I
 think  the difference of the affection of the internal
1 part muft ftill diftinguifh the mifplaced from what I
 have named the Retrocedent Gout.
                       DXXIV.
   What internal parts may be affected by the  mif-
 placed gout I cannot precifely fay, becaufe I have ne-
 ver met witji any cafes of the mifplaced gout in my
 practice; and I find no cafes  of it diftindly marked
 by pra&icai writers, except that of a  pneumonic-
 flammation.
                      DXXV.
   There are two cafes of atranflated gout ; the one of
 which is an affection of the neck of the bladder,  pro-
 ducing pain, ftrangury, and a catarrhus veficae :  The
 other is an  affection of the rectum, fometimes by pain
 alone  in that part,  and  fometimes by hsemorrhoidal
 fuellings there.  In gouty perfons, I have known fuch
 affections alternate with inflammatory affections of the
 joints: But whether to refer thofe affections to the retro-
 cedent, or  to  the mifplaced gout, 1 will not prefume
 to determine.
                      DXXVI.
   From the hiftory  which I have now delivered of
 the gout, I think it  may be difcerned under all its  va-
 lious  appearances,   it is, however, commonly fup-
 pofed, that there are cafes in which i«; may be difficult
 to diftinguifh gout from rheumatifm, and it is poffible
 there  may be  fuch  cafes  : but, for the moft part,  the
 tv. o difeafes may be Jiiilinguifhed  with groat oeitainty
                       K. k i                    ky 
360             PRACTICE

by obferving the predifpofition, the antecedents, th«
parts affeded, the recurrences  of  the difeafe, and its
connedion with the other parts of the fyftem; which
circumftances, for the moft part, appear very different,;
ly in the two difeafes.
                     DXXVII.
   With refped  to the gout, our next bufinefs is to in-
veftigate its proximate caufe ;  which muft be a diffi-
cult talk, and I attempt it with fome diffidence.
                     DXXVIII.
   Upon this fubjed, the opinion which has generally
prevailed is, that the gout depends upon a certain mor-
bific  matter, always prefent in the body ; and that this
matter, by certain caufes, thrown upon the joints orother
parts, produces the feveral phenomena of the difeafe.
                      DXXIX.
   This  dodrine,  however ancient  and  general, ap-
pears to me very doubtful ; for,
   Firft, there is no dired evidence of  any morbific
matter being prefent in perfons difpofed to the gout.
There are  no experiments  or obfervations which ihow
that the blood, or  other humours of gouty perfons,
are in any refped different from thofe of other perfons.
Previous to attacks of the gout, there appear no marks
of any morbid ftate of the fluids ;  for the difeafe gene-
rally attacks thofe perfons who have enjoyed the moft
perfed health, and appear to be in that ftate when the
difeafe comes on.  At a  certain period of the difeafe,
a peculiar matter indeed appears in gouty perfons,
(dxvi.) but  this, which does not appear in every in-
itanee,  and which appears only  after the difeafe has
fubfifted for a long time, feems manifeftly to be the ef-
fed, not the caufe of  the difeafe.  Further, though
there be certain acrids which,  taken into the body,
feem to excite the gout (div.) it is probable that thefe
acrids operate otherwife in exciting  the difeafe,  than
by affording the material caufe of it.   In general,
                                          therefore, 
OF   PHYSIC.          26i
therefore, there is no proof of any morbific matter be-
ing the caufe of the gout.
  Secondly, The fuppofitionsconcerning the particular
nature of the matter producing the gout, have been
fo various and  contradidory to each other, as to allow
us to conclude, that there is truly no proof of the ex-
iftence of any of them.   With refped  to  many of
thefe fuppofitions, they are fo  inconfiftent with chemi-
cal philofophy, and with the laws of the animal ceco-
nomy, that they  muft be entirely rejeded.
  Thirdly, The  fuppofition of a morbific matter being
the caufe of the  gout,  is not confiftent with the phe-
nomena of the difeafe, particularly with its frequent
and fudden tranflations from one part to another.
  Fourthly, The fuppofition is further rendered impro-
bable by this, that, if a morbific matter  did exift, its
operation fhould be fimilar in the feveral parts which
it attacks;  whereas in feems to be very different,  be-
ing ftimulant and exciting inflammations in the joints,
but fedative and deftroying the  tone, in the ftomach :
Which, upon the fuppofition of particular matter  ad-
ing in both cafes, is not to be  explained by any  differ-
ence in the part affeded.
   Fifthly,  Some fads  alleged in proof of a morbific
matter,  arc  not  fufficiently confirmed,  fuch as thofe
which would  prove  the  difeafe to  be  contagious.
There is, however, no proper evidence of this, the
fads  given  being not  only few, but exceptionable;
and the negative obfervations are innumerable.
   Sixthly,  Some arguments  brought in favour  of a
morbific matter, are founded  upon a miftaken expla-
nation.   The  difeafe has been fuppofed to depend up-
on a morbific  matter,  becaufe it is hereditary.   But
the inference  is  not juft : for moft hereditary difeafes
do not depend upon any morbific matter, but upon a
particular conformation of the ftrudure of  the body,
tranfmitted from the parent to the offspring; and this
• 
■■* f) ^
PRACTICE
laft appears to be particularly the ctfe in^ the gout.
It may be alfo obferved, that hereditary difeafes, de-
pending upon a morbific matter, always appear much
more early in life than the gout commonly does.
   Seventhly,  The fuppofition of a morbific  matter
being the caufe  of the gout, has been hitherto ufelefs,
as it has not fuggefted any  fuccefsful method of cure.
Particular fuppofitions have often corrupted the prac-
tice,  and have frequently led from thofe views which
might be ufeful,  and from that pradice which expe-
rience had approved.  Further, though the fuppofi-
tion of a morbific matter has been generally received,
it has been as  generally negleded in pradice.   When
the gout has affeded the ftomach, nobody thinks of
correding the  matter fuppofed to be prefent there,
but  merely of reftoring the tone of the moving fibres.
   Eighthly,  The fuppofition of  a morbific matter is
quite fupernuous: for it explains nothing, without
fuppofing  that matter to produce a change  in the
ftate  of the moving powers ; and a change in the ftate
of the moving powers, produced by other  caufes, ex-
plains every circumftance, without the fuppofition of
a morbific matter; and, to this purpofe, it  may be ob-
ferved, that many of the caufes (div.) exciting the
gout, do not  operate upon the ftate of the fluids, but
diredly and folely upon that of the moving powers.
   Laftly, The fuppofition of a morbific matter is al-
fo fuperfluous; becaufe, without any fuch fuppofition,
I think the difeafe can be explained in a manner more
confiftent with its phenomena, with the laws of the a-
nimal ceconomy, and with the method  of  cure which
experience has approved.
   I now proceed to give this explanation ;  but, before
entering upon it, I muft premife  fome general obfer-
vations.
                     DXXX.
   The firft obfervation is, that the gout is a difeafe of
                                              the 
             o F  1HTY sic.            .&-

the whole fyftem, or depends upon  a certain "-er.eral
conformation and ftate of the body ; which manifeft -
ly appears from the fads  mentioned from ccccxciv,
to ccccxcvn.   £ut the general ftate  of  the fyftern
depends chiefly upon the ftate of its primary moving-
powers ;  and therefore the gout may be fuppofed to
be chiefly an affedion of thefe.
                    DXXXI.
   My fecond  obfervation is,  that  the gout is mani-
feftly an affedion of the nervous fyftem*; in which the
primary moving powers of the whole fyftem are lodg-
ed.  The occafional or exciting caufes (div.) are al-
moft all fuch as ad dircdly upon the nerves and ner-
vous fyftem ; and the greater part of the fymptoms of
the atonic or retrocedent gout are  manifeftly  affec-
tions of the  fame fyftem.   (dxx, and dxxii.)  This
leads us to feek for an explanation of the whole of the
difeafe in the laws of the nervous fyftem,  and  parti-
cularly the changes which may happen in the balance
of its feveral parts.
                    dxxxii.
   My third  obfervation is, that the ftomach,  which
has fo univerfal a confent with the reft of the fyftem,
it the internal  part that is the moft frequently, and
often  very considerably,  affeded by the gout.   The
paroxyfms of the difeafe are commonly preceded by
an affedion of the ftomach; (dvii.) many of the excit-
ing caufes (div.) ad firft upon the ftomach ; and the
fymptoms of the atonic and retrocedent gout (dxx,
dxxii.) are  moft commonly and chiefly affedions of
the fame organ.   This obfervation leads us to remark,
that there is a balance fubfifting between the ftate of
                                              th-i

  * Boerhaave after defcribing the difeafe, uy«, A hornm,  1262.
" From all which it appears that the proximate caule of the gout is
" a vitiated ftate of the moll minute, and confequently nervous vef-
" ftlsof the body ; and alfo i>f that fluid whici- 2oas th^-v.h -.'^
" nervei." 
 264           PRACTICE

 the internal and that of the external parts ; and,  in
 particular,  that the ftate of the ftomach is conneded
 with that of the external parts, (xliv.)  fo  that the
 ftate of tone in the one may be communicated  to the
 other.
                    JDXXX1II.
   Thefe  obfervations being premifed, I fliall now of-
 fer the following pathology of the gout.
   In fome perfons there is a certain vigorous and ple-
 thoric ftate of the fyftem (ccccxevi.) which, at a cer-
 tain period of life, is liable to a lofs of tone in the ex-
 tremities, (ccccxcix, dvi.) This is in fome meafure
 communicated to the whole fyftem, but appears more
 efpecially in the fundions of  the ftomach. (dvii.)
 When this lofs of tone occurs while the energy of the
 brain ftill retains its vigour, the vis  medicatrix natu-
 rae is excited to reftore  the tone of the parts ; and ac-
 complifhcs  it by exciting an inflammatory affedion in
 fome part of the extremities.    When this has fubfift-
. ed for fome days, the tone of the extremities, and  of
 the whole fyftem, are reftored, and the patient returns
 todiis ordinary ftate of health, (dxi.)
   <*                DXXXIV.
   This is the courfe of things, in the ordinary form
 of the  difeafe,  which we name the  regular gout ;
 but there are circumftances of the body, in which this
 courfe is interrupted or varied.   Thus when the ato-
 ny (dvi, dvii.) has taken place; if the re-adion (dix.)
 xlo not fucceed,  the atony  continues in the  ftomach,
 or perhaps in other internal parts, and produces that
 ftate which  we have, for reafons now obvious, named
 the atonic gout*
                    DXXXV.
   A fecond cafe of variation in the courfe  of the gout
 is, when, to the atony, the re-adion and inflamma-
 tion have to a certain degree fucceeded,  but, from
 caufes cither internal or external, the tone of the ex-
                                          tremities, 
              O F   P H Y S  I  C.          2%

tremities, and perhaps of the whole fyftem, is  weak-
ened ; fo that the inflammatory ftate, before it had ei-
ther proceeded to  the degree, or continued for the
time, requifite  for reftoring the tone of the fyilem,
fuddenly and entirely ceafes.   Hence the ftomach,
and other internal parts, relapfe into the Itate of ato-
ny ; and perhaps have  this increafed by the atony
communicated from the extremities :' All which ap-
pears in what we have termed the retrocedent gout.
                    DXXXVI.
  A third cafe of variation from the ordinary  courfe
of the gout,  isj when, to the atony ufually preceding,
an inflammatory re-adion fully fucceeds ;  but  has its
ufual determination to the joints by fome circumftan-
ces  prevented ; and is therefore direded ro an inter-
nal part, where it produces an inflammatory affedion,
and that ftate of things which we have named the mif-
placed gout.
                   DXXXVII.
  We  have thus offered an explanation of  the  cir-
cumftances of the fyftem in the feveral ftates of the
gout; and this  explanation we fuppofe to be confifjt:-
ent  with the phenomena of the difeafe,  and with the
laws of the animal  ceconomy.   There are indeed,
with refped  to the theory of the difeafe, feveral quef-
tions which might be  put; to which we have not giv-
en any anfwer.   But, though perhaps we could give
an anfwer to many of thefe queftions, it does not here
appear neceffary  ; as at  prefent we intend only to e-
ftablifh fuch general fads with regard to this difeafe,
as may lay  a foundation for the cure of it, fo far as
experience has enabled us to profecute it.   Proceed-
ing, therefore, upon the feveral parts of the patholo-
gy given, as fo many matters of fad, I fliall now con-
fider what may be attempted towards the cure of the
difeafe.
  Vol. I.            L  1               QXXXVIII. 
266          PRACTICE
                  DXXXVIII.
  In entering upon this,  I muft obferve,  in the firft
place, that a cure has been commonly thought im-
poffible ; and we acknowledge it to be very probable,
that the gout, as a difeafe of the whole habit, and ve-
ry often depending upon  original conformation, can-
not be cured by medicines,  the effeds of which  are
always very tranfitory, and feldom extend  to the pro-
ducing any confiderable change of the whole habit.
                   DXXX1X.
  It would perhaps have been happy for  gouty per-
fons, if this opinion had been implicitly received by
them; as it would have prevented their having been fo
often the dupes of fclf-interefted pretenders, who have
either amufed them with inert medicines, or haverafh-
ly employed  thofe of the moft pernicious tendency.
I am much difpofed to believe the impoflibility of a
cure of the gout by  medicines; and more certainly
ftill incline to think,  that whatever may be the poffi-
ble power of medicines, yet no medicine for curing
the gout has hitherto been found.  Although almoft
every age has prefented a new remedy, yet all hither-
to offered  have very foon been either negleded as ufe-
lefs, or condemned as pernicious.
                     .DXL.
   Though unwilling to admit the power of medicines,
yet I contend, that a  great deal can be done towards
the cure of the gout by a regimen : And from what
has been obferved (ccccxcviii.)  I am firmly perfuad-
ed, that any man who, early in life, will enter upon
the conftant pradice  of bodily labour, and of abfti-
nence from animal food, will be preferved  entirely
from the difeafe.
   Whether there be any  other means of radically cur-
ing the  gout,  I am not ready to  determine.   There
are hiftories of cafes of the  gout,  in which it is faid,
that by  great emotions of mind,  by wounds, and by'
                                            other 
               OF  PHYSIC.             9.67

other accidents, the fymptoms have been fuddenly re-
lieved,  and never again  returned ; but how far thefe
accidental cures might be imitated by art,  or would
fucceed in other cafes,  is at leaft extremely uncertain.
                       DXLI.
   The pradices proper and neceffary in the treatment
of the gout, are to be  confidered under two heads :
firfi, As they are to be employed  in  the  intervals of
paroxyfms;  or fecondly, As during the time of  thefe.
                       DXLII.
   In the  intervals of paroxyfms,  the  indications  are,
to  prevent the return of paroxyfms, or at leaft to  ren-
der them  lefs  frequent,  and more moderate.    Du-
ring  the  time of paroxyfms, the indications  are,
to moderate the violence,  and fhorten  the duration
of them as much as can be done with fafety.
                      DXLIII.
   It has been already obferved, that the  gout may be en-
tirely prevented by conftant bodily exercife, and  by a
low diet; and I am of opinion, that this prevention  may
take place even in perfons who have a hereditary dif-
pofition to the difeafe.  I muft  add  here, that, even
when the difpofition has difcovered  itfelf by feveral
paroxyfms of inflammatory gout, I am perfuaded  that
labour  and abftinence will abfolutely prevent any re-
turns of it during the  reft of life *.  Thefe, therefore,
are the means  of anfwering  the  firft indication to  be
purfued in the intervals  of paroxyfms ; and  I  muft
here offer fome remarks upon the proper ufe of thefe
remedies.             L 1  2               DXLIV.
   * Several cafes are to met with in practical  authors, which con-
fitm thi^ obfervation.  Van  Swieten relates the cafe of a prielt, who
enjoyed a rich living, and had lori£ been  an old and conftant fufierer
in the gout ; but happening at lalt to be taken by the pirates of Bar-
bary, was detained there in a Itate of flavery for the fpace cf two
years, and kept conftantly at work in the galleys, with only  a very
fparediet.   The regimen he there undeiwent hnd this good efieft,
that after he was ranfomed from his captivity, having loft his trou,
 blefome  and rrionllrous fatnefs, he never once had a lit of the g ■-»'.:?,
 though he lived fcvcv.r years after the event happened. 
-68          PRACTICE

                    DXL1V.
  Exercife in perfons difpofed to the gout, is direded
to two  purpofes :  Gne of thefe  is the  ftrengthening
of the tone of the extreme veffels; and the other, the
guarding againft a plethoric ftate.  For the former,
if exercife be employed early in  life, and  before in-
temperance has weakened the body, a very moderate
deg ee of it will anfwer the purpofe ; and for the lat-
ter, if abftinence be at the  fame time obferved,  little
exercile will be neceffary.
                     DXLV.
  With  refped to exercife, this in general is  to  be
obferved, that it fhould never be violent; for, if vio-
lent, it cannot be long continued, and muft always
endanger the bringing on an atony in  proportion to
the violence of the preceding exercife.
                     DXLVI.
  It is alfo to be obferved,  that the exercife of gefta-
tion, though confiderable and conftant, if it be entire-
ly without bodily exercife,  will not  anfwer the pur-
pofe in preventing the gout.  For this end, therefore,
the exercife muft be in fome meafure that of the bo-
dy ; and muft be moderate, but at the fame time con-
ftant and continued through life.
                     DXLV1I.
   In every cafe and circumftance of the gout in which
the  patient retains the ufe of his limbs, bodily  exer-
cife, in the intervals of paroxyfms, will always be ufe-
ful; and in the beginning of the difeafe,  when the
difpofition to it is not yet ftrong, exercile may prevent
a paroxyfm which otherwife might have come on. In
more advanced ftates of  the difeafe, however,  when
there is fome difpofition to a paroxyfm, much walking
will bring it on ; either as it weakens  the tone  of the
lower extremities, or as it excites an inflammatory
 uifpofition in them ;  and it is probable, that in  the
                                             fame 
               O F  P  H Y S  I C.           269

fame manner {trains or contufions often bring on a pa-
roxyfm of the gout.
                   DXLVIII.
  Abftinence, the other part of our regimen  (dxl.)
for preventing the gout, is of more  difficult applica-
tion.   If an abftinence from  animal food be entered
upon early 10 life, while the vigour of the fyftem is yet
entire, we have no doubt of its being both  fafe and
effectual; but, if the  motive for this  diet fhall not
have occurred till the conftitution fhall have been bro-
ken by intemperance, or by the  decline of life, a low
diet  may then  endanger the bringing on an atonic
ftate.
                     DXLIX.
  Further, if a low diet be entered upon only in the
decline of life, and be at the fame time a very great
change in the former manner of living, the withdraw-
ing of an accuftomed ftimulus of the fyftem may rea-
dily throw this into an atonic ftate *.
                        DL.
  The fafety of an abftemious courfe may be  greater
or lefs according to the management of it.  It is ani-
mal  food which efpecially  difpofes to the  plethoric
and  inflammatory ftate, and that food is to be there-
fore efpecially avoided ;  but, on the other hand, it is
 vegetable aliment of the loweft quality that is in dan-
ger of weakening the fyftem too much, by not afford-
ing  fufficient nourifhment ;  and more particularly,
of weakening the tone of the ftomach by its acefcency.
 It is therefore a diet of a middle nature that is to be
 chofen ; and milk is precifely of this kind, as contain-
 ing both animal and vegetable matter.
   As  approaching to the nature of milk, and as being
 a vegetable  matter containing the greateft portion of
 nourifhment,  the farinaceous feeds ate next to  be cho-
                  '                           fen,
  *  A fudden change from a full to a fpare di-t was juftly enumera-
 ted among the occafional caufes of the gout in article 504. 
27^
PRACTICE
fen, and are the  food  moft proper to be joined with
milk.
                      DLL
  With refped to drink, fermented liquors are  ufe-
ful only when they are joined with animal food, and
that by their acefcency ; and  their ftimulus is only
neceffary from cuftom.  When, therefore, animal food
is to be avoided, fermented liquors are unneceffary ;
and, by increafing the acefcency of vegetables, thefe
liquors may be hurtful.   The ftimulus of fermented
or fpiritous  liquors, is not neceflary to the young and
vigorous ; and, when much employed, impairs the
tone of the fyftem.   Thefe liquors,  therefore are to be
avoided, except fo far as cuitom and  the declining
ftate of the fyftom may have rendered them neceflary.
For preventing or moderating the regular gout,  wa-
ter L  the only proper drink.
                      DLII.
  With refped  to an abftemious courfe, it has been
fuppofed  that an abftinence from  animal food  and
fermented  liquors, or the living upon  milk and fari-
nacea alone for the fpace of one year, might be  fuf-
ficient for a radical  cure of the gout:  and it is poffi-
ble that, at a certain period of life, in certain circum-
ftances of the conftitution, fuch a meafure might an-
fwer the purpofe.   But this is very doubtful; and it
is more probable that the abftinence muft, in a great
meafure, be continued, and the milk diet be perfifted
in, for the  reft of life.  It is well known, that  feveral
perfons who had entered on an abftemious courfe, and
had been  thereby delivered  from the  gout, have,
however, upon returning to their former manner of
full living,  had the difeafe return upon them with as
much  violence as before,  or in a more irregular and
more  dangerous form.
                      DLIII.
  It  has  been  alledged, that  for preventing the
                                           return 
               O F   P  H  Y  S I C.             271

return of the gout, blood-letting,  or  fcarifications of
the feet, frequently repeated, and a: ftated times, may
be pradifed with advantage ; but  of this I have  had
no experience.
                       DLIV.
  Exercife and abftinence are the means of avoiding
the plethoiic ftate which gives the difpofition to  the
gout; and are .thereforethe  means propofed for pro-
venting paroxyfms, or at leaft for rendeiing them  lefs
frequent and more moderate. But many circumftances
prevent the fteadinefs neceffary in  puriuing thefe mea-
fures: and therefore, in fuch  cafes, unlefs great care
be taken to avoid the exciting  caufes,  the ctteafe may
frequently return ; and, in  many  cafes, the prevent-
ing  of paroxyfms is chiefly to be obtained by avoid-
ing thofe  exciting caufes enumerated in  div.  The
condud neceflary for  avoiding  them, will be  fuf-
ficiently obvious to perfons  acquainted  with  the doc-
trines of the Hygieine,  which  I fuppofe to have been
delivered in another place.
                        DLV.
  A due attention in avoiding  thofe  feveral caufes,
(diii, div.) will certainly prevent fits of the gojut;  and
the taking care that the exciting caufes be never appli-
ed in a great degree, will certainly render fits  more
moderate  when  they do come  on.   But, upon  the
whole, it will appear, that  a  ftrid attention to  the
whole condud of life,  is in this  matter neceffary * ;
                                                  and
  * The phyfician has more  difficulty in perfuading his patients to
a proper regimen in the gout than in  any other difeafe ; and if he
would gain reputation, he ought  to  pay peculiar attention to this
part of praftice, and ufe his utmoit art in convincing his patient of
the neceflity of abftemious diet, and a regular conduct..  Gouty pa-
tients arc generally the genuine offspring of jolly Bacchus, and pre-
fer the tranfient indulgence of their jovial inclinations to the ranl;;m
of whole years of torment at the eafy price of a life of fobricty
and temperance, until the invincibleQucen of tortures,as Lucian calls
her, fully convinces them of  their eirors.  They are thin anxiou.
for medical advice, and after confulting the  phyfician, they are will- 
 zyi            PRACTICE

 and therefore, when the pre difpofition has taken place,
 it will be extremely difficult to avoid the difeafe.
                        DLVI.
   I am indeed firmly perfuaded, that, by obviating
 the predifpofition, and by avoiding the exciting cauf-
 es,  the gout may be entirely prevented :  But as the
 meafures neceffary for this purpofe  will, in moft cafes,
 be purfued with difficulty, and even  with reludance,
 men have been very defirous to find a medicine which
 might anfwer the purpofe without any  reftra'nt  on
 their manner of living.   To gratify  this defire, phyfi-
 cians have propofed, and, to take advantage of it, em-
 pirics have feigned, many remedies, as  we have alrea-
 dy obferved.   Of what nature feveral of thefe reme-
 dies have been, 1 cannot certainly fay ; but, of thofe
 which are unknown,  we conclude,  from their having
 been only of temporary fame,  and  from their having
 foon falling into negled, that they hive  b en either
 inert or pernicious, and therefore i  make no inquiry
 after them ;  and  ihall  now remark only upon one or
 two known  remedies  for the gout  which have been
 lately in vogue.
                       DLVII.
   One of thefe is what has been named  in England
 the Portland Powder *.   This  is not a new  medicine,
                                                 but
 ing jypjplicitly to obey his ftritteft injunctions.  They feldom,  how-
 ever, then find much relief; and remain living proofs of the truth
 of the adage :
          ■-------fero medicina paratur,
          Cum mala per longas invaluere moras.
  *  This medicine was fo called from one of the Dukes of Port-
 land being cured by it of an hereditary and very inveterate  gout.
 It confifts of equal parts of the following  bitter aromatics: viz.
 Rad. ariftolochiae  rotundse,  Had. gentianse,  Summitat, chamedry-
 os, fummitat. chamaepityos, fummitat. centaur, min  A drachm of
 this powder is ordered to be taken, in any convenient vehicle, as a
little wine, broth, tea, &c. in a morning, falting, the patient tailing
 nothing for an hour and an half after it ; it muft be ulcd in this dofc
for t!u\.c months without the leaft interruption • Forty-five grains 
                  O  F  P H Y  S I  C.             273

but is mentioned by Galen, and with fome little va-
riation in its compofition,  has been mentioned by the
writers of almoft every age fince that. time.   It  ap-
   Vol.  I.       .       Mm                       pears
are to be taken daily in the fame  manner, for the fuccceding three
months : half a drachm  every day for tke next fix months ; and half
a drachm every other day, during the fecond year.  It is fometimes
two years complete before any change be produced, but the patient
muft not therefore abandon the medicine,  but continue its ufe.
   Thefe aromatic bitt-rs have been long in ufe as remedies for the
gout.^   We find Galen prefcribing in this difeafe the  feeds and tops
of wild rue, birthworth, leffer centaury, gentian, &c.  either fiti-
gly, or mixed in certain proportions.   Trillian defcribes fimilar'an-
tidotes, which he fays,  muft be continued for a great length of time,
vfo. fix or feven months,  or  even for a year and upwards.  The
tetra-pharmacon of Aetius, cdmpofedof gentian, birthworth, bay-
berries'ari'd myrrh, is a fimilar remedy, and is alfo directed to be ufed
for a great length of time.   Caelius Aurelianus likewife mentions
thefe bitters to be  long ufed in tlie gout, and he gives  them the apo-
fite epithet of  annalia.   The Diatefleron, which has  not been long
thrown out of our ftiops, and is ftill retained in fome  of the foreign
pharmacopoeias, is of the fame kind.   The ufe of thefe medicines
has doubtlefs in many cafes completely cured the gout, but in many
cafes, even in  thofe  that have betn cured, fatal difeafes have fupcr-
vened.   The ancients were well aware of the danger of an indifcri-
minate life of thefe medicines :  "  Many," fays Galen, " of a mo-
«'  derate and flender habit of body, have loft their lives by the ufe
"  of drinks compofed of thefe kinds  of remedies, their blood be-
"  ing dried up.   The numerous arthritic cafes cured by thefe me-
"  dicines, encouraged gouty people to have recourfe  to them indif-
««  criminately,  and  without reflecting that thofe, who had been
«'  cured by them, were of a humid and phlegmatic habit, towhbm
'«  medicines of this  fort might be adminiftcred with fafcty." iEgi-
neta has a fimilar  paflage.  " Thofe,"  fays he, " who endeavour
"  to remove the difeafe entirely by medicines, to be ufed through
"  the whole year, will doubtlefs  do fervice to fych patients as are
"  infefted with pituitous and excrementitious, humours in their joints,
"  but they wilLhalten an untimely daath in perfons of  a dry and hoi
"  habit of body, by forcibly driving the morbific matter on the in-
"  teftines, kidneys, lungs, or fome other of the principal bowels."
  The antients, then, were aware of the danger attending the pro-
miscuous ufe of thefe remedies; and the moderns are ftill more con-
vinced of that  danger :  hence thefe aromatic bitters are entirely laid
alide, and in their place the peruvian bark is the only tonic now uf««l
in  tiwfc cafes.                             « 
 274             PRACTICE*

 pea^s to have been  at  times in fafhion, and  to have
 again fallen into negled ;  and  I think that  this laft
 has been owing to its having been found to be, in ma-
 ny inftances, pernicious.   In  every inftance  which I
 have known  of its  exhibition for the  length   of time
 prcfcribed, the perfons who had taken it were indeed
 afterwards free  from  any inflammatory affedion  of
 the joints : but they were affeded with many fymp-
 toms of the atonic gout;  and all, foon after finifhing
 their courfe of the medicine, have been attacked with
 apoplexy, afthma,  or dropfy,  which proved fatal.
                       DLVIII.
   Another remedy which has  had the appearance of
 preventing the gout, is an alkali in various forms, fuch
 as the fixed alkali both mild  and cauftic, lime-water,
 foap, and abforbent earths. Since it became common
 to exhibit thefe medicines in nephritic and calculous
 cafes, it has often happened  that they were given to
 thofe  who were  at the fame time fubjed to  the gout;
 and it has been obferved, that,  under the ufe  of thefe
 medicines, gouty perfons have  been longer free from
 the fits of their  difeafe #.   That, however,  the ufe
                                                    of
  *  Some i-emarkable cafes have lately occured in this city of the
 efficacy of srated alkaline water, in preventing the returns of the
 paroxyfms of the gout. It requires to be taken for a great length of
 time, to infure fuccefs;  but the patient is encouraged to perfevere
 in its ufe, in confequence of a fpeedy removal of fome of the moft
 troublefome fymptoms.  The method of making it is defcribed by
 feveral authors ; but,  for the fake of thofe readers who are unac-   ■
 quainted with the procefs I fhall give an abftradt of it.   Diffolve
 three ounces, troy weight, of s*ood fait of tartar in a gallon and an
 half of rain water,  or good  foft fpring water;  filtre the folution,
 and put as much of it into the middle glafs of Parker's machine as
 will completely  fill the veflel, referving the remainder for a fubfe-
 quent making.  The  effervefcing materials muft then be put into
 the lower veflel,  an^ a gentle ftream of fixed air muft be made to pafs
 through the liquor till it taftes evidently acidulous, which will pro-
 bably require 48 or 60 hours, or in fummermore.  The method of
managing the effervefcenceisof confiderable confequence  ; for if it
it too violent at  firft, 1r.Uk.I1 air efcapes  through the veflels without 
OF  PHYSIC.
275
of thefe medicines has entirely prevented the returns
of gout, I do not know ; becaufe I never pufhed  the
ufe of thofe medicines for a long  time, being appre-
henfive  that' the long continued  ufe of them might
produce a  hurtful change in the ftape of the fluids.
                         DL1X.
   With refped to preventing the gout, I  have only
one other  remark to  offer.   As/ the  preventing the
gout depends very much on fupporting the tone of the
ftomach, and avoiding indigeftion ; fo coftivenefs, by
occafioning this, is very hurtful to gouty perfons.   It  ,
is  therefore neceffary for fuch perfons  to  prevent or
remove  coftivenefs, and, by a laxative medicine, when
needful; but it is at the fame proper, that  the medi-
cine  employed fhould be fuch as may keep the belly
                         M m 2               *  regular9

effect.  Afcertain, by previous experiment, how much  of the vi-
triolic acid, which you have procured, (for it is of very different
ilrengths in the (hops,) will faturate a drachm of the chalk. Put four
ounces of dry powdered chalk into the lower veflel, and fliake it to
one fide ; and under that fide put  a wedge,  fo as to raife it about an
inch and an half from the table.  With a long funnel, which reach-
es to the bottom of the veflel, pour in the quantity of, vitriolic acid
neceflary for  the faturation, which will run down to  the other fide
of the veflel, and  not come into contact with the chalk: through
the fame funnel, pour very flowly as much water as will be fufficient
to cover about a fourth part of the chalk as it then lies.   The vef-
fel being gently fhaken occafionally, the effervefcence will go ori very
flowly, and  the alkaline liquor will be fooner and more effectually
faturated,  than if the effervefcence had been too violent. If the
materials are not fufficient for giving an acidulous tafte to the liquor,
the lower veflel mull be walked, and frefh chalk and acio^again put
into it.  The dofe of this water is half a pint about noon, and  ano-
ther in the evening.  In urgent cafes  half a  pint has been given,
morning, noon and night, for a confiderable time together, without
difagrecing with the  ftomach, or injuring  the  appetite  or general
health of the patient.  If it proves flatulent, a tea-fpoonful or two,
but not more, of fpiritous cinnamon water may be taken in each dofe.
If it inflames, or too violently irritates the urinary paflages, five or
ten, or in»iu _>ent cafes, twenty dro.:» of laudanum  may  be taken,
\vilh  each dofe of the water. 
276              PRACTICE

regular, without much purging.   Aloctics,  rhubarb,
magnefia  alba, or flour of fulphur,  may be employ -
e;l,  as  the one or  the other may happen to  be  beft
fuited to particular pqrfons*.
                         DLX.
   Thefe  are  the  feveral  meafures (from  DXLir,  to
dlix.)  to be purfued  in  the intervals of  the. parox-
yfms ; and we are  next to mention the  meafures pro-
per  during the time of them.
                         DLXI.
   As during the times of paroxyfms the body is in a
fe verifh ftate, no irritation fhould then be added  to  it:
                                                    and

  *  Xhc following formula may be ufed in particular cafes :
             R. Aloes Socotorin. 311.
               Gum. Guaiac. 3m.
                Tinft. Sacrae, q. f.
               M. f. mafia, in philulas equales
        «        xv. aividenda ;
                quarum fumat iii. *el. iv.
                pro  re nata."
              §,. Pulv. Rad. Rhei, 31II.
             •  Magnef. alb. 5fs.
                Gum. Guaiac. 3ii.
                Confect. Aromat.  jii.
                Syrup,  comm. q. f.
                M.f. Elect, cujus fumat magnitudinem,
               juglandis mane" et vefphere, vel pro re nata;.
This laft medicine has been extremely beneficial in removing coftive-
nefs, and in giving a tone to the ftomach.   An ounce,  or an ounce
ana an half, or twoounces of the tinctura facra, is alfo a good purge
fox gouty perfons.  The elixir fennae is  likewife a good medicine
where we cannot ufe aloetic purges, as in cafe's of piles : in thefe
t. Yes alfo we may ufe fulphur ; of which the following form is very
convenient.
               R, Flor. Sirlphuris'^ii.
                  Elect. Lenitivi, ^ii.
                  Pulv. Rad. Jalap. 3£1-
                            Zinzib. jii.
                  Syr. Simpl. q.  f.
                  M. f.  Elect, cujus fumat quantltatero
                             juglandis pro re nata. 
              OF  PHYSIC.           277

and every part,'therefore, of the antiphlogiftic regi-
men, (cxxx,, to cxxxiii.) except the application  of
cold, ought to be ftridly obferved.
  Another exception to the general rule may occur
when the tone of the ftomach is weak, and when the
patient has been  before much accuftomed to the uie
of ftrong drink';  for then it  may be allowable, and
even neceffary, to give fome animal food,  and a little
wine*.
                      DLXII.
  That no irritation is to be added to the fyftem dur-
ing the paroxyfms of gotft, except in the cafes menti-
oned, is entirely agreed upon among phyficians : But
it is a more  difficult  matter  to determine  whether,
during the time of  paroxyfms, any meafures may be
purfued to moderate the violence of re-action and of in-
flammation.   Dr. Sydenham has given it  as  his opi-
nion, that the more violent the inflammation and pain,
the paroxyfms will be the fhorter, as  well a6 the inter-
val between the next paroxyfms longer :  and, if this ^
opinion be admitted as juft,  it will forbid the  ufe of
any remedies which might moderate  the inflamma-
tion ; which is, to  a certain degree, undoubtedly nc-
peflary for the health of the body.  On the  other hand,
acute pain prcfies for relief,  and, although a certain
degree  of inflammation may feem abfolutely neceffa-
ry, it is not certain but that a moderate  degree of it
may anfwer  the purpofe : And ir is even  probable,
that, in many cafes, the violence of inflammation may
weaken the tone of the  parts,  and thereby invite a re-
turn of paroxyfms.   It feems  to me  to be in this way,
that, as the  difeafe advances, the'paroxyfms become
more frequent.
                                          DLXIII.

  * Tlie wine in thefe cafes  fliould be of the btftkind,  and fuch  -
are not apt to turn four  on the ftomach.  The  dry wines, Sherry and
Madeira, arc moft proper, while both the rich fwect wines and thr
 aafterethin i'.Y.i  v.ines are equally improper. 
 273            PRACTICE

                      DLX1II.
   F:om thefe laft confiderations, it feem* probable,
 that during the time of  paroxyfms,  fome meafures
 may be taken to moderate the violence of the inflam-
 mation and pain ; and particularly, that,  in  firft pa-
 roxyfms, and in the young and vigorous, blood-letting
 at the  arm  may be  practifed with advantage : But  I
 am  perfuaded, that this practice cannot  be repeated
 often with fafety; becaufe blood-letting not only weak-
 ens the tone of the fyftem, but may alfo contribute to
 produce plethora.  1 believe, however, that bleeding
 by leeches on the foot, and upon  the inflamed part,
 may be practifed and repeated with  greater fafety ;
 and 1 have  known inftances of its having been prac-
 tifed with fafety, to moderate and fhorten paroxyfms:
 but how far it may be carried, we have not had' expe-
 rience  enough to determine.
                      DLXIV.
   Befides blood-letting, and, the antiphlogiftic regi-
 men, it has  been propofed to employ remedies for mo-
 derating the inflammatory fpafm of the part affected,
 fuch as warm bathing, and emollient poultices. Thefe
have fometimes  been employed with  advantage and
 fafety; bur, at other times,  have been found  to give
 occafion to a retroceffion of the gout*.  •
                      PLXV.
   Bliftering is a very effectual means of relieving and
 difcufiing a  paroxyfm of the gout ; but has alfo fre-
 quently had the effect of rendering it retrocedentf.
                                           DLXVI.

