m.r:-:- $P -■■mm -—^0-v' ^i$$ u ■■%■:. #*f°V, Kb£L '4^ V Yin T • Medical SKETCHES: i N TWO PARTS. tiy JOHN MOORE, M. D. ---TfT S I CJ&CUS ITER MOtfSTRARE VELIT. £" J'JBRAFV » Hor. The just American Edition. Printed at Providence (R. IJJand) by Carter and Wit- kinson, and fold at their Bopk and Stationary-Store, oppofite the Market. 1794, '"3 K i n.-i >! ,U .M ,H >!. ' ,,p'r.''- .'ST. M^r - -■ ... ^......-j .w\ .V. ) ?c h-. Vi" • 1» ^ .• guHn:. , :.iol;' x«i-; WILLIAM LOCK, Efq; DEAR SIR, f' - THE Firft Part of this Work was begun at your feat of Nbrbury Park, where Nature and Art are "fo finely combined, and the charms of fo- cial intercourfe and retirement fo happily united. It was natural, therefore, to think of infcribing the work I was then planning, to the perfon whom fo many circumftances, and all the fur- rounding obje&s, prefented to the mind. And, as xhzfubje&s of thefe Sketches are highly interefting to humanity, thofe who have the happinefs of your ac- quaintance will readily perceive the propriety of addreffing them to you. By this teftimony of my regard, ' however, I am confcious that I faeri- es * fice iv DEDICATION. fice your diflike of public attention to the iifdulgence of my own pride, in fubfcribing myfelf, with the great- eft fincerity, DEARSIR, Your affe&ionate friend, and humble fferyant, J. MO O R E, Clifford-Street, \ . April 15, 1786,-5 PR E F A *C E, lH E S E Sketches were originally un- dertaken on the following occafion : A near relation of mine, who has the, jufteft claims to my affec- tion and efteem, had the health of a confiderable de- tachment of the footTguards entrufted to his care at a very early period of life. They were ordered to reinforce the army at that time in Virginia, un- der the command of Lord Cornwallis. Anxious ta perform that duty with all the efficacy in his pow- er, he requefted me to give him in writing a few obfervations and general rules relative to the nature and treatment of the difeafes moft likely to occur daring the pafTage, and while the party remained te-. parated from the army. I accordingly drew up a hafty compendium or practical treatife on fundry difeafes, beginning with fevers, adding fuch directions as I imagined might en- able him to decide in various exigencies with great- er promptitude and accuracy. Since his return to England I have bellowed fome pains in improving feveral of thofe rude draughts, particularly thofe up- on fevers, which from a few general ideas and detach- ed pra&ical hints have fwelled to the fize in which. they now appear. The obfervations/with which I furnifhed him on fome other difeafes are alfo confiderably enlarged ; Whether I (hall ever hazard their publication, is a point on which I am as yet undetermined. The vl -PREFACE. The Seven Sketches, which form the. Firft Part of this Work, were afterwards compofed upon other oc- caftoBS. Tfyey arc attempts to- explain in familiar laftgtrage certain procefles continually carried on in the animal ceconomy, which are not only curious in themfelves, but eflential to life; and furely as in-* terefting to mankind as any other part of natural phi- lofophy. They may therefore be ccaifidered as no improper intre^a^lkm to-the PradHcaf Eflays which fbikiw; but which,1 after all, I prefent to the Public wish great diffidence, being eonfeious rljat dogmatic confidence in owr ow» opinions never fhuicJs upon more flippery ground, or 19 moreexpofed to ridicule, thau when thole opinions regard the art of medicine ? CONTENTS. mammmm PARTTHE FIRST, SKETCH Pag* I, On the practice of medicine 1 II. Of digeftion 34 m. The circulation of the blood 4<* IV- Of the fecretion or feparation fluids from the blqod of particular 54 v. Abforption 77 VI. Refpiration 90 vn- The nervous Jyflem loo PART tHE SECOND, I. Of fevers in general \ 33 EL. Of inflammatory fevers 168 HI. The remittent or mixed fever 185 IV. Nervous fever 215 MEDICAL > o v- * ,A •. u tv ■ pole, is not eafy, nor fo common a thing as is ufually believed. Wre hear people every day, in talking of their phy- fician, ufe language of this kind—" I own he is a very- weak, filly man, but he has had a great deal of ex- perience ;"—or, u I grant you, he is an oftentatious, parading coxcomb,—next to a fool indeed in other re- flects, but he is an excellent phyfician." They feem to think that common fenfe diverts a man from the ftudy of his profeffion, like the French lady, who: be- ing told that her phyfician had not common fenfe,, re- plied, " So much the better; how can a man, who fpends his time in fludying common lenfe, learn medi- cine, Monfieur Abbe ?—He who talks Greek like. Ho- mer, does not know how to dance." There never was a greater abfurdity, however, than to fuppofe that a man of an uncommonly weak underftanding can be a good phyfician; he may in- deed have a great deal of experience; he may poffi- bly be even a man of learning ; but without natural acutenefs and good fenfe there never was a good phy- fician fince the world began; the thing is literally impofiible. What is the bufmefs of a phyfician:—Why, to apply his knowledge and experience to the cure of difeafes, in which he muft be directed by that degree of underftanding he poffefTes ; and if he is deficient in fenfe, his experience will prove a fource from which he will draw falfe inferences ; ajid learning, if MEDICAL SKETCHES. 9 he has it, will make him more prefumptuous, and lead him farther into error. How many practitioners do we meet with, who are convinced that fevers are cured by the draughts im- pregnated with contrayerva root and cardiac con- fection, with which they teafe the patient every two or three hours :-—And how are they convinced of this ? They will anfwer, from experience ; for the drugs not having actually killed the patient, but only re- tarded his cure, he recovers at length, notwithstand- ing all the draughts he has been obliged to fwallow ; the fagacious doctor imputes the cure to his own pre- scriptions, and perhaps publifhes the cafe for the benefit of pofterity. I have known a very well-meaning man miftake a fprefcription of feeble efficacy for one of the moft pow- erful febrifuges that ever was contrived ; he had order- edit probably at firft when the difeafe be^an to take a favourable turn, or immediately before a happy criiis took place, and imputed the whole effect to the pre- fcription. He gives the fame medicine in another infra nee or two, on the very day the fever commences ; it is an ephemera*, and he is confirmed in his opinion of the power of the medicine, he proclaims it the happieft i combination that ever was invented, which by a kind of elective attraction draws the morbific matter to it- felf, and then hurries it out of the body: After a lew inftances of this kind it is impoilible to open his eyes ; he imputes the unfortunate termination of other cafes to fome latent caufe which oppofed the ialutary effects of his favourite medicine. That any man, partrcular- ly a man of letters, and bred to the j>ivcrit e of phylic, mould be fo eafily deceived, could i'ecuvt\y be believ- ed, if we did not fee fuch examples frequently, aid if we did not know with what partiality mankind in general * A i'ever that begins and ends in the cmr.iJT: of one d'*y. JO MEDICAL SKETCHES. general view what they confider as their own inven- tions, and with what complacency they embrace ,, ©pinions which flatter their own judgment. < p Another thing which prevents fome practitioners from knowing the futility of their own prefcriptions, .and what nature left to herfelf can do, is, that they sever leave nature to herfelf. The inftant they are called, they fall to work with their draughts, juleps, and apozems, and perfevere with unrelenting affiduity till the difeafe terminates one way or other ; if the patent recovers, the medicines get the credit; if lie dies, the difeafe is thought to have been incurable. The being teafed to fwallow drugs, is a fpecies of dlftrefs to which the rich are more expofed than the poor, provided the latter keep out of hofpitals. Na- ture is allowed to cure as many of them as ftie can, and Art being little folicitous of feducing fuch patients out of her lifter's hands, they generally have real need of medicines before they are preffed to take them. But a phyfician whole practice lies among the higheft ipheres of life, if it amounts to three thoufand pounds yearly, is fuppofed, at a moderate computation, to receive two thoufand five hundred of that fum for prefcribing for imaginary complaints, or fuch as would have difappeared fully as foon had they been left to themfelves. But this ought not to be imputed as a crime to the phyfician ; if an old-lady cannot dine with comfort till he has felt her pulfe, looked at her tongue, and told her whether her chicken fhould be roafted or boiled, it is reafbnable he fhould be paid for his trouble. Tl|e difference between a good phyfician and a bad ore is ce?-£nmJy very great; but the difference be- tween a good phyfician and no phyfician at all, in ma- r,y cafes, is very little. If during the courfe of the common epidemic dif- rafes which occur in this ifland every fprino- and au- tumn, MEDICAL SKETCHES. If tumn, two hundred patients were taken promifcuouC- ly, and one half delivered to the care of the faculty to. be treated according to art; that is, "as private pa- tients by whom they are fee'd every time they pre- fcribe ; and the other half delivered to the care of nurfes, inftructed to give them no phyfic whatever, but merely cooling drinks, and fuch light and fimple food as the patients' appetites might lead them to wiffe for, I am convinced the world would be'a good deal furprized at the refult of the experiment. It is aftonifhing how exceedingly apt medical prac- titioners of every denomination are to impute to drugs that falutary effect which proceeds from the univerfal influence of another caufe, which caufe is ' that inherent bias obfervable in the animal ceconomy to reftore health; for as the furface of a lake which clearly reflects the fky and hills and verdant fcenes around its borders, when it is difturbed by the falling of a ftone, immediately endeavours to recover its fcattered imaged and reftore, them to the fame beauteous order in which they are wont to appear ; in like manner when the natural courfe of the animal ceconomy is interrupted and diftur.bed by difeafe, the powers of the conftitution. are continually endeavour- ing to reftore its organs to the perfect ufe of their functions, and to recover its. ufual vigour and fe- renity. This vis medicatrix nature, this conftant tendency in nature to overcome difeafe and reftore health, was obferved by the father of medicine ; and a fen- timent to the fame purpofe is the very firft exprefl- ed by Sydenham in his ineftimable work, %nd is acknowledged by all candid and difeerning practi- tioners, to have a powerful influence in the cure of difeafes. Indeed I am inclined to believe that phyficians, in proportion to their candour and dif- eernment, acknowledge and rely upon this power 12 MEDICAL SKETCHES. in nature ; and in proportion to their felfifhnefs and weaknefs, impute every recovery to their own pre- fcriptions. •• A judicious and 'experienced phyfician ccnfiders hinifelf merely as an affiftant to nature ; when her force feems to be fufficient, he leaves her to perform the cure ; when fhe feems] too feeble, he af- fifts' her by every means in his power- His pa- tients, therefore, are fure, in the firft place, of all the aid which1 nature can give them ; and as often as it is requifite, if art has difcovered or in- vented any thing to alleviate or remove their com- plaints, they are fure ofthatalfo. • Whereas a phyfician who has an overweening conceit of his own powers and thofe of his art, is apt, by unneceffary and officious attempts, to inter- rupt the falutary procefs of nature, and like the inconfiderate man who would plunge his hands into the difturbed lake, in order to affift its efforts to regain its loft tranquility, he oray helps to increafe the diforder and confufion he means to remedy. If well-meaning practitioners, who really wifh to do every thing in their power for the recovery of their patients, and whofe greateft errors proceed from thinking more in their power than-there is, can do fo much harm ; how much greater mif- chief is to be dreaded from the number of cun- ning, unprincipled, interefted practitioners in medi- cine, who, without being deceived themfelves, im- pofe upon the weaknefs and credulity of others?. ThofL generally are men of fuperficial knowledge, | of a 'oniiderable degree of natural fhrewdnefs, and Wjf fuch' a portion of impudence, as fets them above embarraffment, even when their ignorance and fraud are made manifeft. Such men ftudy the foibles of mankind, fatten on the fears and hope:; and caprices of the rich valetudinarians, MEDICAL SKETCHES. *3 valetudinarians, and fqueeze the laft lingering fhil- ling out of the weakened hands of the poor. There is a kind of quackery which fome people feem to invite ; they cannot be fully convinced of their phyfician's fkill and attention without it.— Proofs of this are to be met with every where: In a certain city on the continent I happened to call upon a lady, who, on account of a pain and flight fwelling in her ancle, had confulted a well-known phyfician, who, although he is accufed by his bre- thren of much charlatanical parade in his practice, commands the admiration of his patients in a more fupreme degree than any doctor I was ever ac- quainted with. He had juft left her when I en- tered : She told me he had ordered a poultice of bread and milk to be applied to the part, and then giving her watch to her maid, fhe defired her to take particular care that the poultice fhould be boiled exactly four minutes and a half for fuch were the exprefs orders of Monfieur le Docteur. On my exprefling fome furprize at the minutenefs of thefe orders, fhe exclaimed, u My God, what pre-^ cifion ! he calculates like an angel!" The fortunes that have been made, and are ftill making, by men of this defcription, in the cities of London and Paris, and by the venders and in- ventors of noftrums or fecret and infallible cures, are quite aftonifhing. I mention Paris and London particularly, becaufe, though other towns are, in fome degree, expofed to the fame evil, yet the re- putation of thofe pretended cures is always higheft where the field for impofition is wideft, and the chance of detection leaft. This I take to be the cafe in the largeft and moft populous cities, where phyficians as well as nof- trums without merit have a far better chance of be- ing efteeme4. than in fmaller cities, where the real va- be M MEDICAL SKETCHES. lue of each muft be known to a greater proportion of the inhabitants. Accordingly we find that hard- ly any of thofe vaunted medicines of the capitals fupport their reputation for any length of time in the provincial towns, becaufe the citizens are all in fome degree acquainted with each other, and with the circumftances of each cafe in which the medicine is ufed ; its real effects, therefore, are more fully known. Whereas, in fuch a town as London, a fair and candid inveftigation of the merits of a nof- trum is as difficult as it would be fruitlefs ; for if the miftakes and forgeries brought in its fupport fhould be detected and publifhed to-day, frefh evidence of new miracles would appear in the papers to-morrow, and the minds of the multitude would be divided. When modeft reafon pleads on one fide, and affum- ing ignorance on the other, we may eafily guefs which will have the majority. Befides, it is to be remembered that no man has filch an intereft in attacking ts the noftrum-monger has in defending the character of his fecret ; accord-? ingly, moft people, after they are convinced, either from their own experience, or from that of others, of the futility of the medicine, give themfelves no farther trouble about it, but leave it to their neigh- bours to make the fame enquiry or experiment, if they pleafe. This is precifely what the quack wifhes, and if numbers do make the experiment, he gains his ob- ject ; when his fortune is made, the reputation of his drug will give him no more concern. But*in cafe by any accident its character fhould be blafted before he has accomplished his object, he then me- tamorphofes his infallible pills into infallible drops, gets their praifes founded, and their cures attefted in the newspapers, and very poflibly the drops will finifh what the pills began. It MEDICAL SKETCHES. lS It will be faid that the atteftations of cures arc not always forgeries, for we fometimes find people of character allow their names to appear in fujv port of the efficacy of quack medicines. To this it may be anfwered, in the firft place, that fuch inftances are very rare, in comparifon of the number of obfcure and fufpicious evidences which are brought on fuch occafions ; and we muft recollect befides, that a good character, though it fcreen a man from the fufpicion of being the ac- complice, yet it cannot always fave him from be- ing the dupe of impofition. In difeafes* which are liable to fudden tranfitiors from extreme pain to perfect eafe, and where there are long intervals between the paroxyfms, it i-s not very difficult to perfuade the patient, that he is en- tirely indebted to the noftrum for that abatement in his complaint which takes place at the time 'fee ufes it: Then gratitude to a fuppofed benefactor naturally prompts him to do every thing in his pow- er to ferve him ; and fometimes in the warmth of his zeal, efpecially when difputing with unbelievers, he is hurried into affertions concerning the effects of the medicine, which in cooler moments he would not have made. f The valetudinarian is often as fond of enumerat- ing his complaints, as a foldier is of talking over his battles. ^ And although he feldom finds a liftenen who with a greedy ear devours his difcourfe, yet like the latter he tries to create an intereft; an<* to melt the heart by running through all his difafl- rous chances, his moving accidents and hair-breadth 'fcapes*. It is his hint alfo to fpeak of fome won- der-working noftrum, for it is a thoufand to onr but he has fome favourite of this kind, which he ftrongly recommends, and having once recommend- ed, * Othello, i6 MEDICAL SKETCHES. ed, he becomes a party concerned in its caufe, he reads with pathos and energy every advertifement in its favour, he thinks his own truth and honour connected with the reputation of the medicine he praifes, and imagines he gives the ftrongeft teftimo- ny of his affection to his friends when he teafes them to fwallow a little; it is in vain they affure him they are in perfect health. " This drug can " be taken with fafety at all times ; if the difeafe " has arrived before it is taken, it removes it; if " it is only on the road, it prevents its arrival." By fuch means, many remedies which are fecrets have been brought into vogue in the courfe of our remembrance ; all of them attained a temporary reputation, which none of them could fupport for any length of time ; they were raifed to notice by the breath of impofture'and the voice of credulity,^ they funk into darknefs by the intrinfic tendency of their nature. One medicine muft be excepted from the neglect and contempt due to fo many others.—Dr. James' fever powder has for a number of years enjoyed a con- fiderable degree of reputation in this ifland, and in the colonies connected with'it, although in the continent of Europe it is little ufed. In an hofpital where I had the chief care of the fick for feveral years, I took frequent occafion to compare the powers of this medicine with thofe of antimony* James' powder being generally fuppofed to confift of a preparation of antimony and teftaeeous earth, or fome other infipid powder, to difguife it. The anti- monial with which I brought it moft frequently into comparifon, was emetic tartar, with whofe operation and effects thofe of the powder feem to have a great' refemblance ; whether they are exhibited in full dofes, fo as to excite vomiting and purging; or in fmaller df<^, when they produce only an he.reafed perfpira- tion, MEfrlCAL SKETCHES. 17 tton, a flight degree of naufea; and if the fmall dofes «re repeated at proper intervals, fome evacuation by ftool. On the firft threatening of fever, a full dofe of James' powder operating at once as an emetic, fudori- fic, and cathartic, feems fometimes entirely to throw off the difeafe, and leaves the patient quite cool and free from fever ; and in cafes where the fever is form- ed, arjd has continued fome time before the powder is adminiftered, it frequently diminifhes the force of the fever ; and ufed in fmall doles as an alterative, is of fervice during the courfe of the fever. All thofe effects are alfo produced by proper dofes of tartar emetic, exhibited in the fame manner. The principal difference feems to confift in this, that a full dofe of* tartar emetic operates, with more force and certainty, firft as an emetic, and afterwards as a pur- gative, than a full dofe of the powder, but the latter with moft certainty as a fudorific ; and it often appears to be as efficacious in removing or abating the feverifh fymptoms, although it operates with more mildnefs than the former. When ufed as an alterative in fmall dofes at con- siderable intervals, the fourth of a common dofe of the powder is lefs apt to create a naufea, or to excite vomiting, than a fingle grain of tartar emetic diffolved in a faline draught; in other refpects their effects feem fo fnnilar, that in fevers where I think antimony proper, whether at the beginning or during the pro- grefs, if the patient or his relations have a predi- lection for James' powders, and feem felicitous that he fhould have it, I very chearfully comply with . their wifhes. It will be laid, that if a full dofe of James' pow- der is given as above mentioned, at the firft threatening of a fever, although after its operation the patient fhould be found perfectly cool and free from fe- G ver, i8 MEDICAL SKETCHES. ver, that is no abfolute proof that the medicine re* moved or prevented one, becaufe, very poffibly,- no fever was about to form ; for there is no certain criterion by which we can diftinguifh the firft fymp- toms of a fever, which will laft but one day, from thofe of one which will prove tedious and danger- ous ; fo that James' powder, when given at the firft attack of fuch diforders, may get the credit of curing many complaints, which would have gone off as foon, and more eafily, of themfelves. This obfervation is certainly juft, but it is no jufter when ftated againft James' powder, than againft antimony, or any other medicine whatever. Some phyficians have fuch an averfion to every com-pofition, the materials of which are kept fecret, that they will on no account, and in no cafe, order them ;—they imagine fuch condefcenfion beneath the dignity of the profeflion. Their diflike is, in general, well founded ; but I cannot help thinking there may be particular cafes in which there is more wifdom in the breach than the obfervance of this general rule ; and as for the dignity of the pro- felflon, its chief dignity certainly conilits in curing. difeafes in the ipeediefl way poilible. In cafes where the ufual practice generally fails, or in which a medicine whofe composition is kept fecret has the reputation of acting with more effi- cacy than the known prefcriptions, or even when the patient or his friends have a ftrong defire to try a reticular, medicine, which we know has been iiicd in a thoufand inftances with iafetyy in any of thofe cafes, ohftinately to oppoie the trial, merely becaufe we do not know the precile ingredients of which it is compofed, would, according to my judgment, be unreafonable. For let it be remem- bered, that although we have not a certain know- ledge of the particular ingredients of the medicine in, MEDICAL SKETCHES. to in queftionj yet we have a knowledge of its man- ner of operating, and its ufual effect; this is the moft material knowledge the phyfician can have. What more in reality does he know of Jefuits bark, rhubarb, or any other uncompounded medi-1 cine I The firft is a medicine eonfifting of two or three ingredients, fecretly mixed together by a phy- fician of the name of James. The other two are medicines whofe component parts are ftill more fe- cretly, and in a manner lefs Underftood, combined and mixed together by nature ■. If then he pre- fcribes the latter from a knowledge of their effects only, he ought not to reject all trial of the for- mer, merely becaufe he is unacquainted with the par* ticulars of its combination. Nobody can approve lefs than I do of the prac* tice of keeping any prefcription fecret, which can be of public utility ; but I cannot think that the inventors' not acting in the moft liberal manner po£ fible, is a good reafon for preventing a patient's reaping the benefit of the invention. The enthufiaftic admirers of Dr. James' powder may confider what I have faid above as but cold praife :—Others, whofe authority is far greater than mine, will probably imagine I have gone too far, in putting it upon a level, in particular cafes, with any preparation of one of the moft powerful me- dicines in the whole materia medica. Be that as it mayr, what I have faid proceeds from conviction founded on experience ; however much therefore I am perfuaded of the worthleffhefs of noftrums in general, I thought it fair to diftinguifh this from others. I know it is often faid by the advocates of other noftrums ftill in ufe, that they are condemned from interefted motives only ; that phyficians, although fully fenfible of their efficacy, decry them with un- C 2 ceafmg Sf MEDICAL SKETCHED eeafi'ng induftry, left coming into imiverfal ufe, they fhould annihilate half the difeafes of mankind, and fpoil their trade. ' Phyficians, no doubt, have their fhare of that ufe- fui jealoufy of trade which prevails in this country ;, vet I fhould think it rather a violent fuppofition to imagine them capable of carrying that fpirit fo far, as to allow their fellow-creatures, their relations and friends, to perifli in torment, rather than re- commend what would give them fpeedy and cer- tain relief, merely becaufe the curs was not of their own manufacture. But I will not infift upon this argument, left I fhould offend thofe who are of a contrary opinion, and think a jealoufy of trade cannot be carried too far. Let us take the fuppofition therefore for granted, and admit that the whole faculty had en- tered into an agreement tbt ftifie the reputation of a difeovered cure for a difeafe, for which no cure was known before,—'the gout for example.. The plot would prove ineffectual: The influence of the whole faculty combined, and each individual ad- hering to the fpirit of the confederacy, could not prevent fuch a medicine from coming into univerfai ufe, not in this irland only, but, in lpite of all their jealoufy of trade, even- in Holland, and all other countries *. Ab * Sir George Baker has lately, in a very curious and in- ftruSive paper, mewed by what degrees the reputation of tlic Peruvlin Bark was eftabliflrcd iu Europe, in fpite of all I'.se prejudices and paffions it had to encounter, all of which iv has overcome, although it was fir II: introduced by the cafuat experience of an uncivilized people, fupported by a body of nun who are not phyficians, and never were popular, and its t;ies more particularly developed by a pcri'on to whom the phyficians of the time gave the name of quack.—Vide Medt* ... U Tm>.J'.iilo;;s ly the College of Phjpc;.vu} vol. iii. MEDICAL SKETCHES. ti An improvement in furgery indeed, however in- lerefting to humanity, might be kept down for a longer, time, if we could fuppofe fuch an improve- ment would be difcouraged by the gentlemen, of that profeffion ; for as important, operations feldom .occur, and when they do, are generally perform- ed in hofpitals, where the patient muft fubmit in all refpects to the fancy of the operators, fhould they, from obftiiiacy, pride, or any other unbecom- ing motive, oppofe the improvement, it would of courfe be greatly retarxled in its progrefs. But a thing fo eafdy tried as a medicine, , and which people in pain or in danger are fo eager to make trial ofr if it really poffefled the virtues fup- pofed, could not poffibly be for any considerable time withheld from general ufcu Every day, every hour, would add to its reputation; the beft ;attefued, fpontaneous evidence of cures would come from i'.ll quarters ; every grateful tongue would proclaim the virtues of the medicine ; thofe who talked of riof- rrums and quackery, would be biffed into filence; and the voice of falfehood and envy would be -drowned by the general fuffrage. The practice . Nothing 53 MEDICAL SKETCHES. Nothing can be more certain, therefore, than that all ufeful difcoveries, whofe pretenfions can be brought to trial, will, in time, make their way in every nation, unlefs indeed they are accufed of ftriking at the religion or government of the coun- try. In England they would make their way not- withstanding, or perhaps the fooner, by their ftrik- ing at both. It muft be acknowledged, that by the arts of fraud, impofture, and indefatigable puffing, very worthlefs drugs are fometimes railed to a reputation they do not deferve, in fhorter time than is required to bring an ufeful difcovery to the fame it highly merits ; but then time is fure to fupport, confirm, and eftablifh the latter, and gradually to fhake, weaken, and at length totally to overturn the former. A ftronger pro3f therefore needs not be given, that the vaunted noftrums of former times were undeferving of the character they enjoyed, than their having gradually fallen from eminence to neglect; whereas the virtues of Jefuits bark, mercury, and other valuable medi- cines, have become more and more manifeft; and we fee them daily extended to the relief of other complaints than thofe which at firft gave them repu- tation. The prowefs of fuch Herculean medicines as the two juft mentioned, are fufficient to exterminate all doubt, and eftablifh an univerfal reliance on their virtue in many defperate cafes ;-^-but without hinting at fecret noftrums or drugs, artfully cried up for felf- ifh purpofes, there are medicines univerfally known and in daily ufe, about whofe efficacy practitioners of the heft intentions are of very different opinions, and yet both thofe who think favourably of thefe me- dicines, and thofe who defpife them as ufelefs, de- clare' that they found their opinions upon expe* ritnee* The MEDICAL SKETCHES. 23 The explanation of this aenigma is, that the medi- cines in queftion, though their powers may on fome occafions be coniiderable, yet on others act very fee- bly, and in all cafes ilowly; by which means their virtues appear different, and fometimes are not dis- cerned at all, but are entirely denied by people who have different powers of difeernment, and who view them in different lights. It requires more natural penetration and attention than many people poffefs, or are willing to beftow, to determine the genuine effect of particular regimens or courfes of medicine. Befides natural acutenefs and fagacity, it requires the exact weighing of every concomitant and collateral circumftance which can promote,' retard, or prevent the effect of the medi- cine -at the time it is adininiftered. It is proper to make repeated trials, and on people of various confti- tutions. It is abfolutely requifite to have no favour- ite hypothefis, to be diverted of all partiality for or prejudice againft the medicine, and in fliort to have no view but the difcovery of truth. But when fuch investigations are begun by people already biaf$bd to one fide or the other, or when carried on carelefsly, we need not be furprized to find that the inferences are different, though all are faid to be equally drawn from objervation. But as hafty and fuperficial obfervation often con- tributes to raife the reputation of very foolifh pre- fcriptions, fo it fometimes tends to injure thofe of real utility. For the fame ftrength of underftanding which imputes falutary effects to the former, becaufe they do not always kill, will impute pernicious ones to the latter, becaufe they do not always cure. One declares the bark never agrees with him ; —another will fufter the moft racking pain, rather than fwallow any medicine, till he is allured there C 4 .is 24 MEDICAL SKETCHES. is no laudanum in it.;—and a third will in no cafe take mercury in any fhape or form. All thofe people affert, and are themfelves con- vinced, that thofe prejudices are wife conclufions> founded on the experience they have had of their own conftitutions ;—very poflibly thofe medicines have been given them on fome improper occafion ; or when their complaint was augmenting, ,,and could not be flopped as fbon as they expected: But nothing can be more rafli than to determine, becaufe a medicine does not prove immediately fuccefsful, or becaufe it has been ordered injudicioufly, that it is improper in every future fituation that can happen. •'•■»■■. It will be faid there ought to be great allowance made for the peculiarities of conftitutions ;—that there are antipathies not founded upon reafon, but which feem inherent in the conftitution, which, on certain occafions, mi^ft have great weight with the phyfician. Every thing of this nature ought do'ubtlefs to be duly weighed ; but I am greatly miftaken if there is any human body fo framed as to render it improper in every poffible cafe to give bark, or opium, or mer- cury. It frequently, happens that the medicine repro- bated by the prejudice of patients, is the only one which can give them effectual relief: Yielding.toiuch prejudices, therefore, is a more dangerous thing than many people are aware of, and the patient ought to be reaibned out of them without lofs of time, unlefs reafon fhould unfortunately happen to be a .thing which agrees with his conftitution ftill lefs than,any of thofe falutary mediqines to which he fliews fuch an averfion. While we admit, therefore, that accurate obfer- vations are our fureft guides, we muft keep in mind that carclefs and partial ones are as apt to lead to er^ ,ror as hypothetical reafoning ittclf. Examples MEDICAL SKETCHES. 25* Examples are numberlefs; I will mention one where the error _is as univerfal, and has continued as long as moft: I mean the notion that the figures of animals of various kinds, and other extraordinary marks, are often ftamped on the faces or bodies of the foetus in the womb, by the mere force of the mother's imagination. On queftioning the people thus marked, you are generally told, " that their mothers, while pregnant "••with them, were ftartled by the unexpected fight of " a moufe, a rat, a fquirrel; or that a cherry, a plumb, " a bunch of grapes, or fbmething, in fhort, which " refembjes the mark, had been thrown at them: " That this accident had given much uneafmefs " to their mother ■;■ and as foon as they themfelves " were born, the fimilitude of what had frightened " her, whether animal, vegetable, or whatever it " had been, was found as you fee on their body." Some years ago, I took a good deal of pains to in- veftigate tlus matter: I converfed with a great num- ber of women who either had fach marks on their bodies, or on thofe of their children. They were all in the fame ftory ; the marks on their own bodies, they affured me, proceeded from fomething that had been thrown <*t their mothers; thofe on their children's bodies, from fbmething thaf had been thrown at themfelves, during the courfe of their pregnan- cy. , But on dole enquiry, and examining the relations and attendants, it appeared that the mo- ther never had mentioned any thing of her having had a fright, or of her having an impreflion that her child would be marked, until fhe faw the mark; then indeed, and not before, fhe told them of fome adventure which was the fuppofed caufe of it. This turned out to be the cafe in every inftance I heard of, which could be fairly and accurately exa- mined into. When 26 MEDICAL SKETCHES. When I heard of any woman who Was actually pregnant, and had met with fome accident that gave her a ftrong imprefliori that the child would certainly have a peculiar mark, I watched the event; and the child, when born, was free from every appear- ance of what had made fuch impreffion on the mind of the mother. In fhort, it always happened, either that the wo- man faw the mark firft, and recollected afterwards What had occafioned it; or if fhe really met with fome accident or fright during her pregnancy, and ventur- ed to foretel that her child would be marked, fhe was delivered of her fears and her child together, for no mark was ever to be feen. The cafe of one lady is fo ftrongly in point, and was attended with fuch Angular circumftances, that it is worth mentioninp-. This lady, who had great averfion to monkies, hap- pened unfortunately, during the courfe of her preg- nancy, to yifit in a family where one of thofe animals was the chief favourite ; on being fhewed into a room, fhe feated herfelf on a chair, which flood before a table, upon which this favourite was already placed; —he, not naturally of a referved difpofition, and ren- dered more petulant and wanton by long indulgence, fuddenly jumped on the lady's fhoulders:—She fcreamed, and was terrified, but on perceiving who had treated her with fuch indecent familiarity, fhe actually fainted ; and through the remaining courfe of her pregnancy, fhe had the moft painful conviction that her child would be deformed by fome fhocking feature, or perhaps the whole countenance of this odious, monkey. The pangs of labour did not overcome this im- preffion, for in the midft of her pains fhe often la- mented the fate of her unfortunate child, who was doomed through life to carry about a human foul in the MEDICAL SKETCHES. 27 the body of an ape. When the child was born, fhe called to the midwife with a lamentable voice for a fight of her unfortunate offspring, and was equally pfeafed and furprized when fhe received a fine boy into her arms. After having enjoyed for a few minutes all the- rapture of this change to eafe and happinefs from pain and mifery, her pains returned, and the midwife informed her that there was ftill another child.—Another! exclaimed fhe, then it is as I have dreaded, and this muft be the monkey after all. She was however once more happily un- deceived ; the fecond was as fine a boy as the firft: I knew them both;—they grew to be ftout comely youths, without a trace of the monkey in either their faces or difpofitions. Numberlefs other examples might be brought to prove the neceflity of examining and fifting to the bottom, as often as fuch inveftigation is in ourpower, opinions, however long eftablifhed, and however ge- nerally received; for many are faid to be confirmed by univerfal experience, yet upon minute and accu- rate enquiry, this univerfal experience turns out to be no more than univerfal rumour, founded at firft on carelefs obfervation, and afterwards fwelled by falfe and exaggerated facts. But before we adopt any opinion which is to have an immediate influence upon the practice of medicine, we ought not only to weigh and examine thofe facts which we receive from others, but we muft alfo be exceedingly careful not to be led into error by thofe which we gather from our own obfervation-. It is evident that the firft may lead us into error, becaufe they may be falfe ; and unfortunately the fecond, without attention and fagacity, may alfo lead us in error, although they muft be true. A young practitioner orders a courfe of medicines in a particular difeafe,—a rheumatic complaint we fhall ;8 MEDICAL SK E T CHES. fhall fuppofe ; after this courfe has been continued for fome time, the patient recovers: Well, here is a true fact, from which, if he concludes that the medicines have removed the complaint, he may be in an error. He orders the fame courfe again for the fame com- plaint ; the patient grows worfe. Here is another true fact, Handing directly in oppofition to the former: Well, what does the Doctor conclude now ? After thofe two cafes, if he balances the one by the other, he might infer that the courfe of medicines had juft an equal chance of doing harm or good. But a phyfician will not naturally reafon in that man- ner ; having a partiality for the courfe he has prefcrib- ed, he will moft probably remain perfuaded, that in the firft inflanee the medicines performed the cure ; and in the fecond, fome peculiarity of conftitution counteracted their effect, and made the patient worfe- And here he may be wrong again; the medicines very poflibly may have done neither good nor harm in either cafe, and the different events may have en- tirely depended on certain circumftances, which the practitioner unfortunately overlooked.-----Perhaps a change, of wind from eaft to weft in the firft cafe, and from weft to eaft in the fecond ; or perhaps one patient's chamber was dry, and the other's was damp. It cannot therefore be too often repeated, that every circumftance muft be weighed and attended to with the moft careful circumfpectiou during ths courfe of our experience, left this very experience confirm us in error. This {hews how very prepofterous it is to put rea- foning in oppofition to experience in the practice of phyfic, fome degree of theory or reafoning being ab- solutely neceffary to direct our experiments, and afterwards MEDICAL SKETCHES. 29' afterwards as neceflary to enable us to draw juft conclufions from them, and to apply them ufefully ; not only in cafes in all refpects iimilar, but alfo in thofe which, differing in fome particulars, ftill have a general analogy. He who derives his medical knowledge from books alone, and whofe exalted notions have-not been moderated by experience, will pra&ife medicine as the philofopher who declaimed on the art of war to Hannibal, would have commanded an army; he who has feen much practice without reafoning, as one of Hannibal's pioneers; and he, who to extenfive ex- perience joins the greateft natural acutenefs and all the powers of reafoning, as Hannibal himfelf. Yet fome practitioners have been fo much fhocked and difgufted with the flimfy and fantaflical theories which have been invented as a foundation for rational practice, that they explode almoft every kind of rea- foning in the practice of medicine.—" We truft," fay they, " to experience, and experience only: We " know that Jefuits bark flops the fits of an ague; " and that mercury cures the venereal difeafe : We " therefore order thofe medicines in thefe difeafes, " without any farther reafoning on the fubjecl." No farther reafoning would be neceflary, rf every difeafe made itfelf known by as certain fymptoms as the two juft mentioned ; and if we had fpecifics as efficacious as the bark and mercury for each. This would unqueftionably be exceedingly fortunate for mankind in general; and if thofe ingenious doctors who condemn all theory or reafoning in the practice of meciioine, are aware of the effect it would pro- duce, nothing can be a greater proof of their dif- intereftednefs ; for it would at once annihilate their trade. Every man, as foon as he was taken ill, would know the difeafe and the remedy; he would fend to the chymift's fliop, inftead of fending to the doctor j 3° medical Sketches, doctor; phyficians would be mere drugs, and the only drugs that would be quit ufelefs, and the world would not only get rid of difeafes, but of what, in the opinion of fome people, is very near as great a grievance. ^ But unfortunately difeafes are very numerous, and fpecifics very few; perhaps the whole catalogue of thofe which act with any degree of certainty, is ex- haufted in the two above mentioned; whereas the powers of other medicines are far inferior and much leis certain, and the propriety of adminiftering them often extremely doubtful ; for although fome difeafes manifefl themfelves fo plainly that the moft ignorant cannot miftake them, yet others appear in fuch a queftionable fhape, that the moft knowing are puzzled to decide to what clafs they belong, and the combined powers of experience and fagacity have fufficient em- ployment in treating them. A young man happened to be prefent at the trial of fome caufes of no kind of intricacy, where the proof was full, and where law as well as equity lay clearly on one fide. The judge of courfe decided without hefitation, as any man of common fenfe and honefty" would have done. " Of all profeffions," faid the young man to the judge, a certainly yours is the " eafieft; any body who has eyes may be a judge; " all that is neceflary is to diftinguifh black from " white." " But that is a very difficult matter," replied the judge, " when the caufe is grey." In medicine, as well as in law, there are many cafes of a grey complexion, in which it requires all the ex- perience of the cleareft-fighted to determine whether the black or the white predominates. Till this im- portant point is juftly decided, neither reafoning nor experience can aflift us in treating the difeafe : Although repeated experience in rheumatic and fcor- butic cafes, for example, fhould have convinced a practitioner MEDICAL SKETCHES. 3* practitioner of the efficacy of a particular treatment^ if he happens to miftake the pains and blotches which originate from a venereal fource for rheumatic or fcorbutic, his treatment will not avail. But to refume the comparifon; what renders the fituation of the phyfician more diftreffing than that of a judge is, that it is only in doubtful cafes that the latter is at a lofs ; for when the cafe is quite clear, he has a relief for the white, and a proper remedy for the black in his power: Whereas even in fome of thofe cafes which admit of no manner of doubt, and where the difeafe is perfectly afcertained, the phy- fician knows of no cure. I do not fay he knows of no prefcription; thofe he will find in fome of the prac- tical books in as great abundance for incurable as for curable difeafes. I remember having been fhewn a manufcript copy of a New Practice of Phyfic, wherein the firft article that catched my eye was that on the fcrophulous dif- temper, towards the end of which I perceived the word CURE in capital letters, followed by a number of recipes, which I immediately perufed with the greateft eagcrnefs, and then afked the author if he had known many inftances of cure5 performed by thofe preferiptions. " I never knew one in my life," replied he; " but of what fervice would it be to de- " fcribe a difeafe, if after the defcription I did not " add the cure ?" I do not intend to imitate this gentleman on the prefent occafion, being determined to recommend no- thing but what I know to be ufeful, and where I know nothing of that nature, fairly to own it; and although candour will oblige us often to make this humiliating avowal, perhaps it will appear furprizing that we are »ot forced to make it oftener, when we confider the nature of the human frame, and compare what We know with what we do not know, of fome of the prin- cipal animal functions. IL OF 3* MEDICAL SKETCHES* l II. OF DIGESTION. Previously therefore to any hiftory of particular difeafes, or any practical obfer-- vations reflecting their cure, I fhall, in the cleareft manner I can, cortfiftent with the brevity of my plan, defcribe the different procefles of nature in fupport of fome parts of the animal ceconomy moft effential to life; for as health depends upon their being perform- ed with freedom and eafe, whatever impedes or dis- turbs thofe vital functions, becomes the caufe of dif- eafe. One of the moft important operations of nature, for the maintenance of animal life, is the digeftion of food ; from fome impediment or diflurbance of this procefs, a very great number of difeafes and complaints of various kinds certainly originate. It may there- fore not be improper to confider it in the firft place. Organs of digeftion of fome kind or other are com- mon to all animals with whom we are yet acquainted ; but befides thefe, there are in the ftructure of moft ani- mals, particularly in the human, two fyftems of mecha- nifm equally effential to life, and mutually afliftant to each other, yet diftincl in their functions, and different in the principles upon which they act. Thefe two fyftems are called the vafcular and the nervous. By means of the firft, which is the moft comprehenfive, four very important functions arc performed. I fhall mention them in the order in which they are afterwards to be confidered : I. The MEDICAL SKETCHES. 33 I. The circulation of the blood. 2. The fecretion or feparation of certain fluids from the blood. 3. The abforption by the lecleals and lymphatics. 4. Refpiration by the airveffels of the lungs. The fecond fyftem of mechanifm above alluded to, is the nervous ; it is entirely compofed of the brain and the nerves.—This fyftem, though apparently lefs complex, is in reality more difficult to be underftood than the vafcular. We can examine the ftructure of the brain and nerves, it is true, and have the ftrong- eft proofs that they are the immediate organs of per- ception, fenfation, and motion ; but in what manner thofe offices are performed we have not the leaft con- ception. The order in which we propofe to make this abridged view of thofe animal functions may be thought improper: It may be imagined that it would be more natural to begin with the circulation, and the fecreted fluids which ailift digeftion, becaufe there- can be no digeftion, till the blood cir- culates. But as the animal (Economy confifts of a circular chain of links, in which it is difficult to dif- tinguifh the firft, a fimilar objection might be made at whatever link we began. Were we to begin witli the circulation, it might with equal juftice be faid, it would have been better to have given fome idea of digeftion, fecretion, and abforption, in the firft place ; becaufe the blood is formed and fupplied with" juices from the aliment, and no fluids can be fecreted from it, till by the procefs of digeftion it has been enriched with thofe fluids. Upon the whole, therefore, it may be as well to confider digeftion in the firft place, and then proceed to the other functions in the order above propofed : If I fail in perfpicuity, obPrving this arrangement, I fhould equally ib.il in any other. D Preparatory H MEDICAL SKETCHES. Preparatory for digeftion, the folid food received? into the mouUh is divided into fmall parts by the teeth, and blended with the faliva, a iiquor feparated from the arterial blood to affift. digeftion. The faliva is neceflary in fome degree at all times, for the pur- pofe of moiftening the mouth and throat, but in far greater quantity at meals, when it is required to be ' mixed with our aliment; on this account nature has taken care that the tafte, fmell, and even the fight of victuals inftantly excite a proper fecretion of fa- liva. The food thus* divided, and by the mixture of fali- va, air, and the mucus of the mouth and throat, blended into a pulp, is fwallowed, and defcends into- the ftomach, where it mingles with a fluid of a more active nature than any of the former, called the gaf- Eric juice. Very different opinions have prevailed in all ages, refpeclirig the manner in-which digeftion is performed in the human ftomach. Celfus- informs us this was- ■ a matter of controverfy among the earlieft phy- ficians^ fome affcrting it was by attrition,—others by, putrefac~iip.n; others thought that heat was the. prin- cipal agent iu digeftion, by which the food vrash firft, what they called, concocted, and then digefted. A fourth clafs, defpifing the opinions of the former. * three, declared^ that no fuch things as attri^ tion, putrefaction, or cpncqction, took place in the ftomach ; but the food, undergoing no other change than by chewing, was diftributed all over the body*- Similar controverfies upon the fame fubject have> fubfifted amon^r the moderns ; many have imagined that a kind'.of fermentation takes place in the fto- mach for the purpofe of" digeftion. About the end of the laft century, or beginning of the prefent, the * VktaCsLsus, lib. L Medical sketches. 3S the ancient doctrine of attrition was revived, and acquired new force from the chara&er and calcu- lations of the celebrated Pitcairn; he computed the mufcular force of the ftomach alone, to be fcqual to a weight of above 100,000 pounds; and when the force of the diaphragm and abdominal mufcles is included, to a preffure of about 250,000 pounds weight. But none of the powers fuppofed by phyficians, ancient or modern, to be the agents of digeftion, were confidered by Boerhaave as fufficient for the purpofe, if taken fmgly ; he thought the energy of the whole indifpenfably neceflary, and that digeftion was effected by their united powers, in the follow- ing manner: The food divided, blended, and fwallowed, as has been defcribed, mixes in the ftomach with the gaftric fluid and the liquors We drink, is. there mace- rated and in fome degree diflblved ; the fplution is farther promoted by the natural heat and clofenefs of the place, by the action of the mufcular coat of the ftomach, by the compreflion of the diaphragm and abdominal mufcles, by the pulfatiOn of the aorta and adjacent arteries, by the air received with the food expanding and burfting the cells in which it is included. The folution is ftill farther aflifted by the remains of food in the ftomach, fuppofed to act as a ferment upon the heterogeneous mafs of f refli aliment; and the whole is completed' by fome degree of putrefaction, which he imagines takes place in the animal part of the food.—This account of digeftion, with little variation, is adopt- ed by Halier, and has prevailed pretty generally in the medical fchools of F.urope, The notion that digeftion in the human ftomach is performed by a kind of trituration, certainly arcfe *Vor~, w'nt h obferved to take place in the gizzards D 2 cf 36 MEDICAL SKETCHES. of granivorous fowls. Indeed, if the analogy were exact, there would be no need of heat, fermentation, putrefaction, or any other afliftant. The/experiments lately made by the Abbe^Spallan- zan.1, Profeffor of Natural Hiftory at Pavia, pro.ve that the ftomachs of thofe animals require no fuch auxiliaries ; and are able of themfelves to accomplifh feats, hitherto confidered as fuperior to the power, and even inconfiftent with the nature of any fto- mach whatever. He found . that the ftomachs of pigeons, turkies, and other fowls, can pulverize pieces of glafs ; abrade and fmooth the rugged edges of the hardeft fubftances, even of granite, and for the moft part without any injury to the animal. He mentions two ^experiments in particular, which a pcribn of lefs ardour "for this kind of inveftigation, and more tendernefs for the animal creation, would not have made. He caufed a leaden ball to be formed with needles fixed in its fides, the points outwards, and forced it down the throat of a turkey. He con- trived to make another fw allow a ball of a ftill more formidable conftruction; for it was armed with little lancets, fharp at the points and edges, inftead of needles: Both balls were covered with paper, to prevent the throat of the ar.'mal from being hurt as they defcended, but fixed fo loofely as to fall off in the ftomach. The confequence was very different from what might naturally have been expected ; the needles and lancets were broken to pieces, and voided without wounding the*animal. As there is always a confiderable quantity of little ftones found in the ftomachs of granivorous animals, moft naturalifts are of opinion that the birds are in- liinctively prompted to fwallow them to afiift digef- tion. rT\\e Abbe Spallanzani's experiments however tend to prove, and he himfeif is convinced, that in thofe auimais digeftion can be entirely performed by the flrciiffth MEDICAL SKETCHES. f? ftrength and action of their mufcular ftomachs, with- out requiring the afliftance of thofe little ftones, which he thinks the birds pick up from miftake and ftupidity, not inftinct. But whatever is the power of digeftion in thofe animals, there is little analogy between their mufcular ftomachs and thofe of men, than which nothing can be lefs 'calculated for breaking or grinding hard fub- ftances. Had the human ftomach feemed better formed for fuch purpofes; and had its triturating powers been calculated at even an higher rate by mathematicians, ftill it would have been evident that it performed no fuch functions ; for currants and even. ripe grapes, which burft on a flight preffure, when fwallowed entire, are often voided unbroken. This obfervation, made by men of no \ aft extent of genius or algebraical knowledge, and which in itfelf is not of the moft refined nature, at once overturns the theory of trituration, with all the calculations which fupported it, and fhews to what a height of error men of the greateft learning and acutenefs may build, when they found upon a falfe hypothefis. Were it poffible after this to harbour any doubts on the fubject, they would be dlfpelled by the ex- periments made at Edinburgh by Dr. Stevens, and publifhed in that gentleman's inaugural difcourfe, and by other experiments made by the Abbe Spal- lanzani.—The purport of thofe experiments was to afcertain whether the gaftric liquor acts as a men- ftruumfor diffolving the food, and is the chief agent of digeftion. Dr. Stevens prevailed on a pr-iibn who had the faculty, and had been in the habit of fwaliuv, - ing pebbles, and bringing them up at will, to lwallow little hollow fpheres of fiiver, filled with food of different kinds; the fides of thofe fpheres being per- forated in various places, the gaftric juice had accefs to, and of courfe could act upon their contents. . D 3 When 3S M EPICAL SKETCHES, When thofe balls were brought up, or voided downr wards, the food within them was found diflblved either partially or entirely, according to the nature of the food, and the time the balls were allowed to re- main in the ftomach. Similar experiments to thofe which Dr. Stevens had made by the means of the above mentioned pebble- fwallower, the indefatigable and enterprizing x\bbe made on himfelf. He tried many different kinds of food;—rhe inclofed the balls in little bags of linen, which allowed the gaftric fluid to pafs through their perforated fides, but prevented all fceculent matter from entering during their paffage along the convolut- ed pipe of the interlines. When the balls were voided, thofe which contained food of cafy digeftion had their contents quite diflblved, but fome part of the food of difficult digeftion remained undiflblved. Food put into the balls well mqfiicated, was found quite diflblv- ed, when voided nineteen hours after being fw allowed: The fame food put into the balls uncheived, and voided in the fame time, was found not fo perfectly diflblved, This demonftrates, in the moft convincing manner, the utility of carefully \ chewing the victuals for the purpofe of facilitating their digeftion; and the whole of thofe experiments tend to prove, that no fuch thing as trituration takes place in the ftomach of man, or of animals whofe ftomachs are conftructed like the human; and of courfe the alternate preffure * of the diaphragm and the, mufcles of the abdomen, which was fuppofed to affift the triturating power, will be confidered as of little importance in digeftion. Thofe experiments with the hollow balls, although decifive againft trituration in the human ftomach, prove nothing inconfiftent with the notion of a certain degree * In infplration the ftomach is prefled downwards by the diaphragm, and in expiration it is prefled upwards by the ab-. dqminal mufcles. MEDICAL SKETCHES. 3$ .degree of fermentation being requifite for digeftion: and this is ftill the opinion, I underftaud, of feme phyficians of reputation. It feems difficult however to imagine, that any fer- mentation in the victuals can take place m the ftomach, without our being conftahtly put in mind of it in the moft difagreeable mariner; yet it is only when people are in ill health, and digeftion weakened and drfturbed by.difeafe, that any feerhig or effect that can be im- puted to fermentation is perceived. In good health, and while wc avoid excefs and improper food, the procefs of digeftion is quietly carried on, without our attention being called to it by any difagreeable fenfa- tion whatever. There are three kinds of fermentation defcribec! by chymifts,—rthe vinous, the acetous and the putrid. Vomitings of a vinous fmell, which fome- times occur even when no wine has been druak, and the frequent acid eructations with which fome ••people are troubled, are brought as proofs, that the two firft kinds of fermentation exift in the fto- mach, and are neceflary for digeftion. Animal fubftances, however, in no circumftance, hot even in a ftate of putrefaction, undergo the acetous or vinous fermentation ; when lour eruc- tations or fpitting therefore happen after eating meat, they cannot be imputed to the meat': This with what was formerly remarked, that no fuch difagreeable circumftance attended people in good health, when the digefHoh is in its natural ftate, renders it moft probable that thofe fymptoins proceed from fome fecretion in the ftomach itfelf, and which only takes place when it is difordered, and not from any fer- mentation in the food requifite for its digeftion. The notion that fome degree of putrefaction u neceflary to complete digeftion ; and that It actual- ly takes place in the animal part of our foodbe- D 4 fore 43 MEDICAL SKETCHES. fore it leaves the ftomach, has been combated by various arguments. It has been obferved that the faliva of thofe who have failed for a long time is in fome degree acrimonious ; fo are their other juices; and even their breath, though naturally fweet, is then offenftve ; but foon after eating, the acrimony and offenfivenefs difappear. When a nurfe panes too long a time without frefh fupplies of victuals, her milk becomes rank and bitter, and the child fhe fuckles rejects it with dif- guft. Let . her take a bafon of frefh broth, and within a fhort time her breafts will be filled with fweet milk, and the child will fuck,with avicjity. From thefe facts it is argued that no degree of putrefaction can take place in any part of the food in the procefs of digeftion, becaufe digeftion is in reality the converfion of the food into chyle, and if putrefcency was neceffary jfor that, it would, of courfe, by means of the chyle, be communicated to all the juices of the body; and the breath, fa- liva, and milk, inftead of being fweetened, would be rendered more offenfive in confequence of eat- ing. The circumstances of the bitter alcalefcent tafte of the faliva, the offenfivenefs of the breath, and fait difagreeable tafte of the milk of nurfes after long falling, are certainly true; and it is equally true that thofe qualities are changed and fweetened in confequence of eating,; but that this happens by the means of the food being converted into chyle, and that chyle being mixed with the blood, and diluting and moderating its acrimony, and of courfe fweet- ening the juices fecreted from it, is not very pro- bable ; for it muft take feveral hours after, eating, before a fufficient quantity of chyle can be feparat- ed from the food and mixed with the blood, during all which time the faliva and milk fhould be growing more MEDICAL SKETCHES. >4* more and more offenfive, becaufe they are fecret- ed from the old blood not yet diluted with frefh chyle; whereas in reality the change is made in the faliva and breath almoft inftantaneoufly, and in the milk, in lefs than an hour. The faliva, breath and milk, becoming fb foon .fweet, muft therefore proceed from other caufes, and proves nothing ei- ther for or againft putrefaction being neceffary for' the digeftion of our food. But although it does not apply in thefe particu- lar inftances, the following feems a fair prefumptive argument. , Food undergoes nothing akin to putrefaction in the procefs of digeftion, becaufe it fupplies the blood with frefh juices ; and if it underwent putrefaction, the addition of chyle, inftead of diluting and cool- ing, would naturally render the blood more acri- monious and putrefcent. But the induftry of the Abbe Spallanzani, and of an eminent anatomift and furgeon of this country, has not left the matter to prefumptive arguments. They have proved by irrefiftible experiments, that animal food, fo far from acquiring a putrefcent quality in the ftomach, if it happens to be tainted when fwallowed, becomes fweet and perfectly free from all taint before it is digefted: From which we may naturally conclude, that the fluid conftantly exifting in the ftomach, called the gaftric juice, is endowed with an antifeptic * quality. The idea formerly taken notice of, that a fer- mentation is always raifed by fome remains of the former meal, feems groundlefs, from this circum- ftance, that digeftion is carried on quicker when food is received into an empty ftomach, than when it is mixed with the remains of any former meal. In * What rcQfcs putrefaction. 