  * On this account thefe topical remedies ought t,o be ufed with
 great caution ;  the temporary relief which they afford,  by procuring
 an inteimiflion of the pain, is agreeable to the patient,  but  it is
frequently the occafion of an exacerbation of all the fymptoms.
  f This is a very dangerous praftice.  Blillers are however ex-
 tremely  ufeful, in bringing back  the retrocedent gout to the part
originally affeaed ; but,  the violent d--<;rrc of pain that accompa-
 nies the  gout,  when brought to a part utaady irritated by the blif- 
               O F  P H  Y  S I  C.             279

                       DLXVI.
  The flinging with nettles  I confider as analogous to
bliftering ; and I think it  probable that it would be
attended with the fame danger.
                      DLXVII.
  The burning with moxa*, or  other fubftances, I con-
fider as a remedy of the fame kind.  I have had in*
deed no evidence of  this proving hurtful;  but nei-
ther have I  had any proper  evidence of its having
proved a radical cure.
                      DLXVIII.
  Camphire,  and fome aromatic oils, have the power
of allaying the pain, and of removing the inflamma-
tion from the part affected  : but thefe remedies com-
monly  make the inflammation  only  fhift  from  one
part to another,  and therefore  with the hazard of its
falling upon a part where it may be more dangerous ;
and they have  fometimes  rendered the gout retroce-
dent.
                                            •   DLXiX.

ters, frequently prevents a  patient who has once fuffered it, from
allowing it a fecond  time.  It is however, fo important and necefla-
ry a practice, that it ought not to  be omitted.  As foon as the gout
has  been brought back to its  original place,  the blifters muft be im-
mediately removed,  a piece of foft linen dipt in frefh oil, applied to
the  part, and the whole  well wrapt up in foft flannel;  a moderate
degree of heat muft be preferved in the flannel, and the patient muft
be encouraged to bear with patience, the.violent pain which he fu;-
fers.
  * Moxa, is a foft lanuginous fubftance prepared in japan, fron
the  young leaves of  a fpecies of Artemifia, by beating them  when
thoroughly dried, and rubbing them between the fingers till nothing
but  the finclt fibres  remain.   A little cone of this cottony fubftance
is laid upon the fkin, which is previoufly moiftened to  prevent the
cone from Aiding off.  Fire  is fet to the apex of the cone, and .t
is fuffered to burn till it extinguifhes itfelf.   A finall Efchar is pro-
duced and the ulcer either healed or kept open as occafion requires.
Cotton  impregnated with  a fmall quantity  of a folution of nitre,
and  afterwards dried, anfwers the  et.d as cft'^ur.i'.iy as the Jcpch-J-z
11)0X3. 
280          PRACTICE
                      DLXIX.
   From  thefe reflections (dlxiv, et. feq.) it will ap-
pear, that fome danger muft attend every external ap-
plication to the parts affected,  during a  paroxyfm;
and that therefore the common practice of committing
the perfon to patience and flannel alone, is eftablifhed
upon the beft foundation.
                      DLXX.
   Opiates give the moft certain relief from pain ; but,
when given in  the beginning of gouty paroxyfms, oc-
cafion thefe to  return with greater violence.  When,
however, the paroxyfms fhall have abated in their vi-
olence, but ftill continue to return, fo as to occafion
painful and reftlefs nights,  opiates may be then given
with  fafety and advantage, efpecially in the  cafe of
perfons advanced  in  life,  and who have been often,
affected with the difeafe*.
                     DLXXI.
   When, after paroxyfms have ceafed, fome fwelling
and ftiffnefs fhall  remain in  the joints,  thefe  fymp-
toms»are  to be difcuffed by the diligent  ufe  of the
ftefh-brufh.
                      DLXXII.
   Purging, immediately after a paroxyfm, will be al-
ways employed with the hazard of bringing it on a-
gain.
                     DLXXIII.
   I have now  finiflied  what  has occurred to be faid
upon the means of preventing and curing the regular
                                               gout;
  * The beft form for exhibiting opium, in thefe cafes is the Con-
fertio Opiata of the London pharmacoccpia,  or  the Ekctarium
Thebaicum of the  Edinburgh.  The dofe of the former  iVhalf a
drachm, but of thelattera drachm and an half. As opiates ought never
to be adminiftered  where the inflammation  is violent, but  only in
U.chof.s as are *ttended with little or no inflammation, thefe vrarm
opiates cannot be improper.  If however  the  practitioner fhould
find either  of the abo\e formulae too hot, he c. . lu.ve recjurfe to
the Tiniu'.ra TheLr.Ya. 
               O F   P  H  Y  S I C.           281

gout; and fhall now confider its management when it
has become irregular ; of which,  as I have  obferved
above, there are three different cafes.
                     DLXX1V.
  In the firft  cafe, which I  have  named the Atonic
Gout,  the cure is to be accomplifhed by carefully a-
voiding all debilitating caufes ; and by  employing, at
the fame time, the means of ftrengthening the fyitem
in general, and the ftomach  in particular.
                     DLXXV.
  For the avoiding debilitating caufes, I muft refer to
the doctrines of the Hygieine, as in dliv.
                     DLXXVI.
  For ftrengthening the fyftem in general, I muft re-
commend frequent exercife  on  horfeback,  and mode-
rate walking.  Cold bathing  alfo  may anfwer the
purpofe, and  may be eafily  employed, if it appear to
be powerful in ftimulating the fyftem,  and be not ap-
plied when the extremities  are threatened  with any
pain*.
  For fupporting the tone  of the fyftem in general,
when threatened with atonic gout, fome animal foodf
ought to  be employed, and  the more acefcent vegeta-
bles ought to be avoided..  In the fame cafe,  fome
wine J:  alfo may be neceffary ; but it fhould be in mo-
derate quantity,  and of the  leaft acefcent kinds; and,
   Vol. I.              N n                       if

  *  Cold bathing is a doubtful remedy, and ought to be ufed with
caution.  If it does not prove a tonic, it ought to be abandoned,
and we know by experience that it frequently debilitates-
  f The ufe of animalfood is abfolutely neceffary, and fuch ought to
be chofen as is  moft nutritive. Beef or Mutton, have been with
propriety preferred to all other animal food, and fome eminent prac-
titioners  have recommended fleaks to every other mode of drefling
beef and mutton.  Stews, hafhes, pyes, and all high feafoned difh-
es, ought to be avoided.
  X  The wine which a gouty patient ufes, ought to be generous
and good, asmaderia, fherry, &c. the thin acefcent wines as hock,
claret, &c.  always do mifchief. 
,82            PRACTICE
if every kind of wine fhall be found to increafe the a-
cidity of the ftomach, ardent fpirits and water^muft be
employed*.
                       DLXXVII.
    For ftrengthening the ftomach, bitters and the Pe-
 ruvian bark may be employed;  but care  muft be
 taken thac they be not  conftantly  employed  for^any
 great length of time.   Compare dlvii.
    The moft effectual medicine for ftrengthening the
 ftomach is iron, which may  be employed under  vari-
 ous preparations; but, to me,  the  beft appears to be
 the ruft in fine powder, which may be given in  very
 large dolesf.
    For  fupporting the tone of the ftomach, aromatics
 may be employed ; but  fhould  be  ufed with caution,
 as the frequent and  large ufe of them may  have an
 oppofite effect;  and  they fhould  therefore be given'
 only in compliance with former habits, or for pallia-
 ting prefent fymptoms.
                                                When
   * In order the  more effectually to  guard againft acefcency, the
fpirits and water ought,  if poffible, to be taken with  fugar, and
cold.  No di ink is perhaps more prejudicial for gouty patients, than
what is called rich punch,  viz. with a  large quantity  of fugar and
lemon, efpecially when taken warm,

   f The dofe muft be very fmall at firft, not exceeding four or five
grains in the day ; the dofes may be daily increafed to two grains, till
we arrive at 10 or 12, and after two or three days,  10  grains may
b'given twice a day.  Aromafics  always make it fit eafier on the
ftomach  than it would do if taken alone j the moft convenient form
therefore is the following  :
            R. Rubig. Martis, gr. 10.
               Confect. Card. 3fs.
                Syr. Croci. q. f.
               M, f. bolus.
After the patient has taken two of thefe bolufes for three or four
day?, he may proceed to take three of them, and after afew more days,
if  the ftomach is not difordered, each bolus may be daily increafed
till we arrive at 24, or even 30 grains, thrice a day 
               OF   PHYSIC.    *       283

   When the ftomach happens to be liable to indigef-
 tion,  gentle vomits  may  be frequently given;  and
 proper laxatives* fhould be always employed to obvi-
 ate, or to remove, coftivenefs.
                    DLXXVIII.
   In the atonic gout, or in perfons liable  to  it, to
 guard againft cold is efpecially  neceffary; and  the
 moft certain meai^s of doing this is, by repairing  to a
 warm climate during the winter-feafon.
                     DLXXIX.
   In the more violent cafes of the atonic gout,  blif-
 tering the lower extremities may be ufeful; but  that
 remedy fhould be avoided when any  pain  threatens
 the extremities.   In perfons liable to the atonic gour,
 {flues may be eftablifhed in the extremities, as, in fome
 meafure, a fupplement to the difeafe.
                      DLXXX.
   A fecond cafe of the irregular gout, is that which
 I have named the retrocedent.   When this affects the
 ftomach and inteftines,  relief is to be inftantly at-
 tempted by the free ufe of ftrong wines, joined with
 aromatics, and given warm ; or if thefe  fliall not prove
 enough, ardent fpirits muft be  employed, and are to
 be given in a large dofe.  In moderate attacks, ardent
 fpirits  impregnated with  garlic, or with afa foetid a
 may be employed; or, even without the ardent  fpi-
 rits, a  foluion of afa fee tida with  the  volatile alkali
 may anfwer the purpofe.   Opiates are often an effec-
 tual remedy, and may be joined with aromatics, as in
 the electuarium Thebaicumf; or they may be ufeful-
                       N i« 2                   ly

  * The proper laxatives for gouty conftitutions, ar: mentioned hi
a note on article 559.
  f The following form is extremely efficacious, and at the fame
time pleafant to tho tafte ; it may be repeated three or four times,?
if the fjrft does not procure relief, 
284           PRACTICE

ly joined with volatile alkali and camphire*.   Mufk
has likewife proved ufeful in this difeafe.
   When the affection of the ftomach is accompanied
with vomiting, this may be encouraged,  by  taking
draughts  of warm wine,  at  firft  with warm water,
and afterwards without it; having at length recourfe,
if neceffary, to fome of the remedies above mentioned,
and particularly the opiates.
   In like manner, if the  inteftines be  affected with
diarrhoea, this is to be at firft  encouraged, by taking
plentifully of weak broth ; and  when this fhall have
been done fufficiently, the tumult is to  be quieted by
opiates.
                     DLXXXI.
   When the retrocedent  gout fhall affect the lungs,
and produce  afthma, this  is  to be cured  by opiates,
by antifpafmodicsf, and,  perhaps, by bliftering on
the breaftor back.
                                             DLXXII,
                   I$3. Elect. Thebaic. 31.
                    Aq. Cinnamon, fpirituofa?,  Sjifs.
                    Syr. Croci. 311.
                    M. f. hauft,
  * The beft way of giving thefe medicines is in the following form:
               R. Opii. purificati,  gr. i.
                 Camphor, gr. xii.
                  Spt. Vini. q. f.
                  Confect. Cardiac. 311.
                 M. f. bolus.
  Or the camphire may be made into  a bolus with a drachm of the
Elect. Thebaic, and forty drops  of the Spiritus  Aromaticus, in a
gla'i of ftrong wine, as Madeira or Sherry, may be drank after it.
  -j-  The Spiritus f.r.ureus Vitriolicus is a medicine ufed with much
fuccefs in thele cafes.   The dofe of it  is from twenty to thirty drops
in a o-l.ifs of wine.  The ethereal  fpirit is fo very volatile, that it
will whol'v  evaporate,  if it be fuffered  to ftand in the wine for a few
rniYuus . it muft therefore be drank  fpeedily : and the dofe may be
re;leared eery  two hours, in cafes of emergency.  In moft cafes
laudanum will anfwer every purpofe.   Ammoniacum  has been muck
recommended,  and  its powers in cafes of gouty afthma  have frc- 
              OF  PHYSIC.           285

                     DLXXXII.
  When  the gout,  leaving the extremities, fliall af-
fect the head, and produce pain,  vertigo, apoplexy,
or palfy,  our refources are very precarious    The
moft probable means of relief  is, bliftering the head;
and if the gout fhall  have receded very ent.re! v  from
the extremities, blifters may be applied to thefe alfo.
Together with thefe blifterings,  aromatics,  and the
Volatile alkali, may be thrown into the ftomach*.
                    DLXXXIII.
  The third cafe of the irregular gout is  what I have
named the Mifplaced, that is,  when the inflammato-
ry affection of the  gout, inftead of falling upon the
extremities,  falls upon fome internal part.   In this
cafe, the difeafe is to be  treated by blood-letting, and
by fuch other remedies as would be proper in an idi-
opathic inflammation of the fame parts.
                    DLXXXIV.
  Whether the tranflation fo  frequently  made  from
the extremities to the kidneys, is to be confidered as
an inftance of the mifplaced gout, feems,  as we have
faid before, uncertain : but I am difpofed  to think it
fomething different; and therefore am  of opinion,
that,  in the Nephralgia Calculofa, produced  upon
this occafion, the remedies of  inflammation are to  be
employed  no farther  than they  may  be otherwife
fometimes neceffary in that difeafe, arifing from other
caufes than the gout.
                                           BOOK
q\iently been very confpicuons.  It  may be given independent of
the opiates. Two drachms of it may be made into an emnlfion with
fix ounces of water: and a couple of  table-fpoonfuls of thisemulfi-
pn may be given every two or three hours.
  * Little relief has ever been obtained in thefe cafes from internal
remedies. Large dofes of the Spiritus  Aromaticus have been thought
ferviceable, but the chief dependence is on the effect of blifters on
the extremities, efpecially the feet, with warm fomentations to the
legs, and rubbing the legs with  a flefh brufh, impregnated with
plenty  of dry Hour of muftard. 
 ass        Practice

               BOOK   III.

    OF EXANTHEMATA,  OR  ERUPTIVE
                    FEVERS.

                    DLXXXV.
      THE  difeafes comprehended  under  this  title,
     which make the third Order of Pyrexias, in our
 Nofology, are  in general fuch as do not arife but upon
 occafion of a  fpecific contagion applied, which firft
 produces fever, and afterwards an eruption upon the
 furface of the body; and which difeafes, for the  moft
 part,  affect perfons but once in the courfe of  their
 lives.
                   DLXXXVI.
   Whether the Character of the Order may be  thus
 limited, or if the Order  may be allowed to compre->
 hend alfo the eruptive fevers produced by a  matter
 generated in the body itfelf, and likewife thofe cafes
 which do  not  depend upon contagion, or upon a
 matter generated before the fever, but upon a mat-
 ter generated in the courfe of the fever, I am not rea-
 dy to determine.  Of the difeafes  enumerated by the
 Noiologiils as  Exanthemata, there are certainly three
 dial-rent kinds, which may be diftinguifhed  by the
 circi ■:.(lances mentioned in  this and the  preceding
para  oph.   Of the firit kind are the Small-pox, the
Chicken-pox, the Mealies, the Scarlet Fever, and the
Plague.  Of the fecond kind feems to be the  Eryfi-
pelas; and  of the third kind I judge the Miliaria  and
Petechia to  be.   But as I am not fufiiciently confident
in the facts which  fhould  fupport thefe diftinctions,
or which would enable us to apply them in all cafes;
I go-on in this book  to treat of almoft all the exan-
themata  enumerated  by preceding Nofologifts, with
only fome difference in  the arrangement from what
it was in my former editions.
                                       C II A P< 
OF  PHYSIC.           287
               CHAP.    I.

            OF THE  SMALL-POX.

                  DLXXXVII.
    THE fmall-pox is a difeafe arifing  from a conta-
     gion of a fpecific nature, which firft produces a
fever, and, on the third or fourth day thereof,  pro-
duces an eruption of fmall red  pimples.   Thefe are
afterwards formed into puftules,  containing a matter,
which, in the courfe of eight days from the time of
eruption, is changed into pus.   After this, the matter
dries, and falls oif in crufts.
                  DLXXXVIII.
  This is a general idea of the difeafe;  but there are
two particular forms or varieties of it, well known un-
der the appellations of the  Diflincl  and Confluent,
which require to be fpecially defcribed.
                  DLXXXIX.
  In the former, or the diftinct fmall-pox,  the erup-
tive fever is moderate, and appears to be evidently of
the inflammatory kind, or what we name aSynocha.
It generally comes on about mid- day, with fome fymp-
toms of a cold ftage, and commonly with a confider-
able languor and drowfinefs.  A  hot  ftage  is  foon
formed, and becomes more confiderable on the fecond
and third days.  During this  courfe, children are li-
able to frequent  ftartings from their flumbers ;  and
adults, if they are kept a-bed, are difpofed to much
fweating.   On the third day,  children are fometimes
affected with one or two epileptic fits.   Towards the
end of the third.day, the eruption commonly appears,
and gradually increafes during the fourth ; appearing
firft upon the face, and  fucceffively  on the inferior
parts, fo as to be completed over the whole body  on
the fifth day.
                                           From 
288         "  P R  A C T I C E

  From the third day, the fever abates ; and againft
the fifth, ic entirely ceafes.   The  eruption appears
firft in fmall red fpots, hardly eminent, but by de-
grees riling into pimples.  Thefe are generally upon
the face in fmall number ; but even when more nume-
rous, they are feparate and diftinct from one another.
On the filth or  fixdi day,  a fmall veficle, containing
an almoft colourlefs or whey-coloured  fluid, appears
upon  the top of ea<.h pimple.  For two days,  thefe
veficles increafe in breadth only, and  there is a fmall
hollow pit in their middle ; fo that it is only againft
the eighth day that they are  raifed  into fpheroidical
puftules.
  Thefe veficles or puftules, from their firft forma-
tion, continue to be fuirounded with  an exactly cir-
cular  inflamed  margin, which, when the puftules are
numerous, diffufes fome inflammation over  the neigh-
bouring Ikin, fo as to give fome what of a damafk rofe
colour to the fpaces between the puftules.  As  the
puftules increafe in fize, if they be numerous  on the
face, againft the eighth day the whole of the face be-
comes confiderably fwelled ;  and, in particular,  the
eye-lids are fo  much  fwelled  as entirely to fhut the
eyes.
  As the difeafe thus  proceeds, the matter in the puf-
tules becomes  by degrees more opaque and  white,
and at length of a yellowifh colour.   On the eleventh ■
day, the fwelling of the face is abated, and the puf-
tules feem quite full.   On the top of each a darker
fpot  appears;  and at this place the puftule, on the
eleventh day, or foon  after, is fpontaneoufly broken,
and a portion of the matter oozes out; in confequence
of which, the  puftule  is fhrivelled,  and  fubfides ;
while the matter oozing out dries, and foims a cruft
upon its furface.  Sometimes a little only of the mat-
ter oozes out; and what remains in the puftule be-
comes thick and even hard.   After fome days,  boiti.-
                                              the 
              OF  PHYSIC.     r      289

the crufts and the hardened puftules fall cff, leaving
the fkin which they covered of a brown red colour ;
and it is  only  after many days that the fkin in thefe
places refumcs its  natural colour.   In  fome  cafes,
where the matter of the puftules has  been  more li-
quid, the crufts formed by it are later in falling off,
and the part they covered fuffers fome defquamation,
which leaves in it a fmall  pit or hollow.
  This is the  courfe of things on the face;  and fuc-
cefiively,  the  puftules on the reft of the body take
the fame.   The matter of the puftules, on the arms
and hands, is  frequently  abforbed ;  fo  that,  at the
height of the difeafe,  thefe puftules appear as empty
veficles.  -On  the  tenth and eleventh  days,  as the
fwelling of the face fubfides, a fwelling  arifes in the
hands and  feet;  but which, again, fubfides, as the
puftules come to  maturity.
  When the puftules on the face are numerous, fome
degree of pyrexia appears  on the tenth and  eleventh
days,  but difappears again after the puftules are fully
ripened ;  or perhaps remains in a very flight degree
till the puftules on the feet have finifhed their courfe.
It is feldom that in the  diftinct  fmall-pox the  fever
continues longer.
   When the  puftules on the face are numerous, fome
uneafinefs in the throat, with a hoarfenefs of the voice
comes on upon the fixth  or feventh day,  and a thin
liquid is  poured out- from the mouth.   Thefe fymp-
toms increafe  with the fwelling of the face ; and the
liquids of the mouth  and  throat becoming thicker,
are more difficultly thrown out.   There is, at the fame
time, fome difficulty of fwallowing ;  fo  that liquids
taken in  to be fwallowed  are  frequently rejected,  or
thrown out by the nofe.   But all thefe  affections  of
the fauces abate as the fwelling of the face fubfides*.
   Vol.  I.                O o               DXC.
    1 he difcharge of Saliva is always falutary, and ought to be
moderately encouraged.  It is probably owing to the morbific mat- 
200
PRACTICE
                       DXC.
   In the other form of fmall-pox,'or what iscalledthc
 Confluent, the courfe of the difeafe is, in general, the
 fame with that we have defcribed ; but the fymptoms
 of everv ftage are more violent, and feveral of the cir-
 cumftances are different.
  In  particular,  the eruptive fever is  more violent.
 The pulfe is  more frequent and more contracted, ap-
 proaching  to that ftate of pulfe which is  found in
 the typhus.   The coma is more confiderable,  and
 there is  frequently a delirium.  Vomiting, alfo, is a
 common fymptom, efpecially  at the coming on of the
 difeafe. In very young infanrs, epileptic fits are fome-
 times frequent on the firft days of the difeafe,  and
 fometimes proves fatal before any eruption  appears;
 or they ufher in a very confluent and putrid fmall-pox.
                      DXCI.
  The eruption appears more early on the third day,
 and it is frequently preceded or accompanied with an
 eryfipelatous efflorefcence.  Sometimes the  eruption
 appears in clutters, like that of the mealies.   When
 the eruption  is completed, the pimples ,are  always
 more numerous upon the face, at the fame timefmal-
 ler and lefs eminent.   After  the eruption, the fever
 fuffers fome remiflion, but never goes off entirely; and,
 after the fifth  or fixth day, it again increafes, and con-
 tinues confiderable through the remaining courfe of
the difeafe.
  The veficles formed on the tops  of the pimples ap-
pear fooner;  and while  they  increafe in breadth,  do
                                                not

ter attacking thcfalivary glands, and through them making its exit
 out of the body.  All the afFe&ions of the fauces, and the faliva-
 tion, gradually abate as the fwelling of the face fubfides; but if thefe
fymptoms difappear fun^lenly, or are not fucceeded by a fwelling of
the extremities,  danger is to be apprehended.  This remark is fole-
ly the refult of experience, and the explanation of it feems to be
 involved in confiderable difficulty. 
OF  PHYSIC.
not retain a circular, but are every way of an irregu-
lar figure.  Many of them run into one another, in-
fomuch that very often the face is covered rather with
one veficle than with a number of puftules.   The ve-
ficles, fo  far as they are any-wife feparated, vdo not a-
rife to a fpheroidical form, but remain flat,  and fome-
times the whole of the face is of an  even furface.
When the puftules are in any meafure feparated, their
circumference is not bounded with an enflamed mar-
gin, and the part of the fkin that is free from puftules
is commonly pale and flaccid.
  The liquor that is in the puftules changes from a
clear to an opaque appearance, and becomes whitifh
or  brownifh, but  never acquires the yellow colour
and thick confidence that appear in the  diftinct fmall-
pox.
                     DXCII.
  The fwelling of the face which attends the diftinct
fmall-pox, when they are numerous, and almoft then
only,  always attends the confluent, comes on more ear-
ly, and arifes to a  greater  degree ; but abates on the
tenth day,  and on the eleventh  ftill more.  At this
time  the puftules  or veficles break, and  fhrivelling
pour out  a liquor  that is formed into brown or black
crufts, which do not fall off for many days after. Thofe
of the face, in falling off,  leave the parts they cover
fubject to a defquamation, which pretty certainly pro-
duces pittings.
  On the other parrs of the body, the puftules of the
confluent fmall-pox are more  diftinct than upon the
face, but never acquire the fame maturity and confift-
ence of pus as in the properly diftinct kind.
  The falivation  which  only fometimes  attends the
diftinct fmall pox, very  conftantly attends  the conflu-
ent: and both the falivation and the affection of the
fuic -s above-mentioned  are, efpecially in adults, in a
                     O  o 2                 higher 
292             PRACTICE

higher degree. In infants, a diarrhoea comes frequent-
ly in place of the falivation.
  In the confluent fmall-pox, there is often a confider-
able putrefcency  of the fluids, as appears from petechi-
ae, from ferous veficles, under which the fkin fhows a
difpofition to gangrene, and from bloody urine or o-
ther hsemorrhagy, all which fymptoms frequently ac-
company this difeafe.
   In the confluent  fmall-pox, the fever,  which had
only fuffered a remiflion from the time of eruption to
that of  maturation,  is often, at or immediately after
this period,  renewed with confiderable violence. This
is what has been called the  Secondary Fever ;  and is,
in different cafes, of various  duration and event.
                     BXCIII.
   We have thus endeavoured to defcribe the various
circumftances of the fmall-pox; and from  the differ-
ence of thefe circumftances,  the event of the difeafe
may  be determined.  The  whole of the  prognofis
may  be nearly  comprifed  in the following propofi-
tions.
   The  more exadly the difeafe retains the form of the
diftinct kind, it  is the fafer ; and the more completely
the difeafe takes the form of the confluent  kind,  it is
the more dangerous.
   It is only when the diftinct kind fhows a great num-
ber of puftules on the  face,  or otherwife, by fever or
putrefcency, approaches to the circumftances of the
confluent, that it is attended with any  danger.
   In the confluent fmall-pox there is always danger ;
 and this is  always more confiderable  and certain, ac-
 cording as  the fever is more violent  and permanent,
 and efpecially as the marks and fymptoms of putrefcen-
 cy are  more evident.
   When the  putrid difpofition is  very great,  the dif-
 eafe fometimes proves fatal before the eighth dav ; but
 in moft cafes it  is on the eleventh  that death happens,
                                               and 
OF   PHYSIC.
293
and fometimes it is put off till the fourteenth or feven-
teenth day.
  Though the fmall-pox fhould not be immediately
fatal, the more violent  kinds are often followed by a
morbid ftate of the body, of various kind and event.
Thefe confequences, as  1 judge, may be imputed fome-
times to  an acrid matter produced by the preceding
difeafe, and depofited  in different parts ; and fomeT
times to an inflammatory diathefis  produced, and de-
termined to particular parts of the body.
                     DXCIV.
  It is, I think, agreed among  practitioners, that, in
the different cafes of fmall-pox, the difference chiefly
depends upon the appearance of diftinct or confluent  ;
and, from the above defcription of thefe kinds, it will
appear, that they chiefly differ in the period of the e-
ruption, in the number of  puftules produced,  in the
form of the puftules, in the ftate of the matter con-
rained irithem, in the  continuance of the fever, and
laftly in the danger of  the difeafe.
                      DXCV.
   Upon inquiring  into  the  caufes of thefe differen-
ces, we might readily fufpect, that  they depended up-
on a difference of the contagion producing the dif-
eafe.  This, however, is not probable : for there are
innumerable inftances  of  the contagion,  arifing from
a perfon labouring under the fmall-pox of the diftinct
kind, producing the confluent ;'and on the contrary.
Since the practice of inoculation became frequent, we
have known the fame variolous  matter produce in one   j
perfon the diftinct, and in another the confluent fmall-   I
pox.  It is therefore highly probable, that the differ-   1
ence cf the fmall-pox does not  depend upon  any dif-   \
ference of the contagion, but. upon fome difference in
the ftate of the perfons to whom it is applied, or in the
ftate of certain circumftances concurring with  the ap-
plication of the contagion.
                                         nvrv: * 
2c,4             PRACTICE

                      DXCVI.
  To find out wherein the  difference in the ftate of
the perfons to whom the contagion of the fmall-pox
is  applied confifts, I obferve, tlmt the  difference be-
tween the diftinct and confluent fmall-pox confifts efpe-
cially in the number of puftules  produced ; which, in
the diftinct, are generally  few, in the confluent, always
many.   If, therefore, we  fhall be able to difcover what,
in the  ftate of different perfons, can  give occafion to
more or fewer puftules, we  fliall probably be able to
account  for all  the other differences  of the diftinct
and confluent fmall-pox.
                     DXCVII.
  It is evident, that the contagion of the frnall-pox  is
a ferment with refpect to the human  fluids, and afli-
milatcs  a great part  of them to its  own nature*';.and
it is probable, that the quantity thus affimilated, is,
in proportion to the bulk  of their feveral bodies, near-
ly the fame in different perfons.   This quantity palles
again out of the body, partly by infenfible perfpiration,
and partly by being depofited in puftules ; but  if the
quantities generated be  nearly equal,  the quantities
paffing out of  the  body by  the two  ways mentioned
are very unequal in different perfons ; and, therefore,
if we can explain the caufes  which determine  more to
pafs by the one way than  by the other, we may there-
by  difcover the caufes which give occafion to more
puftules in one perfon than  in another.
                                          DXCVIII.
  * This opinion is molt probably true, but it is by no means (as
the  auttnr  fays,) evident. His reafoning however, is ingenious,
and deferves attention.  Theexpulfion, or rather evacuation of the
morbific matter is admitted as the cure of the difeafe, and the* differ-
ence of the difeafe to the different manner in which this evacuation
is made :  But the author has not proved either of the premiffes he
has advanced, viz. that the quantity of human fluids which the fer-
ment aflimilates,  is nearly the  fame in different perfons, nor that
nny part of the morbific matter, or the morbid affimilated fluids pa'"-
o:i by perfpiration. 
OT  PHYSIC.
*95
                    DXCVIII.
   The caufes which determine more of the variolous
 matter to pafs by perfpiration, or to form puftules, are
 probably certain circumftances of the fkin, that deter-
 mine more or lefs of the variolous matter to ftick in
 it, or to  pafs freely through it.
                     DXC1X.
   The circumftance of the Ikin, which feems to deter-
 mine the variolous matter  to ftick in it, is a certain
 ftate of inflammation depending, much upon the heat
 of it.   Thus we  have many  inftances of parts of the bo-
 dy, from being more heated, having  a greater number
 of puftules than other parts.   In the prefent practice
 of  inoculation,  in which few puftules are produced,
 much  feems to be owing to the care that  is taken to
 keep the fkin cool.  Parts covered with plafters, efpe-
cially with thofe of a ftimulant kind, have more puftules
 than  other parts.   Further, certain  circumftances,
fuch as'adult age, full living, determining to a phlogif-
tic  diathefis, feem to produce a greater number of puf-
tules ; while the contrary  circumftances  have  con-
trary effefts.
                       DC.
  It is therefore probable, that an inflammatory ftate
of the whole fyftem, and more particularly of the fkin,
gives  occafion to a greater number  of puftules: and
the caufes of this  may like wife produce moft of the
other circumftances of the  confluent fmall-pox; fuch
as the period of eruption; the continuance of the fe-
ver ;  the effufion of a more putrefcent matter, and lefs
fit  to be converted into pus;  and,  what arifes  from
thence, the form and other circumftances  of the puf-
tules.
                      DCI.
  Having thus attempted to account for the cMef dif-
ference which occurs in the ftate of the fmall-pox,  we
                                             fhall 
296           PRACTICE
fliall now try the truth of our doctrine, by its applica-
tion to practice,
                     DCIL
  In confidering the practice, we view it firft, in gene-
ral,  as  fuited to render the difeafe more  generally
benign  and fafe, and this by the practice of inocula-
tion.
                      DCIII.
  It is not neceflary here to defcribe the operation of
inoculating; and what we name the practice of ino-
culation, comprehends all the feveral meafures which
precede or fol'ow that operation,  and are fuppofed to
produce its falutary effects.
  Thefe meafures are chiefly the following,
   i.  The chooiing for the fubject of inocuYiion per-
fons otherwife free from  difeafe, and not liable, from
 their age  or  other circumftances, to any  incidental
 difeafe.
   2.  The choofing a perfon at the time of life moft
 favourable  to a mild difeafe.
   3.  The choofing  for the  practice a feafon the moft
 conducive to the mildnefs of the difeafe.
^4.  The  preparing the perfon to be inoculated, by
 abftinence  from  animal food for fome time before ino-
 culation.
  _ 5. The preparing the perfon by courfes of mercu-
 rial and antimonial medicines*.
   6. The taking care, at the time of inoculation, to
 avoid cold, intemperance, fear, or other circumftan-
 ces, which might aggravate the future difeafe.
   7. After thefe preparations and precautions,  the
 choofing a fit matter to be employed in inoculation,
 by taking it from a perfon of a found conftitution, and
 free from  any dileafe or fufpicion  of it ; by taking it
 from a perfon who has had the fmall-pox of the moft
 benign kind; and,  laftly, by  taking the matter from

   ff Lomp;.re tl.isparariv.i 1. with what folloj^j in article 609. 
              O F  P  H Y S I C.            297

fuch perfons, as foon as it has appeared in the puftules,
either in the pait inoculated, or on other parts of the
body.
  8. The introducing, by  inoculation, but  a fmall
portion of the contagious matter.
  9. After inoculation, the continuing the vegetable
diet, as well as the employment of mercurial and an-
timonial medicines ; and at the fame time, frequently
employing purgatives.
  10. Both  before and after inoculation, taking care
to avoid external heat, either from the fun,  artificial
fires, warm chambers,  much cloathing, or being much
in bed ; and on the contrary, expofing  the perfon to a
free and cool air.
   11.  Upon the  appearance of the  eruptive fever,
the rendering that moderate  by  the employment of
purgatives; by the ufe of cooling and antifeptic acids,
and efpecially,  by  expofing the perfon  frequently to
a cool and even a  cold air, at the fame time giving
freely of cold drink.
  12. After  the eruption, the continuing the appli-
cation of cold air,  and the ufe of purgatives, during
the courfe of the difeafe, till the puftules are fully ri-<*
pened.
                       DCIV.
  Thefe are the meafures propofed and practifed in
the lareft and moft improved ftate of inoculation ; and
the advantages obtained by the whole of the practice,
or at leaft by   moft  of the meafures abovementi-
oned, are now afcertained by a  long  experience to
amount to this, That,  in ninety-nine cafes of the hun-
dred, inoculation gives a diftinct fmall-pox only, and
that alfo very generally of the mildeft form :  but  ic
will ftiil be uleful,  for the proper condud of inocula-
tion, to confider the importance and utility of the k-
veral meafures abovementioned, that we may thereby
  Vol.  I.              P p                   moie 
298           PRACTICE
 more exactly determine upon what the advantages of
 inoculation more certainly depend.
                       DCV.
    As the common infection may often feize  perfons
 labouring under another difeafe, which  may render
 the fmall-pox more violent, it is obvious that inocu-
 lation muft have a great advantage, by avoiding fuch
 concurrence.  But, as the avoiding fuch concurrence
 may often, in  the mean while, leave perfons expofed
 to the  common  infection,  it merits inquiry, whether
 every difeafed ftate fliould reftrain from tlie practice
 of inoculation, or what are the particular difeafes that
 fhould do fo.  This is not yet lufficiently afcertained
 by obfervation ;  and we have frequently  remarked,
 that the fmall-pox have often occurred with a  difeaf-
 ed ftate of the body, without being thereby rendered
 more violent.  In particular, we have obferved, that
 a fcrophulous habit, or even the prefence of fcrophula,
 did not  render the fmall-pox more  violent; and  we
 have obferved  alfo, that  feveral  difeafes of the fkin
 are equally innocent.   I am of opinion, that they are
 the difeafes  of the febrile kind, or  ailments ready to
 induce or aggravate a febrile ftate, that efpecially give
 the  concurrence  which  is  moft  dangerous with the
 fmall-pox.   I dare not attempt any general  rules;
 but I am difpofed to maintain, that, though a  perfon
 be in a difeafed ftate, if that ftate be of uncertain na-
 ture and effect, and at the fame time the fmall-pox  be
 exceedingly  life, fo as to render it extremely difficult
 to guard  againft the common infection, it will aways
 be fafer to give the fmall-pox by inoculation, than to
 leave  the perfon to take them by the common  infec-
 tion.
                      DCVL
  Though inoculation  has been practifed with  fafety
upon perfons of all ages; yet, from what has actually
occurred in the cafes of common infection, and from
                                            icvci'-d 
             O F  P H Y S  I  C.           299

feveral other confiderations, there is reafon  to con-
clude, that adults are more liable to a violent  difeafc
than perfons of younger yeais.  At the fame time, it
is obferved, that  children, in the  time of their firft
dentition, are liable, from this irritation, to have  the
fmall-pox rendered more violent; and  that infants,
before the time of dentition, upon receiving the con-
tagion of the fmall-pox, are liable to be affected with
epileptic  fits, which  frequently prove  fatal.   It is,
therefore, upon the whole, evident, that, though  cir-
cumftances may admit, and even  render inoculation
at any age proper ; yet, for the  moft part, it  will be
ftill more advifable to choofe perfons at an age, after
the firft dentition is over, and before the time  of  pu-
berty.
                     DCVIL
   Though.inoculation has been practifed with fafety
 at every feafon of the year ;  yet, as  it is certain  that
 the cold  of the winter may  increafe the inflammato-
 ry, and  the heats of fummer increafe the putrefcent
 ftate of the fmall-pox, it is  highly probable that ino-
 culation may have fome advantage, from avoiding the
 extremes, either of heat or cold.
                     DCV11I.
  Although the original temperament and conftitutions
 of men are not to be readily changed ; it is fufficiently
 certain,  that the conditions of the human body may,
 by various caufes, in many refpects be occafionally ve-
 ry much changed : and therefore, as the ufe of ani-
 mal food may increafe both the inflammatory  and pu-
 trefcent  ftate  of the  human body, fo it  muft render
 perfons, on receiving the contagion of the fmall-pox,
 lefs fecure againft a  violent difeafe ; and, therefore,
 inoculation may derive  fome advantage from abfti-
 nence from animal food, for fome time before  the ino-
 culation is performed : but I am  of opinion, that a
 longer  time than that  ufually prefcribed may be often 
300
PRACTICE
neceflary ;  and I am perfuaded, that the Scottifh mo-
thers  who avoid giving their children animal food
till they are paft the fmall-pox, render this difeafe in
them of a milder kind.
                      DCIX.
   I cannot deny that mercurial and  antimonial me-
dicines  may have  fome  effect  in  determining  to  a
more free perfpiration, and therefore  may be of fome
ufe in preparing a  perfon  for the  fmall-pox ;  but
there  are  obfervations  which  render me doubtful
as to  their effect.   The quantity of both thefe medi-
cines, particularly the antimony, commonly employed,
is too inconfiderable to produce any effect.   It is true,
that the mercurials have often been employed more
freely ;  but even their falutary effects have not been
evident, and their mifchievous effects have fometimes
appeared.   I doubt, therefore, upon the whole, if ino-
culation derives any advantage from  thefe pretended
preparatory courfes of medicines.
                      DCX.
   As it has been often obferved, in the cafe of almoft
all contagions, that cold, intemperance, fear, and fome
other circumftances, concurring with the application
of the contagion,  have greatly aggravated the future
difeafe, fo it muft be the fame in the cafe of thefnall-
pox ; and it is undoubted, that inoculation muft derive
a great, and perhaps its principal, advantage, from a-
voiding the concurrences abovementioned.
                      DCXL
   It  has been commonly fuppofed, that inoculath o
has derived fome advantage  from the  choice of the
matter employed in  it ; but, from what  has been ob-
ferved in  dscv.  it muft appear very  doubtful if  any
choice be neceffan , or can be of any benefit in deter-
mining the  ftate of the difeafe'.
                                           BCXII.
   * To remove all fufpicion, however, it is doubtlefs bett..: to ino*
culate  with matte; til:." from a no,dilate of the difeafe. 
OF   PHYSIC.
3®i
                      DCXII.
   It has been fuppofed by fome, that inoculation has
an advantage, introducing a fmall portion only of the
the contagious ma«ter : But this refts upon an uncer-
tain  foundation.  It  is not known what quantity is
introduced  by the  common infection,  and it may be
a fmall quantity only.  Although it were larger than
that thrown  in by inoculation, it is not afcertaincd
that the cirumftance of quantity would have any ef-
fect.   A certain quantity of ferment may be neceffa-
ry to  excite  fermentation in a given mafs :  but that
quantity given, the fermentation and affimilation are
exi.ended to the whole mafs ; and we do not find that
a greater quantity  than  is juft neceffary,  either in-
creafes the  activity of the fermentation, or more cer-
tainly  fecures the affimilation  of the whole.   In the
.cafe of the  fmall-pox, a confiderable difference in the
quantity of contagious matter introduced, has not dif-
covered any effect in modifying the difeafe.
                      DCXIIL
   Purging has the effect of diminifhing the activity of
the fanguiferous fyftem,  and of obviating its inflam-
matory ftate.   It is therefore  probable,  that the fre-
quent  ufe of cooling purgatives is a practice attending
inoculation which  may be of confiderable advantage ;
and, probable, it is alfo ufeful by diminifhing the de-
termination to the fkin.   It appears to me, that mer-
curials and  antimenials, as  they are commonly  mana-
ged, are ufeful only as they make a part of tiie pag-
ing c.urfc *.
                      DCXIV.
   It is probable,  that the ftate of the fmall-pox de-
                                              pends
  *  All purgatives are extremely naufeous to children ; and it i» of
little coiiHiuience what purgatives we ufe, if we  only avoid the hot
dral'ic ftimulants, we ought to  pay attention to the agrceablcnels of
the form. Children may in general be deceived by the fallowing de-
vice : Put ha!f an ounce  of Senna leaves (after the llalks are all
picked out) into a tea-pot, .'.ith a quaiter of an ounce of ^<ecR 
302
PRACTICE
pends very much upon the ftate of the eruptive fever,
and particularly upon  moderating the intia;v ortory
itate of the fkin ; and, therefore, it is  probable,  that
the  meafures taken for moderating the eruptive f ver
and inflammatory ftate of the fkin, afford the g> eateft
improvement which has been made in the pi nct.ce of
inoculation.   The tendency of purging, and the  ufe
of acids for this purpofe, is furficiently obvious ; and
upon the fame ground, we fhould fuppofe, that blood-
letting might be  ufefal j but probably this  has  been
omitted, for the fame  reafon that might perhaps have
led to the omiflion  of other remedies alfo ;  which is,
that we have found a more powerful and effectual one
in the application of cold air, and the ufe of cold drink.
Whatever doubts or difficulties our theory might pre-
fent to us on this fubject, they may be entirely neg-
                                                 lected,
tea;  pour on it a quart of boiling water.   Let the child fee it
poured into a tea-cup, fweetened with plenty of moiit fugar,  and
cream put to it.  The child will drink it with avidity.  A tea-cup-
ful may be given every hour till it begin to operate.
  If this device fhould fail a fecond time, another fhould be ufed in
its ftead.  Two drachms of Senna-leaves,  pondered, may be added
to half a pound of ginger-bread pafte ;  the mafs may be divided in-
to fifteen fmall cakes to be baked : give the child one of thele cakes
every half-hour till it begina to operate, or till he has taken a fuffici-
ent dofe for his age,  A drachm  of jalap may be ufed infitad of the
Senna.  If neither  of thefe artifices fucceed, a'dofe of powdered
fcnna, with or without a little ginger,  may be given in orange mar-
malade.
  Children will fometimes eat as many tamarinds as vill fufliciently
anfwer all the intentions of a formal purge.  A  little Caffia-pulp,
added to the tamarinds, will increafe their activity, and will not be
eafily perceived by the child.
  The empirics have committed many ftrange chemical blunders
in compounding their purges for inoculation.   Dimfdale's powder
may ferve as an example : it confifts of tartar emetic, and crabs claws.
The  calcareous earth deprives the tartar emetic of it's acid ; in con-
fequence of which, the antimony v/ill be  inert, except ft acciden-
tally  meets with an acid in the ftomach ; and even then the acid muft
be in fuch a quantity as to faturate the crabs claws, before it can act
on the aiitimo:.::il calx. 
OF   PHYSIC.
3°3
 ledted,  as the practice of Indoftan had long ago, and
 the practice of this country has lately, by a'large  and
 repeated experience, afcertained the fafety and effica-
 cy  of this remedy :  and as it may and can be more
 certainly employed with the practice of inoculation,
 than it  can be in cafes of common infection, it muft
 give a fingular advantage to the former *.
                       DCXV.
   After the eruption, when a few pimples only have
 appeared on  the face, the continuing the application
 of cold air,  and the employment ot purgatives,  has
 indeed been  the practice of many inoculators: but I
 think, thefe practices cannot be faid to give  any pecu-
 liar advantages  to inoculation ; for when the ftate of
 the eruption  is determined,  when the number of puf-
 tules is  very  fmall, and  the  fever has entirely ceafed,
 I  hold the fafety of the difeafe to be  abfolutely afcer-
 tained,  and the further ufe ofremed*es entirely fuper-
 fiuous.  In fuch cafes, \ judge the ufe of purgatives to
 be not only unneceffary, but that they  may be often
 hurtful.
                      DCXVL
   I  have  thus  confidered the  feveral  circumftances
 and practices accompanying inoculation, and have en-
 deavoured to afcertain the utility and importance of
 euch.    Upon the whole, I hope I have fufticiently af-
 certained the  general utility and great  advantage of
 this practice, efpecially confuting  in this,  that if  cer-
 tain  precautions, preparations,  and remedies,  are cf
 importance,  all  of them can be employed with more
                                            certainty