4* MEDICAL SKETCHES. • In anfwer to this and other arguments urge 3 egainft the notion of fermentation, thofe who fup- port that opinion arffert, that the digeftive fermenta- tion, which, according to them, takes place in the human ftomach, is of a peculiar kind, unlike either the vinous, acetous, or putrefactive, and not to be judged of by any analogy with them. This is one way, to be fure, of getting rid of many objections ; but when one thing is fo unlike another as to have no refemblance to it at all, I own I am extremely apt to conclude that it is quite a different thing ; and if I were permitted., I fhould choofe to call it by a different name. Upon the whole, it feems probable, that the ga£ trie fluid corrects any tendency to putrefaction that may be in fomte parts' of the aliment ; and withoht exciting any evident fermentation, is one of the moft powerful agents of digeftion ; the procefs be- ing completed by two fluids which mingle with the aliment foon after its expulfion from the ftomach, as fhall be more particularly mentioned hereafter. ft is faid that the gaftric juice has been found to retain this diffolving power out of the ftomach 5 but' it being an exceedingly difficult and painful matter to procure this fluid, a fufficient number of experiments have not yet been made to afcertam this point. An obvious and apparently .ftrong objection, how- ever, prefents itfelf to the opinion, that the gaftric fluid is a menflruum. If the gaftric fluid has the power of diffolving the food, how does the ftomach itfelf, which is of the fame nature with fome parts of our food, remain nndiffoh ed ? Thofe who fupport the doctrine, endeavour to remove this objection, by afferting that the mucus which fheaths the internal coat of the ftomach is fufficient to prevent that effect; or if that is denied, they MEDICAL SKETC-H-E'S. 43 they content themfelves with faying, it is -prevent- ed by fome peculiarity in the ftructure of the ftomach, which we cannot inveftigate. - Mr. John Hunter, the anatomift above alluded to, with more ingenuity, fuppofes that the fame living principle which relifts the putrefcent fenden* cy of the blood and other juices, prevents the fto- mach itfelf from being affected by the gaftric fluid, v/hile it penetrates and diffolves the aliment. In confirmation of which, he obferves that worms can remain a confiderable time unhurt in the fto- mach, while they retain the principle <*f life ; but as foon as they lofe this and die, they are dif- lblved and digefted like other fubftances. In like manner he afferts, that while the ftomach itfelf retains this living principle, the gaftric fluid cannot affect it; but when the perfon dies, that fluid imn mediately begins to corrode it, and fometimes is found to have made its way entirely through the coats of the ftomach into the cavity of the abdo- men. There are fo many inftances, in the annals of medicine, of men of the greater! abilities fupport- ing theoretical opinions which have afterwards been found erroneous, that every new notion, no doubt, ought to be examined with the greateft accuracy before it is fully admitted. The opinion in ques- tion, however, muft be allowed to be highly in- genious, and has the advantage of an advocate able to do it all juftice ; fo that if it falls, it muft be from its own fault, and not his. After the ftomach has retained the food a due time for performing its functions (by whatever means they are performed) and after it has perfectly com-? mingled the various mafh, and rendered it more homogeneous* to the circulating blood, the whole is * Of the fame nature, 44 MEDICAL SKETCHES. *s fqueezed through a narrow paffage called the pylorus, into ttie firft of the interlines. The ftomach being fhaped fome what like a bag- pipe, this paffage, 'as well as that by which the food enters the ftomach, is higher than its bot- tom : In its way to the pylorus, therefore, the food muft proceed contrary to its gravity, which indeed k' mull frequently do afterwards in patting along the various convolutions of the inteftinal canal. To enable the ftomach and inteftines to perform this, they are endowed with a vermicular or pe- riftaltic movement, by which the food is gradual- ly propelled, and the excrement voided. As foon- as the alimentary mafh has left the fto- mach and entered the firft of the inteftines, it meets with the pancreatic juice, and the bile ; the firft fepa- rated from the blood by a glandular fubftance call- ed pancreas, and the other by the liver, and both poured through the refpective duets of thofe or- gans into the interline nearly at the fame place. The • fubftance of the pancreas has great analogy with that of the falivary glands, and its juice with the faliva ; the former, however, if we may judge from the comparative fize of the pancreas and thofe glands, muft be fecreted in far greater quantity. The chief ufe of the pancreatic juice, according to fome phyfiologifts, is to dilute the bile, and ren- tier that vifcid fluid, which is more acrimonious than any other of the animal juices, more mild and more mifcible with the food. But to make one juice imperfect and incapable of performing its functions till it is mixed with another, is very unlike the ufual precifion and fim- plicity of nature. It feems to me, therefore, more prop able, that the pancreatic juice and the bile have diftinct offices," but both tending to the thorough digeftion of the aliment. The MEDICAL SKETCHES. 4? The bile is a penetrating liquor of the nature o£ foap, capable of diffolving gums, refmous fub- ftances, and rendering oily fluids mifcible with water ; this faponaceous fluid, therefore, is of the greatefl ufe, by mingling with the aliment as it comes from the ftomach, completing the procefs begun there, by a more perfect diflblution of the oily vifcid parts, and giving the various fubftanoes of which our food confifts one common appearance • and nature, from which an uniform fluid, refem- bling emulfion, and called chyle, is fucked by the lacteal veffels, and thrown by the thoracic duct in- to the circulating blood, of which it is immediate- ly to become part. The humiliating quality of the bile is likewife fuppofed to be of fervice by exciting the periftaltic motion of the inteftines, and protruding the coarie parts of the food through the inteftinal canal, till they are thrown out of the body in the form of faeces. The whole account of digeftion may be thus abridged.-----The food being previoufly divided and blended with faliva and ah by maftication, is fwal- lowed, and meets in the ftomach with the gaftric juice, whofe diffolving power, affifted by the na- tural heat of the place, is the principal agent of digeftion. The procefs is completed by the pancreatic juice and bile, the nutritious part's of the food being by this procefs oonverted into chyle for the fupport of the Ijotly, and the groffer parts thrown out. MEDICAL 4* MEDiCAL SftETCttftri III. T&E CIRCULATION OF THE BLOOD. 1 HE next important function of the animal ceconomy, and the firff belonging to the va£ cular fyftem we propofed to confider, is the Cir- culation of the Blood. The heart being the center and moft active in-' flrument of the blood's circulation, muft' be confi- dered as one of the moft important, perhaps the moft important part of the bpdyj It is one of the few parts of .the body in which a wound is certain death. Nature has taken care to place thofe organs, up J on which life more immediately depends, in the ftrongeft fituation s, and where they are beft defend- ed from external injuries. Thus the brain is pro- tected by the bones of the fkull; and the heart and lungs are alfo lodged in a bony fortification .compofed of the ribs and vertebras. The heart is probably the firft»part that is formed: In examining the incubated egg, the firft thing that can be perceived is a fmall red point; and the firft movement is a motion like a pulfatiQn of that point, which turns out afterwards to be the left ventricle of the heart; the other parts feem to be all gradually formed from this. Obfervations of this nature cannot be made ori the human body ; but from analogy we fuppofe that the fame circumftances take place in the hii— t man embrio *. The heart has a greater fhare than any * The child uiifiniflied in th« womb. MEDICAL SKETCHES. 4/ any other part, of that fympathy which has been obferved to exift in the various parts of the bo- dy ; and which will be mentioned more particu- larly hereafter. No organ of the conftitution can be feverely af- fected, without affecting the heart, and difturbing its functions ; nor can the heart be in the finallefl degree affected, without difturbing every function of the animal (Economy. But the heart is not only affected by what in- jures the body, but alfo by whatever ruffles the mind. Rage occafions frequent and forcible con- tractions ; forrow, flow and languid ones : And there are inftances of violent paffions fufpending the con- tractions of the heart altogether, and occafioning death. The heart is not only affected by what hurts the body, or mind of the perfon to whom it be- longs, but alfo by what; hurts the bodies or minds*of others. But the extent of this kind of fympathy. differs greatly in different perfons. In fome it em^ feraces children, friends, relations^ countrymen, and, in a certain degree,, the whole human race; in ethers, it feems to be entirely confined within the Umits of^heir own bodies, or at moft reaches with a blunted fenfibility no farther than to thofe whom they conceive to be their own offspring. The human heart is a mufcular fubftance, of ,-r conical form,, fituated withi* the cheft, with its apex or point Inclined, downwards, and to the left" fide. It is divided by a fleftry partition into two cavities, called ventricles. At tlie bafts of the heart, on each fide are placed two little appendixes, call- ed auricles, which receive the blood from the veins before it enters into the ventricles, and- the circu- lation is carried on as follows : Through the left auricle of the heart the blood «*te*s the. left yraitricle, whkh contracting, propels it 48 MEDICAL SKETCHES. it into the large artery, and from thence into the branches, which becoming fmaller and f mailer as they fpreadin infinite ramifications, diffufe heat and nourifli- ment all over the body. Thofe ramifications terminate in the finallefl order of blood-veffels, called capil- laries ; they pour the blood into the fmalleft order of veins, which growing gradually larger as they approach the heart, flowly carry back the blood (after the bile, urine, fpittle, and other juices, have been fucked from it, and after the remainder has been reinforced by the acceflion of the chyle) and pour it into the right auricle, from whence it flows into the right ventricle ;—but before it is allowed to renew its courfe through the body, it is forced, by the contraction of that ventricle, into the pul- monary artery, which immediately fplitting into in- numerable branches, fpreads over, the air-cells of the lungs.—Thofe cells are the terminations of the branches of the wind-pipe, which receive the air in refpiration ; and being equally ramified with the blood-veffels, run in contact with them, and form the fubftance of the lungs. The capillary veffels of the pulmonary artery become the origins. of the pulmonary vein?, through whofe gradually enlarging branches, the blood, af- ter undergoing thofe various changes, is carried back again to the left auricle of the heart, from whence it began its co«rfe ; which courfe, the mo- ment it is finifhed, muft be recommenced as long as life continues. Whatever obftructs, disturbs, or renders this circulation irregular m any degree, creates difeafe. The lungs then are a congeries or mafs of air- veflels, air-cells, arteries, and veins, fo admirably arranged as to perform their diftinct functions with- out confufion, and yet fo intimately blended, that no fingle point could be pierced with the fineft nee-, die, MEDICAL SKETCHES. 49 die, without piercing all thofe different kinds of veflels. The lingular ftrncture of the lungs, the unex- pected courfe which the whole mafs of blood, af- ter having finifhed its circuit through the body, is obliged to make through this fingle organ, plainly demonftrates that fome very important purpofe is ferved by fuch an uncommon arrangement, and fuch expenee of mechanifm. As the chyle joins the blood a little before it is thrown into the pul- monary artery, it is imagined, that this fecond cir- culation through the lungs is abfolutely neceflary to complete fanguifieation, in other words, perfectly to change the properties of the chyle, and mix and fclend it with the blood fo as to form them into one uniform fluid fit for fecretion, and the other pur- pofes of the animal (economy. But without farther enquiry into the ufe of this particular circulation, as it will in fome meafure be refumeody%and the other through the lungs, as ti^s been,deferibed. .,, But there are animals whofehearts have, two au- ricles and only one,yentricle ; in them the- cire.ula- rjon i% carried .on,,\p this maimer ;-—the blood?being brought fyy the pulmonary veins to the left auricle, and by the venie cava into the right, flows from both into,. theijventricle, and on its .contraction part : is thrown; into the-pulmenary artery,:,apd the reft into the ao> ta, which, soany. it \,t ^ Th£re are other. animals, particularly cod and alj^&Jt, fiili, whole hearts have only one auricle ;nul fame, ventricle; in thefe, when the heart contracts, "the blood is'thrown into an artery which'carries it tr» the gills, which'"''iul'fifli .ferve the purpofes of fungs; M E DI C A L S K E T C H E S. 5* lungs ; from thefe it returns by the veins, which uniting, throw it into the aorta, by which it is dif perfed over the body^ and afterwards being brought bacl$ it '.is' thrown by tlie Venae cava* into the au- ricle, and flows frbm1 it into the ventricle. We are told that the heart of One animal is ftill of a fiiii'pler conftructibn, confiftidg of only one ven- tricle and no auricle. This animal, which is a fpe- cies of worm called eruca, has no veins, but an artery iffuing from the heart, and which afterwards branches all over the body; here the blood, inftead of circulating, is ' faid to flow; forward and back- ward ref^ohftve to the contraction and dilatation of this reptile's heart. This diftiiiction of hearts was firft made by that diligent aftd accurate ahatomift Mr: John Hrthter; Our knowledge of the blood's ^circulation has per- haps not made fo great a Change in the practice of medicine, as • might have- been expected; but as it has overturned all the falfe theory that was found- ed upon the fuppofition that the blood moved in an- other manner; and prevents any new theory from being admitted that is ihconfifteht with the eftablifh- ed truth of circulation ; of courfe all the erroneous practice that was or might be formed on fuch falfe theories carl no longer take place. Ih the practice of furgery, by far the moft certain part of the healing art, the improvements derived from this difcovery are great and manifeft. By fhe ufe of the tourniquet alone many opera- tions are rendered fafer than they were formerly, arid many lives - preferved by this and other iiri- prbvem^nts made upon the fame principle, which has been peculiarly advantageous to thofe brave ci- tizens whofe lives and limbs are fo often expofed to the accidents of war. E 2 The 5"2 MEDICAL S K E T € H £ S. rThe circulation of the blood was firft demonflrat- ed by Dr. flarvey, about the beginning qf the lait century $ a difcovery which has,, rendered his name imnK>rtaf, fand reflected luftre on the Englifh; na- tion. Enyy could not quietly bear that .fo much honour fhould fall to the; fhare of $ny individual. That fhe slight have the pleafure of tearing thera from the brows.of Harvey, |he was willing to adorn: the bulls of the ancients witfh his laurels.. The firft attack that JIarvey's enemies made upon his fame, was by aflerting that the circulation of tne blood was known to the. ancients, But if the an- cients knew it, how came thofe learned gentlemen who tell us fo, to have been ignorant of it ? Find- ing that this attack did not focceefl, it was next in- fmuated that Harvey's more immediate precjeeeffors had cleared the road, and pointed it out fo clearly that he could not mifs it, j^tp -ton ; But all attempts to diminifh the; merit of this dif- covery, by enumerating what was known in anatomy before his time, and by enhancing the advances made by Vefalius, Scrvetus, and others, are equally vain and invidious. They had done fo'much, it is faid, that they had left him little to do. But why did thofe great men leave to another-that which would have done themfelves more honour than al^: their paft labours? -;. > '-,,-■ r, _v-r -,_*)_ *=. JIow infinitely abfurd to call that Iittlf, which thefe very men whofe genius and acutenefs are defcribed as prodigious, could not accomplifh, and. which efcap- ed the penetration of all the anatomifts, phyficians and p^i^pfophers, that the^worlcf produced,ftill Hai-yey made the happ>y difcovery—-a difcovery not made, as many ufeful arts have been difcovered, by accident, but in confequence of deep reflection and careful inveftigation; by weighing and compaririK ■ ;r facts,. MEDICAL SKETCHES. 53 facts, drawing inferences from the difcoveries of others, which their authors were unable to do, and advancing ftep by ftep to that important demonflration which has juftly acquired fo much honour to the dif- coverer himfelf, and has added dignity to the name pf an Englishman, E 3 IV. OF V. MEDICAL SKETCHES. IV". -p .' • ibii —■ OF THE SECRETION OR SEPARATION OF PARTICULAR FLUIDS FROM THE BLOOD. JjEF ORE we attempt to. give any iclea of fecretion in general, or of fecreted fluids in par- ticular, it is proper to fay fbmething of the blood itfelf, from which they are all derived. While blood is in circulation, and for fome time after it has flowed out of the body, it feems an homo- geneous red liquor, fomewhat thicker than water.—• While it remains warm, it is cpnftantly throwing off a watery vapour, After having been a certain time out of the body, whether in a cold or warm air, it thickens into a gelatinous mafs, which foon feparates into two*parts; one folid, called craffamentum, the other liquid, called ferum, The craffamentum confifts of a fluid which coagu- lates fpontaneoufly, and on that account has been diftinguifhed by the name of coagulable lymph, and of another fubftance which gives the red colour to the blood. The coagulable lymph may in every ftate of health be feparated from the reft of the bipod by art. In certain difeafes it feparates naturally. The buff-coloured coat which appears on the fur- face of blood in rheumatifms, pleurifies, and other inflammatory difeafes, is no new fubftance formed, as was fuppofed*, by thefe diftempers, but merely the * This was clearly proved by the late very ingenious Mr. I'lew- fon.—Vide his Experimental Enquiries into the Properties of ^e Ulood. '.*•-■ MEDICAL SKETCHES. $$ the coagulable lymph deprived of the red part'of the craffamentum. n' In thofe difeafes the blood fuffers a change which hinders the lymph from coagulating fo foon as it does in health ; when received into a bafon, therefore,- arid Suffered to reft, the red particles, being the heavier, gravitate to the bottom before the lymph congeals, and leave it like a buff-coloured jelly on the furface ; whereas in health the coagulation takes place fo foon after the blood is taken out of the body, that the red part is entangled and prevented from feparating, and of courfe the craffamentum retains the natural colour of blood. From hence we may fee the reafon why this inflammatory cruft, as it is called, is thickeft when the difeafe is moft violent, wears gradually thinner as the difeafe abates, and at laft entirely dis- appears with the complaint. It accounts alfo for this cruft not appearingjon the furface of inflamed blood, if it is ftirred and kept in motion till it congeals. The ferum is a fluid of a yellowifh colour, thicker and a little heavier than water. It confifts of a kind of mucilaginous fubftance diflblved in water, which contains alfo fome neutral fait. The mucilage above mentioned, although it does not coagulate fpont'aneoufly on being expofed to the air, like the lymph of the blood, yet it does coagu- late with a .certain degree of heat, like the white of an egg. Acids and alkohol have the fame effect; but we can hardly fuppofe they ever can be received into th*. circulation in fufficient quantity to have tlus effect there; if they fhould, it is evident, that byVputting a flop to the circulation, they muft occafion imme- diate death. The air is a ftrong coagulant of the blood, produc- ing thateftcct in a few minutes, which does not take place, feom mere reft in the veins, for feveral hours. E 4 ^ 56 MEDICAL SKETCHES, It is alfo remarked by Mr. Hewfon, that it coagulates at different periods in different conftitutions, and in different difeafes. The fame gentleman afferts, that the difpofition of the blood to coagulate increafes in proportion as the animal is weak ; from which he draws this practical inference, that it is improper to roufe a patient fainting from hemorrhage by ftimulating medicines, becaufe the languor or faintnefs favours the contraction of the divided arteries and the coa- gulation of the blood at their bleeding orifices, and thus tends to flop- the hemorrhage. In this manner blood-letting is often expedient in hemorrhages ; for when they are not profufe, but long continued, the difpofition of the blood to coagulate, and of the vef- fels to contract, may not be fufficient ; but when the veffels are emptied fuddenly by bloodletting, both effects may be produced, and the hemorrhage flopped with the lofs of lefs blood than if venefec- tion had not been ufed. To the difpofition to coagulate in the body by reft alone, may be imputed the coagulation found fometimes in the difeafe called aneurifm*, alfo that jn part of the large arteries after amputation, and thofe called polypi found in the heart and the large veffels near it. The laft indeed are generally fup- pofed not to take place till after death. Blood diftilled in a glafs retort yields water, vo- latile fpirit like fpirit of hartfhorn, inflammable oil, and afhes which no force of calcination can con- fume, ",but which, by pouring water on them, yield a fmall Quantity of fixed fait and fome earth, amongft which are found particles fuppofed to be of the na- ture of iron, as they are attracted by the loadftone. The red colour of the blood is thought by fome to be owing to this ferruginous matter ; which opinion they imagine ■■ Vide Mr. 1 Tew Ton's Experimental Enquiries, MEDICAL SKETCHES. S7 imagine is ftrerrgthened by its being obferved that Wood becomes of a more florid Colour after a courfe of flecl medicines. This notion, however, feems to be too Kaftily formed, for the ferruginous matter is in very fmall quantity, no folution of iron out of the body is of a red colour, and as to the blood becoming more florid after a courfe of fleel, it moft probably has this effect merely as a tonic, for it is certain that the blood is florid in proportion to the ftrength of the conftitution. The craffamentum and ferum are in different pro- portions in different habits. c In the laborious, aclrve and ftrong, the crafla- mentum is in greater proportion to the ferum than in the weak and languid. The ferum contains a greater proportion of wa- ter and fait than the craffamentum, the latter more oil ; of courfe when dried it is inflammable. The proportions of the cohftituent parts of the blood muft alfo in fome meafure depend on the diet. That the diet influences the health, nobody will call in queftion, but fome have fancied that it alfo has a very confiderable influence on the character and difpofition. Thofe who entertain this opinion, think that a large proportion of alkalefcent * fa Its in the blood tend to produce a choleric and fierce turn of mind. In proof of which they obferve, that birds and beafts of prey who live conftantly on animal food, which contains a large proportion of thofe falts, are more fierce than other animals. This, however, probably depends on other caufes ; for if animal food alone, even when taken in af- tonifhingly * Any fubftance which eflfervefces when mixed with an acid is an alkali.-----What has a tendency to .this is alkalefcent. 58 MEDICAL SKETCHES. tonifhingly great, quantities, could produce this eS feet, many peaceable citizens and worthy aldermen,' inftead of being the quiet worfhipful creatures they are, would be the fierceft and moft outrageous ani- mals in the world. When the blood is examined with a microfcope, it appears not an homogeneous fluid, but feems to confift of red globules fwimming in a clear liquor. There have been different opinions reflecting the exact fhape of thofe globules ; fome obfervers afferts ing they are of a fpherical, others of a lenticular* form. When a difpute commences, men are un- willing to yield, whether the point in queftion re^- gards their microfcopes or their fenfes. The con- troverfy was, as ufual, carried on with great warmth, While the curious were .ftraining their eyes to af certain this important matter, a great philofopher pronounced that both fides were in the wrong, for the globules in difpute were neither fpherical nor lenti- cular, but that each confifted of fix fmall globules adhering together in the form of a mulberry ; and that notwithftanding their appearing of a red colour while adhering, yet each of the fix fmall globules, when Separate, were not red, but yellowifh or tranfpar- rent. The laft part of the affertion could not well be denied ; for although the microfcope has been.car- ried to a greater degree of perfection fince this philofopher wrote, nobody has been able to per- ceive this union of the fix globules ; and. it is not fair to difpute the colour of an Object till a fight of it can be obtained. This therefore became a matter of faith rather than of demonftration ; and that believers might have free * Of the fom of a lens, that i«, a round ti--rr>. convts '-n both fides, but Hatter dun a ipiicre. M E D I C A L,• SKETCHES. 59 free Scope for the exercife of this virtue, they were farther informed from the fame authority, that the Second order of globules'were no more than the firft of an uniform fpherical furface, but that each'of them was compofed of fix globules of a third order, adhering in the fame manner ; and over and above^ that it was phUofophical to believe it, that the fubor- dination does not flop here, but that there is a fourth, a fifth, and Heaven knows how many more orders of globules, all in the fame ftyle with the firft, with an equal fubordination of veffels adapted for their re- ception ; which beautiful arrangement will become manifeft. as foon as our microScopes are fufficiently im- proved to bring it within the fphere of our vifion. There can be no great harm, however, in fim- pending our abfolute belief till this improvement takes place. While the blood is in circulation, various liquors are Separated from it by a procefs called Secretion, ail thefe fecretions being neceflary for the health and prefervation of animal life. I. The femen is fecreted for the purpofe of ge- neration. 2. The liquor amnii, or fluid in which the fcctus fwims, contributes to its Safety and. preservation in the womb, and facilitates its entrance into the world. 3. The milk is fecreted in the breafts of women after child-birth for the naurifhment of the in- fant. 4. The urine and Jweat, being excrementitious, are thrown out of the body. $. 'She faliva, the gaftric juice, bile, and pancre- atic fluid, are ail flibfervient to the purpofe of di- geftion . 6. The liquors which mciflen the cavities of the thorax* and abdormn^, and the interftitial fluid of * The cheft. (| The belly. • f $0 MEDICAL SKETCHES. pf the cellular membrane, are contrived to admit of eafy motion among the vifcera, and prevent the bad effects of attrition.. Thefe are alfo the pur- pofes of the liquor contained within the pericardii um*, and the watery humour within the tunica vagi- nalis of the teflieles ; without the firft the con- ftant motion of the heart would produce a fatal effect, and by means of the fecond the moft delicate organs of the human body are enabled to elude ma- ny external injuries to which they would otherwifc be liable. 7. The unctuous nature and the bitternefs of that yellow fubftance that is fecreted in the ears, protect them from the invafion of all kinds of in- fects. 8. The mucus which lines the inteftines and the urethra, fheaths and defends thofe canals from the acrimony of the fubftances which pafs through them. 9, The fynovia or mucilage which lubricates the joints, is happily placed to allow the heads of the bones to flip fmoothly over each other, and render t :eir motion eafy. 10. The tears wafh injurious fubftances from the eyes, pre ft rve their transparency; and although fome- times they are expreflive of the weaknefs of human nature, at others they indicate that fympathy and benevolence which are its moft diftinguifhed orna- ment. The wifdom difplayed in providing thofe various fluids for the prefervation and comfort of animal life, is manifeft to the dulleft obferver;—the means by which they arc provided, puzzle the moft acute. Such inveftigations are exceedingly natural to that fpirit of enquiry, with which, for wife purpofes, the mind The membranous bag which loofely furroundsthe he^rt. MEDICAL SKETCHES, 61 mind of man is endowed; and thofe phyfiologifts who have attempted to explain this and other! parts of the animal ceconomy, deferve praife for their good intentions, as well as their ingenuity, although they may have often failed in conveying that conviction to the minds of others, which long thought on fa- vourite fdbje&s, and the ambition of difcovery, feem to have produced in their own. I fhall adjoin however a fhort view of -what is gi- ven by fome of the moft celebrated phyfiologifts, ss an explanation of the manner in which the animal fecretions are performed. The blood, we are reminded, is a mixed liquor, confuting of red globules,and various fluids of differ- ent denfitjes in which they fwim. Thefe globules are the largeft of all the particles which conftitute the blood. The diameter of the fmalleft artery which circulates blood, mult therefore be larger than that of a red globule ; .but veffels or canals whofe dia- meters aredinaHer than red;globules, arifefromthofe arteries; inter them, it is. evident, no red globule, Without unnatural force and ftretching, can poflibly enter : But the fluids whofe particles are fmaller than •red globules, may in the courfe of natural circulation enter this Smaller order of veffels. And if from the above mentioned fecreting veffels a fmaller order of qanalsrferife, whofe diameters cannot admit one of a thinner nature, the thinner parts of this fluid may enter , this third order of canals'. In the fame manner a fourth and thinner fecretion may by the means of a fourth and a fin after order of veffels be feparated from the third, a fifth from a fourth, and So on. It is evident that none of the fecreted fluids can be of a red colour; for if a veffel is large enough to ad- mit the red part of the blood, it would of courfe admit all the other parts, and the contents of the vef- fel 62 MEDICAL SKETCHES. felwoaild not be a fluid fecreted from'the bldod,' but the blond itfelf. , It is equally evident by the above account, of the matter, that the gr»offer: fecretions are made from the fanguineous arteries, ' and the finer from veffels arifing from them, which Secretions be- come finer and finer in proportion tb trie number of removes the fecreting. veffels are froni the real blood-veffels. .ir> 't / •/to « We are affured alfo by fome phyfiologifts, 'that the red globules have no inclination to deviate into the mouths of the fecretory veffels, but on the contrary, that they and the denfer particles of the blood in ge- neral have a natural prppenfity to keep the middle of the tanal, while the thinner particles recede to the fides, and by that means: are more eafily caught by the fecretory orifices. :I?.Ij ;ar; jf But this method of exjorkftring the rrry-ftery of ifecre- tion by a fubordTmation ofveflelsrdrawing off the thin*- ner,, and leaving the thicker, fluids of which the blood is compofed^' and thus forming feparate liquors of va- rious kinds, does not account for the fecretion ttf thofe fluids which are thicker than the blood itfelf Thofe fluids therefore muft be fuppofed to have been thinner at the moment of fecretion, and afterwards t© have become thicker,- which, may happen either by the evaporation of the watery partibles, when the fe- creDedfluid is expofed to the air, as is the ;cafe with the mucus of the nofe * and the wax of- the ears ; or by the abforption- of thofe watery particles, which is ■fuppofed to be performed..by the iniialing veffels of the ducts and canals, through which the fecreted fluid is obliged to make atedioua, inflected, and circuitous courfe, for the exprefs purpofe of giving time for the abforption of the tliin particles. Some •'■>> • 'V- ,. .:,(. * Tb>«- the mucus of the nofe is thin and watery at the inftant isf fecretion. we know by the CjiVet of ikrnutatorics. MEDICAL SKETCHES.- 63 *^ Sdme of the fecreted flukk are depofited in certain receptacles provided for them within the body, where they: are kept as in a> magazine till there is a demand for them. . Thus the bile, after its feparation from the blood hi the livery.is depofited in the gall-blad- der, where it becomes more high-coloured and viS cid ; and in like manner the femen was fuppofed to be depofited in the feminal veficles, ready prepared for the calls of nature ; in confirmation of which it was urged, that in the continent it is of a thicker confidence than in men. who are. of a different tern* perament. . -;|- • 2. But.this argument has' been overturned by later, anatomifts, who affert, and bring: .ftrong proofs in confirmation of the. affertion; that the veficulae ib- minalcs are not a receptacle for fenleny but that they fecrete a different fluid. This however comes nearly to the fame thing, as this fluid is lodged in thefe veficulae ready for the calls of nature and purpofes of generation. And in the fame mariner the milk is kept ready , in the large ducts of the mammas * ■• h ^ In attempting to explain what is difficult and ab- ftruie, it is not Surprizing that every circumftance is laid hold of that can. poflibly be! fuppoSed to af fift in making it out; accordingly we are told thrf the nature of the fecreted fluid depends in fome mea- fure, upon the angle which the fecreting duct maker. With the trunk from which it branches; and as the yeffels are detached at a great diverfity of an- gles, and are ramified in various manners, andasNa?- ture does nothing fin vain, the conclufion is drawn, that this variety of angles and ramifications aflift fii producing the variety of fecreted fluids. Men are too apt to millake their own fancies for the aims of Nature. To allow therefore, that Nature does no- • thing in vain, and to admit all that is above afferted,^. arc^ 64 MEDICAL SKETCHES. are very different conceflions ; for there may be veifP good ufes anfwered by diftributing the fmall branches of arteries-in different manners to different viScera, although the varying the fecreted fluids is not one of them ; befides, it affords but little fatisfa&ion to be perfuaded,. that the variety of the one really contributed to the variety in the other, if, after all, we cannot form an idea how it contributes. To make this matter a little clearer, and to account in fome degree for tke different fluids Secreted in different parts of the body, it has been afferted that the blood which.arrives at the various places of fecre- tion is of a nature and quality fimilar to the humour there to be fecreted« Blood, when is firft iffues from the heart, hefore any of the fecretions have taken place, is fuprjofed to be more watery than afterwards, and on that account, we are told,- *he emulgent arte- ries, from which the urine is fecreted, are placed near the heart. The mammary arteries of nurfes, it is Said, are more plentifully furnifhed with chyle than any others ; and therefore the milk, a liquor refembling Chyle in many particulars, is fecreted from them. The bile, an oily and acrimonious fecretion, is fe- creted from the blood returning fluggiflily loaded -with vl, and contaminated with rancid effluvia from the omentum and other vifcera of the lower belly. And to crown the whole, we are affured that the blood carried by: the carotid arteries to the brain, is of a more fpirituous and refined nature than any of the reft m of the mafs, for. this very fufficient reafon, that the animal fpirits, which are the moft refined of all pofli- ble fluids, are fecreted there, All this is fanciful and well arranged, but would be more convincing, if upon examination the blood of the emulgent arteries were really found more full of water than the blood of other arteries, or if the blood MEDICAL SKETCHES.- &f Wood of the vena portarum* were not found'the fame in all refpedts with blooc* returning by the veins from all the other parts of the body. Had the blood in the firft cafe been fenfibly impregnated with urinous^ ■ and that bf the fecond with bilious particles, it might have been natural to have judged a priori, that urine would be drawn from the one and bile from the other ; but as previoufly to the fecretions, no fuch particles can be found, the matter feems father darker after the explanation thah it was before. As to the affertion concerning the fpirituous quality of that portion of blood Carried by the carotids to the brain, the argument ftands nearly in this Way. The blood fent to the brain is more fpirituous and refined than the reft of the mafs. 1 do no find it fo. Yes, but it muft be fo. Why? r Becaufe the animal fpirits are fecreted from it, and all the world knows that the aniirial fpirit* are the moft refined of all fluids. Where is this fluid ? In the nerves. Cut a large nerve, and fhew it to me. You cannot fee it, it is fo refined. That is unlucky. On. the contrary^ it is the moft fortunate thing in the world; if* we could fee it, it would be good for nothing, but we are fure it is there * How fo ? How fo ? For what other purpofe but the fecretion oi4 this fine artherial fluid would the moft fpirituous part of the blood be fent by the carotids to the brain ? So that it is Clear from this circular demonftration, # F that * The veflel which carries the blood from the vifcera of H\e lower bellyto the liver. 66 MEDICAL SKETCHES, that the moft refined part of the blood goes to the braii*'/ becaufe the animal fpirijs are fecreted ; and that the animal fpirits are fecreted there, becaufe the moft, refined part of the blood goes to the brain. ] The notioQ that the mammary arteries of nurfes are more plentifully ftored with chyle than the other arteries of the body, has arifen on no better founda- tion. The blood of thofe arteries has never been actually found impregnated with a greater proportion pf chyle than that of others; but as on perceiving that the urine, a watery liquor, is fecreted by the kidneys, and the bile, an oily one, by the liver, it is concluded that the blood which goes directly to thofe two organs is fuller of watery and bilious particles than the reft oif the mafs ; fo on finding that milk, a fluid refembling chyle, is fecreted in the breafts of nurfes, it is tafyen for granted that the blood of their mammary arteries is uncommonly full of chyle. , It would appear, indeed, that the chyle is a confider- able time before it changes its nature, and is aflimilat- ed into the mafs of blood; for when blood is drawn after a plentiful meal, the ferum is of a whiter colour than ufual, owing in all probability to the frefh ab- sorbed chyle's not being perfectly aflimilated ; but this regards the mafs of blood in general, and not that of the mammary arteries in particular. It is certain, however, that when a nurfe is kept too long frpm food, and her breafts almoft entirely drained of milk, what little is found there contains an unufual quantity pf fait, and is rejected by the infant with figns of diS guft ;, yet within three quarters of an hour or an hour after eating a competent quantity of frefh broth, her breafts will be replenifhed with milk, and the child will fuck with fatisfaction and avidity. In this cafe the food received into the ftom^h, if not the immedi- ate fourcc of the milk, feems at i#ft the caufe ,of the breafts X MEDICAL SKETCHES. '67 fereafts being filled with that liquor; but the fh'ortnefs of' the interval between the caufe and effect / Seems Surprizing, and,. rfftfisulfc to be accounted HftT. tr i«r We cannot fuppofe) that this food is digefted, con- Jvertedt into chyle, this chyle thrown in the common way into the mafs of bloody and Secreted in the form of milk frpjn the mammary' arteries ; for the , procefs o£ digqftta alone muft: engrpfs much more time than the wimble I interval in jjxteftkm.' But even Upon fche fujapofition that the digeftion could be com- peted and the chyle fprmeslifrom the food within that -interval, this would not remove the difficulty. Let us confider the journey the chyle has to make before it arrives at thfe "breafts: It is firft carried into the thfirafctc ducty thence into the. Subclavian vein to be mingled with the blood ; from the fubckvian vein it flows into the vena cava* -panes through the heart, then through the lungp} returns and. jpafles again through the heart into the aorta, and is diftribnted all over the body, the common proportion only going to the mammary arteries, from whence the chyle is fe- fcreted. When we think on all this, *and recollect alfo tiiatiifefc chyle falls drop by drop into the-'Subclavian veinx,asid is mingled in this circuitous courfe with the blood of the whole body, we cannot poffibly conceive that the proportion of chyle formed from this fingle meal> which falls to the fhare of the mammary arte- ries, is the entire fource of this copious flow of milk. Others jfuppofe that the broth, without waiting the ufnal procefs of digeftion, is abforbed by the lacteals of the mrrfe's %mach, and carried directly to the thoracic duct, and fo into the blood. But this fuppo- fition^ even if granted, would only cut. off the time taken up m digeftion, and leave the other objec- tions in full force, F ?. The i* ME D1 C A L" S K1TG-H E S. The fa& being certain,^and'all thefe'.methods of accounting for it unfatisfactory, fome have fufpected that'there is a fecret* ^oa^eyance undetected by anato^- mifts, by which this nourifliment is fmuggled frosn the nvirfe's ftomach to her breafts, and there convert- ed into milkr without being previoufly either cttanged into chyle ©r bloods , '< *-> —*■•'' : ry:-n' ".'[' ?■ But to this wild hypotfcefis ftrongen objections ariSe than to any of the preceding. r It ftt^pofes "ia- nuidr- to be fecreted, and not from the bloody .which is contra- ry to the 'rule iobferved by Nature ih the other fe- cretions,■- all of which are ^formed frorfci bhe blood, and it renders the mammary arteries ahtioft entire- ly ufelefs. t... '-3 ^ ': 'f-.->L.!i:. . When, ther ftomach is euvpty, ftill there is\ Some milk fecretedi, although in fmail quantity, and of a bad -4 quality ;; if! thereforei we ~admit' - this' hypothe- fis, there muft be two ways of fecreting milk, one . directly,, from > the - nouriffrment in the ftomach, J and the othcH, when >< no noiufifhmeht is jn the ftomach, from the blood in the'mammary: arte- ries", o ori. ');r- '.'/ rrW* rr'n -t -I ; And finally, to fuppofe >ii direct paiTage from the ftomach to the; breafts ;dnobferved. byvanatomiift&, implies a degree;of careleffheis afnd want of attention, which .ill! accord with that fpirit of minute invef- tigation,.and ardour for difcovery, by which this clafs of men are. peculiarly diftragulf bed .?i •.-: i rbi' •' -.. u : r A fuddett and profufe fecretion of mii>k, :afierc all, bnot more difficult to .be accounted for .than, the Sudden and profufe fecretion of tears which'in Some people attends pain and grief, or than the great aug- mentation . of fome other fecretions from-various exciting caufes. . tili:, ;r ' .3 What is lingular in the ihftance of milk, and oc- cafions the peculiar, difficulty, is, that its augmented fecretion fo immediately follows eating, that we are, temptprf MEDICAL SKETCHES, 6f tempted to think, in fpite of reafon and anatomy, that it is the identical food received in the ftomach, which in 'lefs than an hour after ffows from the nurfe's breafts in the form of milk- Difficulties un- queftionably attend every explanation that has been given of this phaenomenon. The following feems lia- ble to the feweft, is the moft fimple, and I imagine the moft'probable. When the nurfe is faint from hunger, hercircu- lation, as that of every perfon in the fame ftate muft be, is languid, and of courfe all the fecretions are di- minifhed; but after fhe has received a Sufficient ipe, cojt- fined in fuch fmall founds, would ^otherwife be very liable. .-, ,-,-.. . ■ ..,•■ ■;. • There are a great many little fubftances, called mefenteric glahds, tfifiperfjed over this membrane* The lacteals pafs through^ thefe glands, in their way to the thoracic duct. .<.. .j Thefe glands, therefore, divide the lacteals int0 two portions;—that from the inteftines to the glan^ called by fome the firft, and that , from the glands, to the thoracic duct, called the fecond order of lacteals. ^he , whole alimentary canal is a,. cpjntinued, pipe, wfiofe various windings and circumvolutions within the belly prolong it generally to at leaft fix times the length of the perfon to whom.it belongs. . » , Though but a .Angle rpipe, we talk of it in the plural number, becaufe it is divided by anatomift^ into fix portions, to each of which they have given a name. .Three of thefe form what are called the Small guts—the remaining three, the great. The former > make by much the longeft portion of the *whole canal, and there the, lacteals are moft numerous. There are, however, a confiderable number in «* the colon, which is the firft of the large inteftines; but few or none in the remaining two. The wifdom of this is obvious and ftrikingj for the food, by the time it arrives at the two laft of the inteftines, being almoft entirely deprived of its nu- tritioul MEDICAL SKETCHES. 7* trjtious juice, what remains begins to acquire art excrementitious taint, and is therefore improper to be ablbrbed and mixed with the blood. The lacteal veffels which are found in the colon, and the few fuppofed to be in the two other large inteftines, though in fmall numbers, fuggefted the practice of injecting clyfters of nourifhing broth and milk, in thofe difeafes which deftroy the power of fwallowing. By the abforption of part of thofe injec- tions, which may be thrown up as high as the colon, the patient Jias .been, fupported till fuch time as the difficulty, or imppffibiiity of fwallowing food was re- moved. , From this defcription it is evident, that whatever obftructs the paffage of the chyle, and prevents it from being mixed with the blood, hinders the nourifli- ment of the body as effectually as if no victuals were allowed to enter the ftomach. For although a perfon fhould eat plentifully of the molt nourifhing food, and although that food ;fhouk! be properly digefted in his ftomach and fyowels, yet if the glands of the mefentery, through which the lacteals pafs, are Swelled and obftructed, the chyle will get no farther, the blood will receive no frefh Supplies, and the body of courfe muft wafle away, and Soon perifh. I have feen fome remarkable inftances of this fpecies of consumption ; one in particular, from various cir- cumilances, made an indelible impreffion on my me- mory,—the cafe of a youth of fifteen years of age, diflin- gu^hed by more brilliant perfonal advantages and ne- bler endowments of mind than I ever faw united at that period of life*. Affifted by the advice of Dr. Cullen, I attended this youth with the moft anxious care * Thofe particulars are foreign, no doubt, to the purpofe of a work of this kind, ami will perhaps be critisifed as improper— let 86 MEDICAL SKE T'C HES. tare through the whole pr6grefs of his difeafe. In the bloom of health, without any apparent caufe, he was obferved to lofej flefh, and gradually to wafte away* although hc^coniplained of no particular uneafmefs, had a ftrong 'appetite, and was Indulged in a fufficient quantity of proper food.' He retained his fpirits to tne lift; but daily 16ft his fiefh and ftrength, and at laft expired without pain. On opening tils body, ^11 the vifeera of the breaft were found perfectly found; The contents of the abdomen were alt in the fariie condition, except the glands of the mefentery, which were fwelied greatly beyond'their haturat;ffze, and to all appearance entirely pbftrucled. ^ No other caufe Could be aflighed for the death of this youth but the £hyle being -flopped' at thofe glands, and1 excluded from the'blood \ fo that he literally died for want of nPurimment. ; -^ Ji" IV; Some late anatomifts affert that they have traced lacteals, in fonie particular Subjects, all the way to the thoracic duct, without their pafling through any of the mefenteric glands. This has not been ob- ferved,' however, by others equally celebrated ; fp that fuch cafes' muft be very rare; and even in the1 Subjects where if was obfervedy only a very0 few were in this" predicament; -/infinitely the greater. number pafling in the ufual way, through the me- fenteric glands." ' *"" The other kind of abforbents, called lymphatics, arife from the internal furface of the breaft, belly,' and every cavity of the body ; they alfo over- Spread the whole external furface of the body; and large lymphatic yeflels are ufually found clofe to the let them.—At the diftance of fixteen years, 1 have never yet, ■without fome fuch impropriety, been able to mention this young man— " By me, fo Heaven will have it, alwjys mowrn'd " And always honour'd."----■ MEDICAL SKETCHES. 81 tlie large blood-veffels of the extremities, befides thofe fmall fuperficial ones which lie above the mufcles in the cellular membrane. The large vifcera generally have two fets of lymphatics, one lying on the furface of the vifcus, and the other accompanying the blood-veffels be- longing to it. That the ufe of the lacteals is to abforb the chyle from the food, and tranfmit it to the blood, has never been queftioned. How could it ? it ad- mits of demonflration.—A few hours after an ani- mal has been fed on milk, the fame fluid found in the inteftines is alfo feen in the lacteals. As the lacteals and lymphatics are parts of the fame fyftem, when it was proved that the former Were abforbent veffels, one might naturally have thought the fecond would alfo have been confidered as fuch. This was not, however, the original opinion. It was imagined, on the contrary, that the lymphatics were not abforbents, but a kind of veins formed for the purpofe of carrying the lymph from fuch arteries, as, being too fmall for circulating red blood, or even ferum, admit lymph only. The theory of the gradation of globules, it is pro- bable, had a confiderable effect in confirming and fpreading this opinion, which kept its ground and was general even after Gliffon, Hoffman, and others, had pointed out the real ufe of the lymphatics. The faculty of abforption, although refufed to the lymphatics, was afcribed, by many anatomifts, to common veins ; and this opinion continued to pre- vail, in fome degree, until Hunter and Monro to- tally overturned it, exploding at the fame time the notion that any of the lymphatics are continuations of arteries, and eftablifliing, beyond a doirbt, that all are abforbent veffels. The chief arguments for this opinion are : G I. The 82 MEDICAL SKETCHES. i. The refemblance, in ftructure, between the lac- . teals, which are proved to be abforbents, and the lymphatics. 2. Both paffmg through glands. 3. Both terminating in the thoracic duct. 4-. Both beginning from cavities, the lacteals from the cavities of the inteftines, the lymphatics from the other cavities- of the body. 5. The tranfmiffion of the venereal and other poi- fons, from the fkin into the conftitution ; as well as that of the virUs of the Small-pox, in inocula-; fion—for this muft' be done by-abforption ; and that this abforption is performed by the lympha-* tics, feems highly probable, becaufe the lympha- tic veffels, and the glands, through .which they pafs, are on thofe occafions found inflamed and: fwelied. When tke venereal infection, for inftance, is re- ceived in the ufual way, the lymphatic gland in the groin is apt to inflame, and form what is call- ed a bubo. When the fame (as fometimes happens) is received at a fcratch or open wound in the fin- ger, the lymphatic ih the arm-pit is as apt; to in- flame aud fuppurate ; becaufe in the 'firft cafe, the abforbing lymphatic paffes through the glands of the , groin, and, in the fecond, through thofe of the &rm-pir. It alfo has been obferved, that when the infection is communicated by the lips, the glands of the neck fwell and are inflamed. Abfcefles fometimes occur in the arm-pit after inoculation, for the fame reafon ; and this was more frequently trae cafe formerly, when a longer iucifion than at prefent was ufed. When tne abforbing power of the lymphatics was thus put beyond the reach of cavil, it was next afferted, that " although they are abforbents, " vet MEDICAL SKETCHES. 8$ n yet the veins are abforbents alfo, the firft being a mere u appendage to the laft; for that the lymphatics are too *' few in number to perform. alone fuch Unimportant " office ;" befides, it was added, ". there are fome u piarts of the body without lymphatics altogether." The perfevering labours of fome late anatOmifts, particularly thofe of Mr. Cruikfhank, have entire- ly removed the firft objection : The refearches of this gentleman alone demonftrate that the lympha- tic veffels are more numerous than the veins. And With refpect to the fecond, I underftand he has traced thofe veffels to every part of the body ex- cept to the brain, the delicate ftructure of that organ putting a flop to the inveftigation ; but this accurate phyftologift has done all that perhaps is poffible, to prove that the brain is furnifhcd with thefe veffels alfo, having difcovered glands at the bafis of the fkull, through which there is every rea- fon to think that lymphatic veffels pafs from the brain. The faculty of abforption being at length yield- ed exclutively to the lymphatics and lacteals, the ftructure of their mouths, and the means by which they are enabled' to perform their functions, be- came a Subject of much inveftigation and difpute. Mr. Cruikfhank, by the means of microfcopes, faw the mouths of the abforbents, which he de- Scribes as arifing from all the furfaces and cells of the body, in the fame manner thai} they arofe from the furnaces and cells of the abforbent glands, that is, by fmall orifices. Six, eight or ten of thefe ori- fices belong to as many fmall branches, which unite in forming the abforbent veilel. Some phyfiologifts imagine that their mouths be- ing always oiv./n, fluids afcend into them, on the fame principle that they afcend into capillar} tubes. C ? Others 84 MEDICAL SKETCHES. Others imagine that the mouths of the abforbent veffels draw in liquor by forming a vacuum, irt the fame,manner that is done by the mouths of in- fants on the breaft, in the act of fucking. The veffels in queftion are fo minute, that they have baffled every attempt that has hitherto been ' made, even by means of the microfcope, of afcer- taining the ftructure of their mouths. The curious inveftigators therefore being able to procure no idea of their manner of operating, by the means of their eyes, have been obliged to have recourfe to their imagination—and it muft be owned that fome of them' have made ufe of the latitude which that affords with the utmoft liberality. Thefe vef- fels certainly feem to fhew fome felection with re- fpeft to the liquors they take in ; they always ab- Sorb the nutritive part of the food in the firft place, and neyjer take any of the excrementitious but in the laft' extremity, and when nothing elfe can be had. And the force of their mouths is quite afton- ifhing, and far furpaffes what is difplayed by any other veffels. Experiments with madder, to be mentioned hereafter, prove that their power of ab- sorption is not confined to fluids.—-—And the phe- nomena of thofe experiments cannot be accounted for, without admitting that they abforb the folid bones themfelves. Other obfervations confirm this, and prove that there is a conftant abforption and renewal of every part of the body without exception. The firft fet of teeth that children receive have roots or fangs as well as the fecond; when they fhed the firft fet, however, no roots are to be feen, of courfe they muft have been abforbed. In very old people, their teeth fometimes drop out, from no other caufe, but becaufe the alveolar procefles, or bony fockets, are entirely abforbed. Some MEDICAL SKETCHE-S. 0*5 Some phyfiologifts not being able to conceive how the mouths of any kind of veffels could poS fibly deftroy hard bony fubftances, have fuppofed that a menftruum is feparated from the blood, or from fome of the juices, which diffolves the bones. In this inftance it happens, as it often does to thofe who, elated by philofophical pride, refufe to believe what they cannot comprehend; they are forced to admit what is equally, if not more incompre- henfible. The phyfiologifts above mentioned, cannot believe that the mouths of veffels can gradually and impercep- tibly deftroy the compact fubftance of bones ; but they can believe that veffels Secrete a menftruum of fuch a corrofive nature as to deftroy the hardeft bones, but which is.not capable of injuring their own foft and pli- able fubftance. In whatever way they are to be ex- plained, the powers and faculties of thefe veffels are fo wonderful, as almoft to juftify the opinion of that gen- tleman who declares himfelf in equal admiration of the force their teeth difplay in deftroying bones, and the good fenfe the veffels themfelves difplay in the choice of aliment. But after all, is it more difficult to underftand how abforbents remove bones, than how arteries have depofited them ?—When the greateft philofo- pher has fully explained the latter, a man of plain fenfe may fafely undertake to account for the for- mer. The liquor tranfmitted from the blood through fmall exhalent arteries, or organized paffages, into the different cavities of the body, we formerly ob- ferved, ferves various ufeful purpofes. The continual beating pf the heart, and the fre- quent movement of the joints, make it peculiarly neceflary that they fhould be kept conftantly moift. The former is accordingly fufpended in a membra- G 3 nous 86 MEDICAL SKETCHES. nous fack, which contains a warm bland water, and all the joints have their ligaments and cavities fup- plied with a mucilaginous fluid, to preferve them in a flexible ftate, and render their motions Smooth and eafy : But as this fecretion is regular and con- ftant, not only thofe cavities, but the belly, breaft, and others, would foon be too full, and the liquor would in time become rancid and acrimonious, if no means were provided to prevent Such effects. This is the duty pf the lymphatic veffels, which arifing from thofe different cavities, abforb the iu- perfiuous liquor, and tranfmit it to the blood, where it again ferves another ufeful purpofe ; and fo ex- quifitely are the two powers balanced, that of the veffels which lodge the fluid, > with that of the veffels which abforb it, that in health, it neither flagnates nor overflows, but a juft quantity of this lymph is kept up, not only in the joints and fack that con- tains the heart, but in every cavity of the body where it is depofited. This feems to be the great and conftant office in. which the lymphatic veffels are employed during health ; they alfo do effential Service in certain complaints, external as well as in- ternal. They Suck up the extravaSated blood which Sometimes is diffuSed below the fkin, and in the inter- ftices of mufcles, in confequence of blows, bruifes, or fprains ; without which, fuch accidents would often be followed by more troublefome confequences than they are. When the biliary ducts have been obstructed, and the gall-bladder is ready to burft, from the retention and accumulation of gall, the lymphatics are fuppof- ed, on fome occafions, to have prevented this fatal event, by abforbing the obstructed bile, and relaxing the tenfion of the gall-bladder, till, by the power of art or of nature, the obftruction was removed. They MEDICAL SKETCHES. 87 They are occafiorially fuppofed to perform the fame falutary office when other glands are obstructed, and in other difeafed ftates of the body. A diftinguifhed anatomift of this country imagines it is by the means of the lymphatic veffels that the body is conftantly renewed, they taking up the old matter, while frefli fupplies are conftantly depofited from the blood. This idea he Supports by many ingenious arguments and obfervations. He mixed madder with the food of a growing pig ; it is known that this root taken in- wardly tinges the bones of animals of a deep red colour; fo ftrongly are they imbued with this tint, that neither maceration in water or fpirit of wine for weeks together, nor even boiling, is able to deprive them of it, or communicate the fmallefl tinge to thofe liquors. But if the animal is allowed to live, and after eating the madder, is fed on its ufual food, after a certain time the red colour is gradually re- moved. By feeding the animal alternately on this root and its ufual food during flated intervals, on killing the pig, he found alternate layers of red and white in the bones, corresponding in thickneSs to the length of the intervals during which the animal had eat or been deprived of the madder. From this and other obfervations it is concluded, that the lymphatics abforb and gradually carry off the hardeft as well as the fofteft parts of our bodies, and are the inftruments of the conftant wafte, as the arteries are of the conftant renewal, of animal bodies. The lymphatics on the Surface of the body arc thought to be conftantly abforbing water from the atmofphere. Without this we could not account for the vaft quantity of water found in the belly in dropf.es: n:any gallons have in fome cafes been collected within G 4 a few 88 MEDICAL SKETCHES, a few days, though the patient has not drank fo many pints during that period. While fo many different ufes are found for the lacteals and lymphatic veffels, it is remarkable, that all the ingenuity of phyficians and anatomists has not only failed in afcertaining the ufe of the glands through which they pafs, but has not been able to form one probable conjecture on the fubject. Indeed there feems to be an impropriety in calling thofe fubftances by the name of glands ; for whatever their office is, it muft be very different from that afcribed to all other glands, every one of which is fuppofed to feparate a fluid of fome kind or other from the blood; at leaft, blood is evidently and di- rectly carried to all other glands, and a very different liquor flows out of their excretory ducts; whereas it is not blood, but chyle and lymph, which are carried to the mefenteric and lymphatic glands, and it is not a different, but the fame fluid, apparently unchanged in any degree, that flows out of them. When we perceive a liquor carried to any organ, and iffue out of it quite altered in all its fenfible qua- lities, we naturally conclude that the organ contri- butes in Some way or other to the alteration; but when the liquor feems to pafs through without under- going any change, we are at a lofs to account for the organ's being placed in the courfe of the veffels, or h> deed for its exiftence *, Our * Yet fome very minute anatomifts have aflerted, that a white fluid is fpund in the cellular iubftance of the lymphatic glands of young animals, but not in thofe of old : They add, that this fluid is globular, and of courfe different from the lymph. It may be con- jectured therefore, that the ufe of the glands is to feparate this fluid ; but as this fluid, whatever is its ufe, makes no apparent change on the lymph, which iflhesout of the glands as pellucid as it entered, and as it is not fomTO in old animals, the whole re- mains in as great obfeurity as before the difcovery of the white whole fluid. MEDICAL SKETCHES. 89 Our perplexity is ftill greater, with reSpect to the mesenteric and lymphatic glands ; for we not only can- not perceive what ufe they are of, but we can.plainly perceive, that on particular occafions they are detri- mental to health, as in the inftances above mentioned, where their being affected in a particular manner, oc- cafions marafmus * and other complaints: This how- ever is only a ftrong inftance of the limited nature pf our faculties. The admirable mechanifm of Na- ture in general, difplayed in ten thoufand aftonifhing examples, and the exquifite wiSdom with which every part is adapted to its peculiar ufe, in the human frame in particular, leave us no room to doubt, that thofe numerous glands ferve fome effential purpofe, al- though this has hitherto efcaped the refearches of phy- fiologifts, What confirms this idea, if a thing fo obvious re- quired confirmation, is, that in proportion as the Spi- rit of fcrutinizing nature has advanced among man- kind, new proofs have appeared of the infinite intelli- gence of its Author in the arrangement of all its parts ; and fome have been difcovered to be effential, which were formerly thought Superfluous. VI. RES- * Marafmus. A particular kind of confumption. 