   * Notwithftanding the juftnefs of thi« rtmaik, bleeding ought to
 he employed, except i" cafes where the phlogillic diathcl's and fymp-
 toms are violent : the flight which children fufftr in confequence of
 the operation, may be productive of much milchief : and purgatives
when properly  admii iitercd,  fupercede the necefiity of bleeding,
efpecially when the eold regimen is employed at the fuine time. 
3°4
PRACTICE
 ceitainty in  the practice of inoculation,  than in the
 cafe of common infection*.
   It remains now that I fhould offer fome remarks on
 the conduct of the fmall-pox,  as received by m'ection,
 or even when,  after inoculation,*t!.e fymptoms ihall
 prove violent.   The  latter fometimes  happens,  al-
 though  every precaution and  remedy have been em-
 ployed.   The caufe of this is  not  well known ; but it
 appeals to  me to be commonly owing to a difpofition
 of the fluids to  putrefcency.   But, however  this may
 be, it  will appear, that, nut only  in the caie or.  com-
 mon infection, but even in  that f.r inocuY'Yc,:i, there
 may be occafion for ftudying  the  cc nduct of this  dif-
 ecife, in all its poffible  varying circumftances.
                      DCXVII.
   When, from the prevailing of fmall-pox as an epi-
 demic, and more efpecially when it is known  that a
 perfon not formerly  affected with the  difeafe  has been
 expofed  to  the infection,  if fuch perfon fliould be feiz-
 ed with  the  fymptoms of fever,  there can  be little
 doubt of its being an attack of the  fmall-pox ;  and
 therefore he  is to be treated in every  refpect as if the
                                                difeafe
    »
   * Thr nuthrr feems to have forgotten a frequent confequence of
 Jnocnlnr or, that demands fome attention,  viz. an inflammation  of
 the axillary glands, that often terminates in  fuppuration.   Manv
 ca&Lpf this kind occurred to me in practice,  and 1 attempted fe-
 veralmethods of preventing the fuppuration ; of which I found the
 following the moft efficacious : If only one arm had been  punctured,
 the gland of that arm, when fuch an accident happened, and not of
 the other,  was inflamed.  In attempting the refolution,  which per-
 haps fome practitioners may think improper, I applied cold compref
 fes, impregnated with a folution of ^accharirn Batumi, to the iu-
 flamed gland, and a warm poultice to the ulcer of the puncture.
 The confequence was an increafed difcharge from the puncture, and
 a diminution of the axillary fwe.ied gland.  Ku ill confequence at-
 tended any of thofe  cafes where the tumour was thus refold! ; but
 when thele tumours fuppurate, they are a;-t to produce iinou* ukcrs,
very difficult to heal. 
              OF    PHYSIC.           305

difeafe had been received by inoculation.   He  is to
be freely expofed to a cool air, to be purged,  and to
have cooling  acids given liberally*.
                     DCXVIII.
  If thefe meafures moderate the fever, nothing more
is neceffary :  But if the nature of the fever attacking
a perfon be  uncertain; or  if, with fufpicions of the
fmall-pox,  the fymptoms  of the fever be violent; or
even if, knowing the difeafe to be fmall-pox, the mea-
fures mentioned dxcvii. fhall not moderate the fever
fufficiently ;  it will be proper to let fome blood : and
this will be more efpecially proper, if the perfon be an
adult, of a plethoric habit, and accuftomed  to full li-
vingf.
                      DCXIX.
   In the  fame circumftances, we  judge  it will be al-
ways proper to give a vomit,  as ufeful  in the com-
mencement  of all fevers, and more  efpecially  in this,
where a determination to  the ftomach appears from
pain and fpontaneous vomiting.
                      DCXX.
   It frequently happens,  efpecially in infants,  that,
during the eruptive fever  of the fmall-pox,  convulfi-
ons  occur.  Of thefe,  if  only one  or two fits appear
on the evening preceding the eruption, they  give a
 favourable prognoftic  of a mild  difeafe,  and require
no remedy ;  but if they occur more  early, and be vior^
lent and frequently repeated, they are very dangerous,
and  require  a  fpeedy  remedy.    For this purpofe,
 bleeding is hardly  ever of fervice j bliftering always
   Vol.  I.               Q^q                comes

   * The cooling acids have been defcribed in former notes,  on par.
 131 and 134.  Whey made with cream of tartar is very ufeful in the
 fmall-pox,  as it is a cooling drink, and at  the fame time laxative.
 It is made by throwing into a quart of boiling milk half an ounce
 or fix drachms of powdered cream of tartar.
   f This pradice  is moft judicious, and ought to be ftridtly fob
 lowed. 
3.5
P  R  A  C  T'l C  E
comes too late ;  and the only remedy I have found ef
fectual, is an opiate given in a large dofe-;.
                      DCXXI.
  Thefe are the  remedies neceffary  during the erup-
tive fever ; and if, upon the eruption, the pimples up-
on the face be very few and diftinct, the difeafe is no
further of any danger,  requires no remedies,  and the
purgatives; which, as has been faid before, are by fome
practitioner., continued, prove  often hurtful.
  Bu: when, upon  the  eruption, the pimples on the
face' are very numerous; when they are not diftinct;
and efpecially when, upon the  fifth day, the fever  does
not fuffer  a confiderable remiflionf, the  diletife will
ftill require a great deal of attention.
                      DCXXII.
  If, after the eruption, the fever fliall continue ; the
avoiding heat, and the  continuing to expofe the body
to a cool air, will ftill be proper.   If the fever be con-
fiderable, with a full and hard pulfe, in an adult per-
fon, a bleeding will  be neceffary ; and,  more certain-
ly,  a  cooling purgative.  It is, however, feldom that a
repetition of the bleeding  will be  proper, as  a lofs of
ft/ength does  ufually come on very foon ; but the re-
petition of a purgative, or the frequent ufe of laxative
glyfters, is commonly ufefulf.
                                           DCXXIII.

  * The dofes for children in thefe cafes arc as follows : A child of
half a year, 5 drops of laudanum : From half a year to a  year, 6
drops.  From one to two years 7 or 8 : From two to three, 9 or I© :
Five year.-,  12, or  at moft 15.   Thefe are large dofee, and are
fuch _s are only to bo given to robu^ children.
  f The practitioner ought to be particularly attentive to the fymp-
toms which appear on the fifth day. The fubfequent paragraphs fen-
der any farther remarks needless.
  X  Laxative glyfters are preferable  to repeated purgatives,  on ac-
count of their not d-b'ilitating the patient  fo much as  purgatives.
The following form  has been found very effectual :
             §>. Fol, Sennae, gfs.
                Sal. cathart. amar. ^i.
               Aq. bullient. lb. 1. 
                OF   PHYSIC.             307

                       DCXXIIL
   When a lofs of ftrength, with other marks of a pu-
 trefcent tendency of the fluids, appears,  it will be ne-
 ceflary to exhibit the'Peruvian bark in fubftance, and
 in large quantity*.   In the fame cafe, the free ufe  of
 acids, and of nitre §, is ufeful; and it is commonly pro-
 per alfo to give wine very freelyj-.
                      DCXXIV.
   From the  fifth day of the difeafe, onward through
 the whole courfe of it,  it is proper to give  an opiate
 once or twice a day ;  taking care, at  the fame time,
 to obviate coftivenefs, by purgatives, or  laxative gly-
 fters.
                       DCXXV,
   In a violent difeafe, from the eighth to the eleventh
 day, it is proper to lay on blifters fucceffively on dif-
 ferent parts of the body;  and that without regard to
 the  parts being covered with puftules.
                      DCXXVI.
   If, in this  difeafe, the tumour of the fauces be con-
 fiderable ; the deglutition difficult; the faliva and rnti-
'cus  vifcid, and with  difficulty thrown  out; it  will
 be proper to  apply blifters to the external fauces,  and
 to employ diligently detergent garglesf.
                                           DCXXVII.
                Colaturse frigidae adde.
                Syr. e Spin, Cervin.  3ji.
                Ol. Olivar. 3 fs.
                M.
 Or even a fimple folution of  Epfom fait in warm water.
   *  The method of  giving the bark in the fmall pox,  is the fame
 with that mentioned in the Dote on article 217.  For children, the
 glyftcr there mentioned, is extremely convenient, and proves won-
 derfully efficacious.
   §  The Spiritus Nitridulcis is the beft form in which nitre can be
 given to children.  See the notes on article 131.
   -f-  The wine beft fuited to thefe cafes is port wine  ; but as children
 fometimes loath  it, good claret  may be fubftituted  in its place.
   X  The belt detergent gargles in this cafe, are the tincture ofrofes 
3c8              PRACTICE

                     DCXXVIL
  During the  whole  courfe  of the difeafe, when any
confiderable fever is prefent,  the frequent exhibition
of antimonial medicines, in naufeating dofes, has been
found ufeful*; and  thefe, for the moft part, fufficient-
ly anfwer the purpofe of nurgatives.
                     DCXXVIIL
  The remedies mentioned from dcxxii. to dcxxvi.
are thofe frequently neceflary, from the fifth day, till
the fuppuration is finifhed.  But as, after that period,
the fever is fometimes continued and increafed ; or, as
fometimes, when after there has been little or no fever
before,  a fever now  arifes, and continues with confi-
derable danger; this is what is  called the Secondary
Fever, and  requires particular treatment.
                     DCXXIX.
   When  the  fecondary fever  follows  the  diftinct
fmall-pox,  the pulfe is full and hard, the cafe is to be
treated as an inflammatory affection, by  bleeding and
purging.  But, if the fecondary fever follow the con-
fluent fmall-pox, and be a continuance or exacerbati-
on of the fever which had fubfifted before, it is to be
confidered  as of the putrid kind ; and in that  cafe,
bleeding is improper.  Some purging may be necef-
fary ; but the  remedies to be chiefly depended on, are
the Peruvian bark and acidsf.
                                              When
with honey ;  or the gargle of fage and rofe tea, with vinegar and
honey, mentioned in the note on article 317 ; or  Dr. Fothergill's
gargle deferibed in that  note.
  *  A folution of two  grains of emetic tartar in  eight  ounces of
 water anfwers thL intention very effe&ually.  The dofe is to be de-
 termined by the naufeating effecT: produced : a table-fpoonful of the
folution may be given occafionally every two or three hours.   Care,
 however, muft be taken, that vomiiing is not produced :  and, at
the fame time, a fufficient quantity muft be given to produce a naii-
 fca.   Both  thefe circumltances depend on the age, ftrength, and
 constitution of the patient and on the violence of the difeafe.
   [■  The fecondary fever is always the worft, and moft dangerous 
                OF  PHYSIC.             309

  When the fecondary fever firft appears, whether it
is after a diftinct or  a confluent fmall-pox, it will be
ufeful to exhibit an  antimonial emetic in naufeating
dofes, but in fuch manner as to produce fome vomit-
ing.
                      DCXXX.
  For avoiding  the pits  which frequently follow the
fmall-pox, many different meafures have been propof-
ed ; but  none of them appear to be fufficiently cer-
tain*.


              ..<..< ..<.<..< < < < <■*< .<ifr,..,..>-> >■>■■>■■»>■ >■■>■■*■•


                 CHAP.      II.


             OF  THE CHICKEN-POX.

                       DCXXXI.
     THIS  difeafe feems  to  depend  upon  a  fpecific
     contagion, and to  affect perfons  but once in their
lives.   It is hardly ever  attended with any danger;
                                                     but

flage of the difeafe.  In the diftinct fmall-p^x, it feldom occurs, but
it is a conftant attendant on the confluent kind. It feems to be owing
to the abforption of the matter ; for it never appears, evidently at
leaft, till after the  fuppuration : and  ceteris paribus, it is always
more violent in proportion to  the quantity of puftules.  8oir:c au-
thors recommend opening the puftules, in order to evacuate the mat-
ter, as a preventative againft the fecondary fever ; and when the
eruption is large, this praftice  is advifable.
  The peruvian bark muft be given in thefe cafes in the largeft quan-
tities that the ftomach can bear, and alfo in glyfters as formerly men-
tioned.  Some praftitioners, befide the internal  ufe of bark, and
giving  it in glyfters, have advifed it to be applied  externally  by
throwing the dry powder on  thofe parts of the body that are  molt
exulcerkted.
  * The moft effectual means of preventing pits,  are, to avoid ur.'.ch
cxpofure to the cold air, to  anoint the face with oil, Sec. 
3*2
PRACTICE
 but as it feems frequently to have given occafion to
 the fuppofition of  a perfon's  having the  finall pox
 twice, it is proper to ftndy this difeafe, and to diftin-
 guifh it from the genuine fmall-pox*.
                     DCXXXII.
   This may be  generally done by  attending to the
 following circumftances.                     > ~r
   The eruption of the  chicken-pox  comes on  with
 very little fever  preceding it, or wnh fever of no der
 termined duration.
   The pimples of the chicken-pox, more  quickly than
 thofe of the fmall-pox, are formed into little veficles
 or puftules.
   The matter in thefe puftules remains fluid,  and ne-
 ver  acquires  the colour  or  confiftence  of the  pus
 which appears in the puftules of the fmall pox.
   The puftules of the chicken-pox are always  in three
 or four days  from  the  firft appearance,  formed into
 crufts.
   See  Dr.  Heberden in Med. Tranfact.  Vol. I. art.
 xvii.

             -«-<■«.«..<..< £•«..< < <{'*$•> >-> >-► > >>•>• >..>.

                C  II  A  P.    III.

              OF THE  MEASLES.

                    DCXXXIII.
     THIS difeafe alfo depends upon a fpecific conta*
     gion,  and affects perfons but once in their lives.
                                       DCXXXIII.

  * As this difeafe is generally mild, and fcarcely ever requires the
afliftance of art in the cure, the author very properly paffes it over
ia a curfory manner.  It  fometimes, however, very much  refembles
the mild fmall-pox ; and in fuch cafes  may require the treatment
which has been recommended as fcnriceable in that difeafe. 
OF  PHYSIC.
                  DCXXXIV,
  It occurs moft frequently in children ;  but no age
is exempted from it, if the perfons have not been fub-
jected to it before.
                    DCXXXV.
  It commonly appears as an epidemic, firft in the
month of January, and ceafes foon after the fummer
folftice: but various accidents, introducing  the con-
tagion, may produce the difeafe at other times of the
year.
                   DCXXXVI.
  The difeafe always begins with a cold ftage, which
is foon followed by a hot, with the ordinary fymp-
toms of thirft,  heat, anorexia, anxiety, ficknef;, and
vomiting ;  and thefe are more or lefs confiderable  in
different cafes.   Sometimes from the beginning, the
fever is fharp and violent; often,  for the firft two
da}s. it is obfcure and inconsiderable, but always be-
comes violent before the eruption, which ufually hap-
pens upon the fourth, day.
                  DCXXXVII.
  This eruptive fever from its commencement, is al-
ways attended with hoarfenefs, with a frequent hoarfe
dry  cough, and frequently with fome  difficulty  of
breathing.  At the fame time, the eye-lids are fome-
what fwelled, the eyes arc a little inflamed, and pour
out tears ;  and, together with thefe  fymptoms, there
is a coryza, and frequent fneezing.   For the moft
part,  a conftant drowfinefs attends the beginning of
this difeafe.
                   DXXXVIII.
  The eruption, as we have faid,  commonly appears
upon the fourth day, fhft on the face, and fuccetfive-
ly on the lower parts of the body.  It difc©vers itfelf
firft in fmall red points; but,  foon after a number of
thefe appear in clutters, which do not arife into vifi^le
pimples, but by the touch are found to be a little t
                                       prominent. 
312
PRACTICE
 prominent.   This is the cafe on the face ;  but on o-
 ther parts of the body, the prominence, or roughnefs,
 is hardly to be perceived.   On the face the eruption
 retains its rednefs, or has that increafed for two days :
 but, on the  third, the vivid rednefs is changed to a
 brownifh red : and, in a day or two more, the eruption
 entirely  difappears,  while  a  meally  defquamation
 takes place.  During the whole time of the eruption,
 the face is fomewhat turgid, but feldom confiderably
 fwelled.
                   DCXXXIX.
   Sometimes, after the eruption has appeared, the fe-.
'ver ceafes entirely :  but this is feldom the  cafe; and
 more commonly the fever continues, or  is increafed
 after the eruption,  and  does  not  ceafe  till after the
 defquamation.   Even then  the fever does not always
 ceafe,  but continues with various duration and effect.
                     DCXL.
   Though the  fever happen to ceafe upon  the erup-
 tion's taking place,  it is common for the  cough to
 continue till after the defquamation, and fometimes
 much  longer.
   In all cafes, while the fever continues,  the cough
 alfo continues, generally with  an increafe of the diffi-
 culty of breathing ; and both of thefe fymptoms fome-
 times arifes  to a degree that denotes  a pneumonie af-
 fection.  This may arife at an^ period of the difeafe ;
 but very often it does not come on  till after the de-
 fquamation of the eruption.
   After the fame period, alfo,  a diarrhoea frequently
 comes on, and continues for fome time.
                     DCXLI.
   It is common for the meafles, even when  they  have
 not been of a violent kind, to be fucceeded by in-
 flammatory affections,  particularly  ophthalmia and
 phthifis.
                                         DCLXII. 
OF   PHYSIC.
3*3
                     DCXLII.
   If the blood be drawn from a vein daring the rcea-
 fles, with the circumftances neceflary to favour the fe-
 paration of the gluten, this always appears feparated,
 and  lying on the furface of the craifamentum, as in
 inflammatory difeafes.
                     DCXLIIL
   For the moft part  of  the mcafles,  even when vio-
 lent, are without any putrid tendency; but in fome
 cafes fuch a tendency appears, both  in the  courfe of
 the difeafe, and efpecially after the ordinary courfe of
 it is  finilhed.  See Dr. Watfon, in London Med. Ob-
' fervations, Vol. IV. art. xi.
                     DCXLIV.
   From what is delivered, from dcxxxvii, to dcxlii,
 it will appear,  that the mealies are diftinguifhed by a
 catarrhal affection, and by an inflammatory diathefis to
 a confiderable degree; and therefore the danger attend-
 ing them arifes chiefly from the coming on of a pneu-
 monic inflammation.
                     DCXLV.
   From this confideration it will be obvious, that the
 remedies efpecially neceffary, are thofe which may ob-
 viate and  diminifh the  inflammatory diathefis ;  and
 therefore, in a particular manner, blood-letting.  This
 remedy may be employed at any time in the courfe of
 the difeafe, or after its ordinary courfe is finilhed.   It
 is to  be employed more  or  lefs according to the ur-
 gency of the fymptoms of fever, cough,  and dyfpncea ;
 and  generally may be employed  very freely*.   But,
 as the fymDtoms of pneumonic inflammation feldom
 come on during the eruptive fever ; and, as this fever
 is fometimes violent immediately before the eruption,
 though  a fufficiently mild  difeafe  be  to  follow ; fo
   Vol.  I.             VR  r               bleeding
  * Bleeding ought to be utd where it is abfolutely neceffary ; bi,t,
 too free a ufe'of it has been attended, with  a long continued weak-
 nefs, and a v«ry  flow recovery. 
3H         '    PRAC  T ICE

bleeding is feldom very  neceffary during the eruptive
fever,  and may  often be referved for  the periods of
greater danger which are perhaps to enfue.
                     DCXLVI.
  In all cafes of mealies, where there are no  marks
of putrefcency,  and where  there is no reafon, from
the known nature of the epidemic, to apprehend pu-
trefcency, bleeding is the remedy to be depended up-
on : but afliftance may alfo be obtained from cooling
purgatives ;  and particularly  from  bliftering on the
fides, or between the fhouldcrs.
                     DCXLVII.
  The dry cough may be alleviated by the large ufe
of demulcent pectorals, mucilaginous,  oily, or fweet*.
It may, however, be obferved, with refpect to thefe
demulcents, that they are not fo powerful in involving
and correcting the  acrimony of the mafs of blood as
                                                   has

  * Two ounces of pearl-barley, and four ounces of dried figs,
cut, boiled in a gallon of water to 3 quarts, is a good drink in thefe
cafes.  If the patient loaths this drink, Lintfeed-tea, or a flight in-
fufion of Orris-root in boiling water,  may be fubftituted in itsplacej
or a folution of an ounce4of gum arabie in a pint of water.   Oily
emulfions, are alfo recommended ; the moft ufual is the following :
             §,. 01. Amygdal. §ii.
               Aq. Font.  Jvi.
               Alkali Caullic. q. f. ut fiat Emulf. cui addc:
               Syrup. Althaeas,  Jii.
  The patient may take half a tea-jupful of this emulfion occafio-
nally, when  the cough is moft troublefome.   The cough may alfo
be relieved, by taking now and then a tea-fpoonful of the following
Lin&us :
                 R. 01. Amygdal.
                    Syrup Althaeas.
                    Conferv. Cynofbat. a a,  zi.
                   M. of Lincl.
                      Or the following.
                 $>•  Mel. anglic.
                   01. Amygdal.  a a Jii.
                    Succ. Limon. gi.
                    M. of Linth 
               OF  PHYSIC.           315

has been imagined ; and  that their chief operation is
by befmearing the fauces, and thereby defending them
from the irritation of acrids,  either  arifing from  the
lungs, or diftilling from the head.
                    DCXLVIIL
  For moderating and quieting the cough in this difeafe,
opiates  certainly  prove  the  moft  effectual  means,
whenever they can be lately employed.  In the mea-
fles, in which an inflammatory Itate prevails in a con-
fiderable degree, opiates may be fuppofed to be  inad-
miflible-, and,  in thofe cafes  in which a high degree
of pyrexia and  dyfpncea fliew either the prefence, or at
leaft the danger, of pneumonic inflammation,  I  think
that opiates might be very hurtful.  In cafes,  howe-
ver,  in  which the dyfpncea is  not confiderable, and
where bleeding, to obviate or abate the inflammato-
ry ftate, has been  duly  employed, and  where  the
cough  and watchfulnefs are the urgent fymptoms,  I
think that opiates  may be fafely exhibited, and with
great advantage*.   I think,  further, that, in all the
exanthemata, there is an acrimony diffufed over the
fyftem,  which  gives  a confiderable  irritation ; and,
for obviating the effects of this, opiates are  ufeful, and
always proper, when no  particular contra-indication
prevails.
                     DCXLIX.
  When the defquamation of the rneafles  is finifhed,
though  there fhould then be  no diforder remaining,
phyficians have thought  it neceffary to purge the pa-
                       R r 2                  tient
 ♦Opiates in all inflammatory cafes ought tobecautioufly ufed. The
danger arifing from them is confiderably obviated,  by ufing only the
^u'amy part of the opium,  and therefore  the watery folution of
opium, is in thefe cafes preferable to any  other fcim.   The fyrup-
us  papaveris albi,  is an opiate peculiarly adapted to this difeafe  ;
the dofe of it is immaterial, provided we do not exceed four ounces
in the four and twenty hours ; a tablc-fpoonful may be taken when
the ctiigji is troublefonv, and  may be repeated every two or three
hours, jfctordinj to the urgency of the fymptoms. 
                                  y

316            PRACTICE

tient feveral times, with a view to draw offthe drogs of
this difeafe, that  is, a portion of  the morbific matter
which is. fuppofed  to remain  long in the body.   I
cannot reject this fuppofition ; but, at the  fame  time,
cannot believe, that the remains of the morbific mat-
ter, diftufed over the whole mafs of blood, can be en-
tirely drawn  off by purging; and  it appears to me,
that,  to avoid tlie confequences of the me'afles,  it is
not the drawing oif the morbific matter  which we
need to ftudy, fo  much as the obviating  and removing
the inflammatory ftate of the fyftem which had been
induced  bv the difeaie.    With  this laft view, indeed,
purging  may ftill be  a  proper remedy ; but bleeding,
in  proportion to  the fymptoms of inflammatory dif-
pofition, is  vet more fo*.
                                                   DCL.

  * The complaints which the mealies leave are chiefly pneumonic.
Tliecou^h is the moit trmiblefome fymptom, and to  relieve the pa-
tient from  it,  not only bleeding and purging muft be ufed, but ex-
pectorant*  ought alfo to be ;i'!miiii ':eral.   The Lac Ammoniacum,
formerly mentioned has often proved beneficial.  On the fuppofition,
that the cough and pneumonic affection remaining after the meafYs,
are owing to a pecuhar acrimony, f>me prao*. turners, have recom-
mended alteratives and demulcents : Experience, however, has found
f.ttle advantage  fre n their life.   1 once faw a  boiiv opened, tint
had died 32 days after the eruption :  the  internal furface of tlie
bronchi?; was covered vu'th fmall furfuraceous fcahs,  fomewhat like
thofe that appear on  tlie fkin when the eruption gets off.  Hence  I
have been induced to  fuppofe, that expectorants are the btft remedied
in thefe cafes,  and indeed, experience confiims the practice.   Bleed-
inor and purging are only to be occahon-Ylv ufed, in order ln prevent
the  inflammation.  J he beif method of avoiding the ii! confeqnencea
ih-it r dhnv the d'feafe. is 3 free ufe of dcmulcem  drink-;, during the
tiuntion, and of expectorant- immediately after it. The Decoctum
hordei  compefuum,  of the  London pharmacopoeia is peculiarly
atlipicd to thefe cafer, hni it is much  improved by  adding  halt an
ounce of Orrice root, uhsn it is nearly boiled enough ; if the Or-
lice be added too foon,  the t fTYacious part of it cvap^ratm.  The
Lac ammoniacum above mentioned, is a  very p't,Kr expectorant,
but if it fliould prove too naufeous, through  ufe, and be loathed
bv the  patient, recouife may  be had to  the weak f/r.tion of the
.Tartar  Emtt.c,  fo often mentioned in thefe notes.

                              I 
               OF   PHYSIC.          317

                      DCL.
  Fiom our Lite  experience of the benefit of cold air
in the eruptive fever of the fmall-pox, fome phyficians
have been of opinion, that the  practice might be
transferred to the meafles ; but we have not yet had
t'ials fufficient to afcertain  this.  There is no doubt
that external heat may be very hurtful in the meafles,
as in moft other inflammatory difeafes ; and therefore
the body ought to be kept in a moderate temperature
during the whole courfe of the meafles ; but how far,
at any period of  the difeafe, cold air may be applied
with fafety, we are yet uncertain.   Analogy,  though
fo often the refourcc of phyficians, is, in general, falla-
cious ;  and further, though the analogy with  the
i-.nail-pox  lead to  the application of  cold air during
the eruptive fever of tlie meafles, the analogy with ca-
tarrh feems to be againft the practice.  After the e-
ruption had appeared upon the ikin, we have had ma-
ny inftances of cold air making it difuppear, and there-
by producing  much diforder in the fyftem; and have
alfo had frequent examples of fuch diforder being re-
moved by reltoring the heat of the body, and thereby
again bringing forth tlie eruption*.

           . < «••«-« •<<< < < < <4"$*<ti^t>- >••>■•>• > >••>•■>■>••>•■>••

               C   II  A   P.     IV.  ,

          OF THE SCARLET LEVER.

                      DCLI.
TT moy be doubted if the fcarlet fever be a d-f 'a'e
It fpoYY,- L\[y  different from the cynanche maligna*
                                             above

  * Though the application of cold p.ir be dangerous, yet ventila-
tion is o!  confideiable ufe in the rr.eafks, as is alfo a frequent change
©f linen,  and cleanlY.f::.
I 
318          PRACTICE
 above defcribed.  The latter is almoft always attend-
 ed with a fcarlet eruption ;  and,  in  all the inftances I
 have feenof what may be called  the fcarlet lever, the
 difeafe,  in almoft every perfon  affected, has been at-
 tended with an ulcerous fore throat.
                       DCLIL
   This vie.v of the matter may create fome doubt ;
 but I am ftill  of opinion, that there is a fcarlet fever
 which  is a difeafe fpecifically  different from the  cy-
 nanche maligna.
   Doctor Sydenham has  defcribed a fcarlet fever,
 which he had feen prevailing as an epidemic, with all
 the circumftances of the fever  and eruption, without
 its being accompanied with  any affection of the throat;
 at leaft he does not take notice of any fuch afLction,
 which fuch an  accurate obferver could  not fail to have
 done, if any fuch fymptom,  as we have commonly feen
 making a principal  part of  the difeafe, had attended
 thofe cafes which he  had  obferved.   Several other
 writers  have defcribe 1 the  fcarlet fever in the fame
 manner, and I  know phyficians who have feen the dif-
 eafe in that form ;  fo that  there can be no ooubt of
 there being a fcarlet fever  not neceffarily connected  •
 with an ulcerous fo.e throat, and therefore  a  difeafe
 different from  the cynanche maligna.
                     DCLIII
   But, further, aUhou^h in all the inftances of fcarlet
 fever which I  have  ken (and  in the courfe  of forty
 years I  have feen it fix or  feven times prevailing as
 an epidemic  in Scotland,) the dileafe, in almoft all the  .
 perfons affecled, was attended  with an ulcerous fore
 throat,  or was  what Sauvages  names the Scarlatina
 Anginofa: and although, in fome inftances, the ulcers
 of the throat were of a putrid  and gangrenous kind.
 and at  the fame time the dileafe in  all its fymptoms
 refembled very exactly  the  cynanche maligna;  yet, I
vi>m ftill perfuadei; thi.: net  only  the fcarlatina of Sy-
                                          denhi'.m, 
OF  PHYSIC.
3*9
denham, but that even the fcarlatina anginofa of Sau-
vages, is a different difeafe from the cynanche malig-
na ; and I have formed this opinion from the follovy-
ing confiderations.
                     DCLIV.
   ifl, There is a fcarlet fever entirely free from  any
affection of the throat, which fometimes prevails as aa
ej'idemic ; and  therefore there is a fpecific contagion
producing a fcarlet  eruption without  any determina-
tion to the throat.
   idly,  The fcarlatina, which,  from its  matter being
generally determined to the throat, may be  properly
termed  Anginofa, has, in many cafes of  the fame epi-
demic,  been without any affection of  the throat; and
therefore the contagion may be fuppofed to be more
efpecially determined to produce the eruption only.
   ^dly, Though in all the epidemics  that I  could al-
lege to be thofe of the fcarlatina anginofa, there  have
been  fome cafes which,  in the  nature of the ulcers,
and in other circumftances, exactly refembled the ca-
fes of the cynanche maligna; yet I have as conftantly
remarked, that thefe cafes have not been above one or
two in a hundred, while the reft have all  of them  been
with ulcers  of a benign kind, and  with circumftances
hereafter  to be defcribed,  fome what different from
thofe of the cynanche maligna.
   4thly, On the other hand, as I have  two or three
times feen the  cynanche maligna epidemically  pre-
vailing  ;  fo, among the  perfons affected, I have  feen
inftances of cafes as  mild as thofe of the fcarlatina an-
ginofa  ufually are :  but here the proportion was re-
verfed ;  and thefe mild cafes were not one fifth of the
whole,  while the reft  were of the putrid and malig-
nant kind.
   Lafilly, It applies to the fame purpofe to obferve,
that, of the cynanche maligna,  moft of  the inftances
terminate fatally ;  while, on the other  hand, that is
                                              the 
P II A C  T I C E
 the event of very few of the cafes of the fcarlatina an-
 ginofa.
                      DCLV.
   Frcra  thefe confiderations,  though it  may appear
 that there is  fome affinity between the cynanche ma-
 ligna and fcarlatina anginofa, it will ftill remain pro-
 bable that the two difeafes are  fpccifical'.y different.
 I have been at fome pains  to  eflablifh this opinion  :
 for, from all my expeiLnce,  I find, that thofe  two
 difeafes require a different treatment ; and 1 therefore
 now proceed to mention v.\ .re particularly  the  cir-
 cumftances of the fcad latina anginofa.
                      DCLVI.
   This dileafe  commonly appears about  the beeLi-
 nincf of winter, and continues throughout th.it feafon.
 It comes on with fome cold ihivering, and other fymp-
 toms of the fever which ufually introduces  the other
 exanthemata.   But here there is no cough, nor the
 other catarrhal fymptoms which attend the meafles;
 nor is there that anxiety and  vomiting which- com-
 monly introduce the confluent fmall-pox, and which
 more certainly introduce the Cynanche Maligna.
   Early  in the difeafe, fome uneafinefs is felt in the
 throat ; and frequently the deglutition is difficult, ge-
 nerally more fo than in the Cynanche Maligna.  Up-
 on looking into the fauces, a rednefs and Lveliing ap-
 pear in colour and  bulk approaching to  the ftate of
 thefe  fymptoms in the Cynanche Tonfillaris ; but,
 in the Scarlatina, there is always more or lefs of Houghs,
 which feldom  appear in the Cynanche Tonfillaris ;
 and the floughs are  commonly whiter than thofe  in
the Cynanche maligna.
  While thefe appearances are difcovered in the fau-
ces,  upon the third  or fourth  day a fcarlet eruption
appears on the Ikin  in the fame form as defcribed in
 cccxiv.  This eruption is commonly mere confidera-
ble and univerfal than in the Cvnanche ; but it feldom
                                             pro- 
OF   P EI Y S I  C.
321
produces a remiffion of the fever.   The  eruption for
the moft part remains till the third or foufth day af-
ter its firft appearance ; but then goes off, ending in a
mealiy defquamation.   At this time the fever ufually
fubfides;  and generally,  at the fame time, fome  de-
gree of fweat comes on.
  The floughs on the fauces, which appeared early in
the difeafe, continue for fome days; but then falling
off, difcover  the fwelling abated, and an ulcer formed
on one or both tonfils  fhowing a laudable pus ; end
foon after the fever has fublided, thefe ulcers heal tip-
entirely.  For the  moft  part  this difeafe has much
lefs of coryza attending it than the Cynanche malig-
na ;  and, when there is a coryza attending the Scar-
latina, the matter difcharged is lefs acrid, and has not
the fetid fmell which it has in the other  difeafe.
  In the Scarlatina, when the  eruption  has  entirely
difappeared,  it frequently happens, that,  in a  few
days after, the whole body is  affected with an anafair-
cous fwelling; which,  however, in a few days more,
gradually fubfides.
  We have thus defcribed the moft common circum-
ftances of the Scarlatina Anginofa ; and have only to
add, that during the time of its being epidemic,  and
efpecially upon its firft letting  in, there  are  always- a
few cafes in which the circumftances of the difeafe-ap-
proach very nearly to thofe of the Cynanche Malig-
na ; and  it is only in thefe inftances that the difeafe
is attended with any danger*.
   Vol. I.                 S  s             DC EVIL
  * Thefe cafes in which the difeafe is attended with danger, ar^
however, very  few, and are only the  effect of art.  Tea/^ng the
patient by doing too much ; tormenting him with a clofe continei*.-nt
to his bed, well furnifhed with blankets; and  aduing  fuel to the
flame, by  forcing him to fwallow large quantities of cordiajs ani
alexipharmics, are tlie Aire methods of increafing the difeafe :  and
ihe patient, diifrelfed by the exceilive  ofEcioufnefs of bis fage doc-
tor, is obliged to take refuge in the arms of death. 
312           f R  A  C T I C JS:

                     DCLVIJ.
  With refpect to the cure of this difeafe, when  thd
fymptoms of it are nearly the fame with thofe of the
Cynanche Maligna, it requires exactly the fame treat-
ment as directed in cccxvn.
                    DCLVIII.
  When the fcarlet fever appears, without any affec-
tion of the throat, the treatment  of it is very fimple,
and is delivered by Dr.  Sydenham.   An antiphlogif-
tic  regimen * is commonly all that is rcquifite ; avoid-
ing, on one hand, the application of cold air ;  and,
on the other, any  increafe of external heat.
                     DCLIX.
  In the ordinary ftate  of the  Scarlatina Anginofa,
the fame treatment b, in moft cafes, fufficient; but as'
here the fever is commonly more confiderable,  and
there is likewife an affection of the throat,  fome re-
medies may be often  neceffary.
                     DCLX.
  When there is a pretty high degree of fever,  with
a full pulfe, and a confiderable fwelling of the tonfils,
bleeding is very proper, efpecially in adults ; and  it
has been frequently practifed with advantage : but as,
even in  the Cynanche  Tonfillaris, much bleeding  is
feidom neceffary ; (cccv.) fo, in the Scarlatina, when
the ftate of the fever and the appearances of the  fau-
ces render the nature of the difeafe ambiguous, bleed-
ing may be omitted"; and, if not altogether avoided,
it fhould  at  leaft  not be large,  and ought not to be
repeated.
                     DCEXE
   Yomiting, and  efpecially naufeating dofes of eme-
tics f, notwithftanding  the inflamed  ftate of the fau-
ces, have been found very ufeful in this difeafe.  An.
                                              open
  "*  The antiphlogiftic regimen muft not however be carried too
far, left we induce a ftate of debility that may prove hurtful,
  f  Thefe have been mentioned in former notes. 
OF  PHYSIC.
323
open belly is proper in every form of this difeafe ; and
when the naufeating dofes of emetics operate a little
downwards, they are more ferviceable.
                    DC L XII.
  In every form of the Scarlatina. Anginofa, througb
the whole courfe of it, detergent gaggles*  fhould be em-
ployed, and more or lefs as the quantity of floughs and
the vifcid mucus in  the fauces may feem to require.
                   DCLXIIl.
  Even  in the milder ftates of the Scarlatina Angino-
fa, it has been common with practitioners to exhibit
the Peruvian  bark through  the whole courfe of the
difeafe ;  but we are affured, -by  much experience,
that in fuch cafes it may be fafely omitted, though  in
cafes any ways ambiguous it  may not be prudent  to
neglect this remedy.
                   DCLX1V.
  The anafarcous fwelling, which frequently follows
the Scarlatina Anginofa, feldom requires any remedy;
and, at leaft, the purgatives fo much inculcated, and
fo commonly exhibited, foon take off the anafarca.
              Q   H   A  P.  ■   V.

           OF  THE   PLAGUE.

               SECT.    I.

OF THE  PHENOMENA OF  THE  PLAGUE.