90 MEDICAL SKETCHES, VI. RESPIRATION. 1 HE digeftion of our food, the circu- lation of the blood, fecretion and abforption, though all effential to life, yet are not fufficient to preferve it even a few minutes, without the conftant flowing of frefh air into the lungs, and its reflux back to the at- mofphere. The firft is called inSpiration, the fecond expiration,—both refpiration. The thorax or cheft in which the lungs are lodged, is compofed of bones, cartilages and mufcles, fo art- fully arranged, that its cavity may be coniiderably enlarged or diminifhed at pleafure. This is brought « about, partly by the elevation of the ribs, and part- ly by the pulling down of the diaphragm or muS cular partition, that divides the cheft Srom the lower belly. This partition naturally bulges convexly upwards, fo as to encroach considerably on the cavity of tha thorax ; but on infpiration, it is pulled downwards from its convex to nearly a plain furface, and thus gives a fpace to the cheft, which it takes from the lower belly. The cavity of the cheft therefore may be enlarged in two different directions,—by the elevation of the ribs it becomes wider, by the dcpreflion of the dia- phragm it becomes deeper. 'She external air has accefs to the lungs by the trachea or wind-pipe ; the uppermoft part of which, called the larynx, opens into the throat, by an aper- ture M EDICAL SKETCHES, 91 turc called the glottis, and communicates with the at. mofphere by the month and noftrils. The trachea is a flexible pipe, compoSed of a Se- ries of cartilaginous rings, joined by mufcular fibres^ and lined with a membrane. This tube, defcending from the throat into the lungs, divides and ramifies in company with the nu- merous branches of the pulmonary artery, and with them and the veins forms that fpungy fubftance called the lungs. The pulmonary artery terminates in the pulmonary vein; but the branches of the trachea end in fmall membranous cells or bladders ; fo that there is not a circulation of air through the lungs, as there is of blood. For the blood nifties in by one fet of veffels (arte- ries) and returns by another fet of veffels (veins) ; whereas the air, rufhing in by the trachea, flowing through all its ramifications, and extending to its moft remote cells, returns to the atmofphere by the Same way it entered. The organs concerned in this are partly active, and partly paflive. The intercoftal muScles and diaphragm are pf the firft kind, the lungs themfelves of the fecond. When the intercoftal muScles elevate the cheft, which the croSs direction of their fibres, and the pecu- liar articulation of the ribs, admirably enable them to do ; and when the diaphragm is drawn downwards, the cavity of the thorax is enlarged, and the air within the lungs expanded, in proportion to the acquired fpace. This air, of courfe, becomes rarer and Speci- fically lighter than it was before. But it was then in equilibrio with the atmofphere j and this equilibrium being now removed by the ex- panfiort, the external air enters the larynx, and flows through all the branches of the trachea, reftoring the ^2 MEDICAL SKETCHES. the balance between the ambient air and that in the lungs. Whether the cheft is Swelled by inSpiration, or de- prefled by expiration, the lungs fill exactly the whole cavity, and are always in contact with the pleura, which is the name of the membrane that lines the inter- nal furface of the thorax ; no air being permitted be- tween this membrane and the external furface of the lungs, for if there was, the lungs could not poffibly play, as this air would counterbalance the preffure of the atmofphere. So many organs being Subfervient to refpiration, and this important function being performed by the means of fuch curious and complicated mechanifm, we need not be Surprized to find that various attempts have been made to explain the immediate cauSe that excites this function. We are told of the compreffion of certain nerves, the interruption of certain fecre- tions, the Stimulus given the lungs by the blood rufhing into the pulmonary artery, the alternate con- traction of antagonist muScles, thoSe of infpiration relaxing thoSe of expiration, Sec. Sec. but, after all, the matter remains unexplained to this day, unlefs what follows can be confidered as an explanation; for when ftripped of improbable conjecture, oftentatious and technical terms, and Superfluous language, the volumes that have been written on the Subject amount to this : We have a SenSation which excites us to expand our cheft, the action accompanies the inclination, and the air flows into the lungs ;■;—when enough is admitted to anSwer the purpoSes of health, we feel an equal defire of expelling it, which is directly followed by the accom- plifhment of our defire ; and thofe alternate feelings are conftantly renewed and gratified, with or with- out reflexion, afleepas well as awake, while lifelafts. A peafant would have laid it in ftill fewer words— *' Wc breathe in confequence of its being in our pow- " er ; MEDICAL SKETCHES, 9$ u er ; and becaufe pain and death would be the effect u of our not breathing." . Phyfiologifts are not.agreed with regard to all the ufes of the lungs, or the benefits refulting to the body from breathing. Some of thofe, however, are evi- dent and undiiputed. No body can doubt that by their means the voice is modulated, the power of Speech* is given to man, and, bv the air entering the noftrils and conveying effluvia, \ bathing becomes in7 flrumental to the fenfe of fmelling. Other ufes have been afligned to this function, which, though they feem manifeft to Some, are not So univerSally admit- ted. One opinion is, that, as the chyle is thrown into the blood a little before it circulates through the lungs, the great ufe of this circulation is to blend the two liquors intimately together, and complete the procefs of fanguification before the blood is difperfed for the nourifliment of every part of the body : Another opi- nion is, that the blood is attenuated in the lungs : Another, that it is condenfed there: And fome think that the particles of blood receive their globular form. there. Still another ufe imputed to the lungs, is to allow of the difchargeof watery vapour in refpiration, Without which the blood, it is Said, could not retain its due denfity ; and other inconveniences would rc- Sult. Others have imagined that the blood acquires its heat in the pulmonary artery ; and that the action of the lungs contributes greatly to that ufeful pur- pofe. It is evident that heat' muft flow in every animal from fome internal fource; for the warmth of their bodies being ufually greater than that of the atmof- phere, they muft lend heat to the air; but can borrow none from it. So, as there is a conftant wafte, there muft be a conftant reproduction. What that is, and where $4 MEDICAL SKETCHES. \ torhere it originates, has long been and ftill is a matter' of difpute. One opinion j as was above hinted, ijfy that the blood acquires its heat chiefly in the lungs; That animal heat depends upon the action of the arteries, and the circulation of the blood in general, is* very natural to imagine ; becaufe whatever increafes the velocity of the circulation, whether exercife, fric- tion, or difeafe, alfo increafes the internal heat; whereas fainting, hemorrhage, and whatever produce* a weak and languid circulation, alfo diminifhes the heat of the body'. When a ligature is put around an artery fo 3S to prevent the blood from being carried to any particu- lar limb, that limb becomes colder than it was, and does not recover its natural heat, till by the expanfion of the lateral branches, which go off from the tied artery above the ligature, the ufual quantity of blood is circulated through the limb. Thofe who believe that animal heat arifes from the circulation, imagine it is immediately produced by the attrition of the particles of blood with each other, and with the fides of the veffels through which they flow; and as this attrition is greateft in the circu- lation through the pulmonary artery, becaufe there the globules are not only rubbed by the action it has in common with other arteries, but alio by the conftant and peculiar action of the lungs, of courfe they conclude that animal heat is principally generated there. This reafoning would be irrefiftible, if the facts wl ich fupport it were not oppofed by facts which have a contrary tendency. For, although the body cannot long retain heat without the circulation in general, and that through the lungs in particular, although the body acquires additional heat in proportion to the force of the circulation, although the increafed action' of MEDICAL SKETCHES. 951 of the whole body or of any part increafes the heat, and although the attrition of folid bodies on each other never fails to generate heat; yet no attrition or agitation of fluids againft Solids, or of very fmall parti- cles of a folid plunged in a fluid againft each other, lias the Same effect. Take any quantity of blood out of the body, let it be agitated in the moft violent manner for any length of time, yet neither the friction of the red particles' againft each other, or againft the fides of the veffel, will produce the fmallefl heat. To obviate the force of this very ftrong objection, it has been obferved that we cannot fafely draw con- clufions concerning the effects of any procefs of the animal economy, from experiments made in imita- tion of them out of the body, the original being always fo different from the copy; any artificial agitation, we can give to blood or other fluids out of the body is fo different from that of the circulation in it, that we ought not pojttively to .conclude, from no heat being produced by the firft, that none will be pro- duced by the fecond, efpeciall^as we find that the exiftence, *increafe, diminution, and abienee of ani- mal heat, always accompany the exiftence, increaSe^ diminution and abScnce of the blood's circulation. The general import of this obfervation is juft ; yet as no friction or agitation of fluids againft 'Solids, how- ever violent, not even the impetuous daihing of tor- rents upon rocks, produce heat, we certainly have no argument from analogy that animal heat proceeds from the friction of the circulating fluids upon the fb- lids. The chymical commotion arifing from fermentation indeed produces heat ; but there is no evidence of any fuch thing ever taking place in the bodies of living ani- mals. And even were we*to adopt the opinion that fome of the Secreted fluids are formed in their fecretory or- gans 96 MEDICAL SKETCHES, gans by fermentation, this could not account for animal heat; for its caufe, be it what it will, cannot be occafional or partial, but conftant and univerfal, as the effect it produces ; and it muft alSo be reconcila- ble with this fact, that increafing the force of the circulationj by whatever means, increafes the heat. There are fluids, however, which on being mixed generate heat without effervefcence or any vifible commotion. This is the cafe on mixing fpirit of vitriol and water, and in other inftances ; but whether any thing of the fame nature can be fuppofed to take place in the body, or by the mixture of the different fluids of which the blood confifls, or whether it can be*fuppofed to operate in conjunction with the action of the arteries and the~lungs (which feem to be inti- mately connected at leaft with the production of heat) I will not venture to determine* An explanation of the manner in which animals acquire and retain heat, and from what fources frefh Supplies are conftantly drawn, has been So often attempted, that one would naturally imagine there was Something more curious and attracting in this than in inveftigating any of tme other caufes of heat* All the known fources of heat are : 1. The fun. 2. Burning fuel. 3. The attrition of folid bodies. 4. Fermentation. 5. The chymical union of bodies. 6. The bodies of living animals and vegetables. And it is remarkable, that every explanation of the latter is founded on a fuppofition that the heat is derived from fome of the five preceding fources. We have already obferved that it has been imputed to attrition and fermentation ; of late it has been fug- gefted (and the doctrine is Supported with ingenuity) that MEDICAL SKETCHES. 9; that the ftomach is the principal Seat of animal heat, and that it arifes from the decompofition of food*. It was formerly hinted by another philofopher, that a fluid fire is attracted by plants in their growth, and becomes confolidated with their fubftance, which is the fource of vegetable heat; and when the plants are decompofed by fermentation, digeftion, or other- wise, the fire recovers its fluidity, and efcapes* Here then are three Suppositions; fire is a fluid; plants have the property of attracting this fluid; and, in the third place, the power of confolidating it. The three together form a mafs of difficulties, at leaft as great as that they are intended to re- move. Indeed every attempt to explain the origin of animal or vegetable heat is open to this objection, of being founded on fome hypothefis at leaft as inexplicable as the phaenomenon it fhould explain. I own I ean See no exclufive title that animal heat has to the labour and ingenuity of phyfiologifts ; but if they choofe to give a preference to it over the other fources of heat, they fhould found their hypothefes on fome other foundation than a Jhppofed analogy with phenomena which are themfelves unexplained. It af- fords not a great deal more Satisfaction to my mind to tell me that animal heat is owing to attrition, than it would to affure me that the warmth which accompanies attrition is owing to animal heat; for, in my apprehen- fion, to endeavour to explain a thing of whofe nature we are ignorant, by telling us it is like another thing, of whofe nature we are equally ignorant, cannot make us ayaft deal the wiSer. It is Bays' anfwer to Smith, in the Rehear- fal----- I am not acquainted with this Amaryllis, fays Mr. Snrth: Pray, who is fhe ? H Amaryllis, * yiieory of the Frtfifo&i?, •- » r. 01 -y -t ?>"?!*"." "re r * r' ::. e^rrpo: u3i;. '' ; ~l<, :/■, ,". .1 < '-'•.» -»' fjl'f ..»■"> il:.>..n ii -.'■i.f i>f.» '•« -n:'> "' :..\Jkmr ^ofiliw .;.."'-.'.'-f • try: */r ***.-.? .ii; . o,. .'. '■'"* li ' Sr«m';-f : f'.")w /fv'J.r.v " ■.rjh r' ;■;• t vilcftJiT-'il IH,-/, •.V'?'; t •"■'■;:.» r. fi L'7?'* .'":'' '' '.'-7 L-U.:.-:'" . ^ 'UT '•"■'f. ifu*.Y ' '.!' /•fyc'V M: '• ; 'i."" "O - ■: '.-::.-'; .;■ n'.i i.;;:. r.Tjff^":. i,l,{7:""° ■' '•' ' :' /" -■=:»:■;-. - ^'i "j i '.' "<< vi rion> ':; 1 " ' ' ' * • \ "i ' "f 1 ' ■ .3J;/!:ry|bt.i ? ■ ■■ /o ■;•' J„-.//'J' ■» •trir- • "■ .'. •-'i ■■ h'.i >U .' -mrS ^ "': ■>.-;' '■■•'.'• • \l>4 ; 1 - ■ flf •.vY'isTi.'irr d 1 :i: :rt■■■■ ■ : . -• ;J . .. ..si ■ lis '.» JL-L-i"'" >i.ii ;:: ■.■';.;. ;■"■. "Jw;"? :«r.;.77 o- <■' .- : -'d '»... '• \.'. i • J '■/'if'" - ns • ; ^ViW c'«' 1 ' ■ * f •i t (ii'.oivy -y ■ • rr* « ■ » «• • ':' . *.'»J.':Jj;.;, „ O-IK .r" :' '.(. '■'rf Vi , "i O ,'. ill; ME D I C A L ■■■<" S K E T C H E S. PART THE SECOND. I. > \ OF FEVERS IN GENERAL.}';?. ■ : :.- • .. -v.. TV 1 NO W proceed to offer a few remarks ■on certain difeafes. I begin with fevers, becaufe the diforders which have been arranged under that deno- mination are the moft common and univerfal of any to which the human body is liable. . .'■ When the circulation of the blood is quicker, and the body is hotter than is natural, there exists a cer- Itain degree of fever. . \. ,\v ~ The moft part of difeafes are attended with an un- ; common quicknefs of the pulfe, and heat; .a. greater orlefler degree, of fever therefore is a fymptom of .moft difeafes. What is ; commonly. underftood by the term fever, however, is a'complaint beginning with a fhivering, or at leafti a fenfation of cold, foon followed by a -quickpulfe,*univerfal heat, and diforder of the natu- ral functions, .-but riot originating from a wound, K 3 .. . • , or «34 MEDICAL SKETCHES. or the direct affection of any particular part of the body. When an affection of any part in particular, whether from an internal" caufe or an external injury, is the pr'^ary and efl^n^ial complaint, the fever w^ich ac- companies this is confidered as a Symptom only, and the diSeaSe is not denominated a Sever ; but when the cauSe of Such a local affection is internal, the difeafe , derives its name from the organ affected ; and if it pro- ceeds from an external injury, it is fimply called a wound or bruife. i Thus an inflammation of the membrane that lines I the interior furface of the thorax (the pleura) is called { a pleurify, an inflammation of the kidneys a nephritis, j of the liver hepatis, and foon. As fevers arife from different caufes, affect people of different conftitutions, vary in different climates and feafons, they muft of courfe be different in their nature, and require a different treatment. , Notwithftanding thofe differences, there are certain 1 iympfcoms and circumftances common to all, which • unite them under the general name of fevers. The eflential fymptoms common to all fevers at their firft attack are, languor, wearinefs, .and Sorenefs of the fiefh and bones, followed by a fenfe of cold, -which beginning hi the back gradually creeps Over the whole body. This coldnefs, in fome, is attended with gentle irregular fhudderings, in others with a ftrong fit of fhivering, with palenefs of the fkin and lips, drynefs of the mouth, a want of appetite, an ina- bility to fleep, impaired fenfibility, and often fome degree of confufton of thought. The coldnefs is fuc- ceeded by an uncommon heat over the whole body, ' and the drynefs in the mouth, by great thirft. At laft a Sweat, more or leSs proSuSe, breaks forth, and the body becomes in Some degree cooler, or perhaps re- turns entirely to its natural ftate. Diviflon ■ MJEDJCALSKETCHES. 135 Difuiflon of Fevers. If the difeafe concludes within the fpace of twenty- four hours, it is called by phyficians an ephemera, or a fever of one day. If the Same Symptoms regularly return and go off at the Stated intervals of one or two days, the difeafe is an ague, or intermittent fever. If, with little or no evident abatement, the difeafe proceeds with equal or increafing violence, it is then called a continued fever. The term is not ftrictly accurate ; for there is rea- fon to believe that all fevers, except ephemera, are attended with diurnal exacerbations and remiffions. As thofe, however, are very different from the inter- vals above mentioned, often efcape the notice of the earelefs, and Sometimes are diftinguifhed with difficul- ty by the moft attentive obServers ; fevers are with propriety divided into two claffes, the continued and the intermittent The latter are readily diftinguifhed from the former by thetotal abfence of fever during their intervals; and they are diftinguifhed from each other by the names quotidian, tertian, and quartan, according to the du> ration of thofe intervals. Diviflon of continued Fevers. Continued fevers have been divided and fubdivided by various authors with fuch a parade of learning, and fuch an affectation of precifion, as terrifies the diffident fludent, and perplexes the moft experienced practi- tioner. Who would not be alarmed, on being informed that fuch a formidable band, Such afebrium cohors as the following, had invaded the earth—febris inflam- matoria,. Scorbutica, SoporoSa, putrida, nervofa, ty- phus petechialis, flava, Sudatoria, colliquitiva, ardcns, ■Uectica, cephalalgia, biloSa, eryfipelacea, Synocha, K 4 (ynochu&i l36. MEDICAL SKET Crt E S. Synochus, paludofa, verminoSa, maligna, &c." &c, &c. And after being thus informed," who could be Surprized to find that death walked with a haftened* ftep through the land * ? To lay hold of the occa- fional fymptoms wmich arife from the j differences of conftitution and other circumstances^ and erect? them into new diSeaSes with terrifying names, bruv thens the memory, and tends to darken rather than elucidate. . >!> He who breaks a loadftone into a great number of pieces, willt throw as little light vmon the na- ture of magnetifm, and difcover as little of its caufe,. as if he had left the loadftone entire. To give terms inftead of ideas,,is a.tpractice not. confined to phyficians : From long eftablifhed cufr torn, however, Such counters feem to pais more cur-, rently, and are oStener received in exchange Sor gold, from them than from others. .-•.. u, - Thofe who are folicitous to bejjthought pro-. found, do not always wifh to be intelligible ; they gain their purpofe. more effectually without it. My cliief aim, on the prefent ..occafixm, is to be ufeful. I muft therefore endeavour in the firft place to be fully underftood. .••*.-..••.;.' ;: , I do not pretend, by any new fyftem, to explain what writers oS far greater genius have left in ol> fclirity ; but .- perhaps ; >giv ing«fome of theirj ideas• in a plainer and Ampler -dreis,. and adding fuch of my own as experience and reflection have confirmed^ will be of fervice. >.. Two very different States of the human body are fuppofed to accompany the difeafes comprehend- ' ... . ed * ------Nova Febrium. Terris incuhuit cohors : Semotique prius tarda neceflitas" Lcthi, cprripuit gradum. Hor, lib. i. carm. 3,. - - MEDICAL SKETCHES. 137 ed under the name of fevers, and*1 to form"- their great and fundamental diftinCtion. One is called the phlogiftic diathefis, or inf amma- tory difpofition ; by which the heart is' excited to rapid and Strenuous exertions, during the continua- tion of which there appears great Strength, in the action of the veffels, and the blood itfelf feems to be of. a' firmer; and denfer texture than ufual. In the other, the brain and nervous fyflem are more directly affected, their energy Seems impaired, the force of the heart and veffels is diminished, the blood is of a loofer texture, and in a morel diflblved ftate, and the animal juices tend, as fome have imagined, to, putrefa-."!Ion. ; '.In-the firft ftate, when the inflammation origi- nates from external caufes, as wounds, Contufions, or burns, the fever follows ■ the local affection, and is in proportion to the degree of inflammation, and to the importance of the part or organ affected. This is alfo the cafe in certain diforders of the lungs, liver, and other vifcera, which arife not from external injuries, but from fome vice in the part, which gradually brings on inflammation, and the inflammation fever. If the local inflammation is removed, the fever is removed alfo:; if it cannot be removed, but increafes, gradually deftroyiug the organization of the part, the patient dies fometimes by the violence of the fever, and fometimes merely becaufe an organ ne- ceffary to life is deftroyed. In all thefe cafes, therefore, the difeafe as not a fever, but a local inflammation producing feverifli Symptoms. Thefe Symptoms are fhiverings, a ftrong, hard, and full pulfe, heat, thirft, refllcffnefs ; and if any blood is drawn, a thick gluey fubftance of a buff colour will be foon formed on its furface. But 138 MEDICAL SKETCHES. But it often happens that people are Seized with . Shivering, and all thefe fymptoms in a ftrong degree, without any external violence, or the affection of any particular organ. In this cafe the fymptoms being the fame with what occur in local and vifible inflammations, the whole mafs of blood is fuppoSed to be affected in the Same manner as when they evidently exift, and this di£- eaSe is naturally enough called an inflammatory fever. The other fpecies of fever, when pure, difplays Symptoms very different, and in fome refpeets op- pofite to this inflammatory irritation. Weak and quick pulfe, debility, and proftration of Strength, heavineSs and dejection of fpirits, as if the vital principle were invaded by fome baleful influ- ence acting directly on the nervous fyftem ;— thofe and other fymptoms have procured this fever the name of nervous. When the fame fymptoms attack with a greater degree of violence, it has been called malignant ; and as dufky brown, violet, or black Spots, and vibices or blue marks like bruifes, imputed to a putrid ftate of the fever, fometimes appear, it is al- io called the putrid fever. Thofe and various other cireumftances, however, feem to form no effential distinction. The whole may be comprehended under one name ; and pro- vided the fymptoms which difcriminate tins from the inflammatory fever be accurately defcribed, it js of no importance which is chofen. If fevers always were found in Nature as pure, unmixed and diftinct, as they are defcribed in au- thors, the labour of thofe who apply their minds to the Study of medicine might be greatly abridged. Afk a very young ftudent of phyfic what is to be done in an inflammatory fever, and he will an- fwer, MEDICAL SKETCHES. 139 fwer, without hefitation, that you muft bleed and dilute. Afk again what is to be done in a nervous, milignant, or putrid fever, and he will anfwer with equal readinefs, you muft give the bark, &c. Carry him to the bed-lide of a patient with a pretty ftrong and hard pulfe, confiderable heat and drynefs of the fkin; here, he will fay, is a vigorous motion at the center of the vafcular fyftem, with great contraction, and Strong refiftance by the veS- fels at the circumference ; to allay the internal com- motion, and relax the fpafm, plentiful venefecfion muft be ufed, and great quantities of cooling bland diluting liquors muft be drank ; but on farther examination, he finds uneafinefs in the head, nau- fea, dejection, and impaired fenfation and debility, fymptoms indicating a direct nervous affection, and for which, had he found them unaccompanied by the former, he would have prefcribed corroborants, cordials, and antifeptics ; but finding them thus combined together, he does not know whether to call the difeafe inflammatory or nervous, and of courfe is at a lofs what to prefcribe. In reality, it requires much experience, Sagacity, and attention, to decide what courfe ought to be followed in thofe complicated cafes, where the two genera are fo intimately blended, as often happens in the continued fevers of this ifland. The Caufes of Fevers. It is ufual for writers to enumerate what they con- 'fider as the caufes of fevers ; thefe they divide into two claffes, the remote and the proximate. Under the firft head, Some have favoured the public with a lift of almoft every tiling that can diforder the human body. Full i4o MEDSCAL SKETCHES.' Full diet, thin Watery diety hot diet, too gfeafc exercife, too little exerciSe, drinking cold Watery liquors whert'-the body is hot, warm liquors when the body is cold, and Spirituous liquors whether the body is hot or cold ; plethora, hemorrhages, flop- ping of iffues and other evacuations, -the retention of excrementitious or other offenfive matter in the ftomach and bowels, cold dry winds, moift wea- ther, hot weather, change of climate, night-watch- ing, intenfe thought, venery, fear, grief, anxiety, the miafmata, or certain particles floating in the air, and which arife from marfhy grounds acted up- on by heat, and the effluvia which conftantly flows from living human bodies pent up or confined from being diffufed in the atmofphere. -" What produces many miftakes and difference of opinion refpecting the caufes of difeafes, is, that we know little or nothing of the relation between caufe and effect, but merely that we fee the one follows the other. .';■ When a philofopher holds any thing in his'hand, a leaden bullet for example,; he. knows it will fall to the ground on his Spreading his fingers-; the moft ignorant peafant- knows the fame, and for. the fame reafon, becaufe he has feen it always happen fo. The difference between the philofopher and-pea-^ fant is, that the former will endeavour to find out why it always happens fo ; whereas the latter will be fully convinced he knows it already, and that he cnild have foretold that lea^, and every heavy fub- ftance, muft :\ceiiarily fall to the ground, although he never had feen or heard of Such a thing in his life : Nothing can be clearer, he would fay, than that a bullet muft fall to the ground, when it is not fupported. Yet it is evident that it might have been as na- tural, for aught he or the greateft philofopher alive kik-v MEDICAL SKETCHES. 14* knew before trial, for the bullet or any other Sub? ilance to have mounted upwards, have taken sn horizontal direction, or remained Seif-fufpended in the air. And although the philoSopher fhould never be able to diScover any other relation between two events, but that the one always follows the other, he will agree with the peafant: in calling the firft the caufe of the Second, and all the world will follow their ex- ample. If we fee the events happen in this fucceflion in a great number of inftances, although the fecond fhould happen without being preceded by the firft in a few, ftill we will fufpect the firft for its caufe, notwith- ilanding that Something or other, we do not know what, prevents its appearance in Some cafes; this however raiSes doubts ; we are not quite So certain as we were. \ But fevers are not always and regularly preceded by the fame events, but fometimes by one, fome- times by another, and fometimes by a number to- gether ; in Such cafes, therefore, we need not be Surprized thatthere are frequent miftakes, and a variety of opinions, refpecting their cauSes. Indeed, if the catalogue of caufes above enumerat- ed is admitted, we never can be at a lofs for a caufe for a fever or any other difeafe, for few events of our lives are not preceded by fome of that lift. But it is evident that the greateft number of them have at moft only a tendency to predifpofe the body in fuch a manner, that fome fucceeding caufe, which of itfelf might not have been fufficient to induce a fever, may have that effect; or if the fucceeding caufe would have been fufficient to produce a fever, the predifpofing caufes above enumerated may render the difeaSe more obftinate and dangerous. I fhall examine only a few of thofe remote caufes, under !42 rVlEDICAL SKETCHES. under which the greater part of the others may hi naturally enough included. I begin with cold. Sydenham Says, CauSa evidens externa febrium quamplurimarum inde petenda eft, quod quis Scilicet vel prarmaturius veftes abjecerit, vel exereitatio in- ' caleScens Se frigori incautius expoSrterk; and a little after he adds, Et fane exiftimo plures modfo jam de- fignato, quam Pefte, Gladio, atque Fame, firoid omnibus perire. This laft feems a very ftrong expreflion, biit is probably applied to all Who die in coflfeqnence of ©bftructed perfipiration.—Whether the drfordef k produces be what is properly called a fever, or a peripneumony, an hepatitis, or any other difeafe; in this SenSe^ and in this ifland, unquestionably more people are deftroyed by the caufes merttioiicd by Sydenham, than by the plague, Sword, and famine. Expofingthe body for any length of time to & greater degree of cold than it has been accrtftomed to, is evidently the fource of a very great number of difeafes. The immediate effect of this is a contraction of the pores on the furface of the body, by which means the fluid particles which ufually pafs this way are retained, and thrown back into the general mafs, which when long continued is found greatly to difturb the animal functions. Knowing that ftoppage of perfpiration fometimes produces dangerous difeafes, it is natural to be Sur- prized that difeafes'are not ftill more frequent; that they do not happen in confequence of every change from a warm climate to a cold, or of every change from warm to cold weather, or of remaining for any time in a colder room than we are accuftomed to; or, in fhort, of all thofe Stoppages or diminutions of perfpiration which muft happen td the mo& wary. This MEDICAL SKETCHES. 