                    DCLXV.
    THE Plague is a difeafe which  always arifes from
     contagion ; which affects many perfons about
                      S  s 2                  the
 *t The detergent gargles wc.redefc: ibe^lin the note on fection 317. 
324
PP. ACTICE
the farn* time ;  proves fatal to great numbers,  gene-
rally products fever; and, in moft perfons, is attend-
ed with buboes  or carbuncles.
                    DCLXVI.
  Thefe are the circumftances which,  taken together,
give the character of  the difeafe ;  but it is accompa-
nied with many fymptoms almoft  peculiar  to  itfelf,
that, in different perfons, are greatly diverfified in
number and degree, and fliould  be particularly ftudi-
ed.   I would with to  lay the foundation for this; but
think it unfit for a perfon who has never feen the dif-
eafe to attempt its particular hiftory.   For this, there-
fore, I muft refer to  the authors  who have written on
the fubject; but allowing thofe only to be confulted,
who have themfelvcs  feen and treated the difeafe in
all its different  forms.
                      DCLXVIL
   From the accounts of fuch authors, it  appears to
me, that the circumftances which particularly diftin-
guifh this difeafe, and  efpecially  the more violent and
dangerous ftates of  it. are
   i//, The great lofs of ftrength in the animal functi-
ons, which  often appears early in the difeafe.
   idly,  The flupor,  giddinefs,  and conftqucnt flag-
Bering, which refembles drunkennels, or the head-ach
wwd various delirium  ;  which are all of them  fymp-
toms denoting  a great diforder in the functions of
lAc  brain.
   3^//y,  The anxiety,  palpitation, fyncope, and efpeci-
ally the weaknefs and irregularity of the pulfe, which
denotes a confiderable  difturbance in  the action of
 the heart-
   4/,6/j', The naufea and vomiting,  particularly ,the
                                                 vo-
Tincbire of rofes is generally ufed, and  i.i moft cafes anfwers every
intention : if, however, the  ulceration isconfiderable, and the floughs
i> noteiiily cai off, recourfj mult b-j h:.d to Dr. Folh-jry.'li's^ir-
gh-,  deferred in artitb 347. 
OF  PHYSIC.
325
vomiting of bile, which fliows an  accumulation of
vitiated bile in the gall-bladder and biliary ducts, and
from thence derived into the inteftines and ftomach ;
all of which fymptoms I fuppofe  to  denote a confi-
derable fpafm, and lofs of tone, in the extreme veffels
on the furface of the body.
  $thly. The buboes or carbuncles, which denote an
acrimony prevailing in the fluids.   And,
  Laftly} The petechiae,  hemorrhagies, and colliqua-
tive  diarrhoea,  which denote  a putrefcent tendency
prevailing to a great degree in  the mafs of blood.
                  DCLXVI1I.
  From the confideration of all thefe  fymptoms, it
appears, that the plague is efpecially diftinguifhed by
a fpecific contagion,  often  fuddenly producing the ,
moft confiderable fymptoms  of debility in  the nervous
fyftem or moving powers, as well as  of a  general pu-
trefcency in the fluids ;  and  it  is from the confidera-
tion  of thefe circumftances as the proximate caufe,
that I  think both the prevention  and  cure of the
plague muft be directed.
                   DCLXIX.
  If this difeafe fliould revifit the  nothcrn parts of
Europe, it is probable, that,  at the time, there will be
no phyficians then alive, who,  at the firft appearance
of the  difeafe, can be guided  by his former expe. i-
ence, but muft be inftructed  by his ftudy of the writers
on  this fubject, and by analogy.   It is,  therefore, I
hope,  allowable for me, upon the fame grounds, to
offer  here my opinion with  refpect to both the pre-
vention and cure of this difeafe.
  This paragraph was written before I had any no-
tice of the plague of Mofcow anno 177 1; but I<hink
ic will ftill apply to the cafe of Great B.itain and,of
many other northern f:atss.
S  y C T. 
pA          PRACTICE


                  SECT  II.

 OF THE PREVENTION OF THE PLAGUE.

                    DCLXX.
  With refpect to the prevention : As we are firmly
perfuaded that the difeafenever arifes in the northern
parts of Europe, but in confequence of its being im-
ported from fome other country ; fo  the firft meafure
neceflary, is the magiftrate's taking  care to prevent
the importation :  and this may generally be done by
a due attention to bills of health, and to the perform-
ance of quarantines.
                     DCLXXI.
  With refpect to the latter,  we are  perfuaded, that
the quarantine of perfons may fafely be much lefs
than forty days ; and, if this were allowed,  the  exe-
cution of the quarantine would be more exact and cer-
tain, as the temptation to break it would be in a great
meafure removed.
                   DCLXXII.
  With refpect to the quarantine of goods,  it cannot
be perfect,  uniefs the fufpected goods be unpacked
and duly ventilated, as well as the  other means em:
ployed for  correcting the infection they may  carry ;
and, if all this were  properly done, it is probable that
the time commonly prefcribed for the quarantine of
goods might alfo be fhortened.
                  DCLXXI1I.
  A fecond meafure, in the way of prevention, be-
comes requifite, when an  infection has reached and
prevailed in any place, to prevent that infection from
ipr.ading into other places.   This can be  done only
by  preventing the inhabitants,  or the goods  of any
infected  place, from going cut  cf  it, till they  have
undergone a proper quarantine.
                                      DLXXIV. 
              OF   PHYSIC.           3:7

                  DCLXXIV. .
  The third meafure for prevention,  to be employed
with great care, is to hinder the infection fromfpread-
ing among the inhabitants  of the place in which it has
arifen.  The meafures  neceffary for this, are to be
directed by the dodrine  laid down in Ixxxii. and from
that doctrine we infer, that all perfons who can avoid
any  near communication  with infected perfons, or
goods, may efcape the infection.
                    DCLXXV.
  For avoiding fuch communication,  a great  deal
may be done by the magiftrate :  1. By allowing as
many of the inhabitants as are free from the infection,
and not neceflary  to the fervice of the  place, to go
out of it.  2.  By prohibiting all affemblies,  or unne-
ceifary intercourfe of the people.   3. By taking care
that neceffary communications be formed without con-
tact.   4. By making fuch arrangements and proviii-
ons as may  render it eafy  for the families remaining,
to fhut themfelves  up in  their own houfes.   5. By
allowing perfons to quit houfes in which an infection
appears, upon condition that they go into lazarettoes.
6. By ventilating and purifying, or deftroying at the
public expence, all affected goods.  Laftly, by avoid-
ing hofpitals,  and  providing feparate apartments for
infected perfons.
   The execution of  thefe meafures will require great
authority, and much vigilance and attention, on the
part of the magiftrate;  but it is not our province  to
enter into any detail on this fubject of the public po-
lice.
                   DCLXXVI.
   The fourth and laft part of the bufinefs of  preven-
tion,  refpedts the conduct of  perfons neceffarily re-
maining in infected places, efpecially of thofe oblig-
ed to have fome communication with perfons infected.
                                      DCLXXVII. 
323           PRACTICE
                   DCLXXVII.
  Of thofe obliged to remain in  infected places, hue
not obliged to have any near communication with the
fick, they may be preferved from tiie contagion by a-
voiding all near communication with  other  perfons,
or their goods ; and it is probable, that a fmall diftance
will anfwer the purpofe, if, at the fame time,  there be
no  ftream of air to carry the effluvia of perfons, or
goods, to fome diftance.
                  DCLXXVIII.
  For thofe who are neceffarily obliged to have a near
communication with the fick, it  is proper to let them
know, that fome of the moft powerful contagions do
not operate, but when the bodies of men expofed to
the contagion are in certain circumftances which ren-
der them more liable to be affected by it ; and there-
fore, by avoiding thefe circumftances and caufes, they
may often efcape infection.
                   DCLXXIX.
  Tyte bodies of men are efpecially liable to be af-
fected by contagions,  when they are any ways confi-
derably weakened by want of food, and even by a fcan-
ty diet, or one of little nourifhment;  by intemperance
in drinking, which, when the ftupor of intoxication is
over,  leaves the body in a weakened ftate; by excefs
in venery ; by great fatigue ;  or  by  any confiderable
evacuation.
                   DCLXXX.
  The caufes which, concurring with contagion, ren-
der it more certainly active, are cold, fear, and full li-
ving.
  The feveral means, therefore, of avoiding or guard-
ing againft the action of cold (xciv, to xcvi.) are to be
carefully ftudied.
                   DCLXXXI.
  Againft fear the mind  is to be fortified as well as
poffible, by infpirin,ra favourable idea of the power of
                                      prefervative 
OF  PHYSIC.
39
prefervative means; by deftroying the opinion of the
incurable nature of the difeafe;  by occupying mens
feiinds  with bufinefs or labour; and by avoiding all
objects of fear, as funerals,  paffing bells, and any no-
tice of the death of particular friends.
                   DCLXXX1I.
  A full diet of animal food increafes the irritability
of the body, and favours the operation of contagion ;
and indigeftion, whether from  the quantity or quality
of food, has the fame effect.
                  DCLXXXIII.
  Befides giving attention to obviate the feveral cir
cumftances (dcx,  dclxxix, to dclxxxii.) which  fa-
vour the operation of contagion,  it is probable that
fome means  may  be employed for ftrengthening the
bodies of men, and thereby enabling them to  reiift
contagion.
  For this purpofe, it is proba'o!% that the  moderate
ufe  of wine,  or of fpiritous liquors, may have a &pod
effed.                                       ?<
  It is probable alfo,  that  exercife, when  it can be
employed, if fo moderate as to be  neither heating nor
fatiguing to the body, may be employed with advan-
tage.
  Perfons who have tried cold bathing, and common-
ly feel invigorating effeds from it, if they  are any
ways fecure againft having alteady received infedion,
may poffibly be enabled to refill it  by the ufe of the
cold bath.
  It is probable, that fome medicines alfo may be ufe-
ful  in  enabling men to refill infedion : but amongft
thefe I can hardly admit the numerous alexipharmics
formerly propofed ; or, at leaft, very few of them,  and
thofe only of tonic power.   Amongft thefe laft  we
reckon the Peruvian bark ; and it is perhaps the molt
effedual.  If any thing is to be expeded from  anti-
feptics, I think camphire, whether internally orex-
  Vol. I.              T t                ternaliy 
33o            PRACTICE

ternally employed, is  one of  the  moft promifing*
  Every perfon  is to be indulged.in the  ufe of any
means of prefervation of which he has conceived a good
opinion, whether it be  a charm  or a medicine, if the
latter be not diredly hurtful.
  Whether iftues be ufeful in preferring from, or iri
moderating the effeds of contagion,  I cannot deter-
mine from the obfervations I have yet read.
                  DCLXXXIV.
  As neither the atmofphere in general, nor any con-
fiderable portion of it, is tainted or impregnated with
the matter of contagions; fo the lighting of fires over
a great part of the infeded city, or other general fu-
r igarions in the open air, are of no ufe for preventing
the dileafe, and may perhaps be  hurtful.
                   DCLXXXV.
  It wouM probably contribuse much to check the
progrefs of infection,  if  the  poor were  enjoined to
n dice a frequent change of clothing, and were fuita-
bly provided for  that purpofe; and if they were, at
the fame time, induced to make  a  frequent ventila-
tion of their houfes and furniture.




              SECT.     III.

     OF  THE CURE  OF THE  PLAGUE.

                  DCLXXXVI.
  In the cure of the pLgue,  the indications are the
fame as thofe of  fever in general, (exxvi.)  but here
they are not all equally neceffary and important.
                  DCLXXXVII.
  The meafures for moderating the violence of re-ac-^
lion, v?hich operate by  dirnjniihing the adion of the
                                             heart
i 
©  F  PHYSIC.
351
 heart and arteries (cxxvin.) have feldom any place
 here, excepting fo far as  the antiphlogiftic regimen is
 proper.  Some phyficians, indeed, have recommend-
 ed  bleeding; and there  may  occur cafes  in which
 bleeding may be  ufeful;  but, for the moft part, it is
 uiineceflary, arid  in many cafes it might be very hurt-
 ful.
   Purging has alfo been  recommended; and, in fome
 degree, it may be ufeful in drawing off the  bile,  or
 other putrefcent matters frequently prefent in the in-
 teftines ; but a large evacuation this way may certain-
 ly be hurtful.
                  DCLXXXVI1I.
   The  moderating the violence of re-adion, fo far as
 it can be done by taking  off the fpafm of the extreme
 veffels,  (cli.) is a meafure of the utmoft neceffity in
 the cure of  the plague ; and the whole of the mo oris
 (clii, to  cc.) fuited to this indication are extremely
 proper.
                   DCLXXXIX.
  The giving an  emetic at the very  firft approach of
 the difeafe, would probably be of great fervice ; and
 it is likely, that at fome other periods of the difeafe e-
 metics might be ufeful,  both by evacuating bile a-
 bundant in the alimentary canal, and by taking off the
 fpafm of the extreme veffels.
                     pcxc.
  From fome principles with refped to fever in gene-
 ral, and with refped to the plague in particular, I am
 of opinion,  that,  after the exhibition of the firft vo-
 mit, the body  fhould be difpofed to fweat;  which
 ought  to be raifed to a moderate degree only,  but
 continued for at leaft twenty-four hours, or longer if
 the patient bear it eafily.
                     DCXCI.
  This  fweating  fhould be excited and eonduded a-
greeablv to the  rules laid down in clxviii.   It is to
                    T t 2                     ha 
332
PRACTICE
be promoted by the plentiful ufe of diluents, render-
ed more grateful by vegetable acids, or more power-
ful  by being impregnated with fome portion of neu-
tral falts.
                     DCXCIL
  To  fupport the patient  under the continuance of
the fweat, a little weak  broth,  acidulated with  juice
of lemons, may be given frequently; and fometimes
a little wine, if the heat of the body be not confider-
able.
                     DCXCIII.
  If fudorific  medicines are judged to be neceffary,
opiates  are the moft effedual and fafe: but they fhould
not be  combined with aromatics;  and probably may
be more effedual, if joined with a portion of emetics,
and of neutral falts.
                    DCXCIV.
  If,  notwithftanding the ufe of emetics  and fudori-
fics, the difeafe fhould ftill continue, the cure muft de-
pend upon the employment  of means for obviating de-
bility and putrefcency ;  and, for this purpofe, the va-
rious remedies propofed  above (from cci, to ccxxvii.)
may all  be  adminiftered, but efpecially the tonics ;
and of thefe  the chief are cold drink and the Peruvi-
an bark.
                     DCXCV.
  In the cure of the plague, fome attention is due to
the management of buboes  and carbuncles : 'but we
do not touch this, as it belongs to the province of fur-
gery*.
                                         C H  A P.

  * The reader rr, Yht pofHYy expect a detail of the medicines ufed
in the plague, with thYr dofes and the manner of adminiflcring them;
but I thought it hctter to refer to the authors who have either feen
the difeafe, or who have exprefsly written on ir.  On confuting dif-
ferent authors,  it appears, that every particular  epidemic requires
a different treatment, in fome part of the cure at leaft.  Should any
young p;?.Y.irY:icr be unfortunate enough to have occafion to exer- 
OF  PHYSIC.
333
              C  LI  A  P.     VI.

   OF ERYSIPELAS,  OR St. ANTHONY's
                     FIRE.

                    DCXCVL
  IN cclxxiv, I mentioned  the  diftindion  which  I
   propofed to make between the difeafes to be nam-
ed the Erythema and the Eryfipelas ; and from thence
it will appear, that Eryfipelas, as an Erythema follow-
ing fever, may have its place here.
                    DCXCVII.
   I fuppofe the eryfipelas to depend on a matter ge-
nerated within the body,  and which, analogous to
the other cafes of exanthemata, is, in confequence of
fever, thrown out upon  the  furface  of the body.   I
pwn it may be difficult to  apply this to every particu-
lar cafe of eryfipelas: but  I take  the cafe in which it
is  generally fuppofed to  apply, that of the eryfipe-
las of the face ; which I fliall therefore confider here.
                   DCXCVIII.
   The Eryfipelas of the face comes on with  a cold
fhivering, and other  fymptoms of pyrexia.  The ho:
ftage of  this  is frequently attended with a confufion
of head, and fome degree of  delirium ; and  almoft
always with  a  drowfinefs, or perhaps coma. The
pulfe is always frequent,  and commonly full and hard.
                    DCXCIX.
   When thefe fymptoms have continued  for one, two,
or at moft three days, there appears, on fome  part of
the face, a rednefs, fuch as that defcribed in cclxxv.
as the appearance of Erythema.  This  rednefs, at
firft, is of no great extent ; but gradually fpreads from
the part  it firit occupied to  the  other parts of the
                                            face,
rife his art in the cure of the nl.:ri;e, he muf! chicly be dircSed by
the cntral indications of the cure of fevers. 
334
PRACTICE
face, commonly till it has affeded the  whole ; and
frequently from the face  it  fpreads over the  hairy
fcalp, or defcends on fome part of the neck.  As the
rednefs  fpreads,  it commonly difappears, or at leaft
decreafes, in the parts it had  before occupied.  All
the parts upon which the rednefs appears are, at the
fame time,  affeded with fome fwelling, which conti-
nues for fome time after the rednefs has abated.   The
whole face becomes confiderablv turgid ; and the eye-
lids are  often fo much fwelled as entirely to fhut up
the eyes.
                      DCC.
  Wben the rednefs and fwelling have  proceeded for
fome time,  there commonly arife, fooner or latar, bli-
fters of a larger or fmaller fize, on feveral parts of the
face  Thefs contain a thin yellowiih  or almoft co-
lourlefs  liquor, which fooner or later runs out.   The
furface of the fkin, in the bliftered places, fometimes
becomes livid and blackifh ;  but  this  livor feldom
goes deeper than the furface, or djfeovers any degree
of gangrene affedihg the fkin.  On the parts of the
face not affeded  with blifters,  the cuticle fuffers, to-
wards the end of the difeafe, a confiderable defquam-
ation.
  Sometimes the tumour of the eye-lids ends in a fup-
puration.
                     DCCL
  The inflammation coming upon the  face does not
produce any remiflion of the fever which had before
prevailed ; and fometimes the fever increafes with the.
increafing and fpreading inflammation.
                     DCCII.
  The  inflammation ufually continues  for  eight or
ten  days; and for the fame time, the fever and fymp-
toms attending it alfo  continue.
                    DCC III.
  In the progrefs of the  inflammation  the  delirium 
u  a  jt n  i S  I C.            23^
and coma attending  it fometimes  go on increafing,
and the patient dies apopledic on the feventh, ninth,
or eleventh day of the difeafe.  In fuch cafes it  has
been commonly fuppofed that the difeafe is tranflated
from the external to the internal parts.  But I have
not feen any inftance in which it did  not appear  to
me, that the affedion of the brain was merely a com-
munication of the external affedion, as this continued
increafing at the fame time with the internal.
                     DCCIV.
  When the fatal event does not take place,  the  in-
flammation, after having affeded^ part, commonly the
whole of the face, and perhaps the other external parts
of the head, ceafes.  With the inflammation, the fe-
ver alfo ceafes ; and, without any evident crifis,  the
patient returns to his ordinary ftate of healttu
                     DCCV.
   This difeafe is not commonly contagious  ; but as
it may arife from an acrid matter externally  applied,
fo it is poffible that the difeafe may fometimes  be com-
municated from  one perfon to another.
  Perfons who have once laboured under this difeafe
are liable to returns of it.
                    DCCVI.
  The event of this difeafe may be forefeen from the
ftate of the fymptoms which denote more or  lefs af-
fedion of the brain.   If neither delirium ncr  coma
come on, the  difeafe is feldora attended with any dan-
ger ; but when thefe fymptoms appear early in  the
difeafe, and are in a confiderable degree, the utmoft
danger is to be apprehended.
                    DCCVII.
  As this  difeafe often arifes in the part, at the fame
time with the coming on of the pyrexia;  as I have
known it, with all its fymptoms, arife from  an acri-
mony applied  to the part ;  as it is commonly attend-
ed with a full, and frequently a hard pulfe; as  the
                                           blood 
33^          PRACTICE
blood drawn in this difeafe fhows the fame cruft upon
its furface, that appears in the phlegmafiae ; and, laft-
ly, as the fwelling of the eye-lids, in this difeafe, fre-
quently ends in a fuppuration; fo, from thefe confi-
derations, it feems doubtful if this difeafe be properly,
in Nofology, feparated from the Phlegmafiae.   At
any rate,  1  take the difeafe  I have  ddvoiYed to be
what phyficians have named the Eryfipelas Phlegmo-
nodes, and that it partakes a great .deal of the nature
of the Phlegmatic.
                    dccviii.
  Upon this conclufioi;, the Eryfipelas of the face is
to be cured very  much in the fame manner as phleg-
monic  inflammations, by blood-letting, cooling pur-
gatives, and by employing every part of the antiphlo-
giftic regimen* ;  and our experience has confirmed
thefitnefs of this method of cure.
                    DCC1X.
  The evacuations of blood-letting and purging, are
to be employed more or lefs according to the urgen-
cy of fymptoms,  particularly thofe of the pyrexia,
an3 of thofe which mark  an affedion of the  brain.
As the pyrexia continues, and often increafes with the
inflammation of the face ; fo the  evacuations menti-
oned may be employed at any time in the courfe  of
the diftafe.
                     dccx.
  In this, as in other difeafes of the head, it is proper
to put the patient, as often as he can eafily bear it, in
to fomewhat of an ered pofture.
                    DCCXI.
  As in this difeafe there is  always an external affec-
tion, and as in many inftances there is no other; fo va-
rious external applications  to the part affeded have
                                             been

  *  The antiphlogiftic regimen, &c. have been ^fcribed in former
notes.  See art. 129, et feq. 
OF    P PI Y S  I  C.
337
been propofed ; but almoft all of them are of doubtful
effed.  The  narcotic*,  refrigerant, and aftringentf
applications, are fufpeded of difpofing to gangrene ;
fpiritousj applications feem to increase the inflamma-
tion ; and all oily or watery § applications feem to oc-
cafion its fpreading.  The application that feems moft
fafe, and  which is  now moft commonly  employed,  is
that of a dry mealy powder frequently  fprinkled  upon
the inflamed parts**.
                      DCCXII.
   An Eryfipelas Phlegmon >des frequently appears on
the other parts of the  body, befide  the face ;  and fuch
other eryfipelatous inflammations  frequently end in
fuppuration.  Thefe cafes are feldom dangerous.   At
coming on, they are fometimes attended with drown-
nefs,  and even with  fome  delirium ;  but this rarely
happens ; and thefe fymptoms do  not continue after
the inflammation is formed.   I have never feen an in-
ftance of the tranflation of this inflammation  from the
limbs to an internal part j and though  thefe inflam-
mations  of  the limbs  be attended  with pyrexia,  they
   Vol.  I.               U u                 feldom

  * The leaves of folanum, of hemlock, of henbane,  and other
fimilar plants applied as fomentations.
  f Solutions ef Saccharum Saturni, or Vitriolum album, applied
Cold.
  X Efpecially if they are fuch as are compounded with aromatics or
volatile falts, as camphorated fpirit of wine,  Hungary-water,  vo-
latile liniment, &c.
  § The  rcafon  is evident, becaufe they confine  the acrimonious
liquor dilcharged from the part affected.
  ** Wheat-flour is apt to run into hard lumps by  the thin acrimo-
nious liquor which always exhales from parts affected with eryfipelas.
Oatmeal not being fo liable to this inconvenience  is therefore pre-
ferable : it ought to be wiped off, and a frefh quantity applied
twice or thrice a day.
  Many practitioners recommend the application of cabbage leaves
to eryfipelatous fwellings, and their efficacy has been frequently ap-
proved. They ought to be removed as foon as they grow warm or
uneafy, and frefh cold ones applied. 
338           PRACTICE

feldom require the fame evacuations as the eryfipelas
of the face.  At firft they are to be  treated  by dry
mealy applications only ; r.nd all humid applications,
as fomentati: ns,  or poultices, are not to be applied,
till, by the continuance of the difeafei,  by the increafe
of fwelling, or by a throbbing felt in the part, it ap-
pears that the difeafe is proceeding to  fuppuration.
                     DCCXIII.
   We have  hiiherto confidered eryfipelas  as in  a
g-eat meafure of a phlegmonic nature; and agreeably
to that opinion, we have propofed our  method of cure.
But it is  probable, that an eryfipelas is fometimes at-
tended vvith, or is a fymptom of,  a  putrid fever ; and,
in fuch cafes,  the evacuations propofed above may be
irr.prviper, and  the ufe of the Peruvian bark  may be
neceffary  ; but I cannot be explicit upon this fubjed,
as fuch putrid  cafes have not come under my obfer-
\ alien.
               CHAP.   VII.


          OF  THE MILIARY FEVER.

                     DCCX1V-
     THIS difeafe is faid to have been unknown to the
     ancients, and that it appeared, for the firft time,
in Saxony, about the middle of the laft century*.  It
                                                   is

  * Hoffman, YVtlfch, and  lYvcral  other  writers, fix the firft ap-
pearancc  of this difeafe at Leiplic,  in the year 1551. and 1652.
This opinion,  however, isfalfe, for defcriptions of miliary eruptions
are tft he founr} in  the writings of the ancients, and among them,
Vk' f;nd Riverius defcribii^ it in Fiance, juft after the appearai.ee
of the comtt in the year 1^18 ; to which phenomenon, that author
afcribes the fatal epidemic, as'well as the ! YcYy w..rs that were zt
th:.i time mailing horrid devaftations in Europe. 
OF  PHYSIC.
339
is faid to have  fpread from thence into all the other
parts of Europe*, and, fiiKe the peri:d mentioned, to
have appeared in many countries in which  it had ne-
ver appeared before.
                       DCCXV.
  From the time of  its having been firft  particularly
obferved,  it has been defcribed and treated  of by ma-
ny different writers ; and by all of the.n, till very late-
ly, has been confidered as a peculiar idiopathic oif afe.
  It is faid to have been conftantly attended with pe-
culiar fymptoms.   It  comes  on with  a  cold  ftage,
which is oYen ccnfiderable.  The hot ftage,  which fuc-
ceeds, is attended ui:hgreat  anxiety,and frequentfign-
ing.    The heat of .he body becomes  great, and  fo->n
produces profufe fweating; preceded, however,   by a
fenfe of pricking, as of pin-poifts,  in the  fkin ; and
the fweat is of a peculiar rank and difagreeahle odour.
The eruption  appears fooner or later  in different per-
fons,  butat no dceio^ined  period of the difeafe.  It
                        U u  2                  feldom

  * We meet with feveral accounts of the appearance  of the  milia-
ry eruption in different part? of Europe foon after the middle of  the
lad century, not only by medical writers, but by general historians ;
among the-latter of w!<om we may mention Robert Sibbald, who
tikes notice of it in his Scotia iilulfrata, publifhed at Edinburgh in
the year 1684.  (Sibbald,  however, was a phyfician^) To enu-
merate the medical w>uerswho have defcribed the diftafe in the dif-
fj • nt parts of Europe, would take more room than the fhort corn-
paf»  of thefe notes admits,  the chief of  them are  WYlfcb,  Hoff-
man,  Langiu.-, .Rcye/ir, Bonetuu,  Grindwaid, Sydenham, Ronia-
zini,  Fuch litis, &c.  Sec.   The authors above mentioned, and fe-
veral  others,  about the end of the laft and beginning of this centu-
ry, entertained various opinions concerning Uie nature of the mili-
ary eruption,  f>me  of the.n fu;;;o;.ng it to be a critical termination
<>f a peculiar fever,  and others on the contrary ftrenuoufly inii.ting
that it was onlv accidental or .fymptomatic, and never critical or fa-
lutary.  The controverfy, which waa-carried on wiih fome wirrnth
is now terminated, as will apptarby what follows  ; but the inqtiifi-
tive young phviicun will tind bo'h cntci't nnment and  in(tru6tion in .
j;erufing it.  A \ery good ablhuol occurs in De  iiaeu's treatife on
the divi.'.iiMi of fevers. 
34<>
PRACTICE
feldom or never appears on the face ; but difcovers it-
felf firft upon the neck and  breaft, and  from thence
often fpreads over the whole body.
                    DCCXVI.
  The eruption named  Miliary is faid to be of two
kinds,  the one named the Red, the other the White
Miliary.   The former, which  in Englifh is ftrictly
named a Raih, is commonly allowed to be a fymp-
tomatic affection ; and  as the latter is the only one
that has  any pretentions to be confidered as an idio-
pathic  difeafe, it  is  this alone that I fhall more parti-
cularly defcribe and treat of in the prefent chapter.
                   DGCXVIi.
  What then is  called the  White Miliary eruption,
appears at firft like the red, in very fmall red pimples,
for the moft part  diftinct, but fometimes cluttered to-
gether.  Their flight  prominence is diftinguifhed bet-
ter by the finger than by the eye. • Soon after the ap-
pearance of this eruption, and at leaft  on the fecond
day, a  fmall veficle appears upon the top of each pim-
ple   At firft the veiicle is whey-coloured ;  but foon
becomes white, and ftands out like a little globule on
the  top of the pimple.  In two or three days,  thefe
globules break, or are rubbed off; and are fucceeded
by fmall crufts, which foon after fall off in fmall fcales.
While one fet of pimples takes this courfe, another fet
fucceeds; fo that the  difeafe often continues upon the
ikin for  many days together.  Sometimes when one
crop of this eruption has appeared, another, after fome
interval, is produced.   And it has been further ob-
ferved, that in fome perfons there is fuch a tendency
to this difeafe, that they have been affected with it fe-
veral times in the courfe of their lives.
                   DCCXVIII.
  This difeafe is faid  to affect both fexes, and perfons
of ail ages and conftitutions; but it has been obferv-
                                               ed. 
              OF  PHYSIC.           341

ed, at all times, to affed efpecially, and moft frequent-
ly, lying-in women.
                    DCCXIX.
  This  difeafe is  often  accompanied  with violent
fymptoms, and  has frequently  proved fatal.   The
fymptoms attending it are, however,  very various.
Thev are,  in one or other inftances,  all the feveral
fymptoms attending febrile difeafes; but I cannot find
that any fymptom or concourfe of fymptoms are ftea-
dily the fame in different perfons, fo as to furniih any
fpecific character to the difeafe?  When the difeafe is
violent, the moft  common fymptoms  are  phrenitic,
comatofe, and convulfive affections, which are alfo
fymptoms of all fevers treated by a very warm regimen.
                    pccxx.
   While there is fuch a variety of fymptoms appear.
ing in this difeafe, it is not to be expected that any
pne particular method of cure can be propofed r and
accordingly we  find, in  different  writers, different
methods and remedies prefcribed ;  frequent diiputes
about the moft proper ; and thofe received and prac-
tifed by fome, oppofed and rejected by others.
                    DCCXXI.
   I have thy^ given an account of what I have found deli-
vered by authors who have confidered the white miliary
fever as an idiopathic difeafe: but, now, after having oft-
en obferved thedifcafe. I muft fay thatldoubt much if it
everbefuchanidiopathicashasbeenfuppofed, and Ifuf-
pect that there is much fallacy in what  has been writ*
ten on the fubject.
                    DCCXXII.
%   It feems to me very improbable, that this fliould have
been really a new difeafe  when it was  firft confidered
as fuch. Thereappear tome very cleartracesof it in au-
thors who wrote  long before that period ; and, though
there were not,  we know that the defcii; tions of the
ancients were inaccurate  and imperfect,  particularly
                                             with 
  342           PRACTICE

  with refpect  to cutaneous aiTaitlms ; whilft  we know
  alfowery well, that thofe affections which ufually ap-
  peared as fymptomatic only, were commonly neglect-
  ed, or coniY-unded together under a general appetla-
' tion.
                     DCCXXIII.
    The antecedent fymptoms of anxiety, Ugh ing, and
  pricking of the ikin,  which have been fpoken of as pe-
  culiar to this di'eife, are, however, common to many
  others;  and,  perhaps to all th  fe in which  fweatings
  are forced out by a warm  regimen.
    Of the ivr.-.ptoTis f .id to be concomitant of this erup-
  tion,,there are none  which cm  be content and pecu-
  liar but that of fweating.   T!:i?,  indeed, alwi\ s  pre-
  cedes'and ec com panics  the crunii :n ; and,  while the ,
  miliary eruption attends mmv/ different odeaf^, it ne-
  ver, however, appe  rs in any of thefe. but ;d'er f-.v eas-
  ing; and, in perfon^  labouring under thefe difeafes, it
  does  not rppear, if Treating be avoided.  It  is there-
  fore prhidYe, that the eruption is the effect  of fweat-
  ing ; and that it is the produce of a m u:e:, not before
  prevailing in  the mafs of blood, but generated, under
  particular circumftances, in the ikin  itfe'if.   That it
  depends upon particular circumftances of the ikm, ap-
  pears further from hence, that, the eruption  f-Mom or
  never appears upon  the face,   although  it idLds the
  whole of the  body befides; that  it comes upon thofe
  places efpecially which are moreclofelv covered ;  and
  that it can be brought  out upon particular  parts  by
  external applications.
                     DCCXXIV.
    It h to be obferved, that this  eruptive difeafe differs
  fro n  the other exa themata in  many  circumftances ;
  in its not being contagious, and therefore never epi-
  demic ;  that  the eruption appears  at no determined
  period of the difeafe ; that the eruption has no deter-
  mined duratiro ; that fucceflive eruptions frequently
                                             i.ppear 
              OF   PHYSIC.          343

appear in the courfe of the fame fever ; and that fuch
eruptions  frequently recur in the courfe of the  fame
perlon's life.
  All thefe circumftances render  it extremely pn.ba-
ble, that, in the miliary fever, the morbific matter is
not a fubfifting contagion communicated to the blood,
and thence, in confequence of fever and affiuiilation,
thrown out upon the furface of the body ;  but a mat-
ter occaiionaily produced in tlie fkin itfelf, by fweat-
ing.
                    DCCXXV.
  This conelu.ion is farther rendered probable  iYoet
hence, that, while the miliary eruption has no peculi-
ar fymptoms, or coiicourfe of fymptoms, belonging fo
i:; yet upon occafion, it accompanies almoft all febrile
difeafes. whether inliaminatory or putrid, if thefe hap-
pen to be attended  with fweating ; and from  thence
it may be prefumed,  that  the miliary eruption is  a
f-niptomcitic affection  only,  produced in the maimer
we have faid.
                    DCCXXVL
   But, as this fymptomatic affection'does not always
accompany every inftance of fweating, ic may be pro-
per  to inquire what are the circumfiances which ef-
pecially determine this eruption to appear ?  To thi ,
however, I  can give  no full and proper  anfwer.  L
cannot lay that there is any one  circumftance winch
in all cafes gives occafion to the eruption ;  nor can I
fay what diilerent caufes may, in different  c de:, give
occafion to it.  There is only one obfervation I can
 ofierto the purpofe of this inquiry; and it is,  that,  of
 the pcribri^ fweating  under febrile difeafes, thofe are
 efpecially liable to miliary eruption, who have- been
 previoufly weakened by  large evacuations, particular-
 ly of blood.  This  will explain why.it happens to ly-
 ing-in women more frequently than to any other per-
fons j and to confirm this exDlanaticn, I have remark-
                                               ed, 
344
PRACTICE
ed, that the eruption happened to women not in child-
bed, but who had been much fubjected to a frequent
and copious menftruation ; and to an almoft conftant
fluor  albus.  I have alfo  had occafion to obferve it
happen to men  in  fevers, after wounds from which
they had fuffered a great lofs of blood.
   Further, that this  eruption is produced by a certain
ftate of debility, will appear probable,  from its often
occurring  in fevers  of the putrid kind, which  are al-
ways attended with  grett debility.   It  is true, that it
alfo fometimes attends inflammatory difeafes, when it
cannot be accounted  for  in the fiime manner; but I
believe it will be found to attend efpecially thofe in-
flammatory  difeafes in which the  fweats have been
long protracted  or  frequently repeated, and  which
have  thereby produced  a debility,  and perhaps a de-
bilitating  putrid diathefis.
                    DC CXXVII.
   It appears fo clearly to me that this eruption is al-
ways a fymptomatic*  and factitious affection,   that  I
am perfuaded it may be in moft  cafes prevented mere-
ly  by avoiding  fweats.  Spontaneous  fweatings, in
the beginning of difeafes,  are very rarely critical; all'
fweatings, not evidently critical,  fhould be prevent-
ed 5 and the promoting them, by increafing external
                                                 heat,

  * As this difeafe is always fymptomatic and never idiopathic, the
method of curing muft neceffarily vary in different cafes ; the chief
attention of  the phyfician muft therefore be turned to the  primary
difeafe,  and to the means of preventing this fymptom from appear-
ing in thofe difeafes which it accompanies.
  The author judicioufly begins his method of cure by giving direc-
tions for preventing the eruption, which  he properly fuppofes to be
entirely factitious, and to depend on the application of too much
heat.  With a proper attention to the directions given in the text,
we may in general prevent the eruption.   If,  however, the eruption
i.<\prefent before the phyfician is called, thofe remedies muft be ufed
for it's removal, that are enumerated in the fubfequent articles. 
              OF  PHYSIC.'           34 j

heat, is commonly very  pernicious.  Even  critical
fweats fhould hardly  be encouraged by fuch means.
If, therefore, fpontaneous fweats arife, they are to be
checked by thecoolnefs of the chamber: by the light-
nefs and coolnefs of the bed-clothes ; by the perfon's
laying out their hands and arms, and by their  taking
cold drink : and, by thefe precautions, I think I have
frequently prevented miliary eruptions, which were o-
therwife likely to have appeared, particularly in lying-
in women*
                   DCCXXVIII.
   But it may happen,  .when  thefe precautions have
been neglected,  or from  other circumftances, that a
miliary eruption docs actually appear; and the quefti-
on will then be put, how the cafe is to be treated ?
It is a queftion of confequence, becaufe 1 believe that
the matter here generated is often  of a virulent kind;
it is frequently the  offspring of  putrefcency; and,
when treated by increafing  the external heat of the
body,  it feems to acquire a virulence which produces
thofe fymptoms  mentioned in  dccxix.  and proves
certainly fatal.
   It has been an unhappy opinion with moft phyfici-
ans, that eruptive difeafes were ready to be hurt by
cold; and that is was therefore neceflary  to cover up
the body ve y clofely, fo as thereby to increafe the ex-
ternal  heat.   We  now know that this is a miftaken
opinion ; that increafing the Eternal heat of the body
is very generally mifchievous; and that feveral erupj
tions not only admit, but  require the application  of
cold air.  We are now* perfuaded, that the practice
                      X x                    which
  * The prefent rational praftice has entirely altered the regimen in
fevers; and inftead of macerating the patient in a hot be1, aid
obliging him to breathe the corrupt air of a confined chamber, we
now cover him with light bed clothes, and  ventilate his loo;:-. ^ It
may, however, be neceffary  to ^uard the  young phyfician again It
the excefs of this praftice.  The precept, Omne nimium nocet. 
346          PRACTICE
which formerly prevailed, in  the cafe of miliary  c-
ruptions, of covering up the body clofe,  and both by
external means,  and internal remedies,  encouraging
the fweatings  which acompany this eruption,  was
highly pernicious, and commonly fatal.   I am there-
fore of opinion, even when a  miliary eruption has
appeared, that in all cafes where the fweating  is not
manyjcftly critical,  we fhould  employ all the feveral
means of ftopping it that are mentioned above ; and I
have fometimes had occafion to obferve, that even thq
admiffion of cool air was fafe and ufefu!.
                     DCCXXIX.
   This is, in general,  the treatment of miliary  erup-
tions: but,  at the fame time,  the remedies fuited  to
the primary difeafe are to be employed ; and therefore,
when the eruption happens to accompany inflammato-
ry affections, and when the fulnefs and hardnefs of the
pulfe or  other fymptoms fhow an  inflammatory ftate
prefent,  the cafe is to be  treated by blood-letting,
purging, and other  antiphlogiftic •medies.
   Upon the other  hand, when  tne miliary  eruption
attends difeafes  in  which  debility  and  putrefcency
prevail, it will be proper to  avoid all evacuations, and
employ tonic and antifeptic remedies, particularly the
Peruvian bark, cold drii|k,  and cold *ir.
   I fhall conclude this fubject with mentioning, that
the venerable  octogenarian  practitioner,  de Fife her,
when treating of this-fuLj: Yi, in laying down the indi-
                                              cations
fliould always be attended to.  If  the patient feels any difagreenble
effefts,  or if he fhould fuffer rigors, or  tremble from theadmifTion
of cold air, it js certainly prejudicial, and its admiffion ought to be
regulated  it may not be improper to mention another caution, viz.
that the young practitioner muft not, by the means here recom-
mended, check fweats that are reall) critical.  To determine what
fweats are, and what are not critical, is perhaps, in fome cafes, at-
tended with  coniiderable difficulty.  In general,  however, critical
fweats may be known by their happening on the critical ih:; > before
mentioned in articles 107, ct feq. and by their always being im me-
diately followed bv an abatement of all, or at le^ll the ^reat'.'it part
    j          '                             or
01 the ivii.poms.
1 
OF  PII Y S I C.
347
cations of cure, has given this as one of them : " E::-
i6  cretionis periphericae non primariam habere rauo-
"  nem." '                                ,
              *. -



              chap.   vm.,      ^

   OF THE REMAINING EXANTHEMATA.

      URTICARIA, PEMPHIGUS, AND  APHTHA.