143 Tt/is would inevitably be the cafe, if Nature did not contrive to prevent k, by inverting the different organs of fecretion with the power of mutually aflift- ing each other ; a deficiency in one being generally compenfated by the augmentation of fome other. The agreeable viciflitude by which art intermediate feafon is always placed, between the heat of fummef and the cold of winter, is another means by which Nature guards againft the diSeaSes to which the human body would be liable, if it were not thus gradually prepared for the fucceeding extreme by a moderate intervening feafon. But the admirable arrangement by Which each feafon is blended with that which precedes it, and then by degrees affumes the nature of that which is to follow, although it certainly prevents in a great meafure the destructive effects which a fudden change from fummer to winter, and from winter to fummer, would have on the human conftitution, does not en- tirely hinder the fucceflive Seafons from producing changes in our bodies which difpofe them to particular difeafes, as is evident from the nature of the epide- mics peculiar to the different feafons, which are more regular in many other countries than in the variable and uncertain climate of Great-Britain. Cold is found, by univerfal experience, to give a difpofition to inflammatory diSorders, and heat to thofe of that nature which has beert called putrid'. During the winter, and early in the fpring, pleurifies, peripneumonies, inflammatory anginas, rheumatiftnf, and inflammatory fevers, prevail. Towards the end of fummer, and particularly in autumn, fevers of a different nature, dyfenteries, and putrid ulcerous fore throats, make their appearance. If the former are more frequent in the fpring than during the winter, this is imputed to the cold being more fteady in winter; whereas in fpring many , people 144 MEDICAL SKETCHES* people are tempted, by the heat of mid-day, to throw ■ off part of their clothes, and contract difeafes from the unexpected chilneSs of tne fame evening. , , . That autumn is more unwholefome than fummer; is thought to be owing to this, that the human body, after being relaxed by the long heats, and enervated by the prpfufe perfpiration of the fuinmer, is their > more affected by the cold of autumn ; and likewife becaufe the.air then abounds with -the exhalations of putrid animal ,anthc increafed Se- cretion and acrimony of the bile aggravating the other Symptoms'of the fever. In what degree it leans to the one or the other, in fome meafure Seems to depend on the ftate of the weather during the courfe of the difeafe, and the par- ticular conftitution of the patient ; the^ redbuft and fan- guine MEDICAL SKETCHES. 147 £ume fhewing a ftrbrtger tendency to the* fontier* iand tlie weakly to the latter. . ^,, Intoxication is reckoned among the caufea of fe- ver. ■•'? ' - n'.'iij, ,'jMr,^-»r The general bad effects of this upon the- human constitution are too obvious to be infifted on., n- Wherever a predifpofition to any particular difeafe foirks in the conftitution^ intemperance in.-; chunking -feldom fails to roiife it into action,. ?r:Ii ci. '." ' '■' Repeated exceffes of this kind fomsthnes prodrrce the epilepfy in thofe never before Subject" to it, and always haften the returns, and augment the; violence of the fits in thofe who are*' n i //o is -:; / ot I have known a fifigle inftance cf intemperance "bring tfnV dreadful diforder back with violence, upon thofe who by former moderation had warded it off for years-. ';,v)) ^ .■' To increafe good-humour, gaiety,' and wit, and pro- long the pleafure of converfation, is the ufual apology for fuch exceffes. But if it werei a general rale to leave the company as foon as our tafte and talents- for fenfible or witty Converfation began to The daily praclice.of drinking to intoxication muft be considered as improper, if there were no other ar- gument againft it than its 4epr$virig us of the advan- tage of an admirable and efficacious remedy in many *»J. L 2 -J*-- -.t ;,difofders- 148 MEDICAL SKETCHES. difordeis, as is well obferved by the celebrated com* mentator on Boerhaave's.aphorifms: ■ u Ilia autem acri- " monia, qua^fermentatis liquidis ineft, miro flimulo " atque efficaciffimo auctam cordis velocitatem efficere " poleft'; unde inmorbis languidis et; frigidis vini et " cereviiias generofioris moderatus ufus adeo prodeft. " Immodico horran. ufu febres, crapulares diet as,, exci- *' tari, nimis notum eft'; verum levia Ikec Sunt, fo- u lentque ab illis, quibUs foleiine eft hefterna venas ha- "* here inflatas Iaccho, contemni f\."_ -:.> For akhough'intoxication, never fails when firft in- dulged to produce moft of the fymptoms which attend fever, as heat, drowth, head-ach, and naufea, it muft be confeffed that thefe wear away by habit; fo that thofe who indulge every day irt the bottle, if they Sur- vive the exceffes.of their youth, and efcape consump- tions, dropfies, and paralytic complaints in more a^i** -vanced life, are in. little danger of being cut off Sud- denly by a fever from drinking ; they will have the ^comfort of-outliving not only their friends, but very probably their own understandings. - Tbofe who are not habituated to intemperance, are often thrown into violent fevers by that degree of 'ex- cels, Which is barely fufficient to put a perfon of the above defcription into tolerable good humour, and diS pofe him to a comfortable night's reft. In fome .inftances where^ people have fallen down irrienfible by extraordinary excefs in drinking, a fuper- vening, fever has been confidered as the only thing that Saved them from a fatal apoplexy; as is remarked alfo by VanSwieten, who having quoted the following max- im from Hippocrates, 4' Si quis ebrius de repente ob- '' mu.tefcat, convulfus moritur, nifi eumfebris corri- tc puerit, aut qua hora crapuja folvitur, vocem ■" edat," adds farther, "fed in Commentariisyy.&^ex " Hippocrate notaturrt fuit fumrnam ebrietatem.fcqui ">,'.. .t '"pbmutejeentjam,- ** Ger*rdi Van Swieten Comment, torn, fecund, p. 51, MEDICAL SKETCHES. 149 " obmutefcentiam, et lethalem quandoque apoplexi- *c am, nifi febris orta remedia fuerit ;" and then quotes from the third book of Hippocrates\Epidemics the in- ftances of two perfons who " ex potibus ambo pericu- " lofa febre decubuerunt; quoriun primus fecundo " jam morbi die furdus factus fuit, dein ferociter deti- xt ravit, quarto die convulfus, quinto die periit. Al- " ter yero port difficileai morbum, vigefimo die " evafit." What appears certain from thefe quotations, is the great danger of exceflive intoxication ; that in fome cafes it inftantly kills, in others produces a vio- lent fever, of which fome die, and others with diffi- culty recover; and that, ;n the opinion of Hippocrates and Van Swieten, the fever was the means Nature. ufed to bring about the recovery. Some people will have the preSumption to diSpute the laft article ; but admitting it, ftill it muft be allowed that a difeafe muft be of a very defperate nature for which a fever is the only remedy, and this remedy not always ef- fectual ; for it fometimes happens, particularly to young perfons of a fanguine habit, that in confequence of great excefs in drinking, a fever of Such violence is rarSed, that the patient dies after a few days of high delirium. Violent paflions of the mind, particularly thofe of rage, fear, and grief, are reckoned among the remote caufes of fever. There are doubtlefs inftances of rage, when kin- dled to an exceflive height, producing an apoplexy : The fame paffion in a fmaller degree, or in a different conftitution, it is faid, may produce a fever: I. cer- tainly fhall not deny that it may, but I never knew an inftance of it. A fudden fright is a very frequent caufe of epilep- fy', particularlv in young people and children. L 3 ' Far w MEDICAL SKETCHES. Fear inftantly checks perfpirationj difturbs all the Secretions^ and the natural courSe of the animal ceco- nomy. Grief has the Same effects in a Smaller degree ; but the paflion is generally of longer duration ; both im* pair the appetite, retard digeftiort, dimin'ifh the ener- gy of the brain, and the action of the heart; and dif* pole,the body fo very much to the difeafe, that in this, fituation we frequently fee a nervous fever arife, for which we-can perceive no other caufe. Long continued coftivenefs, and the retention of excrementitious or other offenfive matter in the fto- mach and bov/els, is alio claffed among the caufes of fever. It is evidently the caufe of lofs of appetite, naufea, flatulencies, feverifh heats, and much general oppref- fion ; but I have never feen a formed fever, in adults,, that I impute to this caufe alone. When a fever takes place indeed, from whatever caufe, coftivenefs generally follows, and unquestiona- bly has a tendency to augment all the fymptoms. I faid I had never feen what could with propriety be ealled a fever, which originated in this caufe alone in adults. I confined my expreflion to thofe of that clafs*, becaufe I do think this caufe, independent of any other that we can perceive, does produce fever in children, not only by ftimulatingthe nerves of the inteftines in the fame manner that worms do, but alfo by part of the acrimonious matter being abforbed and thrown into the mafs of blood by the lacteals. It will be faid, that grown people are expofed ta thofe caufes as well as children : They are fo ; but they feem not to have the fame effect on the firmer and lefs irritable conftitutions of the one, that they have on the other. If this reafon is not thought fufficient, another may fee adopted. The fact remains unmoved. In MEDICAL SKETCHES. 151 In fuch cafes, no doubt, the firft thing that h to be done, is to cleanfe the whole alimentary canal by pro- per purgations; but although this prevents more i\*el from being added, it cannot at once extinguifli the flame already kindled ; the fever continues for fome time, and requires a particular treatment. For the removal of a caufe does not always remove the effects, which fometimes become the caufes of new and obftinate fymptoms. Excefs in venery is alfo reckoned among the remote caufes of fever. The general effects of Such imprudence are languor, weaknefs and dejection ; and that this preditpofes or renders people more liable to be infected by the other direct caufes of the nervous fever than they would other^jfe have been, is moft certain ; and fome peo- ple think exceffes of this nature of themfelves may produce a nervous fever without any other caufe. The Sentiments expreffed by CelSus on this Subject feem highly rational: " Concubitus vero neque nimis ct cone*.pifcendus, neque nimis pertimifcendus eft. Ra- " rus corpus excitat, frequens foivit. Cum autem " frequens, non numero fit, fed natura, rationc cetatis u et corporis; fcire licet, cum non inutilem effe, iC quern corporis neque languor, neque dolor, fequi- u tur."—Celsus, lib. i. cap. I. But fevers are often epidemic, and numbers. of per- fons affected, on whom none of the caufes above enu- merated can be fuppofed to have operated, or cannot be fuppofed to have more force at the period when the epidemic prevails than at any other time. They nn.ft therefore, in many inftances, proceed from Some other cauSe, Certain noxious particles floating in the atmofphere, , and more prevalent, or more powerful, at particular feafons, and in particular places, than in others, are accordingly conlidered as by far the moft general L 4 caufes xs* MEDICAL SKETCHES, caufes of fevers. Thofe miafmata are fuppofed to be the effluvia of ftagnating corrupted water, and putrid fied vegetable and animal fubftances. They are too minute to undergo the examination of our fenfes, yet we can have little doubt of their ex-? iftence, and ftill leSs of their being the chief caufe of intermittent fevers; and combined with cold, the fre- quent caufe of the continued fever to which fo many different names have been given;'as bilious, remit- tent, Sec. The following considerations mjike this amount to a certainty. Intermitting and remitting fevers abound in every climate, in the neighbourhood of moift marftry Soils ; in woody countries, where the air is confined by the number oStrees ; in low flat countries, where there is a great quantity of ftagnating water, and no hills to direct a brifk ventilation. The inhabitants of the mountains and of the valleys, where there arc running waters, a dry foil, and ftrong ventilation, are not Subject at all to agues, an$ very Seldom to the bilious fever, while they remain in their own country; but in general are liable to be feized with one or other, when they come to the fenny countries. Even in thofe countries the richer ranks of inhabi- tants who have dry apartments above ground, are lefs liable than the poorer fort, who are obliged to continue longer in the fields, expofed to the baneful influence of the marfh miafmata, and fleep on ground floors. Of the pooreft Sort, the inhabitants of tlrs towns and larger villages, where the noxious quality of the at? mefphere is corrected by numerous fires, and ventila- tion is produced by the arrangement of the houfes in- to ftreets, are leSs Subject to the diSorders in queftion than thofe who live in detached cottages* Tho, MEDICAL SKETCHES, i*3 The bilious remitting fever very feldom originates pn board a Ship ; but it is often carried on board by feamen or Soldiers who have caught it when on the watering duty, cutting fuel, or any other Service which required their being on fhore. There are inftances of feamen's having been put on fhore on account of the fcurvy; and although the frefh vegeta- bles they then obtained foon cured them of that difeafe, yet if the country on which they landed was marfhy, and in the neighbourhood of woods, it has been obferved, that they foon afterwards were feized with bilious remitting fevers *. The feafon in which fevers are moft prevalent, is the end of fummer and beginning of autumn, when heat and moifture combine to haften the corruption of animal and vegetable fubftances, and fill the atmoS phere with an unufual quantity of miafmata. Thofe considerations render it next to a certainty, that Something effentially connected with a marfhy Soil produces fever ; and we can fuppofe nothing with fo much probability as the effluvia of ftagnating water, and corrupting vegetable and animal Subftances. And if a fudden Stoppage of perfpiration, from the cold of autumn, after the body is relaxed by the pre- ceding heat of fummer, is fufficient of itfelf to produce fever in dry and well ventilated countries, where there is no reafon to think that marfh miafmata prevail, we cannot be Surprized to find them far more .univerfal, and more obstinate, in low and marfhy foils, where the firft caufe concurs with the fecond. But * Vide Medical Obfervations and Enquiries, by a Society of Phyficians, vol.iv, article 12. We are there informed, that in one fhip the officers who never had the fcurvy, on fleeping afhore one night, were feized with this bilious fe.ver ; fo were the carpenters and boat's crew, who were neceflarily afhore: All who remained on board continued free Srpniir. i J4 MEDICAL SKETCHES. But there is another caufe more active than either, or than all the others taken together, in producing fe- vers of peculiar danger and malignity ;—the effluvia conftantly flowing from the living human body, which when long confined in the fame place, and prevented from expanding in the atmofphere, becomes in the higheft degree acrimonious, and the c^ufe of fevers equally contagious and malignant. Wherever numbers of people are crowded together in clofe places, the air of which muft foon be de- prived of part of its vital power, by repeated refpira- tion, this infectious matter will be formed ; but with moft rapidity in gaols, in the holds of fhips, and in hofpitais, where its virulent tendency is haftened by naftinefs, by unwholefome food, by defponding thoughts, or by the effluvia coming from bodies ha a difeafed ftate. It communicates its contagion not only to thofe who approach the places in which it is generated, and the human bodies from which it flows ; but alfo will re- main long entangled in blankets, beds, and other fub- ftances which have been in contact with the patient's body ; retaining its activity, and capable of infecting others at a confiderable diftance of time, or at a confix derable diftance of place, if unhappily thofe contami- nated materials are carried to a diftance. In this manner one perfon who is not himfelf infect- ed may infect another, the firft being lefs predifpofed to the difeafe than the fecond, and carrying the infec- tion in his clothes from one in the fever, to another perfon in good health. Although the contagious miafmata arifing from the living human body, arc not perceived to act at a great diftance from their direct Source, or the fub- ftances with which they are imbued ; yet it feems moft probable that they do not immediately lofe their vi- rulency, but, after they are dijfufed in the atmof- phere, MEDICAL SKETCHES. *ss phere, Continue in fome degree to act in conjunction with the miafmata of marines, with heat, obflructed perfpiration, and the other caufes, in producing fe- vers ; and according to the various proportions of thofe caufes, combined with the circttmftances of fea* fon, climate, and the conftitution of the patient, the nature of the fever is determined. Having pointed out what are confidered as the moft common caufes of fevers in general, I fhall Shortly hint what appears to be the moft probable fource of each particular fpecies of fever, according to the divi- sion adopted above. Other circurnftances may aflift, or poflibly on fome occafions produce them ; but in general it appears that the effluvia of marfhes is the caufe of intermittent fe- vers . Cold, of the inflammatory fever. The human miafmata, of the nervPus fever. And that the mixed fever is the product of all the three fources, which as they happen to be proportion- ed, incline it fometimes to the nature of the inflammato- ry, fometimes to that of the nervous fever; and from the marfh effluvia it derives its remitting tendency, with other features refembling the intermitting fe- ver. It would not be a difficult matter to Support this con- jecture by plaufible reafoning and illuflration ; but it is of little importance in itfelf, and of perfect indif- ference to me, whether it be believed or not. Whatever may be the general or particular caufes of fevers, none of them act with fuch certainty at all times, as that fever nmft follow, as often as the human conftitution is expofed to their influence. For although experience proves, that fevers of an inflammatory nature prevail in cold weather, and thofe of a remitting kind after heat and moifture ; yet ex- perience affords many exceptions to this general courfe, Ij6 MEDICAL SKETCHES. courfe, and fometimes affords examples of the re- verfe. We alfo fee people feized with fevers at feafons when no epidemic reigns, and when they have not been expofed to any of the caufes which are confidered as the fources of that diftempei\ And we fee others preferve perfect health during the progrefs of the fevereft epidemics, and notwithstand- ing their being by neceflity or imprudence much ex- pofed to the infection. For befides all the remote caufes of fever, there muft alfo be a particular difpofition in the conftitution of the individual, to favour the action of the morbific caufe, and render him fufceptible of the difeafe, with- out which, however much he may be expofed to the" other remote caufes, he will not, at that particular time, be feized wkh it. Perfons of a fanguine habit are certainly more fub- ject to inflammatory complaints than thofe who are lefs plethoric ; as the more delicate and weakly are found to be more liable to the nervous fever, than the ftrong and robuft. Other ftrongly marked peculiarities of conftitution may predifpofe to particular difeafes ; but that important power in the conftitution, by which it is enabled to reject fever at one time, and of which it feems deprived at another, has never been ex- plained. Yet many chimerical fyftems intended to afcertain this, ,and demonstrate the immediate caufes of all fe- vers and all their differences, have been received as Satisfactory in different ages, being introduced by the influence of fome great name, and agreeably to the prevailing philofophy of the times. The different temperaments of the human body have been divided into the various claffes of hot and cold, moift and dry; and from tfie proportions in which thofe MEDICAL SKETCHES. *# thofe were mingled, the caufe§. and nature of fevera deduced. At one period imagination fo entirely got the better °f judgment, that the cure of particular organs was expected from certain fubftances, for no other reafon than a refemblance between that fubftance and the or- gan difeafed. Thus euphrafia was recommended for complaints of the eyes, pulmonaria for thofe of the lungs, lemons for thofe of the heart, afarum and faty- rion on account of other chimerical refemblances. At another period all the phenomena of fevers were explained by the predominancy of acid, or of alkali, in the conftitution ; and at a different period nitre and Sal ammoniac having been obferved to refrigerate wa- ter, a fuppofed preponderency of on? or both of thefe was thought a fufficient explanation of the cofd fits of fevers. If the fymptoms were very turbulent and ungovernable, their impetuofity was thought to be clearly accounted for by the deflagration faid to refult from the combination of Sulphureous and nitrous par- ticles in the human body.—And when any conftituent part of the blood or juices was SuppoSed to prevail in undue proportion, or any particular morbid humour SuppoSed to exift, thoSe enthufiafts Seem to have heen perSuaded it was in their power to precipitate, diftil,. . or Sublimate them in the human body, as they could any Subftance in a pot, an alembic, or a tire of arun- ■ dels. The chymical were followed by the mechanfeal-phy- fiologifts, who Saw wedges and darts in the animal fluids, with which they exceedingly annoyed all their . antagonists, and finally drove theg- predeceffors almoft . entirely from the fchpols of medicine. ,.. Many ingenious and learned men adopted the idea, that the operations of the animal oeconomy are, to be •accounted for- on mecttani&al principles, and the caufes i$8 MEDICAL SKETCHES. 'traufes of difeafes and operation of medicines, arc to be explained by the laws of hydrollatics. There muft however be infurmountable difficulty in applying the laws which govern paffive matter to living animals ; and the axioms which are juft when applied to inflexible pipes, will be found erroneous, and to lead into SalSe calculations, when applied to Hthofe which are elaftic, and changing their capacity "every inftant. An obftacle of fomethiirg of* the Same nature pre* trents our forming conclusions that can be relied upon, concerning the effect: of feptic and antifep- tic medicines on the living body, from the effect they are found to have on dead animal fubftances. The experience of ages has proved, that the great and ultimate object of the art of medicine,—the power of curing difeafes, is more effectually attained by diligently cbferving the courfe and fymptoms of diftempers, and the. effects of the means ufed for their relief, than by the moft plaufible reaSonings on their SuppoSed nature and caufes. Yet the lat- ter has proved more attractive to many ingenious men of the profeffion, and, for a reafon Sufficiently obvious, in a particular manner to fuch as are em- ployed in lecturing to Students. No fyftem was ever received with more univer-* Sal approbation than that of Boerhaave. The ac- knowledged learning, ingenuity, and integrity of that illuftrious profeffor, aided the plaufibility of his theory in producing conviction.----The leading maxims of this fyftem are, that all local inflamma- tion depends on '"obstructions ab errore locit as he terms it ; that is;' when globules of blood get by xniftake, as it were, into veffels whofe. diameters are too Small to permit them to pafs. That inflammatory fevers ere owing to a vifcidi- MEDICAL SKETCHES. *JT9 tf or letter prevailing in the mafs of bloody and ftagnating in the capillary veffels. Wfeen this is attended with a particular acrimo- ay in the juices, whether received before the fe- ver, or formed by the fever kfeif, the1 diSeaSe he then fuppoSes to be of the putrid clafs?^ Such is the foundation of the doctrine taught for many years by Boerhaave at Leyden, in his time the moft celebrated fchool of medicine in the World 5 and by the means of this he endeavours to explain •all the phenomena of fevers, and to aceount for the various terminations of inflammation in refora- tion, Suppuration, gangrene, or Schirrus. ■His audience heard him with implicit belief, and spread his dcctrine with all the zeal of conviction over Europe. The ideas of Boerhaave acquired additional force and celebrity from the valuable commentaries and illuftrations of one of his difciples, the Baron Van Swieten, a man diftinguifhed by his learning and ta- lents, and placed at the head of medicine in Ger- many, by the well-directed favour of the late Em- prefs. So that no theoretical fyftem of medicine was ever introduced more advantageoufly, was fupported with greater abilities, or promifed to be more perma- nent. Of late, however, it has been ftrenuoufly attacked, lofes ground daily on the continent of Europe, and in this iff and feems to be almoft if not entirely over- turned. But from whatever caufe it proceeds, therd indisputably does exift, during the cold fit of a fe- ver, a ftoppage of the blood and fluids in the mi- nute arteries and excretory veffels of the body, as appears from the palenefs of the fkin and lips, drynefs of tl*e ikia and mouth, and the drying up eve-ft J6o MEDICAL SKEf Cll.ES. evenofiffues and ulcers. Thofe therefore who re- ject Boerhaave's explanation by a fuppofed vifckUt/ or thickening of the fluids, were obliged to account for all thofe fymptoms otherwife. They aecording-r ly affert, t^iat the fault does not lie in the circulating fluids, but in the extreme veffels, which we are told are Suddenly Seized with Such a conftriction as re- fufes all paffage to the blood, as effectually as if it were converted into glue < They infill farther, that if this vifcidity were to be admitted, it muft be fuppofed to-take place gra- dually, and of courfe would require confiderable time to be produced^ and wouid indicate its progrefs by fome uneafy feeling or eomplaint; but the cold fit of fevers often attacks at once without any previous com- plaint, unlefsit is a fenfe of weaknefs a fhort time be- fore. In their opinion, therefore, a fpafmodic cohftricliori pf the extreme veffels accounts for all the phenomena of the cold fit much more naturally, and is analogous to the effect of certain fudden affections of the mind^ as furprize and fear, which inftantly produce the fame' phenomena. Befides, the lentor TuppoSed, if it really took place in a liquor whofe free circulation is effential to life, would never fail to prove mortal; but as people daily recover from inflammatory difeafes, this circumftance alone is a proof that no univerfal lentor does take place in fuch .difeafes. It is. farther alledged, not only that there is no pofi- ..tive evidence of vifcidity i but thatthere is reafon to believe that even at the beginning, as well as during the progrefs of inflammatory fevers'*, the blood is lefs vifcid than in perfect health ; for it is natural to think that;a thin liquor, other circumstances being equal* will coagulate more flowly than a thick ; and as it is found, in fact, that the blood of people labouring un- der MEDICAL SKETCHES* itSt der inflammatory diforders is longer in coagulating when drawn out of the body, than that of people in perfect health, thofe who combat the notion of lentor prefume from thence that the blood of the former is the thinner of the two ; and add, that the gluey buff coloured pellicle which forms itfelf on the furface of inflamed blood, and was confi- dered. as an irrefragable proof of the morbid vifci- dity in queftion, is no proof at all> this pellicle be- ing nothing elfe but the natural coagulable lymph of the blood left at the Surface and forfaken by the red particles, which the flow coagulation of inflam- ed blood permits to fall to the bottom. With regard to the theory of local inflammation ab err ore loci^ or blood globules getting into veffels which from the narrownefs of their diameters and conical form they cannot pafs, and which, it is faid, the fucceeding fluid muft propel with increas- ing force, and produce the following fymptoms ; fwelling and rednefs, by the accumulation of blood in the minute veffels ; pain, by the distention of thofe veffels ; heat, by the agitation and rubbing of the globules; and throbbing, by the beating of the ob- flrucfted artery; or, in one word, produce "inflam- mation* AH this is without ceremony or circumlocution now denied; and it is farther afferted, that when examined by a microfcope, the blood is feen to pafs through the arteries of an inflamed part with as much eafe and more rapidity than through thofe of a part not inflamed ; and whether the part be inflamed or not, that when a red globule enters a veffel too Small for its tranSmiffion, it is forced back by the contraction of the veffel ; for the force of tlie heart in thofe minute and distant arteries is Spent, and has no effect, and the globule thus thruft M back 762 MEDICAL SKETCHES. back enters Some larger anaSlamdfing branch, with- out occafioning any obstruction or Stagnation. The many fenfible reflections and practical ob- servations made by Boerhaave, and. the judicious commentator on his works, will continue a perma- nent and uSefui monument of their knowledge arid induftry, although the whole fabric of their theory; So long cdnfidered as1 Solid and Subftarttral, fhould yanifli like the bafelefs fabric of avifion. 1 We need be the lefs aflonfmed at finding the the- ory of .Boerhaave in danger of being Pverfet, When we confider that one of the moil important arid comprehensive opinions of all medical antiquity, which originally came from Hippocrates himfelf, and' like a Solid body falling from a vaf! height, feem- ed to acquire additional force as it deScended thrbugji admiring ages, is now" Openly nnPugned, and fS truth disputed, The opinion m queflionis, ;that a- Sever is nothing elfe but art effort of $$£- fur^ to expel fome noxious matter from the cOft* ftitution; but before it can perform this, it is rtC- ceflary very often that this noxious matter fhould undergo coetiofi. CoCiion, in medical language, is a term ufed to fignify the procefs by which Nature attempts to operate fuch an alteration in this noxious matter as" deprives it of its perniciortS qua- lities, or renders it capable of*being expelled thrdrtgh fome of the emunctoiies of the body. The noxious matter, however, is fuppofed to be averfe fo this coition, and Struggles againft it with more or lefs Succefs, according td the virulertCy of the matter arttt the powers of the constitution. In this Strug- gle between the noxious matter and the conftitution the fever cOiififts. When Nature is Strong enough to perform perfect coition and expullion, health 15 immediately reftorcd ; when Nature is quite urt- fqjial to the talk, the patient dies ; when fhe per- forms' M E £> t C A L S K E T C H £ S. to j fernis it impertectiy) there is an abatement of the difeafe; but a new effort muft be made after a * fhort paufe, and, this is called relapfing into the fever. This doctrine \vas believed with a degree of convic- tion that in general is only compelled by rhathe- matical dembnftration, or given to the evidence of the fenfes ; and phyficians were acpuftomed to fpeak with as much. certainty of the coctidh which takes place in a fever, as of that carried on in their' kitchens. &ut this is the age of freethinking ; and fome oaring Spirits treat the whole of this venerable doc- trine as *a mere1 chimera. " What can fevers, almoft inftantly produced by " cold or terror," fay they, *c have to do with "rftoroific matter ? "The impreflion of cold, or an affection or the *£ mind, are^ neither a noxious .fubftance .coming from without, or generated within the? t>pdy% " When a fever with alarming. Symptoms, is re- tl gloved by the critical difcharge of a little blood t£, from the nofe, where, is the coction ? a > u ' Tlie blood diichargect cfiffers in nothing, as far ,c as can be perceived, from what remains in the " When the crifis is by' Sweat,, the Same hap- •'pens; nothing Seemingly more morbific, no differ- " ence* whatever can be difcovered from that critical *' Sweat, and the fame evacuation on any lefs im- li poita'nt occafion*. M 2 "•" There * Fevers are' fometimes eBftin'gniflied by rTie nature of the hoxious matter fhey are fuppofed to be' ftruggling to fhrow dut of the body';, and the various quantfts of this hypothetical matter arc defcribed with as mudt accuracy as if it bar? been examined bv a nat»ralUl,aivl auatized bv a chymift. Thd 164 MEDICAL SKETCHES. " There are indeed difeafes," continue they, " of " a different clafs, in which fever is evidently the ef- " feet of a Specific kind of morbific matter, received " info "the body, and where an irruption takes "place in confequence of the fever, which not only cc clears ihe conftitution of the noxious matter h> u traduced, but deprives it of the power of ever " again receiving it/* Of this nature is the Small-pox, the chicken-pox, the meafles," and Some other Specific contagions, of which the human* body is Sufceptible only once *. But, in thofe. inftances it Sometimes happens that the Sever terminates before the matter is expelled, and the Contagious matter which produces the diS eaSe is never altered in its nature, or rendered mild aud innocent by coction or otherwife, but is thrown out' of' the body, retaining ail its original virulence, and capable of infecting thoufands. ..' . The objecWs above alluded to make no fcruple, therefore,'of afferting, that nothing that cart with, propriety be Called, concoction of morbific matter, particularly ' if altering its nature be implied in that term, takes place .in fevers; neither can any fuch thing happen in the difeafes juft mention- accuracy and minutenefe of thofe defcriptions are fometimes urj|ed at proofs -of the exiftence of the matter im difpute;' and of the truth of "the dentrine that fevers are. efforts of Nature to. throw it out of the body. Without entering into that quef- tion, the, defcriptions of its qualities are certainly' no better proofs of its exHlenci.