                   DCCXXX.
    THE Nettle Rafli is a name applied to two diiier-
     ent difeafes.   The one is the chronic eruption
defcribed by Dr. Heberden in the Medical Tranfacti-
ons, Vol. I. art. xvii.  which, as not being a febrile
diforder, does nrj^elong to this  place.  The other
is  the Urticaria e* our  Synopfis, which, as taken into
every fyftem of Nofology as one of the Exanthemata
Febrilia,  is properly to be treated of here.
                   DCCXXXI.
  I have never obferved thisdifeafe  as contagious and
epidemic ;  and the  few fporadic cafes  of it which
have occurred to me, have feldom  taken the regular
courfe;defcribed by authors.  At  the fame time, as
the accounts of different abhors are not very uni-
form, and hardly confiftent, I cannot enter  further
into the confideration of this fubject:  and  I  hope it
is not-very neceffary, as on all hands it  is agreed to
be a mild difeafe, and fuch as feldom requires the ufe
of remedies.  It is generally  fufficient to obferve an
antiphlogiftic regimen, and to keep the patient in a
temperature that is neither hot nor cold.
                  DCCXXXIL
  The Pemphigus, or Viiicular fever, is  a rare and
uncommon difeafe, and very few inftances of it are
                       X X 2            leCOided 
 348            PRACTICE

 recorded in the writings of phyficians.   As I have ne-
 ver had occafion  to fee it,  it would be improper for
 me to treat of it*;  and I do  not choofe to repeat af-
 ter others, while the difeafe has  yet been little obferv-
 ed, and its character does not feem to be exactly af-
 certained.   Vid.  Acta Helvetica,  vol. ii. p. 260. Sy-
 nopf. Nofolog. vol. ii. p. J 49.
      »               DCCXXXIII.
    The Aphtha, orThrufh, is a  difeafe better known;
 and,  as it commonly  appears in infants, it is fo well
 underftood,  as. not to need our treatirrg of  it here.
 As an idiopathic  difeafe, affecting adults,  I have  not
 feen it in this country :  but  it feems to*be ftt£>re fre-
 quent in Holland; and, therefore,  for the ftudy of it,
 1  lefer  to Dr. Boerhaave, and his commentator Van
 Swieten, whofe  works are in everybody's hands§.
                                           DCCXXXIV.

   * It appears from the following paffage in the author's Synopfis,
 that he had afterwards feen it:  " Collega n^er eximus Francifcus
 "  Ho-ne,  mihihominem leviter febricitantem oftendit, cui, primum
 "  in br;;chi:s, et fucceffive den u,n in toto corpore, veficulae magnitu-
 «'  dine avelianas  obortas funt, ct poft duas trefve dies effufo humoris
 "  feron par.X'ilq, collapfos funt.   Haec febris autem nullam indo-
 "  lem vel typum peculiarem monftrabat,  et citodjfparuit nequaquam
 *(  contagiofa.              \
   $ Boerhaave only faw aphthae twice without, and preceding fever,
 and Van Swieten only one ; but Ketelaer fays he has frequently feen
 them.  They fometimes accompany inflammations of the vifcera,
 and other inflammatory fevers,fand are often difficult to remove.
 They are to be treated in the fame manner as the ulcerations in the
 Cynanche maligna, by gargles in the deterfive kind, until  the  aph-
 thous cruft feparates and falls off; but, when that cruft has fallen off,
 the painfuhiefs of the nakedly expofed fenfible parts requires emolli-
 ent applications; of which  kind a decoftion of Had. Alth. or an
iofufion of lintfeed,_aie proper gargles alone : if honey be added,
 the patient comphons of its making the part fmart.  The patient's
 diet ought f.o be the mildeft kind, that it may be fwallowed without
 caufing much pain.  The aphthous cruft frequently appears at the
 arus, which  fymptom generally leads to conclude, (as is really the
 cafe,)  that a] Liwac cover the whole inteflinal canal.  Hence confi-
 derable clanger anfes.  The  abforbents. are covered, and  refufe ad- 
               O F  P  H Y  S I C.           349

                   DCCXXXIV.
   The Petechia has been, by all our Nofologifts, e-
numerated amongft the exanthemata; but as, accord-
ing to the opinion of moft phyficians, it is very juftly
held to^ie always a fymptomatic affection only,  I can-
not give it a place here.




               BOOK     IV.


        Of  HEMORRHAGHIES,


               CHAP.     I.

     OF HEMORRHAGY IN  GENERAL.

                    DCCXXXV.
   IN  eftablifhing a clafs or  order of difeafes  under
    the title of Hemorrhagies, Nofologifts have em-
ployed the fingle circumfijfrice of  an effufion of  red
blood, as the character of fuch a  clafs or order.  By
this means they have affociated difeafes which in their
nature are very  different; but, in every methodical
diftribution, fuch arbitrary and unnatural affociations
fhould be avoided as much as poffible.   Further,  by
that management Nofologifts have fuppreffed  or  loft
    V:                                          fight
mittance to all nourifhment ; hence an increafed  debility, with all
its evil confequences.  In thefe cafes, a nutritive, liquid, and deter-
11 ve diet, mull be ufed.   For this purpofe a decoction of bread, with
vvine and honey,  is the propereft drink. Such a decoction is extremely
nutritive, and alfo averfe to putrefaction, and therefore well adapted
fo the exigency of the cafe. 
350            PRACTICE

fight of an eftablifhed and well-founded diftiitction of
hemorrhagies into Active and Paffive.
                 . DCCXXXVI.
   It is my defign to reftore this diftrriction ; and I
fhall therefore here, under the title of Hemorrhagies,
comprehend  thofe only which have been commonly
called Active, that is, thofe attended with'fome degree
of  pyrexia;  which feem  always to depend upon an
increafed impetus of the blood, in the veffels pouring
it out, and which chiefly arife from an internal caufe.
In this I follow Dr. Hoffman, who joins the  active
hemorrhagies with the febrile difeafes ; and have ac-
cordingly eftablifhed  thefe hemorrhagies as an order
in the clafs of Pyrexiae.   From this order I exclude
all thofe effufions of red blood that are owing entire-
ly to external violence ; and all thofe which, though
arififlg from internal caufes, are, however, not attend-
ed with pyrexia, and which feem to be owing to a pu-
trid fluidity of the blood, to the weaknefs or to the
erofion of the veffels, rather than to any inoreafed
impetus of the blood in them.
                  DCCXXXVII.
  Before proceeding to treat  of thofe proper hemor-
rhagies wich  form an orde^r in our Nofology, I fhall
treat of active hemorrhagy in general; and indeed the
feveral genera and fpecies, to be treated  of particu-
larly afterwards, have fo many circumftances in com-
mon with one another, that the general confideration
to be now offered will prove  both proper and ufeful.
SEC  T, 
            O F   P H Y  S I C.           351


               SECT.    I.

OF THE PHENOMENA  OF  HEMORRHAGY.

                 DCCXXXVIII.
  The phenomena of hemorrhagy  are generally the
following.  •
  Hemorrhagies happen efpecially in plethoric habits,
and  to  perfons of a fanguine temperament.  They
appear moft commonly in the  fpring, or in the be-
ginning of fummer.
  For fome time, longer or fhorter  in different cafes,
before the  blood flows, there are fome fymptoms of
fulnefs and tenfion about the parts from whence the
blood is to iflue.  In fuch parts as fall under our view,
there are fome rednefs, fwelling, and fenfe of heat or
of itching ; and  in  the internal parts  from which
blood is to flow, there is a fenfe of weight and heat ;
and,  in both cafes, various pains arc often felt in the
neighbouring  parts.
                  DCCXXXIX.
   When thefe fymptoms have fubfifted for fome time,
fome degree of a cold ftage  of pyrexia comes on, and
a hot ftage is  formed ; during which, the blood flows
of a florid colour, in a gfeater or leffer quantiiy, and
continues  to flow for a longer or a fhorter time ; but
commonly, after fome time, the effufion fpontaneouf-
ly ceafes, and together with  it the pyrexia alfo.
                    DCCXL.
   During the hot ftage which precedes an hemorrha-
gy, tjjhe pulfe is frequent, quick* full, and often hard ;
but, ;as the blood flows, the  pulfe becomes fofte'r and
 lefs frequent.
                    DCCXLI.
   In hemorrhagies, blood drawn from  a vein, does,
                                            upon
*   * The difference between a frequent and quick pulfe was menti-
 oned i» 'i uote 0.1  article 336. 
 352            PRACTICE

 upon its concreting, commonly fhow the gluten fepa-
 rated,  or a cruft formed, as in the eafes  of Phleg-
 mafias.
                   DCCXLII.
   Hemorrhagies from internal caufes,  having  once
 happened, are apt,  after a certain interval, to return ;
 in fome cafes very often, and frequently at ftated pe-
 riods.
                   DCCXLIII.
   Thefe are, in general, the phenomena of hemor-
 rhagy ;  and if in fome cafes all  of them be not exqui-
 fiteiy marked, or if perhaps fome of them do not at all
 appear, it imports only, that, in different cafes the fy-
ftem is  more or lefs generally affected ; and that,  in
fome cafes, there are purely topical hemorrhagies, as
 there are purely topical inflammations.
               S  E   C   T.   II.

OF THE PROXIMATE  CAUSE OF  HEMOR-
                    RHAGY.

                   DCCXLIV.
  The pathology of hemorrhagy feems to be fuffici-
ently obvious.  Some inequality in the diftribution of
the blood, occafions a  congeftion in particular parts
of the fanguiferous fyftem ; that is, a greater quanti-
ty of  blood is poured into certain veffels than^their
natural capacity is fuited to receive.   Thefe veifels
become thereby,  preternaturally diftended ;  and this
Biftention, proving a ftimulus  to them,  excites their
action  to a greater degree than ufual, which pulbing
the blood  with unufual force into the  extremities of
thefe veffels,  opens them by anaftomofis,  or rupture;
*rlfi 
OF   PHYSIC.
353
  and, if thefe extremities beloofely fituated on external
  furfaces, or on the internal furfaces of certain cavities
  that open outwardly, a quantity of blood flows out of
  the body.
                     DCCXLV.
    This reafoning will, in fome meafure, explain the
►  production of  hemorrhagy.   But  it appears to  me,
  that, in moft cafes, there are other circumftances that
  occur  to produce it:  for it is probable, that, in confe-
  quence of congeftion, a fenfe of refiftance arifes, and
  excites the action of* the Vis Medicatrix Naturae, the
  exertions of which are ufually made by the formation
  of a cold ftage of pyrexia, inducing a more vigorous
  action  of the veffels ;  and the concurrence of this ex-
  ertion more effectually opens the extremities, and oc^
  cafions the  flowing out of the blood.
                    DCCXLVI.
    What has been delivered in the two preceding pa-
  ragraphs,  feems to explain  the whole phenomena of
  hemorrhagy,  except the circumftance of its frequent
  recurrence, which I apprehend may be explained in
  the  following  manner.  The  congeftion and confe-
  quent  irritation being taken off by the flowing of the
  blood  ; this, therefore, foon after, fpontaneoufly ceaf-
  es ; but, at the fame time,  the internal caufes which
  had before  produced  the  unequal  diftribution of the
  blood, commonly remain, and muft  now operate the
  more readily,  as the over-ftretched and relaxed veffels
  of the  part  will more eafily  admit of a  congeftion of
  blood  in them, and,  confequently, produce the fame
  feries of phenomena as before.
                    DCCXLVII.
    This may fufficiently explain the ordinary return of
  hemorrhagy :   but there is ftill another circumftance,
  which, as commonly concurring,  is to be taken notice
  of;  and that is, the general plethoric ftate of the fyf-
  tem, wdiich renders every caufe of unequal diftribution
    Vol. I.               Y y                    of 
354            P R A C T I C  f.

of more  confiderable effed.   Though  hemorrhagy
may often depend upon the ftate of the veffels of a par-
ticular part being favourable to  a congeftion's  being
formed in them; yet, in order to that ltate's produc-
ing its effed, it  is  neceflary that the  whole fyftem
fhould be at leaft in its natural  plethoric condition ;
and, if this fhould be in any degree increafed beyond
what is natural,  it  will ftill more certainly determine
the effeds of topical conformation to take place. The
return of hemorrhagy, therefore,  will be  more certain-
ly occafioned, if the fyftem  becomes preternaturally
plethoric ;. but hemorrhagy has always a tendency to
increafe the plethoric  ftate of the fyftem,  and,  confe-
quently, to occafion its own return.
                   DCCXLVIII.
   To fhow that  hemorrhagy does contribute to pro-
duce or increafe the plethoric ftate of the fyftem, it is
only neceffary to obferve, that the quantity of ferous flu-
ids being given, the  ftate of the excretionsdependsupon
a certain balance between the force of  the larger ar-
teries propelling the blood, and the refiflance of the
excretories : but the force of the arteries depends up-
on their fulnefs and diftenfion,  chiefly  given to them
by the quantity of red globules and gluten, which are,
for the greateft part  confined to  the red arteries ; and
therefore, the fpoliation made by an hemorrhagy, be-
ing chiefly of red globules and gluten,  the effufion of
blood muft  leave the red arteries  more empty and
weak.  In confequence of the weaker adion of the red
arteries, the excretions are in proportion diminiihcd ;
and, therefore, the ingtfta continuing the fame, more
fluids will be accumulated in the larger veffeff  It is
by this means that  the lofs of blood by  hemorrhagies,
wl'et-.ier  artificial or fponraneous,  if  within certain
 bounds,  is commonly fo foon recovered : but as  the
 diminution of the excretions, from a lefs quantity of
 fluid being impelled into the excretories, gives occafi-
                                                on 
O F  P Ii Y  S I C.
355
on to thefe veffels to fall into aeontraded ftate ;  fo, if
this  fliall continue long,  thefe  veffels  will become
more rigid,  and will not yield to the fame impelling
force as before.   Although the arteries, therefore, by
new blood  colleded in them,  fhall  have recovered
their former fulnefs, teniion. and force, yet this force
will  not be in balance with the refiftance of the more
rigid excretories, fo as to  reltore the former ftate of
excretion; and, confequently, a  further accumulation
will  take place in the arteries, and an increafe of their
plethoric ftate be thereby  induced.   In this manner,
we perceive more clearly,  that hemorrhagy, as  pro-
ducing a more plethoric ftate of  the fyftem, has a ten-
deney to occafion its own recurrence with greater vi-
olence ;  and, as  the renewal and further accumula-
tion of blood require a determinate time, fo,  in the fe-
veral repetitions of hemorrhagy,  that time will be near-
ly the fame ; and therefore the returns of hemorrhagy
will be commonly at  ftated periods,  as has been ob-
ferved frequently to happen.
                    DCCXLIX.
   I  have  thus explained the nature of hemorrhagy in-
general, as depending upon fome inequality in the dif-
tribution of the blood, occafioning a congeftion of it
in particular parts  of  the fanguiferous fyftem.  It is
indeed  probable, that, in moft perfons,  the feveral
parts of the, fanguiferous fyftem, are  in balance with
one another ; and that the denfity,  and confequently
the refiftance, in  the feveral velf/ls, is in proportion to
the  quantity of blood which  each  fliould  receive;
from whence it frequently happens, that no inequality
in  the  diftribution  of  the  blood  takes place in  the '
courfe of a  long  life.  If,  however, we confider that
the  fanguiferous fyftem is  conftantly in a plethoric
ftate, that is, that the  veffels are c inftantlv  diftended
beyond thatfize which they would be of,  if free  from
jmv  diftendinp- force, we fliall be f.itisficd that this ftate
                       Y y  a.                m.iy.
\ 
356          PRACTICE

may be readily changed.  For as, on  the one hand,
the veffels are ejaftic, fo as to be under* a conftant ten-
dency to contra^d upon the withdrawing of any part
of the diftending force; and, on the other hand, are
not fo rigid but that, by an increafe of  the impetus of
the blood in them, they may be more than ordinarily
diftended ; fo we can eafily underftand how, in moft:
perfons, caufes of an increafed contradioji  or diften-
fion may arife in one part or other of the %ftem, or
that an unequal diftribution may take place; anet.how,
in an exquifitely diftended or plethoric fyftem, a frrTall
inequality in the diftribution of the blood may  form
thofe congeitions which  give  occafion  to hemor-
rhagy.
                     DCCL.
   In this manner I endeavour to  explain how hemor-
rhagy may be occafioned at any period of life, or in a-
ny part or the body : but hemorrhagies happen in cer-
tain parts more frequently than in others, and at cer-
tain  periods of life more  readily  than at others ; and
therefore, in delivering the general dodrine of he-
morrhagy,  it may be required that I fhould explain
thofe  circumftances which produce the fpecialities
mentioned;  and I fhall now attempt it.
                    DCCLI.
   The human body, from being of a fmall bulk  at its
firft formation, grows afterwards to a confiderable fize.
This increafe of bulk confifts, in a great meafure, in
the increafe of the quantity of fluids and a proportion-
al enlargement of the containing veffels.   But,  at the
fame time,  the  quantity of folid matter is alfo gradu-
ally increafed ;  and, in  whatever manner we may fup-
pofe this to  be  done, it is probable that the progrefs,
in the whole of the growth of animal bodies, depends
upon the extenfion of the arterial  fyftem ; and fuch is
the conftitution of the  fanguiferous fyftem,  that the
                                          motion 
OF  PHYSIC.
357
motion of the blood in the arteries has a conftant ten-
dency to extend them in every dimenfion.
                    DCCLII.
  As the ftate of the animal folid is, at the firft: form-
ation of the body, very lax and yielding ; fo the ex-
tenfion of the fyftem proceeds, at firft, very faft: but,
as the extenfion gives occafion  to the appofition, of
of more matter to the folid parts, thefe are, in propor-
tion to their extenfion, conftantly acquiring a greater
denfity, and therefore giving more refiftance to their fur-
ther extenfion and growth.   Accordingly, we obferve,
that as the growth of the body advances,  its increafe,
in any given time, becomes proportionally lefs, till at
length it ceafes altogether.
                     DCCLIII.
  This is the general idea of the growth of the human
body, til it attain the utmoft bulk which  it is capable
of  acquhieg :  but, it  is to. be remarked, that this
growth  coca not proceed  equally in every part of the
body,  it being requifite for the ceconomy of the  fy-
ftem, that certain  parts fhould  be firft evolved, and
fhould alfo acquire their full bulk fooner than others.
This appears particularly with refped to the head, the
parts of which  appear to be firft evolved, and fooneft
 to acquire their full fizes.
                     DCCLIV.
   To favour this unequal growth, it is prefumed, that
the  dimenfions or the laxity of  the veffels of  the
head, or that the diredion of the force of  the blood,
are  adapted to  the purpofe ; and from what has been
faid in  dcclii. it  will  alfo certainly follow,  that as
the veffels of the head grow fafteft, and fooneft acquire
their full fize, fo they will fooneft alfo acquire that
denfity  which will prevent their further extenfion.
While, however, the force of the heart, and the quan-
tity of the fluids, with refped to the whole fyftem, re-
main: the fame, the diftending and extending powers 
353
PRACTICE
will be direded to fuch parts as have not yet acquired
the fame denfity and dimenfions of thofe firft evolved j
and the diftending and  extending powers wli  pro-
ceed  to  operate  till  every part of the  fyftem,  in
refped  of denfity  and refiftance,  fhall  have been
brought to be in balance with every other,  and  till
the whole be in balance with the force of the he ot,
fo that there can be no further growth in any particu-
lar part, unlefs fome preternatural circumftance fliall
happen to arife.
                    DCCLV.
   In this  procefs of the  growth of  the body, as  i^
feems in general to depend upon a certain balance be-
tween the force of the heart, or diftending power, an4
the refiilance of the folids ; fo  it will app-.ar, that,
while the folids remain  very lax and yielding, fome
occafional increafe of the diftending  power may arife
without  producing any  very  perceptible  diforder in
the fyftem.   But, it will alfo appear, that, in propor-
tion as the diftending power and refiftance of the folids
some to be more nearly in equal balance with one an-
other, fo any increafe  of the diftending power  will
more readily produce a rupture of veffels,  which, dp
not eafily yield to extenfion.
                   DCC L VI.
   From all this, it muft follow, that the effeds of any
unufual plethoric ftate of the fyftem,  will be different
according as this fhall occur at different periods of the
growth of the body.  Accordingly, it is evident, that
if the plethoric ftate arifes while the head is yet grow-
ing, and while the determination  of the blood is ftill
more to the head  than to the other parts, the increaf-
ed quantity of the blood will be efpecially determin-
ed to the head ; and as there alfo, at  the fame time,
the balance  between the diftending  and  extending
power is moft nearly adjufted, fo  the determination
of the blood will moft readily produce in  that  part u
                                          rupture^ 
U  t  f ri f  S I C.           359
rupture of the veffels,  or an hemorrhagy.  Hence it
is, that hemorrhagies of the nofe fo frequently hap-
pen in young perfons ; and  in thefe more readily, as
they approach nearer to their acme,  or full growth ;
or, if it may be faid, perhaps more properly, as they
approach nearer to the age of puberty, when, perhaps,
in both fexes, but efpecially in the female, a new de-
termination arifes in the fyftem.
                    DCCLVII.
   The determination of  a  greater quantity of blood
to the veffels of the head, might be fuppofed to occa-
fion  a rupture of veffels in other parts of the head, as
well as in the nofe :  but fuch a rupture does not com-
monly happen '; becaufe in the nofe there is, for  the
purpofe of fenfe, a confiderable  net-work  of blood-
veffels expanded on the internal furface of thenoftrils,
and  covered only  with  thin and  weak teguments.
From this circumftance it is, that upon any increafed
impetus of the blood in  the veffels of the head, thofe
of the nofe are  moft eafily broken ; and the effufion
from the nofe taking place, it not only relieves  the
other extremities of the external carotid, to which the
arteries of the nofe, chiefly belong, but relieves  alfo,
in a great  meafure, the fyftem of  the internal carotid.
For, from the internal carotid, certain  branches ar-
fent to the nofe, are fpread out on its internal furface,
and  probably inofculatcd with the extremities of the
external carotid :  fo that,  whichfoever of the extre-
mities are  broken,  the vis derivationis of Halier  will
take place ; the  effufion will relieve the whole  fan-
guiferous  fyftem of the head ;  and the fame elfuiion
will alfo commonly prevent an hemorrnagy  happening
at the fame time in any  other part of the bodv.
                    DCCLVIII.
   From thefe principles, it will  appear why hemor-
 rhagies of the nofe, fo frequent  before the period of
 puberty,  or of the acme,  feldom  happen after thefe
                                          periods: 
360          PRACTICE

periods :  and I  muft obferve further, that although
they fhould occur, they  would not afford any objec-
tion  to my dodrine, as fuch hemorrhagies might be
imputed to a peculiar laxity of the veffels of the nofe,
and perhaps to a habit acquired with refped to thefe
veffels, while the balance of the fyftem might be other-
wife  adjufted.
                    DCCLIX.
  When the procefs of 'the growth of the body goes
on regularly, and the balance of the fyftem is  proper-
ly adjufte'd  to the gradual growth  of the whole, as
well  as to the fucceflive growth of the feveral parts,
even a plethoric ftate does not produce any hemorrha-
gy, or at  leaft any after that of the nofe :  but if, while
the plethoric ftate continues, any inequality fhall alfo
fubfift in  any of the  parts of the fyftem, cor.geftions,
hemorrhagic or inflammatory,  may  be  ftill  readil/
formed.
                    DCCIX
  In general, it  may be obferved, that, when the feve-
ral parts of the fyftem of the aorta have attained their
full growth, and are duly balanced with one another,
if then any confiderable degree of plethora remain or
arife', the nicety of the balance will be  between the
fyftems of the aorta and pulmonary artery, or between
the veffels of the lungs  and thofe of all the reft of the
body.  And although the leffer capacity of the veffels
of the lungs is commonly compenfated by the greater
velocity of the  blood in  them ; yet,  if this velocity
be not always adjufted  to  the neceffary compenfation,
it is probable that a plethoric ftate of the whole body
will  always be efpecially felt in the  lungs; and, there-
fore, that an hemorrhagy, as the effed of a  general
plethora, way be frequently occafioned  in the lungs,
even though  there  be no fault in their conforma-
tion.
                                       DCCLXI. 
OF  PHYSIC.           361
                    DCCLXI.
   In fome cafes, perhaps,  an hemorrhagy. from the
 lungs, or an hemoptyfis,  does arife from the general
 plethoric itate of the body ; but an hemoptyfis more
 frequently does, and may be expeded to happen, from
 a faulty proportion between the capacity of the lungs
 and that of the reft of the body.
                   DCCLX1I.
   When fuch a disproportion takes place,  it will be
 evident, that an hemoptyfis will efpecially happen a-
 about the time that the body is approaching  to its
 acme ; that is, when the fyftem of the aorta has arrived
 at its utmoft extenfion and refiftance, and when, there-
 fore,  the  plethoric ftate of the whole muft efpecially
 affect the lungs.
       .   ....       DCCLXIII.
   Accordingly, it has been conftantly obferved, that
 the hemoptyfis efpecially occurs about the time of the
 body's arriving at its acme ; but I muft remark alfo,
 that the hemorrhagy may occur fooner or later,  ac-
 cording as the  balance between the veffels of the lungs,
 and  thofe of the fyftem of the aorta, happen to be
 more or lefs exadly adjufted  to one another;  and it
 may therefore  often occur much later than the period
 mentioned, when that balance, though not quite even,
 is however not  fo ill adjufted, but that fomcother con-
 curring caufes  are neceffary  to give it effed.
                   DCCLXIV.
  It was anciently remarked by Hippocrates, and has
 been confirmed by modern  obfervation,  that the he-
 moptyfis generally occurs in perfons between the age
 of fifteen and that of five-and~thirty ; that it may hap-^
 pen at any time between thefe two periods; but that
it feldom  happens before the former,  or after the lat-
ter ;  and it may be proper here to inquire into the rea-
fon of thefe two limitations.
  Vol. I.               Z z            DCCLXV. 
362            PRACTI C'E
                    DCCLXV.
  With refped to the firft, the reafon of it has been
already explained in dcclxii,  and dcclxiii.
  With refped to the fecond limitation,  I exped that
the reafon of it will be underftood from the following
confiderations.
  It has been already obferved, that the  extenfion and
growth of the  body require the plethoric ftate of the
arterial fyftem; and nature has provided for this, part-
ly by the conftitution of the blood being fuch, that a
great portion  of it is unfit to pafs into the exhalents
and  excretories;  partly by giving  a certain denfity
and refiftance to the feveral exhalents and  excretories
through which the fluids might pafs out  of the red ar-
teries ; and partly, but efpecially, by a refiftance in
the veins  to the   free paffage of the blood into them
from the arteries.
                   DCCLXVI.
  With refped to this laft and  chief circumftance, it
appears from the  experiments of Sir Clifton Wintring-
ham, in his Experimental Inquiry, that  the proporti-
onal denfity of the coats of the veins to that of the
coats of the arteries, is greater in young than in old
animals,: From which it may be prefumed, that the re-
fiftance to the paffage of the blood  from the arteries
into the veins, is greater in young animals than in old;
and, while this refiftance continues,  the plethoric ftate
of the  arteries muft be conftantly continued and fup-
ported.  As however the denfity of the coats of the
veffels confining  chiefly of  a cellular texture,  is in-
creafed by preflure; fo,  in proportion as the  coats of
the arteries are more expofed to preflure by diftenfion
than thofe of the veins, the former, in the progrefs of
the growth of the body,  muft increafe much more in
denfity than the  latter; and, therefore,  the  coats of
the arteries,  in refped of denfity  aud refiftance,  muft
come, in time, not only to be in balance with thofe of
                                               the 
              O F   P H Y  S I C.           363

the veins, but to prevail over  them :  a fad which is
fufficiently proved by the  experiments  of the above-
mentioned ingenious author.
  By thefe means,  the  proportional quantifies  of
blood in the arteries and veins muft change in  the
courfe of life.   In younger animals,  the quantity of
blood in the arteries muft be proportionally greater
than in old ones ; but by the increafing denfity of the
arteries, the quantity of blood in them  muft be contir.
nually diminifhing, and that in the veins  be proporti-
onally increafing, fo  as at length to be in a proporti-
onally greater quantity than that in the arteries. When
this  change  happens  in the proportional quantities
of the blood in the arteries and veins, it muet be evi-
dent that the plethoric fUte of the arteries will be in
a great meafure taken  olf; and,  therefore, that the ar-
terial hemorrhagy is  no longer likely to happen ; but
that,  if a general plethoric ftate afterwards takes place
in the fyftem, it  muft efpecially appear in the veins.
                  DCCLXVII.
  The change I  have mentioned  to happen in  the
ftate of the arterial  and  venous fyftems,  is  properly
fuppofed to take place in  the human body about the
age of thirty-five, when it is manifeft that the vigour
of the body, which depends fo  much upon  the  full-
nefs and tenfion of  the arterial fyftem, no longer in-
creafes ; and therefore it is,  that the fame age is  the
period,  after which  the arterial hemorrhagy,  hemop-
tyfis,  hardly ever appears.   It is true, there are inftan-
ces of the hemoptyfis happening at  a later period ; but
it is for the  reafons given (dcclvui.) which fhow that
an  hemorrhagy may  happen at any period  of life,
from  accidental caufes  forming congeftions, independ-
ent of the ftate of the  balance of the  fyftem at  that
particular period.
                  DCCLXVIIl.
  \ have faid (dcclxvi.) that if, after the age of thirty-
                     Z z 2                    five,. 
364          PRACTICE
five, a general and preternatural plethoric ftate occur,
it muft efpecially appear in the venous fyftem ; and I
muft now obferve, that this venous plethora may alfo
give occafion to hemorrhagy.
                   DCCLXIX.
  If a plethoric ftate of the venous fyftem take place,
it is to be prefumed, that it will efpecially and in the
firft place affed the fyftem of the vena portarum,  in
which the motion of the venous blood 5s^#nore flow
than elfewhere ; in which the motion of thelefcdood is
little aflifted by external compreffion ; and ih-%wch,
from the want of valves in the veins that form tfie^p-
na portarum, the motion of the blood is little aflifted
by the compreffion that  is  applied ; while, from the
fame want of valves in thoife  veins, the blood  is more
ready to  regurgitate in them.   Whether any regurr
gitation of the  blood  ca!n  produce  an  adion in the
veins, and Which inverted, or direded  towards their
extremities, can force thefe, and occafion hemorrhagy,
may perhaps be difputed :  but it appears to me  that
an hemorrhagy,  produced by a plethoric ftate of the
veins, may be explained in another and more probable
manner.   If the blood be accumulated  in  the veins,
from any interruption  of its proper courfe, that accu-
mulation muft refift the free paffage of the blood from
the arteries into the veins.   This again  muft  produce
fome congeftions in the extremities of the red  arteries,
and therefore fome increafed adion in them, which
muft be determined with more than ufual force, both
upon the extremities of the arteries, and upon  the ex-
halants proceeding from them; and this force may
occafion an effufion of blood, either by anaftomofis  or
rupture.
                   DCCLXX. .
  In this manner I apprehend the hemorrhoidal flux
is to be explained, fo far as it depends upon the ftate
of the whole fyftem.  It appears moft commonly  to
                                          proceed 
            OF    PHYSIC.           365

proceed from the extremities of the hemorrhoidal vef-
fels, which, being the moft dependent and diftant
branches of thofe veins that form the vena portarum,
are therefore the moft readily affeded by every accu-
mulation of blood in that fyftem of veins,  and confe-
quently by any general  plethora  in  the venous  fyf-
tem.
                   DCCLXXI.  x
   It is here to be obferved, that I have fpoken of this
hemorrhagy  as proceeding from tho hemorrhoidal
veffels only, as indeed it moft commonly does ; but it
.%ill be readily underftood, that the fame accumula-
tion and refiftance to the venous blood may, from va-
rious caufes, affed many of the extremities of the vena
portarum, which lie very fuperficirdly upon the inter-
nal furface of the alimentary canal, and give  occafion
to what has been called the Morbus Niger or Melcena.
                   DCCLXXII.
   Another part in which an unufualiy plethoric ftate
of the veins may  have particular effects,  and  occafion
hemorrhagy, is the head.  In this, the venous fyftem
is of a peculiar conformation, and fuch  as feems in-
tended by nature to give there a flower motion to the
venous blood. If, therefore, the plethoric ftate of the
venous fyftem in  general, which feems to increafe as
life advances,  fhould at length increafe to a great de-
gree, it may  very readily affed the venous veflels of
the  head,  and produce there fuch a  refiftance to the
arterial blood, as to determine this to be poured  out
£rom the nofe, or  in the cavity of the( cranium.  The
fpecial effed of the  latter effufion will be,  to produce
the difeafe .termed Apoplexy ; and which, therefore,
is properly named by Dodor Hoffman,  Hemorrha-
ge Cerebri: and  the explanation of  its caufe,  which
j have  now given, explains well  why it  happens
efpecially to  men  of  large heads and  fhort necks,
2nd to men in the decline  of life,  when the powers
                                        promoting 
355
PRACTICE
promoting the motion of the blood are much weak-
ened.
                  DCCLXXIII.
  I have thus attempted to give  the  hiftory of  the
plfcthoirc and hemorrhagic ftates of the human  bo-
dy, as they occur at the different .peiiods of life ;  and
hope I  have thereby explained, not  only the nature
of hemorrha/y in general,  but alfo of the  particular
hemorrhagies which moft  commonly appear, and as
they occur fucceifively at the different periods of  life.




              SECT.     HI.-

  OF THE REMOTE CAUSES OF HEMOR-
                    RHAGY.

                  DCCLXXlV.
  In the explanation hitherto given, I have efpecially
confidered the pred:fpo(ition  to hemorrhagy ; but it
proper is alfo, and  even neceffary ;  to take notice of
the occafional caufes, which not only concur with the
predifponent, in exciting  hemorrhagy, but may  alfo
fometimes be the fole caufes of it.
                  DCCLXXV.
  Thefe occafional caufes  are,
   i. External heat, which, by rarefying the blood,
produces or  increafes the plethoric ftate of the body ;
and the fame heat,  as giving a ftimulus  to the whole
fyftem,  muft urge any particular  determinations  be-
fore eftablifhed,  ftill further, or  may urge to  excefs
any inequality,  otherwife innocent; fo that, in either
way, external heat  may immediately excite hemorrha-
gies, to  which there was a  predifpofition, or may form
congeftions where  there were none before, and there-
by  occafion hemorrhagy.
                                            2. A
+ 
               OF   PHYSIC.          3C7

  2.  A  confiderable and  fudden diminution  of the
weight of the atmofphere, which  feems to occafion
the fame effeds as heat, by producing alfo an  expan-
fion of the blood;
  3.  Whatever increafes the force of the circulation,
and thereby the velocity of the blood,  may operate
in the fame manner as heat, in urging not only pre-
vious determinations with viclence,  but alfo  in urg-
ing to excefs inequalities, otherwife innccenr.  All vi-
olent exercife, therefore, and efpecially all  violent
efforts, which, not only by a larger and longer infpi-
ration,butalfoby.thefim\iltaneous adion of many muf-
cles interrupting the free motion of the blood, impel
it with unufual force into the extreme veffels more ge-
nerally, and, according to the different poftures of  the
body, and mode of the effort, into certain veffels more
particularly.
   Among the caufes  increafing the force of the circu-
lation,, anger* and other violent adive paffions are to
be  reckoned.
   4.  The violent exercife of particular  parts of  the
body.   If thefe are already affeded with congeftions,
or  liable to them, fuch exercife may be confidered as
a ftimurus applied to the veffels of that particular part.
Thus, any violent exercife of refpirationf may excite
hemoptyfis, or occafion its return.
   5.  The poftures of the body increafing determina-
tions,  or ligatures occafioning accumulations of  the
blood in particular parts of the body.
   6. A determination into  certain  veffels rendered
habitual  by the frequent repetition of hemorrhagy
from them.
                                            7.  Cold
  * Paflionate children frequently bring on a bleedingof  the nofe ;
and when  fuch an accident happens, the childs  face, before the
blood  breaks out, becomes red, and all the veffels of the  head and
neck feem diftended and full.
  f As playing on the German flute, or any other u Yd !; "rument
that uquires a great force to blow it. 
368          PRACTICE
  7. Cold, externally applied, as changing the diftri-
bution of  the blood, and  determining jt in greater
quantity into the internal parts.
               SECT.    IV.

     OF THE CURE OF HEMORRHAGY.