*, than the records of the trials and con- demnation of witches are proofs that it once was the fafhio* in tluVifland for old women to ride through the air on broom- fticks, and to have perfonal communication with Satan ; or than the ruins of the aneknt temples are of the exiftence- of Jupiter, Juno, Apollo, Venus, and all the deities of Greece, „ * Jt is very lingular that it is the /w;Wbody only that is luf- ceptible of thefe particular contagious difeafes ; the brute cre- ation being entirely free from them, as. well as from the *e- nqreal difeafe. MEDICAL SKETCHES. i6j ed, fince the noxious matter which produces the difeafe is thrown out of the body as unconcocted ■aud noxious as when it entered. It has been attempted to give fome idea of the nature of concoction, by comparing it to the pro- cefs of digeftion, in which the different kinds of food, after remaining fome time in the ftomach, lofe their own peculiar natures, the finer parts being min- gled and transformed into one uniform liquor be- fore it enters the mafs of blood, and the groffer being expelled out of the body ; and during the pro- cefs of digeftion it is obferved that there is a dis- turbance and uneafineSs in feme degree like that occafioned by a flight fever. But the analogy fails in the moft effential point ; for even admitting that morbific matter received or formed in the body is the caufe of fever, there is no evidence that any alteration is made upon it by the procefs of con- coction ; but nobody will queftion that a Striking one is made on food by digeftion. After all, thofe who are the moft averSe to the an- cient doctrine of coction feem to object rather to the expreffion than to the meaning; for while they deny that noxious matter received into, or formed within the body, is the proximate caufe of fever, and that Nature concocts this matter during the courfe of the fever, and expels it, or renders it innocent before the difeafe terminates ; yet they acknowledge, what comes pretty nearly to the fame thing—they allow of the vis medicatrix naturae. Let us confider for a moment what then is the ftate of the corttroverSy. The old orthodox doctrine is, that a fever is an effort of Nature to change or concoct fome noxious or morbid matter that is in the conftitution, So as that it fhall either be rendered quite innocent, or thrown out of the body. M 3 The i6$ MEDICAL SKETCHES. The new herefy is,, that there is no Such thing as coction of morhific matter, but that as often as the bo dy is injured, Nature directly excites Such motions as are Suited to remove the cauSe of the injury, obviate its bad effects, and reftore the constitution to its wonteel good health. The difference between the two doc- tries is not prodigious. The Sate of every theory hitherto invented to ex- plain the proximate caufe of fevers, might, one would naturally think, deter from an attempt in which fp many have failed ; yet fo partial are we to what we conceive to be our own original ideas, fo natural are fuch investigations to the active and inquifitive mind of man, and fo neceffary are difquifitions of this nature to thofe whofe profeffion it is to lecture to medicaj ftudents, that it is probable a new *theory will al- ways be founded on the ruins pf the laft that is over- fet. The lateft attempt of this kind was made by a per- fon for whom I muft ever have the higheft efteem, from whom I received my earlieft medical instructions, and whofe character and abilities will give weight to every opinion he adopts.—The theory in queftion is Shortly this :—Whether the remote caufes pf fever be fear, cold* contagious miafmata, or whatever elfe; their firft effect is that of diminifhing the energy oS the brain, and thereby weakening all the functions, parti- cularly the action oSthe extreme veffels. Debility then is the firft Symptom of a lever, and the caufe of the cold fit and a SpaSmodic contraction of the extreme veffels, particularly thofe of the furface, fuppofed to attend it. It is not found eafy to explain how debility produces this fpafmodic contraction, but it is imputed to the vis medicatrix nature, or the law in the animal ceconomy above mentioned, by which motions are excited to ob- viate the effects of any thing noxious to the conftitu- tion ; MEDICAL SKETCHES. 167 tion ; and that the fpafm exifts, appears from the fup- preffion oSall excretions, and the fhrinking oSthe ex- ternal parts, during the cold Stage. This proves an in- direct Stimulus to the SanguiSerous fyftem, by throw- ing the blood back with violence upon the heart and large arteries, and exciting them to ftronger and more frequent contractions; which increaSed action oS the heart and arteries continues till it reftores the dimi- nifhed energy of the brain, extends this energy to the extreme veffels, overcomes the SpaSm, reftores, their action, on which Sweat breaks Sorth, the other excre- tories are alfo relaxed, and the fever abates* Such (abridged and imperfectly lketched) is the doctrine of fever taught by Dr. Cullen, a name which muft give it weight, independent of its intrinfic merit; which no doubt will appear Still greater in the eyes of thofe who have the advantage of hearing from the mouth of that enlightened phyfician all the illustra- tions, explanations and proofs, which his ingenuity and eloquence can bring in its Support. Whether it is in danger of falling, when it loSes thofe great props; and whether it will be more or lefs permanent than its predecefTors', is yet to be triad. M4 II. OF 168 MEDICAL SKETCHES. II. OF INFLAMMATORY FEVERS. 1.N treating of fevers in general, it was remarked, that in thefe difeafes the human body is liable to two morbid ftates, with very different fymp- toms. In one, the heart and whole arterial fyftem is Stimu- lated to rapid and ftrong exertions, while the nervous fyftem Seems leSs directly affected. In the other, the nervous fyftem is more immediate- ly affected; there is a weaker exertion of the heart and arteries, and more evident figns of general de- bility. The difeafe at prefent under difcuffion is accompa- nied with the firft of thefe ftates, and with many of the fymptoms which attend local inflammation. From this laft circumftance it derives the name inflam- matory. Some phyficians have afferted, that no inflamma- tory fever can exift without local inflammation. This is faying, in other words, there is no Such diS eafe as an inflammatory Sever ; for when there evi- dently is a local inflammation, the complaint is not called a fever, but derives a name from the part in- flamed . But thofe who affert, that as often as the fymp- toms of this fever appear, there muft be a particular inflammation of fome part of the body, acknowledge at the fame time, that they cannot always tell where that particular inflammation is, becaufe it may be in fome MEDICAL SKETCHES. 169 fome internal, indolent, or infenfible part, and confe- quently is neither to be feen nor felt. I do mot know whether this manner of reafoning will be thought convincing, but it certainly is conve- nient. If along with the fymptoms of fever, any particular part of the body is found in an inflamed ftate, thoSe who Support the opinion in queftion tell you, this is • exactly what they expected, and knew from the begin- ning to be the cafe. v And if you carry them to a patient who has all the Symptoms of this fever, and yet no partial inflamma- tion appears, they then tell you they are very foriy you cannot fee nor the patient feel the particular part where the inflammation is" ; but they are fure, from the fymptoms, there muft oSneceflity be Some particular part inflamed ; that this was all they ever afferted, for they never had undertaken to make you fee or the patient feel more acutely than ufual. On Such occafions thofe gentlemen Seem to Sorget, that however indolent and inSenfible certain parts of the human body may be in a natural ftate, inflamma- tion never fails to roufe and render them fenfible; and although this were not the cafe, ftill the Seat of inflam- mation would probably be difcovered by opening the body after death; but there are many inftances of people dying of inflammatory fevers, whofe bodies have been examined and diffected by accurate ana- tomifts, and no appearance of local inflammation found. When fevers therefore difplay every inflammatory fymptom, while no part of the body can be perceived to be particularly affected, it feems highly reafbnable to behVve, that the Sever is not Supported by any par- tial inflammation, but is diffuSed over the whole fyf- tem. Inflammatory %79 MEDICAL SKETCHES. Inflammatory fevers occur at any SeaSon of the year, and in any kind of weather ; but they are moft likely to be produced after a Sudden change from mild wea- ther to froft, or on a change of the wind from any other quarter to the north or north-eaft. The Same Sudden changes are undoubtedly often fol- lowed by catarrhs by the cynanche tonlillaris, or in- flammation of the tonfils, by pleurifies, and other dif- eafes of local inflammation ; all which complaints have many fymptoms in common with this fever, but are each of them diftinguifhed t>y peculiar Symptoms. "The pleurily, for example, occafions coughing and painful refpirajion ; the fore throat, difficult degluti- tion, and So on. When partial infiammatioc is not very confiderable, or affecting an organ of great delicacy and importance, the action of the heart is not much augmented, and of courfe the feverifh fymptoms are but moderate, al- though there feems to be a great impetus of blood in the veffels of the inflamed part. But when the topical inflammation affects a vital or- gan, as the lungs ; or when the inflammation is vio- lent and extenfive in any part of the body, the heart itfelf is then Stimulated to rapid and ftrong exertions,, and the whole maSs of blood difplay s the fame appear- ance as in the inflammatory fever. After a perfon has been attacked with the ufual Symptoms of the inflammatory fever, if he Suddenly perceives a throbbing pain in a particular part, it is an : indication that the diSeaSe is not what is Strictly called an inflammatory Sever, but a local inflammation- Whether that is to be confidered as a fortunate or unSortunate circumftance, depends on the nature of the part that now feems peculiarly affected. If there is an uncommon clamminefs of ti,j mouth and throat, with a fharp pain darting through one or both ears in fwallowing, the difeafe will turn out an in- flammatory MEPICAL SKETCHES. 171 flammatpry fore throat, and probably a fuppuration of the tonfils will take place. Soon after the fame Se- verifh fymptoms, if there comes a frequent dry cpugh, with opprelfed breathing, and pain in one fide, a pneu- monic inflammation is threatened. The firft cafe might be reckoned a Safe, the f&r cond a dangerous exchange for an inflammatory fe- yer- Feyers entirely of an inflammatory nature are, I imagine, not very frequent any where; certainly thofe of a mixed kind are moft common in this ifland. Even thofe which begin with every fymptom of in- flammation, and continue for Some time with the fame indications when prolonged beyond the ufual term, that is, beyond the Second week, without a favourable crifis, then difcover fymptoms which are confidered as belonging more properly to the nervous fever ; this circurnftance Sometimes gives" rife to diSputes of fmall importance in themfelves, but which have been at- tended with difagreeable confequences. A phyfician called at the beginning of a complaint, is afked whft is the patient's difeafe ? Perhaps he an- fwers, an inflammatory fever: Another called towards the end, when ftupor and SubSultus tendinum have ta- ken place, being afked the Same queftion, may very probably call thediSeaSe a nervous Sever. They are both in the right; yet an impreflion is left on the minds of the patient's relations, that one or other muft have been in tfie wrong. Names can have no influence on a judicious and ex- perienced practitioner, who carefully examines fymp- toms, weighs every concomitant circumftance, and forms his treatment accordingly. But there are prac- titioners who pay more regard to the name than to any other circumftance of the difeafe : Only be fo obliging as to furnifh them with that, and it is all the informa- tion they require; let it be inflammatory fever, ner- vous ?72 MEDICAL SKETCHES. vous fever, hectic fever; be what it will, they confult the laft new practice of phyfic, and give you a pre-1 feription directly. I knew an inftance of a phyfician who was called at the commencement of a Sever, which he diftinguifhed by a name applicable to the Symptoms which at that pe- riod of the difeafe were predominant, and he prefcrib- ed accordingly ; but not having it in his power to con- tinue his attendance when the fever had changed its nature, the patient was put under the care of fuch a practitioner as has been defcribed above ; who, among other circumftances, being informed by the attendants of the name by which his predeceffor, a man of fome authority in the profeffion, had diftinguifhed the diS eaSe, overlooking the alteration which had Since taken place, this Sagacious Doctor fixed his attention upon the name only ; and (as the firft phyfician exprefSed himfelf in narrating the ftory) having conSulted his oracle, had very near killed the patient by approved good prescriptions. I leave it to thoSe who have had the greateft oppor- tunities, to declare, whether they have not in the courSe of their experience met with cafes exceedingly fimilar to this. It was hinted in the preceding chapter, that there was good reafon to believe that the true inflammatory fever takes place independent of marfh or human miaf- mata ; for when they co-operate, the fever is of a mixed nature, difplaying at once Symptoms of inflam- mation, of nervous debility, and greater tendency to remiffion than is ufual in inflammatory fevers; and what renders this more probable is, that intermittent and malignant fevers, which we have fuch ftrong rea- fon to be convinced proceed from thefe caufes, gene- rally happen in Spite of all the care againft cold and all the attention to regimen which the patient can take.— Let him do as he pleaSes, if he lives in the neighbour- hood MEDICAL SKETCHES. 173. hood of fens and marfhes, he will probably be feized with an ague ; and let a perfon be as guarded as poffi- ble in other refpects, if he has any perfonal intercourfe with people in malignant fevers, he will be in great danger of catching one alfo; and very poflibly the difeafe may come, in the one or the other cafe, wheal it is leaft expected. Whereas the inflammatory Sever, although more apt to come at one Seafbn than another, when people are unguarded, yet Seldom or ever, in any feafon, attacks thoSe who avoid exceffes in exer- cife and regimen, and are careful not to catch cold. So far from appearing when leaft expected, we gene- rally know and can point out fome particular piece of imprudence or inattention, to which the inflammatory fever may reafonably be imputed. But if it is obfti- nately infilled upon that thefe miafinata muft have a fhare in this Sever, we fhall only Say, that when there is the ftrongeft reaSon to conclude that Such miafmata do act in conjunction with cold, the effect is generally dif- ferent ; but, as was obferved on a former occafion, it is difficult to prove that an invifible fubftance is not prefent ; however, according to Celfus, " has laten- " tium rerum conjecturas ad rem non pertinere, quia " non interfit, quid morbum faciat, fed quid tol- " lat." The youthful, the Sanguine, and the active, are moft liable to this (.\ifeafe. The fame elegant wri- ter probably alludes to this when he fays, "■ Si *' plenior aliquis, et fpeciolior, et coloratior Sactus " eft, Sufpecta habere bona Sua debet." One reafon for young and active people being more liable to this fever than perfons of more ad- vanced age and lefs activity, no doubt is, becaufe the Sormer are more prone, from imprudence and love of bodily exertions, to expofe themfelves to the fituations that bring it on. It i?4 MEDICAL SKUTC ME & It generally invades Suddenly With a ftrong colcf fit, followed by thoSe Symptoms which mark vi- gorous* contractions Of the heart, a ftrong, rapid, full, and Cqual PUlSe", exceflive heat, a remarkable* diminution of all the fecretions, eVMfied by a dry-*' ftefs of the ikm, tongue, throat, nofe, and bowels^ great thirfr, lofs of appetite, with impairment or the Smelling' and tafte ; the urine of a high red colourj Scanty, and evatuated with heat j the face full and florid, with a rednefs of the eyes and aver- sion to light; pain and confusion of the head \ quick fefpirationj and Sometimes a dry cough ; yet the patient does nPt display much alarm about his own fituationt nPr that dejection of Spirits which attends the nervous Sever, When he Seerfls juft ready td fall afleep, or has* actually begun to fleep, he is apt to awake with at Sudden Starting. This Symptom is alfo' cOmmPrt irt the" eruptive fever of the* Small-pox*. The abatements or rCmiffions ate hot very evi- dent, and arVvayS fhort when they appear. Whert this fever is very violent, and the Symp* toms riot relieved in Some degree by evacuations at the beginning, a high delirium CnSueSj the pa* tient cannot be kept without difficulty in his bed, fhe pain and ConfufiOrt in the head rifes to frenzy 5 and he is fbm'e'tiihes hurried off ort the fifth Of fixth day. The nervous fever generally is of longer dura- tion than the inflammatory ; yet in fome very fna* lignant cafes of the former, the' patient is alio Car- ried off with fymptoms of high delirium before fhe Seventh day. ". What difttnguimes the two in Such violent cafes' is, that irt the inflammatory the pulSe is vigor6u$ almoft until the laft, and the patient himfelf dif- play s great bodily ftrength in his Struggling ; where- MEDICAL $KET£h£& i?i as in the nervous, the pulfe Is contracted and fmaH, and although the patient is exceeding reftlefS, and Struggles alSo to get out ■ of bed, yet his efforts are eafiry corttrouled. But the moft frequent termination of this ftv€t is about the Seventh, or before the end 6f the ninth day, and always before that of the four~ teenth Or fifteenth; for when prolonged after that time, it totally changes its character, the phlogiftic diathefis is gone, it is no longer an inflammatory fe- ver. The fame fymptoms which belong to the ner- vous fever then appear, and require the fstme treat- ment. •■■*- The. obvious indications of* cure in this diSeafe are", to 'achate1 the violent action of the heart, which gives rife to all the other fymptom*, and relax the conftfhfrion of the vefTefs on the furface of the bo- dy, which Seems to fupport and aggravate them. Nothing has been difcovered ffrtce the earlieft medical records, which So effectually gives relief in all difeafes where the blood is too hnpetudrtfry pfopeffed, as diminifhing its quantity. In doing this, however, great attention muft be paid to the degree of viojetice of the difeafe, the fex, age, and conftitution of the-patient. From a Strong man P'f a fartgtiintf habit it may fee expedient to take a rjotmd of Wood at once, and to repeat the operation, if the violence conti- ' flues', in the fame or in ditfimifhed quantity, a fe- cond or third time, at the diftance of eighteen or twenty-four hours. In plethoric patients the pulfe becomes Sometimes frtofe free and even stronger after bleeding than it was before, by reftPring that degree of elastici- ty to the arteries which was impaired by too great fulnefs. Tire kind of oppreffioh of the pulfe which proceeds from plenitude, can eafily be diftinguifhed !7 medical Sketches. 179 no more than empty the rectum, leaving much impure matter in the higher bowels. It is therefore highly expedient foon after bleeding, to give fuch a purgative as will effectually empty the whole courfe of the canal, and at once remove the ir- ritation of indurated faeces and pent-up humours, pre- vent acrimonious abforptions, drain the arteries and other veffels which pour their excretions into the cavi- ty of the inteftines, and by this evacuation weaken the too violent contractions of the heart and impe- tuofity of the circulation; in other words, • abate the fever. The propereft purgatives for anSwering all thofe intentions are thoSe whoSe cooling and deobftruent na- ture enables them to wafh away the contents of the bowels effectually, without Occafioning gripings, or Otherwife Stimulating the fyftem; The materia medi- ca furnifhes an ample variety offiich. What in my opinion is equal if not Superior to any other, is a So- lution offal Catharticus glauberi, or Sal rupellenfis, in water, or in a decoction of tamarinds ; to thofe whofe ftomachs cannot bear the Saline purgative given alone, the milder vegetable purgatives, of which rhubarb and fena are the beft, may be given either alone, or combined with fal polychreftus, Cremor tartari, or trr- tariim folubile. After the cavity of the inteftines is entirely emptied by a purgative at the beginning, emollient cryfters, administered at proper intervals, will be Sufficient to prevent coftiveneSs through the courSe of the difeafe. They are alfo fuppofed to promote urine, and to act as fomentations. Vomits cart feldom be proper in this fever ; let us recollect the fymptoms, a hard, full and impetuous pulfe, burning heat, a Swelled glowing Sacc, the vef- fels of the eyes turgid with red blood ; in inch a Slate oS the body, when the vefiels Seem ready of them- N 2. Selves MEDICAL SKETCHES. felves to burft with plenitude and rapid circulation, to excite the violent exertion of vomiting might be high- ly dangerous. Antuhonials, however, given irt fuch Small doSes as do not occafion vomiting, are often of great Service, by promoting perfpiration, and gently moving the bowels, fo as to render other laxatives uny neceflary. In this way they very often contribute to ahate the force of, or entirely to throw off the fever ; and none operate more gently and more effectually than Dr. James' powder given in fmall dofes. As the moft diftinguifhing features of this fever feem to depend on the violent action of the vafcular fyftem, whatever contributes to ftimulate muft do harm. The impreflions made by noife, light, external heat, and thirft, are all of this kind* In preventing and remov- ing them we follow the impulfe of nature, which in- clines the patient to ftillnefs, to darknefs, to a cooL well-ventilated chamber, and the conftant ufe of aci- dulated drinks. The exclusion of light and oSnoiSe was always con- fidered as expedient in Severs : but it is only a late- practice in this ifland to indulge the patient in breath- ing a cool air, and in being freed from an oppreffive load of bed-clothes. Yet this is So obvious and So na- tural a way of giving relief to thofe who Suffer from heat, that nothing could have prevented its being uni- verfally adopted, but fome deeply rooted prejudice or erroneous theory reflecting the nature oS Sever, and the necelfity of forcing fweats. That thefe opinions were not founded on fair experience is now evident/ from the comfort and benefit found to flow from allow- ing the patient's bed-chamber to be frequently refrefh- ed with ftreams of cool air, by Sprinkling it with vi- negar, by keeping it always unencumbered with the perSons and unheated by the reSpiration of too many people, and by relieving his body from oppreffive co- vering.- It MEDICAL SKETCHES. 1S1 It is of fervice alfo to wafh the hands and face of the patient from time to time with tepid water and vi- negar, which, may be done more conveniently in a fit- ting than in a horizontal pofture. To be Seated in an eaSy chair for a confiderable part of the day, in- ftead of laying in bed, is peculiarly proper when the head is much affected, and a delirium is threatened; be- caufe, in an erect pofture, the blood moving contrary to its own gravity, its motion is retarded, and its im- pulfe upon the brain diminifhed. Shaving the head, wafhing it frequently with vi- negar, and keeping it thinly covered, are always re- frefhing, and fometimes give confiderable relief. Befides abating the uneafy and irritating SenSation of thirft, indulging the patient to the height of his defire in proper drinks, is alfo of fervice, by diluting and cooling the overheated blood and juices. Thefe drinks fhould be varied, and adapted to the varying tafte of the patient : pure water, barley wa- ter, feltzer water, lemonade, imperial, rennet, orange, lemon, or forrel wheys, rafberry or currant jelly diffolved in water, apple tea, brim tea acidulated with lemon juice, and other combinations, may be given with propriety ; and he fhould not only be al- lowed but even prompted to drink them in confidera- ble quantities ; Sor thoSe cooling and mild Subacid drinks not only quench and dilute, but alSo afford ma- terials for free perfpiration, and contribute fo re- move the constriction oS the veffels. The manner in which they contribute to this is difputed. Some think it is by dilatation, as the liquors paSs through the excretories oSthe veffels ; but to this it is'object- ed, " that the obstruction muft have already been re- " moved before they can pafs ;"—to which thofe who fupport the idea of dilatation reply, " that the con- " traction is never fo great as to prevent perfpiration " altogether, but only to diminifh it; That thin di- N 3 "luting 18a MEDICAL SKETCHES. u luting liquors received into the blood, tend ih the " courfe of circulation, to the extreme veffels, and " by an uniform and gentle preSTure, Swell the larger a veffels, and So gradually dilate and remove the con- " traction of the fmaller." This mechanical method feems improbable to others, who explain the effect of the liquors in tending to remove the SpaSm, by the Sympathy and connection between the ftomach and fkin, which they Support by various illuftrations ; this in particular : " A draught " of cold water," Say they, "- is oSten a pleaSant *' and effectual means of producing fweat; and it has " that effect long before it can be fuppofed to have *' entered the circulation, and have been determined " to the fkin." The material thing to know is, that thofe cooling drinks do certainly promote perfpiration, and abate the fever ; the means by which they do it, if lefs cer- tain, are alfo lefs important. The tepid bath has often been recommended in this fever, upon the fuppofition that it muft be of fervice in promoting the relaxation of the veffels on the Sur- fiice, which See ns So m.ich required ; and when, on account of the difficulty of moving the patient, the en- tire bath cannot be ufed, fleeping and fomenting the legs, thighs and belly, with flannel cloths wrung af- ter being dipped in warm water, or applying large bladders filled with warm water to the patient's body, have been recommended as fubftitutes to the bath: But the pulfe is fo vehement, and the fkin lb hot in this fever, that any additional heat feems dreadful to the patient; and it is almoft impolhble to ufe the bath, or thefe fomentations, without doing more harm, by fatiguing and heating the patient, and Stimulating the heart to more rapid contractions, than Service, by the relaxation they arc expected to produce. Keeping MEDICAL SKETCHES. 1% Keeping the patient's body lightly covered, and ad- mitting a cool ftream of frefh air to pafs from time to time through the bed-chamber, is a more probable means of abating the violence of the fever than fuch fomentations, whofe inconveniences are instantaneous, and whoSe benefit is uncertain. With regard to diet, very little needs be Said ; Na- ture herfelf generally takes care that no error fhall be committed during the continuance of this difeafe in that article; even when injudicioufly urged, the pa- tient feldom is perfuaded to fwallow any thing but drink: If by accident he fhould have an inclination for fbmething more folid, panado, roafled apple, a few grapes, or fome other mild ripe fruit,, is all that fhould be allowed. The moft important relief that art can afford in this fever, proceeds undoubtedly from the evacuations of bleeding and purging at the beginning, the con- tinued ufe of cooling diluting drinks, with antimonial alteratives -; all the good 'effects expected from thefe, however, will be promoted by the aperient, quench- ing, refrigerating, .and diaphoretic qualities of fome of the neutral falts, particularly of nitre; as much of this Salt therefore as is thought requifite, may be dif- Solved in the patient's drinks. One inconvenience Sometimes attends the ufe of this medicine in due quantities, which is its Sitting uneaSy on the Stomach,. This effect will be prevented, in Some conftitutions, by combining the nitre with the Saline draughts of Riverius, inftead of mixing it with the patient's drinks ; fifteen or twenty grains of the former may be added to each of the latter, and given every four or every fix hours : But if the nitre ftill Seems to give uneafineSs, Riverius' draught, which is equally agreeable to the tafte and ftomach, may be given alone, and repeated everv two or three hours. N 4 This 184 MEDICAL SKETCHES. This fever fometimes is entirely carried off by a fmall hemorrhage at the nofe, and often yields to thG evacuations ufed at the beginning ; if neither happen, but yet the fymptoms feem confiderably checked, and their violence abated, in all probability a favourable crifis by Sweat may be looked for about the end of the firft week ; but whether it fhould take place then, or at fome future period, the following Symptoms announce the abatement Of the fever : The pulfe becoming Soft- er and flower, the head-ach and thirft abating, the urine increafing in quantity, and moifture returning to the noSe and mouth. Soon after thefe flattering appear- ances an univerfal fweat breaks forth, the urine depo- fits a light reddifh or a white fediment, the patient gets fome refreflhing fleep, and the pulfe becomes mo- derate, the fever is gone, and the patient requires nothing but a gradual return to nourifhing diet to re- ftore his former health. JII. THE MEDICAL SKETCHES. 