                  DCCLXXVI.
  Having thus confidered the proximate and remote'
caufes of hemorrhagy in. general,  our next bufinefs
is, to treat of the cure of the difeafe in the fame man-
ner.                       H
  In entering upon this fubject, the firft queftion which
prefents itfelf,  is, Whether the cure of hemorrhagies
ought to be attempted by art, or if they fhould be left
to the condud of nature ?
                  DCCLXXVII.
  The latter opinion was the favourite dodrine of the
celebrated  Dr. Stahl,  and his  followers.   They
maintained, that the human body is much  difpofed
to a  plethoric ftate; and, confequently, to many dif-
orders which nature endeavours to obviate and relieve
by exciting hemorrhagy : that this, thereforeyis  often
neceflary to the balance  and health of the fyftem :
that  it  is accordingly to be  generally encouraged,
fometimes folicited, and is not  to be fuppreffed, un-
lefs when it goes to great excefs, or happens in  part3
in which it may be dangerous.
                 DCCLXXVIII.
  Much of this dodrine may be admitted.   The hu-
man  body, upon many occafions,  becomes  preterna-
turally  plethoric ; and the  dangerous confequences
which might from thence be apprehended, feem  to be
                                             ob- 
u t  if ti  Y S  I C.          369
obviated by an hemorrhagy taking  place:  and,  fur-
ther, the neceflity of hemorrhagy often appears fron^
hence, that the fuppreflion of it feems to occafion ma-
ny diforders.
  All this feems to be juft ; but, in the conclufion
drawn from it, there is a fallacy.
                  DCCLXXIX.
  It appears to me certain, that hemorrhagy,  eitLsr
upon its  firft attack, or upon its after  recurrence,  is
never neceffary to the health of the body, excepting
upon the fuppofition, that  the plethoric ftate  which
feems to  require the evacuation, cannot be  otherwife
prevented or removed; and as I imagine  it poffible
by other means to prevent or remove a plethoric ftate,fo
I do not think that hemorrhagy is, in all cafes, neceffary.
In general,  I am of opinion, that hemorrhagy is to be
avoided.
   1. Becaufe it does not always happen in parts where
it is fafe.
  2. Becaufe often,  while  it  does relieve a plethoric
ftate, it mtiy,  at the fame time, induce  a very danger-
ous difeafe.
  3. Becaufe it may often go to excefs,  and  either en-
danger life, or induce a dangerous infirmity.
  And, laftly, Becaufe  it has a tendency to increafe
the plethoric ftate it was meant to relieve ; to occafion
its own recurrence, (Dccxxi.)  and thereby to induce
a habit, which, if lefc to the precarious and unequal
operation of nature, may, from the frequent errors of
this, be attended with much danger.
                    DCCLXXX.
  It is further to be confidered, that hemorrhagies do
not always arife from the neceffities of the fyftem, but
often proceed from  incidental caufes.  It  appears to
me, that all hemorrhagies of the latter kind may b-;
immediately fuppreffed, and the repetition of them, as it
  Vol. I                 3 A             induce- 
370             PRACTICE
induces a plethora, and a habit not otherwife neceflary
may be prevented with great advantage.
                  DCCLXXXJ.
  Upon the whole of this fubjed  I  conclude, that
every preternatural hemorrhagy, or, in other words,
every one except that  of the  menfes in females, is to
be avoided, and efpecially the returns of it prevented ;
and I therefore now proceed to mention, how  hemor-
rhagy, and its  recurrences, may, and mould be pre.
vented.
                 DCCLXXXII.
  From the principles delivered above, it will imme-
diately appear,  that the prevention,  either of  the firft
attacks, or the returns of hemorrhagy, will chiefly, and
in the firft place, depend upon the preventing or re-
moving, any confiderable degree of a plethoric ftate
which may happen to prevail  in the  body.   It is true,
that, where the  hemorrhagy depends upon the particu-
lar conformation of certain parts, rather than upon the
general plethoric ftate of the whole; the meafures for
removing or preventing the latter, may not always be
fufneient for preventing hemorrhagy :  but at the fame
time it muft be evident, that  determinations, in con-
fequence of the conformation of  particular parts, will
always be  urged more or lefs, in proportion to the
greater or  leffer degree of the plethoric ftate of the
whole fyftem ;  and therefore,  that, even in the cafes
depending upon particular conformation, the preventing
or removing an unufualiy plethoric  ftate, will always
be a  chief means  of preventing hemorrhagy.  It is
further to be attended to, that there may be feveral in-
equalities in  the  balance  of the fyftem, which may
have little or no effed unlefs when the fyftem becomes
preternaturaily  plethoric;  and therefore,  that, in all
cafes, the preventing  or  removing of the plethoric
ftate of th* fyftem, will be a chief means of prevent-
ing  the firft attacks, or the returns of hemorrhagy.  It
                                              now 
OF  PHYSIC.
371
now, therefore,  remains to explain, how the plethoric
ftate of the fyftem is to be prevented or removed.
                  DtCLXXXIII.
  The fluids of the human body are in continual wafte
by the excretions, but are commonly  replaced by the
aliments taken in ;  and if the Quantity of aliments in
any meafure exceed that of the excretions, an increafe
of the quantity of the fluids of the body, or,  in other
words, a plethoric ftate, muft neceflarily arife.  This,
to a certain degree,  is  requifite for the growth of the
body,  but, even  then,  if the proportion  of  the ali-
ments  to the  excretions, be  greater than  is fuited to
the growth of the body,  and more certainly  ftill,  if,
after the growth  is completed,  when  an equality be-
tween  the ingeflaand the excreta fhould be eftablifhed,
the difpioportion ftill continue,  a  preternaturaily ple-
thoric  ftate muft arife.  In both cafes, it is evident,
that the plethora muft be  prevented or correded by
adjufting the ingefta and excreta to each other ; which
generally may be done, either by  diminifhing the in-
gefta,  or by increafing the excreta*.  Theformermay
be effeded  by the management  of  the diet, the latter-
by the management of exercife.
                  DCCLXXXIV.
  The ingefta may be  diminifhed, either by giving ali-
ment in lefs quantity than  ufual, or by giving aliments
ofalefs nutritious quality; thatis, aliments of a fubftance
which, under the fame bulk and  weight,  contain lefs
cf a matter capable of being  converted into animal flu-
ids,  and more of a matter ready to pafs off by the ex<
cretions, and confequently lefs of a matter to be letain-
ed and accumulated in the veffels.
  The  choice of aliments  fuited to  thefe purpofes
                       3 A 2                muft,

  * This effeel may farely be more fpeedily produced by ufing both.
£hefe mcjna at once. 
37*
PRACTICE
muft be left  to be direded  by the dodrines  of the
Materia Medica.
                  DCCLXXXV.
  The increafing of the excreta, and thereby dimi-
nifhing the plethoric ftate of the fyftem,  is to be ob-
tained by increafing the exercife of the body;  and ge-
nerally for adjufting the  balance between the ingefta
and excreta,  and  thereby  obviating the  plethoric
ftate, it is neceffary that exercife, in a due meafure, be
very conftantly employed*.
                  DCCLXXXVI.
  The obferving abftinence,  and the  employment of
exercife,  for  obviating  or  removing the  plethoric
ftate of the body, were formerly confidered pretty ful-
ly,  when treating of the  gout, (dxlviii, to dlii.) fo
that the lefs is neceffary to be faid here: and it is now
only requifite to obferve,  that the fame doubts,  as in
cafe of the gout, do not occur here wdth  regard to the
fafety of thofe meafures, which, in a plethoric ftate of
the body difpofing to hemorrhagy, are always  admiflir
ble and proper.   Here, however, it is to be oblerved,
that fome choice in the mode of exercife is neceffary,
and that it fhould be different according to the  parti-'
cular determinations which  may happen to  prevail in
the fyftem.   In general, in the cafe of plethora difpof*
ing to hemorrhagy bodily exercife will always be  ha-
zardous, and geftation more  commonly fafe.
                  DGCLXXXVII.
   Artificial evacuations may be employed to diminifh
the plethoric ftate of the body; and when, at any time,
                                                  it

  * The exercife beft adapted  to thefe cafes is fuch as does not heat
the body or increafe the force of the blood.  Hence riding mode-
rately, travelling in a carriage,  or failing, are preferable to walking.
Young people may ufe fuch  gentle  exercife as may amufe the mind,
and at the fame time conduce to bodily health, as gardening, feve-
ral agricultural labours, or mechanical  operations ; or fome of the
fportsthat require a gentle bodily exertion as bowling, archery, See. 
OF  PHYSIC.
373
it has  become confiderable, an I immediately threat-
ens a difeafe, thefe evacuations fhould be made to the
quantity that the fymptoms feem to require.   But  it
is conftantly to be attended to, that blood-lettings are
improperly  employed  to prevent a plethora,  as they
have a tendency to increafe it dccxxi.) and as they
require  to be often repeated,  and  are thereby apt to
induce a habit which may be attended with much dan-
ger*.
                   DCCLXXXVIII.
   While a plethora, and thereby the predifpofition to
hem rrhagv, is avoided, or removed, the  other mea-
fures nee aTny for preventing the  occurrence of this,
 are thofe for avoiding the remote caufes.   Thefe have
 been enumerated in dcclxxv, and the means of avoid-
                                                    ing

   * Briflc  purges are  perhaps preferable to every other mode of
 evacuating the ingefta ;  and in thefe cafes we may have recourfe to
 draftics without any apprehenfion  of danger    The following formu-
 lae may ferve as fpecimens of the purges ufeful in thefe cafes.
              &. Pulv. Rad. Jalap. |fs.
                 Aromat. 3i.
                 Sal. Tart. 365.
                 Syr. Simp. q. f.
                 M. f. Eleft.
 This cle&uary may be divided into four dofes, one of which may be
 taken early in the morning, as occafion may require.
              $. Pilul. Run. 3fs,
                 Calomel, gr. vi.
                 Syr. Simpl. q.  f.
                 M. f, MafTain pilulas equales fcx dividend.
 Two of thefe pills may be taken in the  evening, and the remaining
 four the following morning.
              &.  Refin. Jalap. 3i,
                 Tere in mortar, cum facch. alb. 3fs.
                 Amygdal. dulc. decorticat. No. ii.
                 Adde gradatim Aq. Cinnamon  fimpl. ^i.
                 M. f. hauil. mane fumend.
 This is a very elegant purge, and has the peculiar advantage of ope-
 rating powerfully without gvipin.^ or occafioning much inconveni-
 ence. 
374             PRACTICE

ing thpn, fo far as within our power, are fufficiently
obvious.
                  DCCLXXXIX.
   Having thus mentioned the means of preventing ei-
ther the firft attacks, or the recurrence of hemorrhagy;
I muft next fay how it is  to be  managed when it has
adually come on.
                     DCCXC.
   When an hemorrhagy has come on whieh appears
to have arifen from a  preternaturaily plethoric ftate,
or from fome change in the balance of the fanguiferous
fyftem, no meafures are to be immediately taken for
fuppreffing it;  as we  may exped, that, when  the
quantity of blood neceffary for the relief of the fyftem
is  poured  out, the effufion will fpontaneoufly ceafe*.
                     DCCXCI.
 . In many cafes, however, it may be fufpeded,  that
the quantity of blood poured out, is not exadly in
proportion to the neceftities of the fyftem, either for
relieving a general plethora or a particular congeftion,
but that it is often to a greater  quantity than thefe
require.   This we fuppofe to happen in confequence
of an inflammatory diathefis prevailing,  and of a fe-
brile fpafm being formed; and therefore it is in ma-
ny cafes proper, as well as for the moft part fafe, to
moderate the evacuation,  and, when it threatens to ga
to  excefs, to fupprefs it altogether.
                    DCCXCII.
   An hemorrhagy may be  moderated  by avoiding
any irritation that might concur to increafe it; lo that
every part of the  antiphlogiftic  regimen* is to be ob-
                                            ferved ;
                                            *
  * The doftrine here delivered, and the praftice founded on it, is
pure Stahlianifm ; and is,  doubtlefs, in thefe cafes the beft practice.
A patient, however, is not always fatisfied wheu the phyfician is in-:
aftive, which often obliges him to prefcribe fome of the medicamen-
ta iturtiora, and the choice of them muft be left to the practitioner's
own fagacity.                       _ 
                O  F   P H Y S I C.           375

ferved; particularly external heat, both as it rarefies
the fluids, and ftimulates the folids,  is to be  carefully
avoided : and, it is probable, than in all cafes an he-
morrhagy may be fafely moderated by cool air appli-
ed, and cold drink exhibited.
                    DCCXCI1I.
   A  fecond means for the fame purpofe,  is, the ufe
of refrigerant medicines, and particularly of acids and
nitre*.
                    DCCXCIV.
   A third means which has been frequently  employ-
ed, is that of  blood-letting.   The propriety of this
pradice may be doubtful,  as  the quantity of blood
poured out by  the hemorrhagy, may be fuppofed to
anf.ver the purpofe of an evacuation in any other way;
and I  am ready to allow,  that the pradice  has been
often fuperfluous,  and fometimes hurtful,  by making
a greater evacuation than  was neceffary or fafe.  At
the fame  time, I apprehend it is  not for the mere pur-
pofe of evacuating, that blood-letting is to be practif-
ed in  the cure of hemorrhagy ;  but that it is further
necefTry  for  taking  off  the  inflammatory  diathefis
which prevails, and  the febrile fpafm that  has been
formed.    Accordingly, in the cafe of hemorrhagy,
when the pulfe is not frequent, but quick  and full,
                                                 and

   * The refrigerent medicines have  been enumerated  in former
nous, art.  134 and 135.  The Tinftura rofarum is a very proper
acid refrigerant in moft hemorrhagies. The dofe of it muft be pro-
portioned to the exigency of the cafe ; it ought never to exceed four
ounces in the fpace of an hour ;  an ounce every half hour is gene-
rally fufficient, and a greater quantity at a time frequently occafions
gripes, and by its irritation, increafes the difeafe ; efpecially if it
does not produce  a diarrhoea which is feldom the cafe. With refpeft
to nitre, the precautions,  mentioned in the note on  article 135,
muft be obferved.   The dulcified fpirit of vitriol or of nitre are not
always fafe  medicines in thefe cafes, as they heat and irritate.  The
acid of tartar, in the form  defcribed in the note on ait. 134.. -r-
fwci» very  well in moft cafes. 
 376           P R  A C T 1 C  jl

 and does not become  fofter or flower upon the flow-
 ing of the blood, and that the effufion is profufe, and
 threatens to continue fo, it appears to me, that blood-
 letting may be neceffary,  and I have often found it
 ufeful.   It feems probable alio, that the particu ar cir-
 cumftances of venefedion may render it more power-
 ful for taking off the tenfion  and inflammatory irrita-
 tion of the fyftem, than any  gradual flow from an ar-
 tery.
                   DCCXCV.
   That a fpafm of the  extreme veffels has a fhare in
 fupporting  hemorrhagy, appears to me probable t\om
 hence, that bliftering has been often found ufeful in
 moderating and fuppreffing the difeafe.
                   DCCXCVI.
   Do emetics and vomiting contribute to the cure of
 hemorrhagy ? See Dr  Bryan Robinson on the vir-
 tues and  power  of medicines.
                   DCCXCVII.
   When an hemorrhagy is very profufe, and feems to
 endanger life, or even threatens to induce a dangerous
 infirmity, it is agreed on all hands, that it is to be im-
 mediately fuppreffed by every means in our power j
 and particularly, that, betides the means above-men-
 tioned for moderating the  difeafe, aftringents, inter-
 nal or external, where  the latter can be applied, are
 to be employed  for fuppreffing it.
                  DCCXCVIII.
   The internal aftringents are either vegetable or'
foffil.
   The vegetable aftringents are feldom very powerful
 in the cure  of hemorrhagies,  except thofe  of the ali-
 mentary  canal.
   The foffil aftringents are  more powerful; but fome
 choice amongft  the different kinds may be proper.
   The chalybeats, fo frequently employed,  do not ap-
 pear to me to be very powerful.
                                            The
i 
                Of  PHYSIC.       .      377

   The preparations of lead are certainly more fo, but
are otherwife of fa pernicious a quality, that  they
fhould not be employed except in cafes of the utmoft
danger.    The  Tindura Saturnina,  or Antiphthifica,
as it has been called, appears to be of little efficacy*;
but whether from the  fmall portion  of lead which it
contains, or from the ftate in which the lead is  in it, I
am uncertain.
   The foffile aftringent that appears to me the  moft
powerful,  and  at  the  fame time the  moft fafe, is
alumf.
                     DCCXCIX.
   External aftringents, when they can be  applied, are
more effedual than the internal.   The choice of thefe
is left  to the furgeons.
                       DCCC.
   The moft powerful of all the aftringents appears to
me to be cold,  which may be employed, either by ap-
plying cold water to the  furface of the"Jbo'dy,  or by
throwing it into the internal partsf.
                      DCCC1.
   For fuppreffing  hemorrhagies, many  fuperftitious
remedies and charms§  have been recommended, and
   Vol.  I.               3  B               pretended

  * 11 is a very dangerous medicine, and ought to be ufed with the
utmoft caution.  But fince its efficacy is doubtful,  we had better
abandon it altogether, except when every other remedy fails.
 ' *f Alum frequently irritates if given in too large dofes  at firft,
proving fometimes a purgative and fometimes an emetic.  In cafes
of great danger, however, it muft be given in large quantities by
frequently repeating fmall dofes.   Five grains is a fufficient dofe to
begin with, but it may be repeated every hour, or every half hour.
Some authors have given it in dofes of afcruple feveral times a day ;
but that is certainly too great a quantity at once,
  ± Van Swieten relates a cafe of a bleeding at the nofe being flop-
ped by the application of pledgets, dipt in cold wine and water,  to
the fcrotum, a fhivering was produced, and the bleeding flopped.
  § It isaftonifhing that thefe charms fhould continue in ufe in this
enlightened age.  They are praftifed among the country people fi- ■
quently.  Some of them, however, aft mechanically, as the appli- 
 378           P R A C'T I C  E
                      ■ f
 pretended to have been employed  with fuccefs.  The
 feeming fuccefs of thefe,  however, has been generally
 owing to the by-ftanders iniltaken a fpontaneous ceaf-
 ing of the hemorrhagy tbr  the effed  of the remedy.
 At the fame time, I believe, that thofe remedies may
 have been fometimes ufeful, by imprefling the mind
 with horror, awe, or dread.
                      DCCCII.
   Upon occafion of the profufe hemorrhagies, opiates
 have been employed with advantage ;  and, when the
 fulnefs and inflammatory diathefis of the fyftem have
 been previoufly taken off by the hemorrhagy itfelf, or
 by blood-letting, I think opiates may be employed
 with fafety*.
                     DCCCIII.
   For reftraining hemorrhagy, ligatures have been ap-
 plied upon  the limbs, • in the view of retarding the
 return of the  venous blood from  the extremities;
 but they appear to me to be of uncertain andambigu-
 ous ufe.                                          '
                     DCCCIV.
   In the cafe of profufe hemorrhagies, no pains are to
 be taken to prevent a  Deliqtiium Animi, or fainting,
 as the happening of this is often the moft certain means
 cf ftopping the hemorrhagyf.
                                           DCCCV.

cation of the great, key of the church-door to the nape of the neck,
ie. bleedings at the nofe ;  drinking large draughts of cold water out
of a human fcull; &c.   The cold  iron and the cold water were in
faft proper remedies.
   * Opium, however, ought to be cautioufly employed in aftive
hemorrhagits, which are frequently accompanied with a phlogiltic
diathefis;  opium is generally, if not univerfally, hurtful.  But, as
the author obferves, when the hemorrhagy has reduced the inflam-
 matory diathefis, we may then give opium freely : and for this pur-
 pofe large dofes are p/cferable to fmaller ones.
  f Attention, however, is neceffary in  this cafe,  as fainting is
frequently the forerunner ©f death. 
- OF  PHYSIC.
379
                    DCCCV.
  Having thus  delivered  the general dodrine of he-
moirhagy,  I proceed to confider the particular cafes
of it.   It may perhaps be remarked, that I have mark-
ed fewer of thefe than are commonly enumerated by
the  nofologifts;  but my  reafons for  differing  from
thefe authors, muft be left to a nofological difcuffion,
to be entered into elfewhere more properly than here.
              CHAP.    II.

9F THE LPISTAXIS,  OR HEMORRHAGY OF
                  Ti4E NOSE.

                    DCCCVI.
    THE ftate of the veffels upon the internal furface of
      the nofe being fuch as already mentioned (dcc-
lvii.), renders  hemorrhagy from that more frequent
than from any other part of the body.
                   DCCCVII.
  The blood commonly  flows from one noftril only,
and probably becaufe an hemorrhagy frona one veflel
relieves the congeftion in all the neighbouring veffels.
  The blood flowing from both noftrils at the fame
time, fhows commonly a more confiderable difeafe.
                  DCCCVIII.
  This hemorrhagy happens to perfons of every con-
ftitution and temperament,  hut moft frequently to
thofe of a  plethoric habit, and fanguine temperament.
It happens to both fexes,  but moft frequently to the
male.
                   DCCCIX.
  Tfiis hemorrhagy may occur at any time of life ;
                      3 B  2                 but 
380          PRACTICE
but moft commonly happens to young perfons, owing
to the ftate of the balance pf the fyftem peculiar  to
that age, as mentioned in dcclvi.
                    DCCCX.
  Although generally it happens  to  perfons  before
they have arrived at their full growth ; and moft rare-
ly afterwards; yet fometimes it happens to perfons
after their acme, and during  the ftate of manhood :
and it muft then be imputed  to  an unufual plethoric
ftate of the fyftem ; to an habitual determination  of
the blood to the veffels of the nofe; or to the parti-
cular weaknefs of thefe.
                   DCCCXI.
  In all thefe cafes the difeafe may be confidered as an
hemorrhagy purely arterial,  and depending upon an
arterial plethora; but it fometimes occurs in the decline
of life, when probably it depends  upon and  may be
confidered as a mark of a venous plethora of the vef-
fels of the head.  See dcclxxii.
                   DCCCXII.
  This hemorrhagy happens alfo at any period of life,
in certain febrile difeafes,  which are altogether  or
partly of an inflammatory nature, and which fhow a par-
ticular determination of the blood to the veffels of the
head.  Thefe difeafes often admit of a folution by this
hemorrhagy, when it mav be properly termed critical.
                  DCCCXIII.
  The difeafe fometimes comes  on without any pre-
vious fymptoms; particularly,  when  fome external
violence  has a fhare in  producing it.   But, when it
proceeds entirely from an internal caufe, it is common-
ly preceded by headachs, rednefs of the eyes, a florid
colour of the face, an unufual puliation in the tem-
ples, a fenfe of fulnefs about the nofe, and an itching of
the noftrils.   A round belly, pale urine, coldnefs of the
feet, and cold fhivering over the  whole body,  are alfo
fometimes among the fymptoms that precede the dif-
eafe.                                  DCCCXIV. 
O F  P H Y  S I C.           3S1
                   DCCCXIV.
  From the weaknefs of the veffels  of the nofe, the
blood often flows from them without any confiderable
effort of the whole fyftem, and therefore without any
obfervable febrile diforder ; which, however, in many
cafes, is, in all its circumftances, very difcernible.
                    DCCCXV.
  An hemorrhagy of the  nofe  happening to young
perfons, is, and may generally be confidered as a flight
difeafe of little confequence, and hardly requiring a-
ny remedy.   But, even in young perfons, when it re-
curs very frequently, and is very copious,  it will re-
quire particular attention, as it is to be confidered as
a mark of arterial plethora ; and,  as frequently ^ re-
turning, it may  increafe the  plethoric  ftate; which,
in a more advanced ftage of life,  may give  the blood
a determination  to parts from which the hemorrhagy
would be more dangerous.  All this will more parti-
cularly require attention, according as  the marks of
plethora,  and of a  particular congeftion, preceding
the hemorrhagy, are more confiderable ; and as the
flowing of the blood is attended with a more confider-
able degree  of febrile diforder.
                    DCCCXVI.
  When the epiftaxis happens to  perfons after their ac-
me,  returning frequently,  and  flowing copioufly, it  is
always to be confidered as a dangerous difeafe,  and
as more certainly threatening the confequences men-
tioned in the laft paragraph.
                   DCCCXVII.
   When  this hemorrhagy happens in the decline of
life,  it may be confidered as in itfelf very falutary:
but  at the fame time, it is  to be confidered as a mark
of a very dangerous ftate of the fyftem ;  that is  as a
mark of a very ftrong tendency to a venous  plethora
in the veflels of the head :  and I have accordingly ob-
                                           ferved, 
382             PRACTICE

ferved it often followed by apoplexy, palfy, or fuch
like difeafe 1.
                  DCCCXVIII.
  When an hemorrhagy from the nofe happens in fe-
brile difeafes, as mentioned in dcccxii, and is in pret-
ty large  quantity, it may be confidered as en-ical and
falutary ;  but it is very apt to  be  profufe, and even
in this way dangerous.
  It upon fome occafions occurs during  the eruptive
fever ot  feveral exanthemata, and is in fuch cafes fome-
times falutary ; but, if thefe  exanthemata be accom-
panied with  any  putrid tendency, this hemorrhagy,
like artificial blood-lettings,  may have  very bad  ef-
feds.
                   DCCCXIX.
  Having thus explained the feveral  circumftances of
epiftaxis, 1 proceed to confider  the  management and
cure of  it.  I ufe the expreffion of management, be-
caufe it  has been ufually thought to  require no cure,
but that nature  fhould be allowed to throw  out blood
in this way very frequently ;  and as often as it appears
to arife from internal caufes, that is, from a ftate of
the fyftem fuppofed to require fuch evacuation.
                   DCCCXX.
  I am however of opinion,  for the reafons given in
dcclxxix. that  this dileafe  is  veiy feldom to be left
to the condud of nature; and that in all cafes it fhould
be moderated by keeping the patient in cool air; by
giving cold drink; by  keeping the   body  and head
ered ; by avoiding any  blowing of the nofe, fpeaking,
or other irritation : and, when  the  blood has  flowed
for fome time,  without  fhewing any tendency to ceafe,
a profufe bleeding is to  be prevented by meafures em-
ployed to flop it  ;  fuch as preffing the noftril from
which the blood flows, wafhing the face with cold wa-
ter, or applying  this toother parts of the body.
                                     DCCCXXI. 
               O  F  P H Y S I  C.           383

                     DCCCXXI.
   Even in the cafe of young perfons,  where the dif-
eafe is leaft hazardous, and even in the firft attacks,
I judge fuch  meafures to be proper ; but they will be
ftill more proper if the difeafe frequently recurs without
any external  violence; if the returns fhall happen to
perfons of a habit difpofed to be plethoric ; and, more
particularly, if the marks of a plethoric ftate appear in
the precedent fymptoms.   (dcccxiii.)
                    DCCCXXII.
   Even in young perfons, if the bleeding b-° very pro-
fufi and  long continued, and more efpecially if the
pulfe become weak and i\ie face pale, 1 appteh'nd it
will be proper to  fupp ; fs the-hemonha<e>  by every
means in our power.  See dccxcvii. and foiLwing pa-
ragraphs*.
                   DCCCXXIII.
   Fuither,  in the fame cafe  of  young perfons,i when
the returns of thishemorrhagybecome frequ'iit, aod ef-
pecially with the marks of a plethoric habit, I think it
neceffary to employ  fuch a regimen as mav prevent a
plethoric ftate. (occlxxxui.—dgclxxxvu.)  At the
fame time,  care fhould be taken to avoid all circum-
ftances which may derermine the blood more fully to
the veffels of the head, or prevent its  free return from
them ;  and by keeping an open belly,  to make fome
derivation from themf.
                                      DCCCXXIV.

  * Befide the general direftions referred to above, plugsnf lint or
cotton,  impregnated with vinegar and a fohuion of alum, are re-
commended.  Thick cotton threads, impregnated with thefe ftyptic
folutions, have been paffed through the noftril, and brought out by
the mouth by means of a bent probe, with great fuecefs.
  f For this purpofe  Glauber's fait feems peculiarly adapted.  It
operates fpeedily, and without too much  irritation ; evacu;;Un£, at
the fame  time, not only the contents of the intcflin.il canal,  but the
Superfluities of the fanguiferous fyflem. 
384           PRACTICE

                   DCCCXXIV.
  In  adult perfons, liable to frequent returns of the
epiftaxis, the whole of the meafures propofed (dccc-
xxni.), are more certainly and freely to be employed.
When, with the circumftances mentioned in dcccxiu,
the tendency to a profufe hemorrhagy appears, a bleed-
ing at the arm may be proper, in young perfons; but
in the cafe of adults,  it will be ftill more allowable,
and even neceffary.
                   DCCCXXV.
  In perfons of any age  liable to frequent returns of
this  hemorrhagy,  when the meafures propofed in
dcccxvu. et. feq.  fliall have  been negleded, or from
peculiar circumftances  in  the balance of the fyftem,
ihall have proved ineffedual, and the fymptoms threat-
ening  hemorrhagy  (dcccxviii.) ihall appear,  it will
then be proper, by blood-letting, cooling purgatives,
and every part of the antiplogiftic regimen, to prevent
the hemorrhagy, or at leaft to prevent its being profufe
when  it does happen.
                  DCCCXXVI.
  In the circumftances juft now mentioned (Dccexxv.)
the meafures propofed are proper, and even neceffary ;
but it fliould at the fame time be obferved, that thefe
are pradifed with much lefs advantage than thofe point-
ed out in dcccxxtv. becaufe, though thofe fuggefted
here may prevent the coming on of the  hemorrhagy
for the prefent,  they certainly however difpofe to the
return of that plethoric  ftate which required their be-
ing ufed ; and there can be no proper fecurity againft
returns of the difeafe, but by purfuing the means pro-
pofed  in dcccxxiii.
                  DCCCXXVII.
  When the hemorrhagy of the nofe happens to per-
fons approaching their full growth, and when its re-
turns  have been preceded by the fymptoms dcccxiu.
it may be fuppofed, that, if the returns can be pre-
                                           vented 
              OF.PHYSIC.           385

vented by the meafures  propofed in  dcccxxv.  thefe
may be fafely employed ; as the plethoric ftate induced
will be rendered late, by the change which is foon to
take place in the balance of the fyftem.   This,  how-
ever,  cannot be admitted ;  as the evacuations pradifed
upon  this plan will have all the confequences which,
I have already obferved, may follow the  recurrence
of the hemorrhagy itfelf.
                  DCCCX XVIII.
  When the hemorrhagy of the nofe fhall  be found to
make  its returns atnearlyftated periods, the  meafuresfor
preventing it (dcccxxv.) may be pradifed with greater
certainty ; and, upon every repetition of blood-lettings
by  diminifhing the quantity taken away, its tendency
to induce a plethora may be in fome meafure avoided.
When, indeed, the repetition of evacuations is  truly
unavoidable, the diminifhing them upon every repeti-
tion is properly pradifed :  but it is a pradice of nice
and precarious management, and fhould by no means
be trufted to, fo far as  to  fuperfede the meafures pro-
pofed  in dcccxxv.  wherever thefe can be admitted.
                  DCCCXXIX.
  When the hemorrhagy of the nofe happens in con-
fequence of  a venous plethora in the veffels of the
head,  as in dcclxxh. the flowing of the blood pretty
largely may be allowed,  efpecially when it happens af-
ter  the fuppreflion or ceafing of the menitrual or he-
morrhoidal  flux.   But,  though  the  flowing of the
blood is, on its firft occurring, to be  allowed, there h
nothing more proper than guarding againft its returns.
This is to be done not only by the meafures propofed
in dcclxxxui. et.feq. but, as the ciFeets of a pletho-
ric  ftate of the veffels of the head are very uncertain,
fo,  upon any appearance of it, and efpecially upon any
threatening  of hemorrhagy, the plethora  is  to be re-
moved, and the hemorrhagy to be obviated  immedi-
ately  bv proper evacuations ;  as blood-letting, purg-
Vol.  1.'             3 c                     inS 
386          P R  a u i  i  <J n.
ing, and iffues, or by reftoring fuppreffed evacuations,
where tins can be done.

              r<..< .<..«..«..<. <..<..<..<,$» ,j.>.•►..>.•> .>>..>..>. > >>-

               CHAP.  «III.

OF THE HEMOPTYSIS,  OR  HEMORRHAGY
             FROM THE  LUNGS.
               SECT.    I.
 Of tht PHENOMENA and CAUSE  of  HEMOPTYSIS.

                  DCCCXXX.
       WHEN, after fome affedion  of the breaft, blood
       is thrown out from the mouth, and is brought
out with more or lefs of coughing, there can be  no
doubt that  it comes  from  the lungs ;  and this gene-
rally ascertains the difeafe of which I am now to treat.
But there are cafes in which the fource of the blood
fpit out is uncertain ; and  therefore, fome other con-
fiderations  to be mentioned  hereafter,  are often ne-
ceffary to afcertain the exiltence of an hemoptyfis.
                  DCCCXXXI.
  The blood-veffels  of the lungs  are more numerous
than thofe  of any other part  of the body  of the fame
bulk.  Thefe veifels, of the  largeft fize, as they arife
from the heart,  are  more immediately than  in any
other part fubdivided into veflels of the fmalleft fize  ;
and thefe fmall veffels fpread out near to  the internal
furfaces of the bronchial cavities,  are fituated in a
loofe cellular texture, and covered by a tender mem-
brane only  : fo that,  conliueiing how readily and fre-
quently thefe veflels  are goree 1 with  blood,  we may
underftand why an hemorrhagy  from them is, next to
trut of the nofe,  the moft frequent of any; and par-
ticularly, why any violent fhock given to the whole
body fo readily occafions an  hemoptvfis.
                                    DCCCXXXII. 
              O F   P H Y S I C.           387

                  DCCCXXXII.
  An hemoptyfis may be occafioned by external vio-
lence,  at  any period of  life;  and I have explained
above (dcclx.) why, in adult perfons, while the arte-
rial plethora ftiil prevails in the fyftem, that is,  from
the age of fixteen  to that of five-and-thirty,  an he-
moptyfis mav at  any time be produced, merely by a
plethoric ftate of the lu tas.
                  DCCJXXXIIL
  But it has been aho obferved above, (dcclxi.) that
an hemoptyfis more frequently arifes iruo a f uuty pro-
portion between the  capacity of the veffels of the
lungs and  that of thofe of the reft of  the body.   Ac-
cordingly  it is often a hereditary difeafe, which implies
a peculiar and faulty conformation.   And the  difeafe
alfo happens especially to  perfons who  difcover the
iina'ler capacity of their  lungs, by the nar:ownefs of
their coet, and by  the prominency of their fhoulders;
which laft is a mark of their having been long Lame to
a difficult refpiration.
                  eLCCC XXXIV.
  With thefecircumftances alto the difeafe happens
efpecially  to perfons of a fanguine temperament ; in
whom, particularly, the arterial plethora prevails.  It
happens likewife  to perfons of a flender delicate make,
of which a long neck is a mark ; to perfons of much
fenfibility   and fritability,  and  therefore of quick
parts, wnofe bodies are generally of a delicate ftruc-
ture ; to perfons who have been formerly liable to fre-
quent hemorrhagies of the nofe ;  to perfons who have
fuffered a  flip predion of any hemorrhagy they had for-
merly  been liable to,  the  moft  frequent inftance of
which  is in females  who have fullered a fuppr olion
of their menftrual flux ;  and,  laftiy, to perfons  who
have fuffered the amputation of a;:v coniiderable limb.
                     DCCCXXXV.
  In moft of thefe  cafes (dcccxxxiv.) the difeafe Jiap-
                   3 €  2                    pen& 
3S8            PRACTICE

pens efpecially to perfons about the time of their com-
ing to their full growth, or foon after it, and this for
the reafons fully fet forth above.
                 DCCCXXXVI.
  From all that  has been  faid from dcccxxxi,  to
dcccxxxv, the  predifponent caufe of hemoptyfis will
be fufficiently  underftood, and the difeafe may hap-
pen from  the mere  circumftance of the predifponent
caufe arifing to  a confiderable degree.   In the predif-
pofed, however, it is often brought  on by the recur-
rence of various occafional and exciting caufes.   One
of thefe, and perhaps a frequent one, is external heat;
which, even in  no great  degree, will bring on the dif-
eafe in fpring,  and  the  beginning  of fummer, while
the heat rarefies the  blood more than it relaxes the fo-
lids which had  been before contraded by the cold of
winter.  Another exciting caufe is a hidden diminu-
tion of the weight of the atmofphere, efpecially when
concurring with any effort in bodily  exercife.  The
effort, too, alone, may  often, in the predifpofed,  be
the exciting caufe ;  and, more particulary, any violent
exercife of refpiration.  In fhort, in the  predifpofed,
iiny degree of external violence alfo  may^bring on the
difeafe.
                 DCCCXXXVII.
  Occafioned by one or other of thefe caufes (dccc-
xxxvi,) the difeafe  comes on with a fenfe of weight
and anxiety in  the cheft, fome uneafinefs in breathing,
fome pain  of the breaft or other parts of the thorax,
and fome  fenfe of heat  under the fternum ;  and very
often, before the difeafe  appears,  a faitiili tafte is  per-
ceived in the mouth.
                 DCCCXXXVIII.
  Immediately  before the  appearance  of blood, a de-
gree of irritation is felt at the top of the larynx.  To
relieve this, a  hawking is made, which brings up a
                                             little 
               O F  P H Y S I C.          389

little blood, of a florid colour, and fomewhat frothy.
The irritation returns;  and, in the fame  manner,
more blood of a like kind is  brought up, with fome
noife in the wind-pipe, as of air paffing through  a
fluid.
                  DCCCXXXIX.
   This is commonly the manner in which the hemop-
tyfis begins ; but fometimes at the very firft the blood
comes  up by coughing, or at leaft fomewhat of cough-
ing accompanies the hawking juft now  mentioned.
                    DCCCXL.
   The blood iffuing is fometimes at firft in very fmall
quantity,  and foon difappears altogether: but, in o-
ther cafes,  efpecially when it repeatedly occurs, it is
in greater quantity, and frequently continues to appear
at times for feveral  days  together.   It  is fometimes
profufe; but rarely in fuch quantity as either by its
excefs, or by its fudden fuffocation, to prove immedi-
ately  mortal.   It commonly  either ceafes fpontane-
oufly, oris flopped by the  remedies employed.
                   DCCCXLl.
   When blood is thrown out from the mouh,  it is not
always eafy to determine  from wha,t  internal  part it
proceeds ;  whether from  the  internal fin face of the
mouth itfelf, from the  fauces, or adjoining cavities of
the nofe,  from the ftomach, or  from the lungs.   It
is, however, very neceffary to  diftinguifh the different
cafes ;  and, in moft inftances, it may be done by at-
tending to the following confiderations.
                   DCCCXLII.
   When the blood fpit out, proceeds from fome part
of the internal furface of the mouth itfelf, it comes out
without  any hawking or  coughing; and generally,
upon infpedion, the particular fource of it becomes
evident.
                  DCCCXLIII.
   When blood  proceeds  from the fauces, or adjoin-
                                             ing 
39^
PRACTICE
ing cavities of  the nofe,  it may be brought out by
hawking, and fometimes by coughing, in the manner
we have defcribed in dcccxxxvh, and Dcccxxxtx, fo,
that,  in this way, a doubt may arife concei eag its
real fource.  A patient often lays hold of  thefe cir-
cumftances to pleafe himfelf wit'i  the opinion  of its
coming from  the fauces,  and he may be allowed to
do fo : but a phyfician cannot  readily be  'c eived, if
he confider, that a bleeding from the fauc-'s> is more
rare than one  from the lungs;  that the former feldom
happens  but to perfons who have  been  before liable
either to  an hemorrhagy of the nole. or  to  fome evi-
dent caufe of erofion ; and, m molt caf-s, by looking
into the   fauces, the  diltillation of the  blood, if it
comes from thence, will be perceived.
                   DCYCXLIV.
   When blood proceeds from th .■  lungs, the manner
in which it is brought up will  commonly fhow from
whence it comes : but,  independent of that,  there
are many circumftances which may occur  to point it
out, fuch as the period of life, the habt of body, -dnd
other marks of a predifpofition  vdcccxxxiii.—dccc-
xxxv.) and together with  thefe, the occafional caufes
(dcccxxxvi.) having been immediately  before appli-
ed.
                   DCCCXLV.
   When vomiting accompanies the throwing  out of
blood  from  the mouth,  as vomiting and  coughing
often mutually excite each other ; fo they may be fre-
quently joined,  and render it  doubtful  whether the
blood thrown out proceeds from the lungs or from the
ftomach.  We may however generally decide, by con-
. fidering,  that blood does  not fo frequently proceed
from  the ftomach as from the lungs : that blood pro-
ceeding from the Itomach commonly appears in great-
er quantity,  than when it proceeds from the  lungs :
that the  blojd proceeding from the  lungs is ufutily
                                               of 
O  FHP H Y S I C.
39<
of a florid colour, and mixed with a frothy mucus on-
ly ;  whereas the blood from the ftomach is commonly
of a darker colour, more grunv u>,  and mixed with
the other contents < f the ftomach : that the coughing
or vomiting,  according as the one or  the other  firft
arifes in the cafes in wuioh they a e afterwards joined
may fometimes point out the fource of the blood: and,
laftly,-that much may be learned from the circum-
ftances  and fymptoms which  have preceded the he-
monhagy.
  Thofe which precede the hemoptyfis, enumerated
in dcccxxxvii. are moft of them evident marks of an
affedion of the lungs.  And, on the other hand, the
hematemelis, or iffuing of  blood from the  ftomach,
has alfo its peculiar fymptoms and circumftances pre-
ceding it; as, for  inftance, fome morbid affedion of
this  organ, or at leal fome pain, anxiety, and fenfe of
weight,  referred diftindly to  the region of the fto-
mach.  To all this may be added, that the  vomiting
of blood happens more frequently to females than to
males;  and to the  former, in confequence of a fup-
preffion of their menftrual flux : and, by attending to
all thefe confiderations (dcccxlu.—dccclv.) the pre-
fence of the hemoptyfis may commonly be fufficiently
afcertained.


               SECT.     II.

       OF THE CURE OF HEMOPTYSIS.

                 DCCCXLVI.
  This difeafe  is fometimes attended with little dan-
ger ; as when it happens to females in confequence of
a fuppreffion  of  the menfes* ;  v.hen,  without  any
                                            mark.*
  * The autr-nr might have acJJcd, "and when r,o fyn.^tora8 of
phthifis have preceded or accompanies the hemorrhage." 
392
PRACTICE
 marks of a predifpofition, it arifes from external vio-
 lence ;  or when, from whatever caufe arifing,  it. leaves
 behind it no cough, dyfpncea,  or other  affedion of
 the lungs.   Even in fuch cafes, however, a danger may
 arife from  too large a wound being made in the  veffels
 of the  lungs;  from a quantity of  red blood  being
 left to ftagnate in the cavity of the bronchke;  and par-
 ticularly, from any determination of the blood being
 made into the veffels of the lungs, which, by renewing
 the hemorrhagy,  may have dangerous confequences.
 In every inftance therefore of hemoptyfis,  the effufion
 is to be moderated by the feveral  means mentioned
 (dccxci i. to DCCXCV.)
                   DCCCXLVII.
   Thefe meafures are efpecially neceffary when the he-
 moptyfis arifes in confequence of a predifpofition; and
 in all cafes where there is the appearance of a large ef-
 fufion, or where the hemorragy frequently returns, the
 effufion is not only to be moderated,  but to be entirely
 flopped, and  the returns of it prevented  by  every
 means in our power. See dccxcvii. and following*.
                  DCCCXLVIII.
   To flop an hemoptyfis, or prevent the  returns of
 it, two medicines  have  been frequently  employed ;
 neither of which I can approve of.   Thefe are, chaly-
beates, and the Peruvian bark.  As both of them con-
tribute to increafe the phlogiftic diathefis of the fyftem
they can hardly be fafe in any cafe of adive hemorrha-
gy, and 1 have frequently found them hurtful.
                                      DCCCXLIX

  * The tinfture of rofes has been frequently employed with fuccefs
 in thefe cafes: alum, however, is the principal allringent.  It may
be given, either by itfelf in fmall and often repeated dofes, or com-
bined with terra  Ja^ouic-i.  The foiiovving formula is very con-
venient.
                15,. Alamin.
                  Terr. fponic. a a 3!.
                  Conferv. Rofar. ^ i.
                  M. f. Eletf. cum. fyr. commun, q. f. 
OF   PHYSIC.
393
                   DCCCXLIX.
   As the  hemoptyfis which happens in  confequence
of predifpofition, is always attended  with a phlogiftic
diathefis :  and, as the bad confequences of the difeafe
are efpecially to be apprehended from the continuance
ot" that  diathefis ; fo this is to be induftrioufly taken
off by blood-letting, in greater or fmaller quantity, and
more or  lefs  frequently  repeated, according as the
fymptoms  fliall dired.   At the fame time, cooling pur-
gatives are to  be employed,  and every part of the an-
liplogiftic  regimen is to be ftridly enjoined.   The re-
frigerants  may alfo be adminiftered ; taking care,  how-
ever, that  the acids, and more efpecially the nitre*, do
not excite coughing.
                       DCCCL.
   From what was obferved in dccxcv. it will appear,
that bliftering upon the breaft or back may be a reme-
dy of hemoptyfis, when it is  prefent ; and that iftues
   Vol. I.                 ^ D                      in

The dofe ought to be proportioned to the exigency of the cafe : in
general, the  above prefcribed mafs may be divided  into ten equal
paits; one of which  may be given every two hours, or in urgent
cafes, every hour.   In ufing this medicine, it will  be neceffary to
keep the belly open ; but for this purpofe purgatives are ill adapt-
ed, as they  carry  off with them the medicine that  is employed :
clyfters are therefore preferable, and in  order that they  be the
more effectual, they  ought to be fomewhat of a ltimubtin^ nature :
as,
            g,  Infus. Sennas  ^vi.
              Sal. Cathartic. Amar. |ji.
              Decodl. Hordei. ^viii.
              Tvi.
                          Or,
             §,. Pulp. Tamarind. 1-ii.
              Crem. Tart. ^fs.
              Coque in Aq. font. q. f. ad. colaturse *xii.
              Adde Mann. ^ii.
              M.
  * Nitre ought to be cautioufly ufed in all complaints of the lungs,
on account of the irritation which  it produces,  and the fubfequent
• v.t Y which  it ^xj;u«. 
394           PRACTICE
 in the fame places may be ufeful in preventing the re-
 currence of it when it has ceafed.
                          DCCCLI.
    The avoiding of motion is generally  a proper  part
 of the  antiphloeiftic regimen ; and, in the hemoptyfis,
 nothing is more neceliary than avoding bodily* exercife ;>
 but ome kinds of gcftation, as failing'*, and travelling
 in an eafy  carriage on fmooth roads, have often proved
 a remedy.
                        DCCCLII.
    Such is  the treatment I con propofe for  the hemop-
 tyfis, confidered merely as an hemorrhagy :  But whea
 in fpite of all our  precautions, it continues to  recur, it
 is often, followed by an ulceration  of the lungs, and a
 phthifis pulmonalis.   This, therefore, I muft now pro-
 ceed to confider ; but, as it arifes alio from other cauf-
 es  befides  the hemoptyfis, it muft be treated of with a
  more general viewf.
                                              C H A F.
                       ».

    * A.  fea-vcyage has often been prefcribed for hemoptyfis : it is,
  nevertheltfs, a very dangerous praftice, on account of the violent
  agitation produced by the fea ficknefs  in the aftten of vomiting.
  The violence of tlu  Teachings in fea-fickuefs, efpecially after the
  c>  .rents of the ftomach are thoroughly evacuated, has been knewrv
  to caufe hemoptyfis,  by  a rupture of  fome  confiderable veffel.—
  The hemorrhagy  indeed, hence proceeding, is  not an  active he-
  rrc: ih?.gy ; "but, neverthelefs, in a phlogiftic diathefis, which pre-
  anpofes to an active hemorrhagy,  we ought  always to be cautious
  how we employ remedies, which, although they do not immediately
.  incrciife the predifpoling  "diathefis,  produce  the leall irritation,, or
  give any violent fhock in their action.
    Speaking  loud,  finging,' playing  on  wind-inftruments,  and
  whatever requires any  exertion of the  lungs ought carefully to  be
  avYcYd.
    -f- In the cure of the hemoptyfis, the patient's drink ought to be
  of the acidulous kind, or of the acidulous and aftringent  kinds con-
 joined   1 he vitriolic acid is therefore the mol* eligible, but it ought
  to be well diluted.  A pleafant drink may be compofcd of one part
  of the tincture of rofes,  and four of cold water  ; or the tincture of
  rofiw may be prefcribed  with five times the quantity of water that 
OF  PHYSIC.
595
C   H   A  P.     IV.
OF THE PHTHISIS PULMONALIS, OR CON-
         SUMPTION OF THE LUNGS.
S   E  C   T.   I.
Of the PHENOMENA and CAUSE of the PHTHI-
                  SIS  PULMONALIS.


                      DCCCLIII.
     THE Phthifis Pulmonalis I would define to be, an ex-
      pectoration of pus or purulent matter from the
lungs, attended with a fever.
   As  this is the principal fpecies of phthifis,  I  fhall
frequently in this chapter employ the general term of
phthifis, though ftricfly meaning the phithifis pulmo-
nalis.
                      3 D 2                DCCCL1V.

is ordered in the pharmacopoeia.  The  acid of tartar difTolved  in
twenty times it's weight of  water,  and fweetened \vith a little fy-
rup of rofes, is alfo a fuitable drink.  A  decoction  either  of the
frefh fruit of quinces,  lweetened with fugar, or an infufion  of
quince  marmalade,  is another excellent acid aftringcnt.  In addi-
tion to what has beeafaid, it may be proper to obferve, that opium
is  admifiible only in very few cafes of  hemoptyfis ; viz.  when the
hemoptyfis is the confequence of coughing.   Thefe cafes  are very
difficultly diftinguifhed.   If the blood be thrown out into the lungs,
a cough is excited for it's difcharge, and then the hemoptyfis is the
primary difeafe  ; in this cafe opium does more harm than good---
But if  a cough  arifing from* any other irritating caufe, than extra-
vafated blood in the lungs fhould by it's violence  and  long continu-
ance, produce an hemoptyfis, then  opium, joined with fuch reme-
dies as are. fuitable to remove the peculiar irritation, is the only
medicine  on which we can have any reliance ; and in thefe cafes we
muft ufe it in large dofes, fuch as forty or  fifty drops of laudanum. 
396            PRACTICE
                    DCCCLIV.
  I have met with fome inftances of an expectorati .in ot
purulent matter, continuing for many years, accompa-
nied with  very few  fymptoms of hectic, and at leaft
without any hectic exquifitely formed : but in none of
thefe inftances were  the perfons fo entirely free from
fymptoms of hectic,  as to form any exception to  the
general definition.
                    DCCCLV.
  In every inftance of an expectoration of pus, I pre-
fume there is an ulceration of the lungs. The late Mr.
Haen is the only author that  I know of, who has ad-
vanced another opinion,  and has fuppofed, that  pus
may be formed in the blood veffels, and be from thence
poured into the bronchiae.  Admitting his  fact, I have
attempted  an explanation of the appearance of pus
without ulceration  in cccxlix.  but, after all,  1 can-
not help fufpecting the accuracy of his obfervations;
muft entirely reject his  explanation of them ;  muft
however allow, that  we ftill want fiicls to fupport the
explanation  I have offered ; and doubt much if it will
apply to any cafe of  phthifis.   For thefe reafons I ftill
conclude, agreeably to the faith of all other diffeclions,
and the opinions of  all phyficians, that the fymptoms
mentioned in our definition depend always upon an ul-
ceration formed in the lungs.
                    DCCCLVI.
  It has fometimes happened, that a catarrh wasattended
with an expectoration of a matter fo much refembling
pus, that phyficians have been often uncertain whether
the  difeafe was mucus or pus, and therefore whether
the difeafe was a catarrh or a phthifis.  It is often of
confequence to determine thefe queftions ; and  it ap-
pears to me that it may be generally done, with fuiii-
cient certainty, from the following confiderations, of
which each particular is not always fingly decifive, but
when they are taken together can hardly deceive us.
                                          t.  From 
OF  P H  Y S I C.
397
  j. From the colour of  the maftter; r.s mucus is na-
turally tranfparent, and pus always opaque.  When
mucus becomes opaque, as it fometimesdoes, it becomes
white, yellow, or  greenifh ; but the laft  mentioned
colourjis hardly ever fo remarkable in mucus as in pus.
  i. From the confiftence ; as mucus is more vifcid
and coherent, and pus lefs fo, and may be more fria-
ble.  When mucus is thrown into water, it is not rea-
dily diffufed, but remains  united in uniform and circu-
lar maffes: but pus, in the fame circumftances, though
not readily diffufed, does not  remain  fo uniformly
united, and by a little agitation  is broken into ragged
fragments.
  3. From the odour ; which is feldom perceived in
mucus, but frequently in pus.   It has been propofed
to try the odour of the matter expectorated, by throwing
it upon live coals : but in fuch a trial both mucus and
pus give out a difagreeable fmell, and it is not eafy to
diftinguifh between them.
  4. From the fpecific  gravity compared with wa-
ter; and, indeed, it is  ufual for the mucus  of  the
lungs to fwim on the furface of water, and for pus to
fink in it.  But in this we mav  fometimes be deceiv-
ed ; as pus which has entangled a great deal of air
may fwim, and mucus that is free from air may fink.
  5. From  the  mixture which is oifcernable in the
matter brought up : for if a yellow or greenifh matter
appears furrounded with  a quantity of tranfparent or
iefs opaque and lefs coloured matter, rhe more ftrong-
ly colaured  matter may  be generally confidered as
pus; as it is not  eafy to underilaiki how  one ponim
of  the mucus of the lungs can be very cor.fiderably
changed, while  the reft  of ic is vjry little, fo,  or re-
mains in its ordinary ftate.
  6.  From  the  admixture of certain fiibflancs with
the  matter  thrown  out  from  the  luv.gs   To  thY
runW'' «v are informed bv the cx'KTiee^nts of the late
1                                            M r. 
39^         .PRACTICE

Mr. Charles Darwin : a. That the vitriolic acid  dif-
folves both mucus and pus, but moft readily the form-
er : That, if water be added to  fuch a folution of
mucus, this is feparated, and either fwims on the fur-
face, or, divided into flocculi, is fufpended in  the li-
quor; whereas,  when water is added  to a like folution
of pus, this falls to the bottom, or by agitation is dif-
fufed  fo  as to  exhibit  a uniformly turpid liquor.
b. That a  folution  of  the cauftic fixed  alkali, after
fome time, diflblves mucus, and generally pus ; and,
if water be added to fuch folutions, the  pus is preci-
pitated, but the mucus  is not.   From  fuch experi-
ments it is  fuppofed, that pus and mucus  may be cer-
tainly diftinguifhed from each other,
   7. From the  expectoration's being attended with a,
hectic fever.  A catarrh, or expectoration of mucus,
is often attended with fever ; but never, fo far as I
have obferved,  with fuch a fever as I am prefently to
defcribe as  a hectic.  This, in my opinion, is the moft
certain mark of a purulent ftate in fome part of the
body ; and if others have  thought differently, I am
perfuaded that it has been owing to this, that, prefum-
ing upon the mortal nature of a confirmed or puru-
lent phthifis, they have confidered every cafe in which
a recovery happened,  as a catarrh only:  but,  that
they may have  been miftaken in this, fhall be fhown
hereafter.
                   DCCCLVII.
   Having thus  confidered the firft part of the charac-
ter of the  phthifis pulmonis as  a mark of an ulcera-
tion of the lungs; and  having juft now faid, that the
other part  of the character, that is, the hectic fever,
is a mark or indication of the fame thing ;  it is pro-
per now to confider this here, as I had with that view
omitted it  before (i.xxi v.)
                   DCCCLVIII.
   A IiccTic fever has the form of a remittent, which
                                               has 
O  F  P  H Y S I C.
399
has exacerbations twice every day.   The firft of thefe
occurs about noon, fometimes a little fooner or later •
and a flight remiflion of it  happens about five after-
noon.   This  laft is foon fucceeded by another exa-
cerbation,  gradually increafing  till after midni-ht  :
but after two o'clock of the morning a remiflion'takes
place, which  becomes more and more confiderable as
the morning  advances.  The exacerbations are fre-
quently attended with feme degree of cold fhivering;
or at leaft the patient  is exceedingly  fenfible to any
coolnefs of the air, feeks external heat, and  often
complains of  a fenfe of cold, when, to  the thermome-
ter, his fkin  is preternaturaily warm.   Of thefe exa-
cerbations, that of the evening is always the moft con-
fiderable.
                   DCCCLIX.
  It has commonly been given as  a part of the cha-
racter of a hectic fe\er,  that an exacerbation  of it
commonly appears  after the taking food ; and it is
true  that  dinner, which is taken at noon or after  it,
does  feem to occafion fome exacerbation.  But this
muft  not make us judge the mid-day exacerbation to
be the eifecfof eating only ; for I have often obferved
it  to  come on an hour before noon,  and often fome
hours before dinner ; which, in this country at prefent,
is  not taken  till  fome  time afternoon.  It is indeed
to be obferved, that in almoft every perfon, the taking
food occafions fome degree of fever :  but I am per-
fuaded this would not appear fo confiderable in a hec-
tic, were  it not that an exacerbation of fever is pre-
fent from  another caufe ; and accordingly, the taking
fo©d in the morning has hardly any fenfible effect.
                   DCCCLX.
  I have thus defcribed the general form of hedfic fe-
ver ; but many circumftances attending it, are further
to be taken notice of.
  The fever I have defcribed does not  cdmmonly fub-
                                              fift 
 4c<5            P  K. A C  T  I  C f.

 fift long,  till the evening exacerbations become at-f
 tended with Lveatings ; which continue to recur, and
 to  prove more and more profufe, through the whole
 courfe of the difeafe./
   Almoft from the  firft appearance of the hectic, the
 urine is high-coloured, and  depofites a copious bran-
 ny red fedime;::,  widen, hardly ever falls clofe to the
 bottom of the  veifel.
   In the hectic, the appetite for food is generally lefs
 impaired than»in any other kind of fever.
   The  thirft  is feldom confiderable ; the mouth is
 commonly moift ; ..and  as  the dileafe advances, the
 ler.-uebecomes free frumfur, appears very clean; and
 in toe advanced ftages" of the difeafe, the tongue and
 fauces appear to be  fomewhat inflamed, and become
 more or lefs covered with aphthae.
   As the difeafe advances, the red veffels of the adna-
 ta of the eye difappear,  and the whole of the  adnata
 becomes of a pearly white.
   The face is commonly pale ; but, during  the exa-
 cerbations,  a florid  red, and an almoft circumfcribed
 fpot, appear on each cheeck.
  For fome time, in the courfe of a hectic, the belly
 is bound ; but, in the advanced ftages of it, a"diarrhoea
 almoft always comes on,  and continues to recur fre-
 quently during  the  reft of the difeafe, alternating in
 fome meafure with the fweatings mentioned above.
   The difeafe  is  always  attended with  a debility,
 which gradually increafes during the courfe of it.
   During the fame  courfe an emaciation takes place,
 and goes to a greater degree than  in almoft any other
cafe.
   The falling ctt" of the hairs, and the adunque form
 cf the nails, arc alfo fymptoms of the want of nourifh-
ment.
  Towards the end of the difeafe, the feet are often
affected  w::h ctdsmiitcus, fwelliut/s.
                                              The 
OF  PHYSIC.
401
  The exacerbations of the fever are feldom attend-
ed with,any headach, and fearcely ever with delirium.
  The fenfes and judgment  commonly remain entoe
to the very end of the difeafe ; and the mind, for thq
moft part, is confident and full of hope.
  Some days before death, a delirium comes on, and
commonly continues to the end.
                   DCCCLXI.
  The hectic fever  now defcribed (dccclviii, dccc-
lix.)  as accompanying a purulent ftate of the lungs,
is perhaps the cafe in which it  moft frequently ap-
pears : but I have never feen it in any cafe, when th'.To
was not evidently, or when 1  had  not ground to fup-
pofe,  there was a permanent puruleud^* or ulceration
in fome external or  internal part.   It  was for this rea-
fon  th u in lxxiv.   I conclude^ it to be a fympto-
matic fever only.  Indeed, it appears to me to be  al-
ways the effect of an acrimony,abforbed from abfeeffes
or ulcers, although it is not equally-the effect of every
fort of acrimony;  for the  fcorbutic and cancerous
kinds often fubfift long in the body without producing
a hectic.   What is  the precife ftate of the  acrimony
producing  this I cannot determine, but it feems to be
chiefly that of a vitiated purulency.
                   DCCCLX1I.
 ""tfowever this may be, it appears, that the hectic's
depending  in general upon an acrimony, explains its
peculiar circumftances.  The febrile ftate feems to  be
chiefly an exacerbation of that frequency of the pulfe,
which occurs twice every day to perfons in health, and
may be produced by acrimony alone.   Thefe exacer-
bations, Indeed, do not happen without the proper cir-
cumftances of pyrexia ; but the fpafm of the extreme
veflels in a  hectic does not feem to be fo confiderable
as in other fevers :  and hence the ftate of fweat and
urine which appf ars lb early and fo conftantly in hec-
tics.  Upon  'the fame  fuppofition  of an acrimony
  Vcl. 1.              3f            corrupting 
402
PRACTICE
corropting  the fliuds,  and debilitating the moving
powers, 1 think that moft of the other fymptoms may
alfo be exputined.
                   DCCCLXlil.
  Havine; thus coiuYlered the cha aetei iftical  fymp-
toms and  thief p^rt of the proximate came of the
phthifis puimon oi>, I proceed to obferve, rh.it an ulcer
of the  lungs,  ar.d  its  concomitant  circumbance  o£
hectic fever,  may arife  fix.u ddfeient previous  affec-
tions of the limes : ad of which  however may, in my
opinion, be referred to five  head^ ;  that is 1.  To an
hemoptyfis; 2. To a fuppuration of  the lungs in con-
fequence of pneumonia ; 3. To catarrh ;  4.  To afth-
ri:a ; or, 5. To a tubercle.  Thefe  feveral affections,
as caufes of ulcers, fliall now be confidered in the order
mentioned.
                   DCCCLX1V.
   It has been  commonly fuppofed, that an hemopty-
fis was naturally, aud almoft neceffarily, followed by
an ulcer of the lungs : but 1 will prefume to fay, that,
in general, this is a miftake; for there  have been ma-
ny inftances  of  hemoptyfis occafioned by external
violence, without being followed by any ulcer of the
lungs ; and there  have aifo been many inft'ances of he-
moptyfis from ;in internal  caufe, without any confe-
rment ulceration. And this too has been the cafe, not
only v.hen . ue her a pyfis happened to young perfons,
and recurred for  feveral times, but  when  it has  often
recurred during the courtc of along life.   It is indeed
eafy to conceive, ihat a rupture of  the veflels of the
lungs like that of the veffels of the nofe, may be oft-
en healed, as tlie hugeous fpeak,  by  the firft intention.
It is probable therefore,  Hiat it is  an hemoptyfis in
pardcuiar ei cumftances only,  which is  neceffarily fol-
lowed by an ulcer ; but what thefe circumftances arer
it i> di.ri<:ult to determine.  It is poffible, that  mere-
 ly the  d. gi ee of rupture,  or frequently repeated rup-
                                              ture 
Of  P  H Y 5 I C.
403
t*ire preventing the wound from healing by the firft
intention, may occafion an ulcer ; or it is poffible that
red blood effufed,  and not brought up  entirely by
coughing,  may,  by ftagnating in the bronchiae* be-
come acrid, and  erode the parts.  Thefe however are
but fuppofitions, not fupported by any clear evidence.
And,  if we confider that thoTe  caks of hemoptyfis
which  follow ihe  predifpofition (dcccxxxii.—dgcc-
xxxv.) are thofe efpecially which end in phthifis, we
fhall be led to fufpect that there are fome other cir-
cumftances which concur here to determine  the con-
fequence of hemoptyfis, as  I fhall hereafter endeavour
to lhow.
                   DCCGLXV.
   Any fuppofition, however, which we can mike widi
refped: to the innocence of an hemoptyfis, muft not
fuperfede  the meafures propofed above for its cure ;
both becaufe  we cannot certainly forefee what may be
the confequence of fuch an accident, and becaufe the
meafures  above  fuggefted are fafe; for, upon every
fuppofition, it is a diathefis phlogiftica that may urg£
on every  bad confequence to be apprehended.
                  DCCCLXVI.
   The fecond caufe of an ulceration of the lungs, to
be confidered, is  a fuppuration formed in confequence
of pneumonia.
                  DCGCLXVII.
   From  the  fymptoms mentioned in dccclviii—
dccclix. it may with reafon be  concluded, that an
abfeefs, or, as it is called, a vomica, is formed in fome
part of the pleura, and moft frequently in that portion
of it invefting the  lungs.  Here purulent matter fre-
quently remains for fome time, as if enclofed in a cyft :
but commonly it is not long before it comes to be ei-
ther abforbed, and transferred to fome other part of
the body ; or that it breaks through into the cavity of
the lungs, or  into that of the thorax.   In the latter
                     3 E 2                 ciie, 
4<H             PRACTICE
cafe, it produces the difeafe called empyema ; but it is
only when the matter'is poured into the cavity of
the bronchiae, that it properly conftitutes the phthifis
pulmonalis.   In the cafe of empyema,  the  chief  cir-
cumftances of the phthifis are alfo prefent;  but I fhall
here confider that cafe  only in which the abfeefs of
the lungs gives occafion to a purulent expectoration.
                 DCCCLXVIII.
   An abfeefs ©f the lungs,  in confequence  of pneu-
monia, is not always followed by a phthifis:  for fome-
times a hectic fever is  not formed ; the matter pour-
ed into the bronchiae is a proper and benign pus, which
is  frequently  coughed  up very  readily,  and fpit out:
and, tnough this purulent expectoration fhould conti-
nue for fome  time, yet if a hectic does not come on, the
ulcer foon heals, and every morbid fymptom difap-
pears.   This  has happened fo frequently,  that  we
may conclude,  that neither the accefs of the air, nor
the conftant  motion of the lungs, will prevent an ul-
cer of thefe parts  from  healing, if  the  matter of
it  be  well-conditioned.   An  abfeefs  of the lungs,
therefore, does not neceffariiy  produce  the phthifis
pulmonalis ;  and if it  be followed by  fuch  a  difeafe,'
it  muft be in confequence of particular circumftances
which corrupt the purulent matter produced, render
it  unfuitable  to the healing of the  ulcer, and at the
fame time make it afford an acrimony, which,  being
abforbed, produces a hectic and its confequences
                   DCCCLXIX.
   The corruption of the  matter of fuch abfeeffes may
be owing to  feveral caufes, as,  i. That the matter
effufed during the inflammation,  had not been a pure
ferum fit to be converted into a laudable pus, but had
been united with other matters which prevented that,
and gave a confiderable acrimony to the whole :  Or,
2. That the  matter effufed, and  converted  into pus,
either merely by a long ftagnation U\ a vomica, or by
                                               ire 
•OF    PHYSIC.
4^i
its r?bnnecf ion with an empyema, had been fo corrupt-
ed, as to  become  unfit for the purpofe of pus in the
healing of the ulcer.   Thefe feem to be poffible cauf-
es of the corruption of  matter  in  abfeeffes,  fo  as to
make it the occafion of a phthifiY in perfons otherwife
found ;  but it is probable, that a pneumonic abfcefr,
does efpecially produce phthifis when  it happens to
perfons  previoufly  difpofed to that difeafe, and there-
fore only as it concurs with fome other caufes of it.
                  DCCCLXX.
   The third caufe fuppofed to  produce phthifis,  is a
catarrh ;  which in many cafes feems in  length of time
to have the expectoration of mucus proper to it, gradu-
ally changed into an expectoration of pus; and at the
fame time, by the addition of a hectic fever, the  dif-
eafe, which was at  firft a  pure catarrh, is converted into
a phthifis. This fuppofition, however, is not eafily to be
admitted.  The catarrh is properly an affection of the
mucous glands of the trachea and bronchiae, analogous
to the coryza, and lefs violent kinds of cynanche ton-
fillaris, which  very feldom terminate in fuppuration.
And although a catarrh fhould be difpofed to fuch ter-
mination,  yet  the ulcer produced might readily heal
up, as it does in the cafe of a cynanche tonfillaris;  and
therefore  fliould not produce a phthifis.
                   DCCCLXXI.
   Further, the catarrh, as purely the effect of cold, is
generally  a mild difeafe, as well as of fhort duration ;
and of the numerous  inftances of it, there are at moft
but very few cafes which can be faid to hp.ve ended in
phthifis.   In all thofe cafes in which this feems tr have
happened, it is to  me  probable, that the p< rfons affect-
ed were peculiarly predifpofed  to phthiijs.   And the
beginning of phthifis fo  often rejembks a  catarrh,
that the former may have  been mifiaken for the Iattc.
Befides, to increafe the  fallacy, it cfcen  happens that
the  application of cold,  which  is  the  moft  frequent
                                             caufe 
 4c5           PRACTICE     *

 caufe of catarrh, is alfo frequently the exciting caufe
 of the cough which proves'the beginning of phthifis.
                  DCCCLvXU.
  It is to me,  therefore,  probable,  that a catarrh  is
 very feldom the foundation of phthifis ; but I would
 not pofitively  aflert that it never is fo ; for it is poili-
 ble that the cafes of a more violent catarrh may  have
 joined with them a pneumonic affection, which may-
 end  in a fuppuration ; or it may  happen that a  le-ng
 continued catarrh, by the violent agitation of the lungs
 in coughing will produce fome of thofe tubercles which
 are prefently to be mentioned  as  the moft  frequent
 caufe of phthifis.
                 DCCCLXXUI.
  It muft be particularly obferved here,  that nothing
 faid in dccclxxii. fhould allow us  to  neglect any ap-
 pearence of catarrh, as is too frequently done; for it
 may be either the beginning of a phthifis,  which is mif-
taken for a genuine catarrh,  or that even as a catarrh
continuing  long, it may produce  a phthifis, as  in
 DCCCLXXI I.
                  DCCCLXXIV.
  Many phyficians have fuppofed  an acrimony of the
 fluids eroding fome of the veffels of the lungs, to be a
frequent caufe of ulceration and phthifis.   But this ap-
pears  to me to be a mere fuppofition : for in any  of
 the inftances of the production of phthifis which I have
feen, there  was no evidence  of any acrimony of the
 blood capable of eroding the veffels.   It  is true, in-
deed, that in many cafes an acrimony fubfifting in fome
part of the  fluids, is the caufe of the difeafe ; but it is
at the fame time probable, that this acrimony operates
by producing tubercles, rather than by any direct cro-
 ft on.
                   DCCCLXXV.
  It has been mentioned in dccclxiu. that an afthma
 may be considered as one of the caufes of phthifis; and'
                                               by 
O^TH? H Y S  I C.
4r7
   by afthma I mean, that fpeciesof it which has been com-
   monly named the Spafmodic.  This difeafe frequenilv
   fulf.fts very long without producing any other,'  and
   may have its own peculiar fatal termination,  as fhall
   be  explained  hereafter.  But I have feen it frequent-
*  h end in phthifis ; and in, fuch c. fes I  fuppofe it to
   ope. ate  n\  the  manner above alledged of catarrh,
   that is, by producing tubercles, and their confequen-
   ces, which fliall be prefently mentioned.
                     DCCCLXXVY
     I come now to confider the fifth head  of  the caufe
   or phthifis, and which  I uppieherd to be the moft  fre-
   quent cf any.  This I  have faid; in general, to be tu-
   bercles;  by which terms are meant, certain fmall tu-
   mours,which have the appearance oA indurated glands.
   Defections have frequently fhown fuch tubercles form-
   ed in the lungs ;  and although at firft indolent, yet at
   length they become inflamed, and are thereby changed
   into little abfeeffes, or vomicae, which breaking,  and
   pouring their matter  into the bronchiae,  give a puru-
   lent expectoration,  and  thus  lay the foundation of
   phthifis.
                    DCCCLXXVII.
     Though the matter expectoratedupon thefe occafions
   has  the appearance of pus, it is feldom th«t of a lau-
   dable kind ;  an 1, as the ulcers do not readily heal, but
   are attended with a hectic fever, for the molt part end-
   ing fatally, I prefume that the matter of the ulcers is
   imbued with a peculiarly7 obnoxious acrimony, which
   prevents their healing, and  produces a phthifis in all
   "is circumftances, as  mentioned above.
                    DCCCLXXV1II.
     it is very probable that the acrimony which thus dif-
   covets itfelf in tiie ulcers, cxifted before, and produced
   the tubercles thcn.felves ; and it  is to this  acrimony
   that we muft trace up the caufe of the rhihifis follow-
   ing thefe tubercles.   This aciim ny is  probaoly, in
                                            different 
4c3          PRACTICE

different cafes,  of different kinds ; and it will not be
eafy to determine its varieties : but to a certain length
1 fhall at temp. it.
                  DCCCLXXTX.
   In one cafe,  and that, too, a very frequent oiie, of
phtlioY. it appears, that the noxious acrimony is of the
fame kind with that which prevails  in  the fcrophula.
This may be concluded from obferving, that a phthifis,
at its ufual periods, frequently attacks perfons born of
fcrophulous parents ;  that is, of parents who had been
affected with fcorphula in their younger years : that ve-
fy often, when the phthifis appears, thefe occur at the
fame  time feme  lymohatic  tumours in the  internal
parts ; and very often I have found the tabes mefente-
rica, which is a fcrophulous affection,  joined with the
phthifis pulmonalis.   To all  this I would add,  that,
even when no fcrophulous affection has either mani-
feft ly'prcceded or accompanied  a phthifis^ this laft
however moft commonly affects perfons of a habit re-
fembling the fcrophulous;  that is,  perfons  of a fan-
guine, orof afanguineo-melancholictemperament, who
have very fine fkins, rofy complexions, large veins, foft
flefh, and thick upper lip : and  further, that in fuch
perfons the phthifis comes on in the fame manner that
it dors in perfons having tubercles, as fliall  be imme-
diately explained.
                  DCCCLXXX.
   Another fpecies of  acrimony producing tubercles of
the lungs,  and thereby phthifis,  may be faid to be the
exanthematic.  It is  well known,  that the fmall-pox
fometimes, and more frequently mealies, lay the foun-
dation of phthifis.  It is probable alio, that other exan-
themata have the fame effect; and from the phenome-
na of the difeafe, and  the diffections of perfons who
have died of ir, it is probable, th it all the exanthema-
ta may cccalion a phthifis, by affording a matter which
in the firft place produces tubercles.
                                   DCCCLX^I. 
O  F  P  H Y S I C.           409
                  DCCCLXXXI.
  Another acrimony, which feems fometimes to pro-
duce phthifis, is the fiphylitic; but.whether fuch an
acrimony produces phthifis in any other perfons than
the previoufly difpofed,  does not appear to me certain.
                DCCCLXXXI1.
  What other fpecies of acrimony, fuch as from fcur-
vy, from pus abforbed from other parts of the body,
from fuppreffed  eruptions, or from other fources, may
alfo produce tubercles and phthifis, I cannot now de-
cide,  but muft leave to be determined by thofe who
have had experience of fuch cafes.
                DCCCLXXXIII.
  There is one  peculiar cafe of phthifis, which fiom
my own experience I can take notice of.  This is the
cafe of phthifis from a calcareous matter formedin the
lungs, and coughed up, frequently with  a little blood,
fometimes with mucus only, and fometimes with pus.
How this matter is generated, or in what precife part
of the lungs it is feated, I acknowledge myieff igno-
rant.  In three  cafes of this kind which  have occur-
retf'to me, there was at the fame time no appearance
of ftony or earthy concretions in any other part of the
body.  In one of thefe cafes,  an exquifitely formed
phthifis  came on,  and proved mortal: While in the
other two,  the fymptoms of phthifis were never fully
formed ; and after fome time, merely  by a  milk diet
and avoiding irritation, the patients entirely recovered.
                DCCCLXXXIV.
   Another  foundation  for phthifis,  analogous,  as  I
judge, to that of  tubercles, is that which occurs to
certain artificers whofe employments keep them almoft
conftantly expofed to duft ;  fuch as ftone-cutters, mil-
lers, flax-dreffers, and fome others.  I have not obferv-
ed in this country many inftances of phthifis which
could be referred to this caufe ; but, from Ramazzi-
ni, Morgagni, and fome other writers,  we muft con-
   Vol.  I.              3  F                  elude 
410             PRACTICE

elude fuch cafes to be more  frequent in the fouthern
parts of Europe.
                DCCCLXXXV.
  Befides thefe now mentioned, there  are  probably
fome other caufes producing tubercles, which have
not yet been afcertained by  obfervations ;  and it  is
likely, that in the Itate of tubercles there is a variety
not yet accounted for ; but all t;ns  muft be  left to fu-
ture obfervation and inquiry.
                DCCCLXXXVL
  It has been frequently fuppofed by phyficians, that
the phthifis is a contagious dileafe ; and i dare not af-
feitthat it never is fuch :  but in  many hundred in-
ftances of the difeafe which I have feen, thei'e has been
hardly one which to me could appear to have arifen
from o.nta >,ion.  It is poffible, that in warmer cli-
mates the effects of  contagion may be more discerni-
ble.
  After having faid that a phthifis arifes from  tuber-
cles  more frequently than from any other caufe,  and
after having  attempted  to aflign the variety of thefe, I
now proceed to mention  the  peculiar  circumftances*
and fymptoms which ufually accompany the* coming
on of the difeafe from tubercles.
                DCCGLXXXVII.
  A tuberculous and purulent ftate of the  lungs has
been  obferved  in very young children,  and in fome
others at feveral different periods before the  age of
puberty and  full  growth ; but inftances of this kind
are rare :  and the attack of phthifis, which we have
reafon to impute to tubercles, ufually happens at the
fame period  which I have ailigned for the coming on-
of the hemoptyfis.
               DCCCLXXXVIII.
  The  phthifis from tubercles does alfo  generally af-
fect the fame habits as the hemoptyfis, that is,  perfons.
©f a flender make,  long necks, narrow chefts,  and
                                       prominent 
OF  PHYSIC.
411
.prominent fhoulders :  but very frequently the perfons
liable to tubercles have lefs of a florid countenance,
and of  the other  marks of an exquifitely fan<mine
temperament, than the perfons liable to hemoptyfis.
                 DCCCLXXXIX.
   This difeafe, arifing  from the  tubercles, ufually
.commences  with a flight and fhort cough,  which be-
comes habitual, is often little remarked by thofe af-
fected, and fometimes fo little as to be abfolutely de-
nied by them.   At the fame time their breathing be-
comes eafily hurr-ied by any bodily motion,  their body
grows leaner, and they become languid and indolent.
This ftate fometimes continues for a year, or even for
-two years, without the perfons making any complaint
cf it, excepting only that they are affected by cold
more readily than ufual, which frequently increafes
their cough, and produces fome catarrh.  This, again,
however, is fometimes relieved ; is fuppofed to have
arifcn from cold alone ;  and therefore  gives no alarm
either to the patient or to his friends,  nor lead$ them,
to take any precautions.
                   DCCCXC.
   Upon one or other of thefe occafions of catching
<cold, as we commonly fpeak, the cough becomes more
Confiderable :  is  particularly troublefome  upon the
patient's lying down at night, and  in this ftate  conti-
nues longer than is ufual in the cafe of a  fimple ca-
tarrh.  This is more  efpecially to  call for  attention,
if the increafe and continuance of cough come on du-
ring the fummer feafon.
                   DCCCXCI.
   The cough which comes on as in dccclxxxix. is
very often for a long time without any expectoration ;
but when, from repeatedly catching cold, it becomes
more conftant,  it  is then at the fame  time attended
with  fome expectoration, wdiich is moft confiderable
jn the mornings.  The  matter of  this expectoration
                      3 F  2             becomes 
412
PRACTICE
becomes by degrees more copious,  more vifcid, and
more opaque ;  at length of  a  yellow or greenifh co-
lour, and of a purulent appearance.  The whole of
the matter, however, is not always at once entirely
changed in this manner; but, while one part of it re-
tains the ufual form of mucus, another fuffers the
changes now defcribed.
                   DCCCXCII.
  When the cough increafes, and continues very fre-
quent through  the night, and when the matter expec-
torated undergoes the changes I have mentioned, the
breathing at the fame  time becomes more  difficult,
and the emaciation and weaknefs go on alfo increafing.
In the female  fex, as the difeafe advances, and fome-
times early in  its progrefs, the menfes ceafe to flow ;
and this circumftance is to be confidered as commonly
the effect, although  the  fex themfelves are  ready to
believe it the fole caufe of the difeafe.
                  DCCCXCIII.
  When the cough comes on  as in dccclxxxix. the
pulfe is often natural, and for  fome time  after conti-
nues lobe fo ; but the fymptoms have feldom fubfifted
long before the pulfe becomes, frequent, and fome-
times to a confiderable degree, without much of the
other fymptoms of fever.  At  length, however, even-
ing exacerbations  become remarkable ;  and by de-
grees the fever affumes the exquifite form  of hectic, as
defcribed in dcccxlviii—dccclx.
                  DCCCXCIV.
  It is feldom  that the cough, expectoration, and fe-
ver, go on increafing, in the manner now defcribed.
without fome pain being felt in fome part of the tho-
rax.  It is ufually and moft frequently felt at firft un-
der the fternum, and that efpecially,  or almoft only,
upon occafion  of coughing: but very often, and that
too early, in the courfe of the difeafe, a pain is felt on
*^e fide, fometimes very conftantly, and fo as to  pre-
                                            vent 
OF  PHYSIC.
4^3
vent the perfon from lying eafily upon that fide ; but
at other times the pain is felt only upon a full infpi-
ration, or upon coughing.   Even when no pain is felt,
it generally happens  that phthifical perfons  cannot
lie eafily on fome one of their  fides, without having
their difficulty of breathing increafed, and their cough
excited.
                   DCCCXCV.
   The phthifis begins, and fometimes proceeds to  i;:$
fatal iffue, in the manner defcribed from dccclxxxix,
to dcccxcv. without any appearance of  hemoptyfis.
Snch cafes are indeed rare; but  it is very common
for the  difeafe to advance far, and even to an evident
putulency and hectic ftate, without any appearance of
blood in the fpitting : fo that it  may be affirmed,  the
difeafe is  frequently not founded  in hemoptyfis.   At
the fame time, we muft allow,  not only that it fome-
times begins with an hemoptyfis,  as is faid  in dccc-
lxiv. but further,  that it  feldom happens that in the
progrefs of the difeafe more or lefs of an hemoptyfis
does not appear.  Some degree of blood-fpitting does,
indeed,  appear fometimes  in the  ftate mentioned
(dccclxxxix, dcccxciii.) but more commonly in the
more advanced ftages of the difeafe only, and particu-
larly upon the firft appearance of  purulency.  Howe-
ver this may be, it is feldom, in the phthifis from tu-
bercles, that the hemoptyfis is confiderable, or requires
any remedies different from thofe which are otherwife
neceflary for the ftate of the tubercles.
                   DCCCXCVI.
   I have now defcribed a fucceffion of fymptoms
 which, in different cafes, occupy  more or lefs time.
 In this climate they very often  take up fome years,
 the fymptoms appearing efpecially in the winter and
fpring, commonly  becoming  cafier, and fometimes
 almoft  difappcaring, during the fummcr : but return-
 ing again in winter, they at length, after two or three
                                            years, 
4*4
PRACTICE
 years, prove fatal, towards the end of fpring or the ber
 ginning of fummer.
                  DCCCXCVII.
   In this difeafe, the prognofis is for the  moft part
 unfavourable.  Of thofe affected with it, the greater
 number die; but there are  alfo many of them  who
 recover entirely, after having been in very unpromif-
 ing circumftances.  What are, however, the circum-
 ftances more .certainly determining to a happy or to a
 fatal event, I have not vet been able to afcertain.
                  DCCCXCVIII.
   The following aphorifms are the  refult of  my ob-
 fervations.
   A phthifis pulmonalis from hemoptyfis, is more fre-
 quently recovered than one from tubercles.
   An  hemoptyfis not only is not  always followed by
 a phthifis, as we have faid above 864 ; but even when
 followed by an ulceration, the ulceration is "fometimes
 attended with little of hectic, and frequently admits cf
 being foon healed.   Even when hemoptyfis and ulcer-
 ation have happened to be repeated, there are inftances
 rf perfons recovering entirely  after lcveral fuch repe-
 titions.
   A phthifis from a  fuppuration  in confequence  of
 pneumonic iniluirnation, is  that  which moft  rarely
 < ccurs in  this climate ; and a phthifis does not alwavs
 follow fuch fuppuration, when the  abfeefs formed fooi*
 breaks and difcharges a laudable pus ;  but,  if the ab-
 feefs continues long fhut up,  and till after a confider-
 able degree of hectic  has been formed,  a phthifis  is
 then pioduceei, equally dangerous, as that from other
 caufes.
   A phthifis from tubercles has, I think, been reco.
 vered : but it is of all others the moft dangerous; and,
 whem fifing from a hereditary taint almoft certainly
fatal.
   The danger of a  phthifis,  from whatever caufe  it
                                             may 
              6  F  P  H  Y S  I C.          4i$

may nave arifen, is moft certainly to be judged of by
the degree to which  the hectic and its  confequences
have arrived.  From a certain degree of emaciation,
debility, profufe fweating, and diarrhoea,  no perfon
recovers.
  A mania coming on, has been found  to remove dl
the fymptoms, and fometimes has  entirely cured the
dileafe; but, in other  cafes, upon the  going off of
the mania the phthifis has recurred, and proved  fatal.
  The pregnancy of women has, often  retarded the
progrefs  of  a  phthifis ;  but comra< nly it is only till
alter delivery, when  the fymptoms of phthifis return
with violence, and foon prove fatal.
               SECT.     II.

        OF THE CURE OF PHTHISIS.

                  DCCCXCIX.
  From what has been juft now faid, it will readily
appear, that the cure of the phthifis pulmonalis muft
be exceedingly difficult; and  that even the utmoft
care and attention in the employment  of remedies,
have feldom fucceeded.   It may be doubtful whether
this failure is to be imputed to the imperfection of ouv
art, or to the abfolutely incurable nature of the dif-
eafe.  1 am extremely averfe in any cafe to admit of
the latter fuppofition, and can always readily allow of
the former; but, in the mean time, muft mention here,,
what has been  attempted  towards  either curing or
moderating the violence of the difeafe.
                    DCCCC.
 ' It muft  be  obvious,  that according to  the dif-
                                           ferent 
416    '         PRACTICE
                                 >*•
ferent  circumftances of this difeafe,  the method ©f
cure muft be different.  Our firft attention fhould  be
employed in  watching the approach  of the difeafe,
and preventing its proceeding to an incurable ftate.
   In all  perfons of a phthifical habit, and efpecially
in thofe  born of phthifical parents, the flighteft fymp-
toms of the approach of phthifis, at the phthifical pe-
riod of life, ought  to be attended to*.
                    DCCCCI.
   When an hemoptyfis occurs,  though it be not  al-
ways followed with ulceration and phthifis, thefe how-
ever are  always to be apprehended ;  and every pre-
caution is to be taken againft them.  This is efpecial-
ly to be done by employing every means of  moderat-
ing the hemorrhagy, and of preventing its return,
directed  in  Dcccxcn. et feq. and thefe precautions
ought  to be continued for feveral years after the#oc-
currence of the hemoptyfis.
                    DCCCCII.
   The phthifis  which  follows  a fuppuration from
pneumonic inflammation, can only be prevented with
certainty, by obtaining a refolution of  fuch inflamma-
tion.  -What may be attempted  towards the cure of
an abfeefs and ulcer which have taken place,  1  fhall
fpeak of  hereafter.
                   Dccccri.
   I have faid, it is  dcubtful if a genuine catarrh ever
produces a phthifis  ; but have allowed that it poffibly
may :  and both upon this account, and upon account
of the  ambiguity which may arife, whether the appear-
ing catarrh be a primary difeafe, or the effect of a tu-
bercle, I  confider it as of confequence to cure a catarrh
as foon as  poffible  after its  firft appearance.  More
                                             efpe-
  * This early attention to the firft'fymptom of the difeafe is of
the utmoft confequence, for it is only in the early flage that any re-
medies can be employed with fuccefs, as experience has fuflieie:itly
taught; fee  art. 906. et. feq. 
OF  PHYSIC.
4»7
efpecially when it fhall linger, and  continue for feme
time, or fhall, after fome intermifiion, frequently re-
turn, the cure of it fhould be  diligently attempted.
The meafures requifite for this purpofe ihall be men-
tioned afterwards, when we come to treat of catarrh
as a primary difeafe ; but, in the mean time, the means
neceffary for preventing its producing a phthifis fliall
be mentioned immediately, as they are the fame with
thofe I fhall point out as neceffary for preventing a phthi-
fis from tubercles.
                    DCCCCIV.
  The preventing  of a phthifis from  afthma muft be,
by curing, if poffible, the afthma, or  at leaft by mode-
rating it as  much as may be done :  and as it is proba-
ble that afthma occafions phthifis,  by producing tu-v
bercles, the  meafures neceffary for preventing  phthi-
fis from afthma, will be the fame with thofe neceflary
in the cafe of tubercles, which  I am now about  to
mention.
                    DCCCCV.
  I confider tubercles as by much the moft frequent
caufe of phthifis;  and  even in many cafes where this
feems to depend upon hemoptyfis, catarrh, or afthma,
it does however truly arife from tubercles.   It is upon
this fubject, therefore, that I fhall have occafion to treat
of the meafures moft commonly requifite for curing
phthifis.
                   DCCCCVI.
   When, in a perfon born  of phthifical parents, of a
phthifical habit, at the phthifical period of life,  the
fymptoms (dccclxxxix.) in the fpring, or the begin-
ning of fummer,  fhall appear in the flighteft degree,
we may prefume that a tubercle, or tubercles,  either
have been formed, or are forming in the lungs ; and
therefore, that every means we can devife for prevent-
ing their formation, or for procuring their refolution,
fhould be employed immediately, even although the
   Vol.  I.                3 G             patient 
418          PRACTICE
patient himfelf fhould overlook  or neglect the fymp-
toms, as imputing them to accidental cold.
                  DCCCCVII.
  This is certainly the general indication ;  but  how
it may beexecuted,  cannot readily fay. I do not know
that,  at any time, phyficians have propofed any reme-
dy capable of preventing the formation  of the tuber-
cles, or ofrefolving them when formed.  The analogy
of fcrophula, gives no affiftance in  this  matter.   In
fcrophula the remedies that are feemingly of moft power,
are,  fea-water, or certain mineral waters; but thefe
have generally proved hurtful in the cafe of tubercles
of the lungs.  I have known feveral inftances of mer-
cury very  fully employed for certain difeafes, in per-
fons who were fuppofed at the time to have tubercles
formed, or forming,  in  their lungs ; but though the
mercury proved cure  for thofe other difeafes, it was of
no fei vice in preventing phthifis, and in fome cafes
feemed to hurry it on.
                   DCCCCVIII.
  Such appears to me to be the prefent ftate of our art,
with refpect to the cure of tubercles ; but I do not def-
pair of a remedy for  the purpofe being found hereaf-
ter.  In the mean time, all that at  prefent  feems to
be within the reach of our art, is to take the meafures
proper for avoiding the inflammation of tubercles.  It
is probable that tubercles may  fubfift long without
producing any diforder; and  I  am difpofed to think,
that nature fometimes refolves and difcuffes tubercles
which  have been formed; and that nature does  this
only when the tubercles remain in an uninflamed ftate;
and therefore, that the meafures neceffary to be taken,
are chiefly thofe for avoiding the inflammation of the
tubercles.              DCCCCIX.
  The inflammation  of a tubercle of the lungs is to
be avoided upon the  general plan of avoiding inflam-
mation, by blood-letting, and by an antiphlogiftic re-
                                          gimen j 
OF  PHYSIC.
419
gimen ;  the, chief part of which, in this cafe, is the
.ufe of a low diet. This fuppofes a total abftinence from
animal food,  and the ufing of  vegetable food almo#
alone : but it has been  found, that it is not neceffary
for the patient to be confined to vegetables of the weak-
eft nourifhment, it being fuflicient that the farinacea
be employed, and together with thefe,  milk.
                    DCCCCX.
   Milk has been generally confidered as the chief re-
medy in the phthifis, and in the cafe  of every tenden-
cy to it ; but whether  from its  peculiar qualities, or
from its being of a lower quality, with refpect  to nou-
rifhment, than any food entirely  animal, is not certain-
ly determined.  The choice and adminiftration of milk
will be properly directed,  by confidering the nature of
the  milk  of the feveral animals from  which  it may
be taken,  and the particular ftate of the patient with
refpect to the period and circumftances  of the  difeafe,
and to the habits of his ftomach with  refpect to milk.
                   DCCCCXL
   A fecond means of preventing the  inflammation of
the tubercles of the lungs, is by  avoiding any particu-
lar irritation of the affected part, which may arife from
any violent exercife of refpiration; from any confider-
able degree  of bodily exercife; from any pofition of
the'body, which ftraitens the capacity of the thorax 5
and laftly, from cold applied to the furface of the  bo-
dy, which determines the blood in greater quantity to
the internal parts, and particularly to the lungs.
                   DCCCCXII.
   From the laft-mentioned confideration, the applica-
tion of cold in general, and therefore the winter-fea-
fon, in cold  climates, as diminifhing the  cutaneous
perfpiration, is to be avoided; but more particularly,
that application  of cold is to be ftiunned  that may fup-
prefs perfpiration, to the degree of  occafioning a ca-
tarrh,  which confifts  in an inflammatory  deteiminaT
                      3 G 2                  tion 
420
PRACTICE
tion to the lungs, and may therefore moft certainly pro-
duce  an inflammation of the tubercles there.
   By confidering,  that the avoiding heat is a part of
the antiphlogiftic regimen above recommended,  and
by comparing this with what has been juft now faid
refpecting the avoiding cold,  the proper choice of cli-
mates and feafons for phthifical patients will be readi-
ly underftood.
                    dccccxiii.
   A  third means of  avoiding the inflammation of the
tubercles of the  lungs confifts, in diminifhing the de-
termination of the blood to the  lungs,  by fupporting
and increafing the determination to the furface of the
body ; which is to be chiefly and moft fafely done by
warm clothing*, and the frequent ufe of the exercifes
 of ge flat ion.
                     DCCCCX1V.
   Every mode of geftation has  been  found of ufe in
 the phthifical cafes; but riding on horfeback, as being
 accompanied  with a great deal  of bodily  exercife,  is
 lefs fafe  in perfons liable to an  hemoptyfis.  Travel-
 ling  in a carriage unlefs upon very fmooth roads  may
 alfo  be of doubtful  effect; and  all the modes of gefta-
 tion that are employed on land, may fall  fhort of the
 effects expected  from  them,  becaufe they cannot be
 rendered fufficiently conftant;  and therefore it  is that
 failing, of all other modes  of geftation, is  the moft ef-
 fectual in pneumonic cafes, as being both  the fmooth-
 eft and moft conftant.
    It has been imagined, that fome benefit is derived
                                                from

    *  Th's is a mo1 eflential part in the cure of phthifis, and many
 other difeafes prevalent in cold climates.  The warm  clothing that
 is moll effectual is flannel fhirts next the fkin.  It feels a little difa-
 greeAble at tirit to a perfon unaccuilomed to it ; but the  g'eat  re-
 lief it affords, and the comfortable fenfati >n it produces, are fo Itron^
 inducements for continuing it's ufe, that few people who have once
 experienced  itY beneficial effeds, have any defire to reliiiquifh it. 
OF  PHYSIC.
421
from the ftate of the atmofphere upon the fea ; but I
cannot find  that any impregnation of this which can
be fuppofed  to take place, can be of fervice to phthi-
fical perfons.  It is however probable, that frequent-
ly fome benefit may  be derived  from the more mode-
rate temperature and greater purity  of the air upon
the  fea.
                   DCCCCXV,
   In order to take off any inflammatory determination
of the blood into the veffels of the lungs, blifters ap-
plied to fome part of the thorax may  often be of fer-
vice ; and for the fame purpofe, as well as for  mode-
rating  the general  inflammatory ftate of the  body,
iffues of various kinds may be employed with advan-
tage.
                    DCCCCXVI.
   The feveral meafures to be purfued in the cafe of
what  is properly called an Incipient Phthifis, have
now been mentioned ; but they have  feldom been em-
 ployed in fuch cafes in due time, and have therefore,
perhaps, feldom proved effectual.  It has more com-
monly happened, that after fome time, an inflamma-
tion has come upon  the tubercles,  and an abfeefs  has
 been formed,  which opening into the cavity of the
 bronchiae,  has produced  an ulcer,  and a confirmed
 phthifis.
                 DCCCCXVII.
   In this flare of matters, fome  new indications differ.
 ent from the former may be fuppofed to arife, and in-
 dications for preventing  abforption, for  preventing
 the effects of the abforbed matter upon the  blood, and
 for healing the ulcer, have been actually propofed. I
 cannot find, however, that any of the means propof-
 ed for executing thefe indications, are either  probable
 or  have proved effectual.   If, upon fome occafions,
 they have appeared to be ufeful, it has been  probably
 by  anfwering fome  other intention.
                                            While 
42 2
PRACTICE
  While no antidote againft the poifon which efpcci.-
ally operates here,  feems to  have been as yet found
out, it appears to me,  that toe great a degree of in,
flammation has a great fhare in preventing the healing
of the ulcers which  occurs; and fuch inflammation  is
certainly what has a great fhare in urging on its fata)
confequences.  The only practice, therefore, which I
can venture to propofe, is the fame in the ulcerated as
inthe crude ftate of a tubercle ;\hat is, the employment
of means  for moderating inflammation,  which  have
been already mentioned (dccccix. et feq.)
                   DCCCCXVIII.
  The balfamics  whether natural or artificial, which
have been fo  commonly advifed in  cafes of phthifis,
appear to me to have been propofed upon no fufficient
grounds, and to have proved commonly hurtful. The
refinous  and acrid fubftance of myrrh, lately recom-
mended, has not appeared to  me  to be of any fcrvice,
and in fome cafes to have proved  hurtful*.
                  DCCCCXIX.
  Mercury, fo often ufeful in healing ulcers, has been
fpecioufly enough propofed in this difeafe ; but  whe-
ther that it be not adapted to the particular nature of
the ulcers of the lungs oceurring  in phthifis, or that it
proved hurtful becaufe it cannot have effect, without
exciting fuch an inflammatory ftate of the whole fyf-
tem, as, in a hectic  ftate,  muft prove very hurtful,  I
cannot determine.   Upon many trials which I have
feen made, it has proved  of no-fervice, and commonly
has appeared to bemanifeftly pernicious.
                   DCCCCXX.
  The Peruvian bark  has been recommended  for fe-
                                              veral

  * From the preceding account of the difeafe,  it is fufficiently
evident tint all acrid and hot fubilances muft be hurtful in phthifis.
The balfamics have  been long recommended in thefe cafes, eve:i
by the beft authorities, but on what principle is not eafy  to de-
termine. 
              O FTH Y S I  C.          423

veral purpofes  in phthifical cafes;  and is faid, upon
fome occafions  to have been ufeful; but I have feldom
found it to be fo ; and as by its tonic power it increaf-
es the phlogiftic diathefis of the fyftem, I have frequent-
ly found it hurtful.  In fome cafes, where the morn-
ing remiflions of the fever were confiderable,  and the
fioon exacerbations  well marked, 1  have obferved the
Peruvian bark  given in large quantities, have the ef-
fect of flopping thefe exacerbations, and at the fame
time of relieving the  whole of the phthifical fymp-
toms :  but in the cafes in which I obferved thjs,  the
fever fhowed a conftant tendency  to recur; and at
length the phthifical  fymptoms alfo returned,  and
proved quickly fatal.
                   DCCCCXXI.
  Acids of all kinds, as antifeptic and refrigerant, are
ufeful in cafes of phthifis; but the native acid of vege-
tables* is more ufeful than  the foffil acids, as it can be
given in much  larger quantities, and may alfo be giv-
en more fafely than vinegar, being lefs liable to excite
coughing.
                 DCCCCXXII.
  Though our  art can  do fo little towards the cure of
this  difeafe,  we  muft, however, palliate the uneafy
fymptoms  of it as  well as  we can.  The  fymptoms
efpecially urgent, are the cough and diarrhoea.   The
cough may be  in fome meafure  relieved by demul-
cents, (dccclxxiii.) but the relief obtained by thefe is
imperfect and tranfitory, and very  often the ftomach
is difturbed by the quantity of oily,  mucilaginous, and
fweet fubftances,  which are on  thefe occafions taken
into it.
                                    DCCCCXXIII.

  * The  acid fruits, acid of tartar, acid of forrel, and other plants
yielding an acid, but not an acrid juice.   The eating of oranges is
therefore fcrviceablc. 
424
PRACTICE
                 DCCCCXXIII.
  The only certain  means of relieving the cough, is
by employing opiates.  Thefe, indeed, certainly in-
creafe the phlogiftic diathefis of the fyftem; but com-
monly they do not fo much harm  in this way, as they
do fervice  by quieting the cough, and giving  fleep.
They are fuppofed to be hurtful by checking expecto-
ration : but they do it for a fhort  time only; and, af-
ter a found fleep,  the  expectoration in the morning is
more eafy than ufual.  In the advanced ftate of  the
difeafe, opiates feem to increafe the fweatings that oc-
cur ; but they compenfate this, by the eafe they afford
in a difeafe which cannot be cured.
                 DCCCCXXIV.
  The diarrhoea which happens in the advanced ftate
of this difeafe, is  to be palliated by  moderate aftrin-
gents, mucilages, and opiates.
  Rhubarb,  fo commonly  prefcribed in every diar-
rhoea, and all other  purgatives, are extremely danger-
ous in the colliquative diarrhoea of hectics.
  Frefh fubacid fruits, fuppofed to be always laxative,
are often in the diarrhoea of hectics,  by their  antifep-
tic quality, very ufeful.                         -^
CHAP. 
              O F  P H Y  S I  C.           425


              CHAP.     V.

OF THE HEMORRHOIS,   OR,  OF THE HE-
  MORRHOIDAL SWELLING AND FLUX.

               SECT.   I.

Of the PHENOMENA and CAUSES of the HEMORRHOIS.

                 DCCCCXXV.
A DISCHARGE  of blood  fiom fmall tumours on
      the verge of the anus, is the fymptom which
generally conftitutes the Hemorrhois ; or, as it is vul-
garly called, the Hemorrhoidal Flux.  But a difcharge
of blood from within the anus,  when the blood is of a
florid colour, fhowing it to have come from no great
diftance,  is alfo confidered as the fame  difeafe ; and
phyficians have agreed in making two cafes or varie-
ties of it, under the names of External and Internal
Hemorrhois.
                 DCCCCXXVI.
  In both cafes it is  fuppofed that the flow of blood
is from tumours previoufly formed, which are named
Hemorrhoids, or Piles ;  and it frequently happens,
that the tumours exift without any difcharge of blood;
in which cafe,  however, chey are;fuppofed to be a part
of the fame difeafe, and are named Hemorrhoides Cse-
cae, or  Blind Piles.
                DCCCCXXVII.
  Thefe tumours,  as they appear without the  anus,
are fometimes  feparate, round, and prominent, on the
verge of the anus;  but frequently the tumour is only
one tumid ring, forming, as it  were, the anus pufhea
without the body.
                DCCCCXXVIII.
  Thefe tumours,  and the  difcharge of blood from
                    3 H                  them, 
426            PRACTICE

them,  fometimes come on as an affection purely to-
pical, and without any previous diforder in other parts
of the body :  but it frequently happens,  even before
the tumours are formed, and more efpecially before
the blood flows, that various diforders are felt in dif-
ferent parts of the  body,  as headach, vertigo,  ftu-
por,  difficulty of  breathing,  ficknefs,  colic-pains,
pain of the back and loins ; and often, together with
more or fewer of thefe fymptoms, there occurs a con-
fiderable degree of pyrexia.
  The coming on of the difeafe with thefe fymptoms,
is ufually attended with a fenfe of fullnefs,  heat, itch-
ing,  and pain in and  about the anus.
  Sometimes the difeafe is preceded by a difcharge of
ferous matter from the anus : and  fometimes this fe-
rous difcharge, accompanied with fome fwelling, feems
to be in place of the difcharge of blood, and to relieve
thofe diforders of the  fyftem which we have mention-
ed.  This ferous difcharge, therefore, has been named
the Hemorrhois Alba,
                 DCCCCXXIX.
  In the hemorrhois, the quantity of blood difcharged
is different upon different  occafions.   Sometimes the
blood flows only upon the perfons going to ftool; and
commonly,  in larger  or leffer quantity, follows the
difcharge of the faeces.  In other cafes, the blood flows
without any difcharge of faeces ;  and then, generally,
it is after having been preceded by the diforders above-
mentioned, when it is alfo  commonly in larger quan-
tity.  This difcharge of blood is often very confidera-
ble ; and, by the repetition, it is  often  fo great, as
we could hardly fuppofe the body to bear but  with
the hazard of life.   Indeed, though rarely, it has been
fo great as to prove fuddenly fatal.  Thefe confidera-
ble difcharges occur efpecially to perfons who  have
been frequently liable to the difeafe.  They often
                                           induce 
OF  PHYSIC.
427
induce great debility ; and frequently a leucophlegma-
t5a, or dropfy, which proves fatal.
  The tumours and difcharges of blood in this difeafe,
©ftcn re^ur at exactly ftated periods.
                  DCCCCXXX.
  It often happens, in the decline of life, that the he-
morrhoidal flux, formerly frequent, ceafes to flow ; and,
upon that event,  it generally happens that the perfons
are affected with apoplexy or palfy.
                 DCCCCXXXI.
   Sometimes hemorrhoidal tumours are affected with
confiderable inflammation ; which, ending in fuppu-
ration, gives occafion to the formation of fiftulous ul-
cers in thofe parts.
                 DCCCCXXXII.
   The hemorrhoidal  tumours have been often  confi-
dered as varicous tumours, or dilatations of veins ; and
it is true, that in fome cafes varicous  dilatations hav«
appeared  upon diffection.  Thefe, however, do not
always appear;  and I prefume it is not the ordinary
 cafe, but that the tumours are formed by an effufion
 of blood into the cellular texture of the inteftine near
 to  its extremity.  Thefe tumours, efpecially when re-
 cently formed,  frequently contain fluid blood ; but,
 after they have remained for fome time, they  are com-
 monly of a firmer fubftance.
                  DCCCCXXXIII.
    From a confideration of their caufes, to be  hereafter
 mentioned, it is fufficiently probable, that hemorrhoi-
 dal tumours are produced by fome interruption of the
 free return of blood from the veins of the lower extre-
 mity of the rectum ;  and it is poffible, that a confider-
 able accumulation of blood in thofe veins, may occa-
 fion a rupture of their extremities,  and thus produce
 the hemorrhagy or tumours I have mentioned.  But,
 confidering that the hemorrhagy occurring here is of-
 t-m preceded by pain, inflammati. 11, and a febrile ftate,
                      3 H 2         f          as 
428          PRACTICE

as well as by many other fymptoms which fhow a con-
nection between the topical affection and the ftate of
the whole fyftem,  it  feems probable that the inter-
ruption of the venous blood, which we have fuppofed
to take place, operates in  the  manner  explained in
dcclxix. and therefore, that the difcharge  of blood
here is commonly from arteries.
                DCCCJXXX1V.
   Some phyficians have been of opinion,  that a differ-
ence in the nature of the hemorrhois, and  of  its ef-
fects upon the fyftem, might arife from the  difference
of the  hemorrhoidal veffels  from which  the blood if-
fued.   But it appears to me, that  hardly in any  cafe
we can diftinguilh the veffels from  which the blood
flows ;  and that the frequent inofculations, of both
the arteries and veins which belong to the lower  ex-
tremity of the rectum, will render the effe£ts  of the
hemorrhagy nearly  the  fame,  from whichfoever  of
thefe veffels the blood proceed.
                 DCCCCXXXV.
   In dcclxix. I have endeavoured to explain the man-
ner in  which a certain ftate  of the fanguiferous fyftem
might  give occafion to an hemorrhoidal  flux ; and I
have no doubt, that this flux may be produced  in that
manner.   I  cannot, however, by  any means, admit
that the difeafe is fo often produced in that manner, or
that, on its firft appearance, it  is fo frequently a fyf-
tematic affection,  as  the Stahlians have  imagined,
and would have us to believe.   It occurs  in  many per-
fons before the period of life at which the venous ple-
thora takes place ; it  happens  to  females,  in  whom
a venous plethora,  determined to the hemorrhoidal
veffels, cannot be fuppofed ; and it happens to both
fexes, and to perfons of all ages, from caufes which do
not affect  the fyftem,  and  are manifeftly  fuited to
produce a topical affection  only.
                DCCCCXXXVI.
   Thefe caufes of a topical affection arc, in the  firft
                     '                      place, 
OF   PHYSIC.
  place, the frequent voiding of hard and bulky feces,
  which, not only by their long ftagnation in the rectum,
  but efpecially when voided, muft prefs upon the veins
 ^of the anus, and interrupt the courfe  of the blood  in
  them.   It is for this reafon that the; difeafe happens  fo
  often to perfons of a flow  and bound  bell v.
                   DCCCCXXXVII.
    From thecaufcs juft nowmentioned, thedifeafe hap-
  pens  efpecially to perfons liable  to fome degree of a
  prolapfus ani.   Almoft every perfon in voiding faeces
  has the internal coat of the rectum more or lefs pro-
  truded without the body ; and this will be to a greater
  or Icffer degree, according as the hardnefs and bulk of
  the faeces occafion a greater  or  leffer effort or preflure
  upon the anus.  While the  gut is tl us puflied out, it
  often happens that the fphincter ani is contracted before
  the gut is replaced ; and,  in confequence thereof, a
'  ftrong conftriction is made,  which preventing the fal-
  len-out gut from being replaced;  and at the fume, time
  preventing the return of blood from  it, occafions  its
  being confiderally fwelled, and its  forming a tumid ring
  round the anus.
                   DCCCCXXXVIIL
    Upon the fphincter's being a little  relaxed, as it is
  immediately after its ftrong contraction, the fallen-out
  portion of the gut is commonly  again taken within the
  body; but by the frequent repetition of fuch an accident,
  the fize andfullnefs of the ring formed by the fallen-
  out gut, is  much  increafed.  It is  therefore moreflow-
  ly and difficultly replaced ; and  in this confifts the
  chief uneafinefs of hemorrhoidal perfons.
                  DCCCCXXXIX.
    As the internal edge of the ring mentioned,  is ne-
  ceffarily divided by clefts, the whole often affumes the
  appearance of a number of  diftinct fwellings ; and it
  alfo frequently happens, that fome portions of it, more
  confiderably fwelled than others,  become more pro-
                                           tuberant, 
43°
PRACTICE
tuberant, and  form thofe fmali tumours more ftri&ly
called Hemorrhoids, or Piles.
                x  DCCCCXL.
  From  confidering  that the preflure of faeces, and
other caufes interrupting the  return of venous blood
from the lower extremity  of the rectum, may operate
a good deal higher up in the gut than that extremity,
it may be edily underftood that tumours may be form-
ed within the anus ; and probably it alfo happens, that
fome  of the tumours  formed without the anus, as in
dccccxxxix. may continue when taken within the bo-
dy, and even be increafed by  the caufes juttnow men-
tioned.  It is thus that 1 would explain  the production
of internal  piles, which, on account of their fituation
and  bulk, are not protruded on the perfon's going to
ftool, and  are  often, therefore, moie  painful.   The
fame  internal  piles are more efpecially  painful,  when
affected by the hemorrhagic effort defcribed in dccxlv.
and dcclxix.
                   DCCCCXU.
   The production of piles is particularly illuftrated by
this, that pregnant women are frequently affeded with
them.  This is to be accounted for,partly from the pref-
fure of the uterus upon the rectum,  and  partly from the
coftive habit to which pregnant women are ufually lia-
ble.   I have known many inftances of  piles occurring
for the firft time during the ftate of pregnancy ;  and
there are few women  that have borne children who are
afterwards  entirely free from piles.   The  Stahlians
have commonly aliened, that  the male fex is more fre-
quently affected with this difeafe than the female ; but
in this country I have conftantly found it otherwife.
                  DCCCCXLII.
   It is^ commonly fuppofed, that  the  frequent ufe of
purgatives,  efpecially of thofe of the more acrid kind,
and  more particularly of aloetics, is apt to produce the
hemorrhoidal affection ; and as thefe purgatives ftimu-
                                              late 
OF  PHYSIC.
43»
 late chiefly the great guts,  it feems fufficiently proba-
 ble that they may excite this difeafe.
                   DCCCCXLIIL
   I have now mentioned feveral caufes which may pro-
 duce the hemorrhoidal tumours and flux as a topical
 affection only ; but muft obferve farther, that although
 the difeafe appears firft as a purely topical affection, it
 may, by frequent repetition, become habitual, and there-
 fore may become connected with the whole fyftem, in
 the manner already explained, with refpecft to hemor-
 rhagy in general, in uccxlviii.
                  DYCCCXLIV.
   The doctrine now referred to, will, it is apprehended,
 apply very fully to the cafe of the hemorrhoidal flux;
 and will the  more readily  apply, from the perfon who
 has been once affected being muchexpofed to a renew-
 al of the caufes which firft occafioned the difeafe ; and
 from many perfons being much expofed to a congefti-
 on in the hemorrhoidal veffels, in confequence of their
 being often in  an erect pofition of the body, and in an
 exercife which pufhes the blood into the depending
 veffels,  while at the fame  time the effects of thefe cir-
 cumftances are much favoured by the abundance and
 laxity of the cellular texture about the rectum.
                  DCCCCXLV.
   It is  thus that the hemorrhoidal flux is  fo often ar-
 tificially rendered an habitual  and fyftematic affection ;
 and I am perfuaded, that it is  this which has given oc-
 cafion to the Stahlians to confider the difeafe as almoft
 univerfally fuch.
                   DCCCCXLVI.
   It is to be particularly obferved here, that when the
 hemorrhoidal difeafe has either been originally,  or has
become, in the manner juft nowexplained, a fyftematic
 affedion, it then acquires a particular connection with
the ftomach, fo that certain affections there excite the
   t                                 hemorrhoidal 
432.          PRACTICE
hemorrhoidal difeafe, and certain ftates of the hemor-
rhoidal affection excite diforders of the ftomach.
-   It is perhaps owing to this connection, that the gout
fometimes affects the rectum.  See dxxv.


           .«.<..<..«••<■•<•■<■•< ■<-<-<^^>4-^,>">">'>">">">">'>">">"


               SECT.    II.


  OF THE CURE OF HEMORRHOIDAL AF-
                   FECTIONS.


                 DCCCCXLVII.
   Almost at all times it has been an opinion amongft
phyficians, and from them fpread amongft the people,
that the  hemorrhoidal flux is a  falutary  evacuation,
which prevents many difeafes that would otherwife have
happened ; and that it  even  contributes to give long
life.  This opinion, in later times, has been  efpecial-
ly maintained by Dr. Stahl, and his followers ;  and
has had a great deal of influence upon the practice of
phyfic in Germany.
                DCCCCXLVIII.
   The queftion arifes with  refpect to hemorrhagy in
general, and indeed it  has been exiended fo far by the
Stahlians.  I have accordingly confidered it as a ge-
neral queftion (dcclxvii—dcclxxx ) but it has been
more efpecially agitated with regard to the difeafe now
under our  confideration :  And as to trfi-., although I
am clearlv of opinion that the  hemorrhois may take
place in confequence of the general ftate of the  fyftem
(dcclxix,) or, what is ftill more  frequent, that by re-
petition  it may become connected with that general
ftate  (occccxlui.) and in  either cafe cannot bf fup-
                                           preffed 
OF  PHYSIC.
433
preffed without great caution ; I muft beg leave, not-
withftanding this,  to maintain, that the iirft i,  a rare
cafe ;  that generally the difeafe firft appears as an af-
fection purely topical (dccccxxxv.—dccccxlii.), and
that the allowing it to become habitual is never proper.
It is a nafty difagreeable difeafe, ready to go to excefs,
and to be thereby very hurtful, as well as fometimes
fatal.  At beft  it is liable to accidents, and thereby to
unhappy  confequences.  I am therefore  of opinion.,
that not only the firft approaches of the difeafe  are to
be guarded againft, but even that,  when it  has  taken
place for fome time, from whatever caufe it  may have
proceeded,  the flux is always to be  moderated, and
the neceffity of it,  if poffible,  fuperfeded.
                 DCCCCXLIX.
  Having delivered thefe general rules, I proceed to
mention more  particularly, how the difeafe is  to  be
treated, according to the different circumftances  under
which  it may appear.
  When we can manifeftly difcern the firft appearance
of the  difeafe to arife from  caufes acting upon the part
only,  the ftricteft  attention fhould be employed  in
guarding  againft the renewal of thefe caufes.
                     DCCCCL.
  One  of the  moft frequent of the remote caufes  of
the hemorrhoidal affection, is  a flow and bound belly
(dccccxxxvi.)  and this is to  be conftantly obviated
by  a proper diet*, which each individual's own  expe-
rience  muft direct; or, if the management of diet  be
not effectual, the belly muft be kept regular by fuch
medicines as may prove gently laxative, wuhout irri-
tating  the rectumf.   In moft cafes it will  be oFad-
  Vol. I.              3  I                 vantage

  *  Broths of all  kinds are proper in thefe cafes;  barley broth is
preferable to that  which  is made with rice.   Barley-grutl, with
prunes, is an excellent laxative broth.
  f The lenitive electuary alone may in many cafes be fufficYrt.
when given in the quancity of  half  an ounce  or fix drachrr.s.— 
43-^
PRACTICE
vantage to acquire a habit with  refpect to time,  and
to obferve it exactly.
                    DCCCCLI.
   Another caufe of hemorrhois to be efpecially attend-
ed to, is the prolapfus  or  protrufion  of the anus,
which is apt to happen  on a pcrfon's having a ftool,
(nccccxxxvu.)  If it fhall  occur to any confiderable
degree, and at the fame  time be  not eafily and imme-
diately replaced,  it moft certainly produces piles,  or
increafes  them when otherwife produced.  Perfons
therefore liable to this  prolapfus,  fhould,  upon their
having been at ftool, take great  pains to have  the gut
immediately replaced, by lying  down  in a horizontal
pofture, and preffing gently upon the anus, till the re-
duction fliall be completely obtained.
                    DCCCCL1I.
   When the prolapfus of which I fpeak, is occafioned
only by voiding  hard and bulky taeces, it  fliould  be
obviated  by the  means mentioned in dccccl.  and
may  be thereby avoided.  But  in  fome perfons  it is
owing to a laxity of  the rectum  ; in which cafe  it is
often moft confiderable  upon occafion of a loofe ftool:
and then the difeafe is   to be treated  by aftringent*,
as well as by proper artifices for preventing the falling
down of the gut.
                    DCCCCLIII.
   Thefe are the means to be employed upon the firft
                                         approaches

The following formula may  be  added where  greater coftivenefs
prevaib.
            &. Sal. Nitri.  fn.
              Pulv. jalap,  -fu
              Elect. Lenitivi. £i.
              M. f. Elect, cujus fumat q. n. m. pro re nata.
   * Aftringents may be ufed both internally and externally.  The
internal aftringents are Alum,  Kino, Terra Japonica, &c.  But in
cafes of hemorrhoids from laxity,  nothing produces a better effect,
than the frequent applYatLa  of pledgets, dipped in a ftrong infufi-
on of ^ei'ls, or Oak-baik. 
              O  F  P H  Y S  I  C.           435

approaches of the hemorrhoidal affection; and when
from neglect it fliall have frequently recurred, and
has become in  fome meafure eftablifhed, they are no
lefs proper.   In the latter cafe, however, fome other
means  are alfo  neceffary.  It is particularly proper to
guard  againft a plethoric  ftate  of the body; confe-
quently, to avoid  a fedentary life, a full diet, and par-
ticularly intemperance in the  ufe of ftrong liquor,
which, as I fhould have obferved before, is, in all caf-
es of hemorrhagy, of the greateft influence in increaf-
ing the difpofition to the difeafe.
                   DCCCCLIV.
  I need hardly repeat here,  that exercife of all kinds
muft be a chief means of obviating and removing a
plethoric ftate of the body ; but upon occafion of the
hemorrhoidal flux immediately  approaching, both
walking and riding, as increafing the determination
of the blood into .the hemorrhoidal veffels,  are to be
avoided.   At other times,  when no fuch determina-
tion has been already formed, thofe modes of exercife
may be very  properly employed*.
                   DCCCCLV.
  Col.d bathing is  another remedy that may be em-
ployed to obviate  plethora, and pi event hemorrhagy ;
but  it is to be ufed with caution.  When the hemor^
rhoidal flux is approaching,  it may be  dangerous to
turn it fuddenly afideby cold  bathing : but during the
intervals of the difeafe, this remedy may be  employed
with advantage ;  and in perfons  liable to a prolapfus
ani, the frequent wafhing of the anus with cold water
may be very ufeful.
                   DCCCCLVI.
  Thefe  are  the means for  preventing the recurrence
                    3 I 2                      of

  *  It is doubtful whether riding is ever advifable in any period  of
t-he difeafe.  Riding frequently produces piles, in pci ions not in the
i-.ml iredifpofed tj them. 
436          PRACTICE

of the hemorrhoidal flux ; and in all cafes, when it is
not immediately approaching, they are to be employ-
ed.  When it has actually come on, means are to be
employed for moderating it as much  as poffible,  by
the peifon's lying in a horizontal pofition upon a hard
bed; by  avoiding exercife in an erect pofture ; by  uf-
ing a  cool diet; by avoiding  external  heat;  and by
obviating the iiritation of hardened faeces by the ufe of
proper laxatives,  (dccccl.) From what has been faid
above, as to the being careful  not to increafe the de-
Termination of the blood into the hemorrhoidal veffels,
the propriety of thefe meafures muft fufficiently appear;
and if they were not fo generally neglected, many per-
fons would efcape the great trouble,  and various bad
confequence s, which fo frequently refult from this dif-
eafe.
                  DCCCCL VII.
   With refpect to the further  cure of this difeafe, it is
almoft in two  cafes  only  that  hemorrhoidal perfons
call for the  affiftance of the  phyfician.  The one is.
when the affection is accompanied with much pain ;
and of this there  are two cafes, according as the pain,
happens to attend the external or the internal piles.
                 DCCCCLVIII.         .   •
   The pain of the external piles arifes efpecially when
a confiderable protrufion of the rectum has happened;
and when, continuing unreduced, it  is ftrangled by
rhe conftriction of the fphincter; while, at the fame
time,  no bleeding happens, to take off the fwelling of
the protruded portion of the inteftine.   Sometimes an
inflammition fupervenes,  and greatly aggravates  the
pain.   To relieve the pain in this cafe, emollient fo-
mentations and  poultices are fometimes of fervice ;  but
a more  effectual  relief is to be obtained by applying
leeches to the tumid parts.
                  DCCCCUX.
   The other cafe in which hemorrhoidal perfons feek
                                         affiftance, 
              OF  PHYSIC.           437

sififtance, is that of exceflive bleeding.  Upon theo-
pinion fo generally received of this difcharge being fa-
lutary,  and from the obfervation that upon the dif-
charge occurring, perfons have fometimes found relief
from various diforders, the moft part of perfons liable
to it are ready to let it go  too  far;  and indeed the
Stahlians will not allow it to be a difeafe, unleft when
it has actually gone to excefs.   I am,  however, well
perfuaded, that this flux ought always* to be cured as
foon as poffible.
                   DCCCCLX.
  When the difeafe occurs as a purely topical  affec-
tion,  there can be no doubt of  the propriety of this
rule; and, even when it has occurred as a critical dif-
charge  in the cafe of a particular difeafe, yet when
this difeafe fliall have been entirely cured and remov-
ed,  the  preventing  any return  of  the hemorrhois,
feems to be both fafe and proper.
                   DCCCCL^I.
  It is only when the  difeafe arifes from a plethoric
ftate of the body, and from a  ftagnation of blood  in
the hypochondriac region, or when, though originally
topical,  the difeafe, by frequent repetition, has be-
come habitual, and has thereby acquired a connec-
tion with the whole fyftem,  that  any doubt can arife
as to the fafety of curing it entirely.   Even in thefe
cafes, however, I  apprehend it  will be always proper
to moderate the bleeding ; left by its continuance or
repetition, the plethoric ftate of the-body, and the
particular determination of the blood  into the heruor-
rhoidal veffels, be increafed, and the' recurrence of the
difeafe, with all its inconveniences and danger, be too
much favoured.
                  DCCCCLXII.
  Further, even in the cafes ftated (dcccclxi.) in  fo
far as the plethoric ftate of the body, and the tendency
to that ftate, can be obviated and removed, this is al-
                                             ways 
438             PRACTICE

ways  to  be diligently attempted;  and if it can be
executed  with fuccefs,'  the flux may be entirely fup-
preffed.
                 DCCCCLXIII.
  The Stahlian opinion, that the hemorrhoidal flux is
only in excefs  when it occafions great debility,  or a
leucophlegmatia, is by no means juft ; and it appeais to
me, that  the fmalleft approach towards producing ei-
ther of thefe, fhould be confidered as an excefs, which
ought to be prevented from going farther.
                 DCCCCLXIV.
  In all cafes,  therefore, of excefs, or of any approach
tovvards it, and particularly when the difeafe depends
upon a prolapfus ani, (dccccli.) I am of opinion, that
aftringents, both internal, and external, may be fiifely
and properly employed ; not indeed to  induce an im-
mediate and total fuppreffion, but to moderate the he-
morrhagy,  and by degrees to fupprefs it altogether,
while at the fame time meafures are taken  for remov-
ing the neceffity of its recurrence.
                 DCCCCLXV.
  When the  circumftances (dccccxlvi.)  marking a
connection between the hemorrhoidal affection and the
ftate of the ftomach occur, the meafures neceffary are
the fame as in  the cafe of atonic gout.
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