185 III. THE REMITTENT OR MIXED FEVER. JTi AVING endeavoured to defcribe the Symptoms, and detail the method of cure, in what is, Strictly Speaking, called the inflammatory fever, before I proceed to that in which the fymp- toms are of a nature directly oppofite, I fhall give the beft idea I can of a fever much more common than either, in which the fymptoms which proceed from an over-violent action of the heart, are blend- ed with thofe which feem to proceed from marfh or human miafmata, and which indicate a direct affection of the brain and nerves. One reafon for preferring this order is, that when the diathefis which reigns during the for- mer, and which appears at the beginning of this mixed fever, is Subdued by the continuation of ei- ther difeafe, they then entirely affiume the Same Symptoms and appearance which occur in the ner- vous fever, and are to be treated in the fame man- ner. In enumerating the remote cafes of fevers, a floppage of the perfpiration, by expofing the body to cold, was affigned as the ufual caufe of the in- flammatory fever, and this not from any reafoning & priori on the nature of cold, or the probable ef- fects it might produce by fhutting up the perfpi- rable matter or otherwiSe, but merely becauSe we See that inflammatory difeaSes oS various kinds, and fevers in particular, often occur after the body has been tto MEDICAL SKETCHES, been fo expofed, and when we know of no other caufe to produce them. In like manner we conclude, that the vapour ari- fing from ftagnating water and putrefying vegetable and animal fubftances, being abforbed by or applied to the human body, produces intermittents ; but we form this conclufion from no philofophical deduc- tion drawn from an inveftigation of the nature of the vapour, but fimply becauSe intermittents are moft Srequent in low and marfhy countries, where this vapour moft abounds. And having obServed that a ftill more malignant fever often ariSes in places where men are greatly crowded together, we inSer that the effluvia or miaSmata of the human body produce the nervous malignant fever. But although no human genius or inveftigation would diScover, a priori, that cold produces inflam- matory Severs ; the vapour of marfhes intermittents, or the human miafmata nervous fevers ; yet when we have fo much reafon to think that this is real- ly the cafe, a very moderate capacity would fuf- pect that thofe caufes acting in conjunction, would pro*. duce a difeaSe complicated with the Symptoms of all the genera. It would not be unnatural even to pro- ceed to other conclufions, fuch as, that this mixed fever would be moft prevalent, when an uncom- monly cold and moid autumn fucceeded an uncom- monly hot fummer ; that in the winter and Spring the inflammatory Symptoms would be Stronger than in the Summer or autumn ; that it would be more Severe in fleets and armies during campaigns, be- cauSe Sailors and Soldiers are then more expoSed than other men to the influence of all the three caufes ; that in armies the foot foldier would be more liable to the difeafe than the dragoon, the private eentinel than the officer ; that the fymptoms would MEDICAL SKETCHES. r&7 would vary in different countries, according to the degrees of heat, cold, and moifture ; that in bar- racks, and in hoSpitals, the nervous Symptoms would preponderate, and in the field, the inflammatory ; and finally that the various conftitutions on which this diSeaSe might be engrafted, would contribute to form various fhades and differences in the fymp-. toms. All thoSe inferences, which feem fo obvious, are confirmed by experience. This mixed fever is defcribed under various names by different authors, particularly under thofe of bilious fever, remitting fever, autumnal fever; which defcriptions when attentively confidered, are found to imply a difeafe effentially the fame ; but wherein parti- cular fymptoms predominate in one cafe, and others in another, in confequence of the ftate of the weather, the conftitution of the patient, and the place in which he refides at the time he labours under the complaint. Perhaps all the above names might be objected to on good grounds : Bilious may be faid to be improper, becaufe the fymptom which gives rife to the name does not always attend the dif- eafe ; remitting may be objected to, as not fuffi-r ciently dillinguifhing, becauSe all Severs remit in Some degree ; and autumnal may be thought equally open to criticiSm, becaufe the diSeaSe occurs alSo in other SeaSons. Whichfoever of thofe names I may occafionally ufe in treating of this mixed fever, I fhall always mean the fame difeafe, although I may apply that name which I think beft adapted to the Symptom under consideration at the time. The mixed Sever uSually begins with a Seeling of wearinefs, a frequent inclination to yawn, an irre-> gular fenfation of cold, approaching to chillinefs, a confufed 188 MEDICAL SKETCHES. conSuSed pain in the head, nauSea, thirft, and very often vomiting. It feldom attacks fo brifkly or fuddenly as the in- flammatory fever. The pulfe, though hard and quick, is not fo ftrong, Sull, and equal ; neither is the heat So great nor So uniform; the remiflions are more evident and permanent ; and when they appear, there is a moifture on the fkin, which fel- dom is found at the beginning of the true inflam- matory fever. The naufea in this fever is greater than in the inflammatory, and more apt to produce bilious vomitings, which are generally preceded by a pain about the pit of the ftomach. In the in- flammatory fever the tongue is dry ; in the remit- ting fever it is covered from the beginning with a whitifh moifl mucus, which gradually, as the fe- ver advances, becomes dry, and of a brown co- lour. The fymptoms both of the inflammatory and the mixed fever augment in the night ; but in the latter there is a remiifion attended with fweat towards morning; after an abatement of a few hours the fame Symptoms return, but are Seldom introduced any more by a Senfe oS cold or chillineSs. In this manner the Sever Sometimes continues, with acceffions towards night, and remiflions in the morning, for feveral days ; the former, however, gradually gaining ground, till at length the latter are hardly perceptible. There are inftances of this fever attacking in a much more violent manner, the patient complain- ing of acute head-ach, thirft, exceflive beat, and the fever increafing within a few hours after his being firft Seized, to a high and frantic delirium. I have Seen many caSes of this kind in Dutch Bra- bant ; for this laft fymptom feldom or never hap- pens in the remitting fever, except in hot climates, or MEDICAL SKETCHES. 18$ 6r if in a moderate climate, in the moift, low, and marfhy countries, at the hotteft Seafbn oS the year, and to thoSe who from neceffity or impru- dence have ufed fevere exercife in the midft of fogs, or during the ardour of the fun. Sir John Pringle gives inftances of Such violent cafes ; they happened in the flatten: and moft foggy country in Europe, in the neighbourhood of Bois-le- duc, to foldiers obliged to ufe hard exercife on the duty of foraging, while the adjacent plains were in- undated *. But in all thofe cafes the influence of marfh miafmata formed an effential difference between them and the inflammatory fever, arifing alfo from vio- lent exercife, but ufed in countries free from all Such miafmata, as is hinted in the foregoing chap- ter on fevers in general, and alfo in that on in- flammatory fevers § ; for in the former, notwith- standing the SuddenneSs oS the attack and the high outrageous delirium, aSter a few returns of fuchpa- roxySms, there are So great Signs of debility as to oc- cafion fainting, when the patient i$ raifcd from a recumbent to an erect pofture. The patient is alfo generally troubled with much naufea and retching, and the delirium goes off in a few hours with profiife Sweati in Some caSes return- ing next day, and remitting in the Same manner ; none of which circumftances occur in the unmixed inflammatory fever, when it attacks in the fame vio- lent manner with high delirium. But Such violent cafes are rare, this mixed fever ufually beginning with milder fymptoms, irregular chillinefs, laffitude, confufion of the head, aching of the bones, and diforder of the ftomach. If * Vide Pringle's Obfervations, &c. 7th edition, page 7S—7%~ i Vide page 309 and page 343. too MEDICAL SKETCHES. If the ftrength and hardnefs of the pulfe induce the phyfician to order bleeding, the blood general- ly throws up abundance of inflammatory cruft, not- withftanding which, inftead of greater and more dif tinct remiflions, which he probably expects from the evacuation, a Sudden and dangerous degree oS weakneSs not unfrequently follows ; for in the pro- grefs of this fever the pulfe is not fo Steady as in the inflammatory. This difeafe is Sometimes accompanied at the be- ginning with cofliveneSs, at other thries with a ten- dency to looSeneSs ; the firft caSe fprriis a preSump- tion of an inflammatory bias in the difeafe. Exceflive ficknefs, bilious vomiting and purging, . are often the predominant fymptoms at the be- ginning of this fever ; and when thefe evacuations are judicioufly encouraged and affifted by repeated draughts oS mild Subacid drinks^ and plentiSul di- lution continued Sor Some time after the evacua- tions have abated, this treatment alone frequently carries off the fever ;—-in my opinion it performs this fervice oftener than it gets the credit of it. For as the cholera, a difeafe confifting oS alter- nate vomiting and purging of bilious matter, is not uncommon at the time of the year when this fe- ver is moft apt to prevail ; when the fever is ac- companied with bilious vomitings and purgings, and . is aCtually cured by encouraging thefe evacuations, it is fometimes imagined that the whole of the difeafe was a cholera, although in reality a formed fever had commenced, of which the vomiting and purg- ing were only fymptoms. It may be faid that it is impoffible to know that a difeafe, which Suddenly retires, would ever have advanced ; and the cholera is a difeafe which frequently occurs, independent of any formed fe- ver. But MEDICAL SKETCHES, t$t But as the cholera often occurs without fever,. when a perfon is feized with a cold fit, followed; by heat and other fymptoms of fever? although bi- lious vomiting and* purging fliould accompany of follow thefe feverifh fymptoms, the difeafe fhould be confidered as a fever, and not a cholera. Befides, when this fever is epidemic, we fee fre- quent inftances of its beginning with vomiting and purging; but the patient refufing to encourage by any means thofe evacuations, they flop of themfelves, in which cafe the fever generally continues,, with great ficknefs and oppreffion through the remaining courfe of the difeafe: Whereas when the patient has the re- solution to perSevere, in Spite oS naufea and ficknefs^ in drinking abundantly oS mild diluent liquors, and al- fo allows them to be injected by the anus, till the redundant and acrimonious bile is entirely waflied from the alimentary canal, the feverifh fymptoms are more apt to ceafe along with the vomiting and the purging, the whole diforder terminating in a profufe and univerSal perSpiration, ChillineSs, head-ach, and every indication of a be-- ginning fever, had accompanied the vomiting and purging in the laft cafie as in the firft,. and there was the Same reaSon to dread the continuation of it in both inftances. Since, therefore, it feldomer continues when thofe evacuations are freely promoted than when they are not, it feems highly probable that promoting them by plentiful dilution, is not only the propereft treatment of a cholera, but alfo a likely means of car- rying off a fever which begins with the fymptoms of a cholera. And although this method does not Succeed in re- moving every Sever that begins with thoSe Symptoms, there is the greateft reaSon to believe that it is always oS Service, and alleviates or prevents many trouble- fome Symptoms in the courSe of the fever. The ifr MEDICAL SKETCHES: The good effects which antimonial medicines, given! at the beginning oS this fever, often produce, render this ftill more probable ; the vomiting, purging and per- fpiration which they excite (for it is when they excite all the three that they are moft fuccefsful) often hav- ing the fame efficacy in removing this fever when it begins without thofe fymptoms, that promoting them by continued dilution has when the fever fets in with them. When the fymptoms of a fuperabundance of bile appear from the commencement of this fever, there is a great probability that the patient will be peculiarly fubject to ficknefs, oppreflion, drought, bilious flools,' with Swelling and tenfion of the belly, through the courfe of it. Thofe painful and difagreeable Symptoms Sometimes' fake place, notwithftanding all the care that can be taken to promote the evacuation of bile from the be- ginning, but are apt to be more fevere, to be attend- ed with gripes, with heat, and fometimes even with excoriation about the fundament, when this is no- glected. Worms are Sometimes palled by ftool, fometimes' they are thrown up by vomiting in the courSe of this" fever, and fometimes efcape by the mouth without vomiting, and in fuch cafes the griping and ficknefs are remarkably obftinate and Severe. Lancifius firft gave an opinion, which has been fince adopted by Sir John Pringle and Dr. Donald Monro, in their books upon the diSeaSes of the army, that as thefe animals fometimes lie long in the bowels without creating much uneafinefs to perfons otherwife well, he fuppofes that in all who liave this fymptom, the worms' are lodged before the fever begins ; and then being annoyed by the increafe of heat, and the cor- ruption of the humours in the primse vis (confequent on the fever) they begin to move about andftruggle to ^et MEDICAL SKETCHES. i$g get out, and fo occafion the difagreeable fymptoms above mentioned. Notwithstanding the refpectable authority by which this opinion is fupported, I cannot help thinking it more probable that thefe animals are produced by the ef- fects Of the fever, than that they exift previoufly ; and that being Seduced and perverted Srom their original fl'ate of innocence by the corruption of the difeafe, they then, for the firft time, become miS- chievous wanderers all over the alimentary canal : Which opinion is greatly confirmed by this circum- ftance^ that worms are very Seldom Sound in the bowels of grown-up perfons who die of other dif- eafes. The urine is generally high-coloured and trans- parent, and rendered in fmall quantity at - the be- ginning of this fever ; in the ptogrefs of the difeafe it affumes a citron colour, or becomes turbid ; if the diSeaSe takes a Savourable turn, it is made in confiderable greater quantity, and Sometimes (not always) depofits a pale brick-coloured Sediment. The duration of this fever, like that of all fe- vers, is uncertain ; as I am convinced that it is fometimes checked and fometimes entirely removed by affifting fpontaneous or exciting artificial eva^ cuations on its firft appearance ; I am alSo con- vinced that its courSe may be fhortened by other means which may be uSed during its progrefs : I therefore cannot be furprized at that uncertainty. As for the ancient and venerable doctrine of cri- tical days, without calling in queftion the veracity or judgment of thofe great men, who in other cli- mates^when the mode of living was more Simple, and at a period when the practice oS medicine was more paflive than it is at preSent, firft point- ed them out ; I have only to Say, that what ob- O fer vations 194 MEDICAL SKETCHES. fervations I have been able myfelf to make, have not taught me to rely upon them. I therefore look up with admiration at the fupe- rior penetration of thofe who inform us, that they can perceive them take place with wonderful regu- larity even in this uncertain climate, and in thefe days of luxury and excefs, and notwithstanding the varijus methods of treating fevers now in ufe. For even admitting that Nature of herfelf had a defire of terminating a fever on one day rather than an- other, and that a few faline draughts, caftor bo^- lufes, or a little cordial confection-, could not much 411111143 the natural courfe of things, yet it feems reafonable to expect that fuch powerful medicines as antimony and Peruvian bark Would make a great alteration in the progrefs and periods of the fever, and put it out of the reach of every eye but that of faith, to difcern the critical movements m queftion. To fuppofe that thefe medicines will abridge the fever, without difconcerting the critical periods, is to fuppofe a great deal. If it is difficult to point out a regular plan of treatment in difeafes whofe appearance is more uni- form, it muft be ftill more difficult in fuch a diS temper as this, whofe remiflions announce it of a middle nature between the continued and remittent fever, while another combination of fymptoms in- cline us to think it alfo of an intermediate kind be- tween the inflammatory and the nervous ; and whofe Proteus difpofition, after displaying the ftrongeft like- neSs to the former, is apt Suddenly to affume the moft malignant features of the latter. As bleeding is So beneficial in the one and So hurtful in the other, one of the firft and moft important points to be decided in our treatment of this mixed fever, is, in what degree that evacuation is-proper, and in what cafes it is .'proper at all. We MEDiCAL SKETCHES. 19 jf \Ve find a vety great difference of opinion among medical writers on this important head ; and there are fome who firft infift at great length upon the rteceflity of repeated bleedings at the beginning, when the pulfe is ftrong and frequent* warn us, in pathetic terms, of the danger of delay ; becaufe the opportunity of doing good by that evacuation, if neglected, * will never return ; and in a Subse- quent paragraph the prudent author informs us, that however ftrong the phlogiftic diathefis appears to be at the commencement of fevers, yet in ma- ny inftances it does not form the effential part of the difeafe, and will not continue through the courfe of it. We are reminded, that " to diminifh the " quantity of blood is an eafy affair, but to reftore u that Source of ftrength is tedious and difficult, <£ and intreated to be upon Pur guard, for perhaps " nervous debility and putreScency are lurking be- " hind the inflammatory Symptoms, ready to Start u forth and ravifh the patient out of our hands as " foon as he has loft a little blood." Such admonitions are rto doubt well meant, and deferve our gratitude, as much as the com- mander in chief did that of the officer whom he detached upon a hazardous expedition, with pref- fing orders to haften his march and attack the ene- my as foon as poffible, taking care at the Same time not to precipitate things in the leaft, but to wail patiently fot a proper opportunity; as the enemy, on their part, were extremely well diSpoSed to deftroy him and his whole army, if they could. Admonitions to avoid the dangers by which we Seem equally prefled, of bleeding or letting it alone, are of little fervice, unlefs they are accompanied with Such particular directions as may aflift our judg- ment in determining on the one meaSure or the 196 MEDICAL SKETCHES. The ftate of the weather and feafon of the year will aflift a little in deciding this point, becauSe the nature oS the fever will more probably incline to what is called the putrid kind in autumn after a ve- ry hot fummer, than during the frofts of winter or the piercing winds of the fpring. Eleeding there- fore will more probably be requifite in the one feafon than in the other, and may be ventured in greater quantity, although the fymptoms fhould be nearly the fame. When the patient is coftive, there is more reafon to believe the fever to be of an inflammatory na- ture than when his body is loofe. When difeafes of a nervous malignant tendency prevail, or have lately vifited a perSon in a fever of that fpecies, or when the patient is lodged in an hofpital, we ought to be more cautious oS bleed- ing at all, and more moderate in the quantity to be taken, than iS no Such diftempers were epidem- ic, or than if the patient had not had any inter- courfe with a perfon from whom he could re* ceive the contagion, or than if he breathed an at- mofphere more free from human effluvia than is to be found in hofpitals. The Same caution and moderation are more re- quifite with patients whoSe natural conftitution is. weakly, than with thofe who are robuft and ple- thoric . Due weight being allowed to all thefe circurn- ftances, we fhall be enabled to determine with Still more accuracy upon the propriety of venefection, by attentively confidering the fymptoms themfelves ; and when we find thofe which indicate the opera- tion blended with thofe which forbid it, our deci- iion will depend upon which preponderate. Should a robuft man, for example, complain of a fenfation of cold, with irregular fhiverings, fucceed- ed MEDICAL SKETCHES. 197 ed by great heat, a ftrong and rapid pulSe, with pains in the loins and head, and is at the Same time coftive, it Mill be expedient to let Some blood previous to giving an emetic or ufing any medicine, although the diSeaSe occurs in autumn, and the pa- tient has a yellowifh tinge in his eyes, a bitter tafte in his mouth, and much naufea. But if the cold St is preceded by long continued, liftlcflheSs, iS it amounts only to a feeble SenSe oS cold or irregular chillinefsj if attended with an open belly, and if the patient Seems dejected, it will be beft to wave the bleeding, although the fkin fliould be very hot and the pulfe pretty full and ftrong. The two circumftances which deferve to have the greateft weight in deciding this quefiion, are the na- ture of the prevailing epidemic, if any prevails, and the conftitution of the patient ; for if fhe laft is not ex- ceedingly ftrong and plethoric indeed, and the pulfe Strong and Sull in proportion, it will be fafeft to omit bleeding when nervous malignant Severs are frequent in the neighbourhood. But if the ftrength oS the patient and the fympton*'; of inflammation determine us to rifk this evacuation, it fhould be in a much more moderate degree than we might have thought expedient, had no fuch epidemics reigned at the time. After all the accuracy that can be difplayed in pointing out the proper treatment in this important article, cafes occur that puzzle phyficians of the greateft natural Sagacity and moft improved expe- rience—and perhaps puzzle thoSe of this defcription only ; for there are fome to whom no extenflon of prac- tice can give experience, and to whofe felf-fuffi- ciency no cafe, however complicated with oppofmg fymptoms, feems intricate. After bleeding, or having decided that the evacu- ation is not neceffary, the meafure to be taken in O 3 the • I93 MEDICAL SKETCHES. the next place admits of no doubt. The ftomach and whole length of the alimentary canal fhould be emptied. The remains of food, the redundancy of bile and other fecretions, with the wind and faeces there ac- cumulated, have, doubtlefs, confiderable effect in aggravating every fymptom at the beginning of the fever, and wc fometimes have the fatisfaction pf finding the Sever entirely removed in conSequence pf the means taken to cleanfe the firft paiTages. If there is a confiderable degree of naufea, it will be to no purpofe to begin with a purgative; be- caufe in this fituation the patient would in all pro-? bability throw it up. It will be beft, therefore, to begin by ordering a laxative clyfter ; and after the operation of that medicine is over, to giye an emetic. The firft will wafh the hardened faeces from the rectum, and render the operation of the fecond more effectual. It will be beft not to give the emetic at the time of the acceffion ; but rather wait till that feems to abate. Two or three grains of tartar emetic diflblved in a little water will generally prove a fufficient dofe, and in this fever is more efficacious than ipe- cacoanha, which in the dyfentery is preferable tq tartar emetic. The vomiting, wheri it begins, muft be promoted by drinking very plentifully of warm water ; and in cafe the firft dofe fliould not ope- rate within half an hour after it is taken, three grains more may be diflblved in a quart of warm water ; and half a pint of this folution may be drank every quarter of an hour till it has had the defired effect. Exhibited in this manner, the antimonial gene- rally proves both emetic and purgative, effectually •cleanfing the whole inteftinaf canal, and often pro- ducing MEDIC AL SKETCHES. 19$ ducing fuch a determination to the furface, as brings on an univerfal diaphorefis, and removes the- con- ftriction of the extreme veffels, all of which effects united, Sometimes carry off the fever. As there is reafon to think that much acrimo- nious bile is fometimes accumulated in the gall-blad- der and flexure of the duodenum, and much rancid matter retained in the bowels at the beginning of this fever, it follows of courfe that Such accumu- lations muft aggravate every Symptom of the fe- ver ; and it cannot be doubted that throwing fuch a load out of the body muft have confiderable ef- fect in cooling and relieving the opprefled patient ; but then it is urged, that this redundancy and ac- cumulation of bile and other acrimonious matter be- ing the effect and not the caufe of the fever, the removal of it, although it do produce an abatement of the fymptoms, cannot poffibly remove the fe- ver, However plaufible this may feem, I am fully convinced from obfervation, that vomits, and par- ticularly thofe of emetic tartar, are often of great fervice, independent of their effect of unloading the ftomach, Sometimes even when the ftomach Seems to have been quite clean, and when nothing has been thrown up befides the emetic itSelf and the water. The action of vomiting is violent and convul- sive ; the retchings, which continue aSter the fto- mach itSelS is quite empty, are ftill more So : They produce a copious and univerfal perSpiration ; they affect every veffel of the body ; the ftomach has a ftronger fympathy than any other organ, the heart excepted, with the whole body ; and I have not a doubt that emetic tartar, exhibited in the manner above mentioned, fometimes entirely fhakes off fe- vers. I fhall not make any farther attempt to cx- O 4 plain 203 MEDICAL SKETCHES. plain, how; fuch an attempt would be as Superflu- ous as it might be unfucceisSul; for thofe who ex- pect nothing Srom this medicine but cleanfing the firft paffages, and preventing noxious abforption, may think the antlmonial neceflary for thofe pur- pofes at leait ; and if, upon trial, they find that it has another falutary effect befides that which they expected, the good refulting to the patient will be deemed, it is to be hoped, a Sufficient compensation for the refutation of their argument. If at the beginning of the fever the. patient has a violent vomiting, it will not be proper to give either tartar emetic or ipecacoanha, but rather to promote the fpontaneous vomiting by plentiful and repeated draughts of warm water, until the ftomach is completely cleanSed, and the vomiting ceafes ; for vomiting is the cure of vomiting in all cafes, except when it proceeds fiom an inflammation, or fom of 22$ MEDICAL SKETCHES. of force in that caufe, and upon the difference of conftitution of the perfons feized. But their displaying different Symptoms at the beginning, and requiring a very different treatment in their progrefs, feems to announce that their caufes muft- be different: And he who believes it to be the famej becaufe when the perfeverance of the diS temper has confirmed every fouree of distinction in the nerves, in the fibres, and in the veffels, all fe- vers terminate in the fame deplorable ftate of co- jttiatofe infenfibility, may with equal reafon believe that all the vaft variety of plants, however differ- ent in appearance and virtue, fpring from the fame feed:; arid that their only difference depends on the quality of the feed and foil, becaufe by calcinatioii they may all be reduced to a fixed fait of the fame nature. But here is another' fever, different in its Symp- toms from the inflammatory or even the mixed, and in which We evidently and Speedily do harm, iS we obferve the fame practice which does good in the former; we therefore eannbt help thinking it pro- ceeds from a different caufe. Cold, marfh miafma- ta, and the other caufes afligned as the fources of the o#ier fevers, do not account to us for the greater malignity of this. In endeavouring to trace this new difeafe to its Source, we confider attentively what particular fi- liations people generally are in, or what peculiar eirCumftances ufually attend them when they are feized with this fever ; and, as in other difeafes, we call thefe its caufes, ajthough we can perceive no other relation between them and it. We find that thofe who have been long Subjected to Scanty diet, thoSe who' are naturally of a weak- ly conftitution, or who, having been originally of a vigorous habit, are weakened by exceffes, by dif- eafe, MEDICAL SKETCHES, 22* eafe, by long courfes of medicine, particularly of mercury, by profufe hemorrhages, are then moft lia- ble to this fever ; we find this is alfo the cafe with thofe who are under the impreffions of fear, forrow, and remorfe ; of courfe we ' confider fear, forrow, and remorfe, and all the fources of weaknefs above enumerated, with whatever elfe impairs the appetite and perverts digeftion, or in any way debilitates and exhaufts the conftitution, as predifpofing cauSes of this difeafe. + And as the depreflfh^ paflions are found liable to promote this difeafe, So whatever rouSes and exhi- larates the mind, has a tendency to render the con- ftitution leSs SuSceptible oS this damping contagion, and aflifts the recovery of con vale Scents. The Salutary effects of victory on the conftitutions of Britifh feamen, are well defcribed by Dr. Blane, late phyfician to the fleet under the command oS Lord Rodney, who furnifhed that gentleman with more frequent opportunities of making fuch comforta- ble obfervations, than the medical practitioners in any other fleet enjoyed during the laft war *., One of the moft diftinguifhing fymptoms of this fever being great dibility, a natural connection is obfervable between thefe caufes and the fever ; it may therefore be thought, that even a priori we could have predicted the effect from confidering the caufes. But when we attempt this, for one instance in which we predict right, in ninety-nine we fhall pro- Q, .3 phecy * It is ho.ped that none of the furgeons of the navy will Imagine, that any reflection is here intended againft them ; there can be no doubt that they would have been equally ready to have made fimilar obfervations, had fimilar occafions occurred : It is only meant here to do juftice to Dr. Blane, who having had the good fortune to meet with fuch .opportunities, did net allow them to pais unimproved. ?3o MEDICAL S.K ETCHES, phecy wrong ; and even here the Sole connection that we can perceive, lies in the debility ;^—theft? imputed caufes feem to have no relation to the other fymptoms of the difeafe. But obfervation has acquainted us with a differ- ent fouree of this fever, which acts with more* force and more certainty than all the others*, and is produced by the crowding and coniining too great a number of people within any place where there is not a free ventilation, angj which we therefore con- clude to be the effluvia flowing Atom the human body *, Here enr reafoning a priori would probably have been at fault, for it would not naturally occur to the imagination of any man, that the effluvia of his own body is more noxious to his health than cold, than the effluvia of putrifying vegetables, infects, corrupted water, and all the other caufes of fevers. Experience alone could have inftruCted us in this ; and the fame experience has taught us, that when the fever is once generated, by people in health being thus crowded, it is rendered ftill more ma-! lignant, by the contagion of thofe who are feiz- ed * Dr. John IluntePj in a very fenfible paper in the Medical Ti*anfaer been lb habituated. MEDICAL SKETCHES. 233 ed to active exertions of the mind and body, and Such of the inferior clafs as can by moderate la- bour procure all the neceffaries, and fome of the con- veniences of life, and who are naturally cleanly, would be ftill lefs liable to this Sever than the luxu- rious, were it not Sor the Single circumftance of their having more frequent and immediate commit nication with the indigent, who are fo much expofed to its moft. powerful fouree. Upon the whole, we know that people of delicate, exhaufted and Sickly conftitutions, and thoSe whoSe minds are Saddened by depreffing paflions, are greatly predifpofed to this diSeaSe, the immediate feeds of which, we alfo know, may be generated in places where the human effluvia is collected and confined. And this is the moft effential part of our knowledge re- specting the cauSe of this difeafe ; and even this little is disturbed with uncertainty, Sor we Sometimes meet with inftances of people of robufl conflitutions, who are feized with the difeafe in all its malignity, when they -are under no depreffing paffion, when the difeafe is not epidemic, to whom we cannot trace it from any place where the human effluvia could be fuppofed to be con- fined in an uncommon degree, or from any perfon in the-difeafe, of which perhaps there is no other perfon ill in the neighbourhood for feveral miles around; and in fhort, when we cannot connect it with any of the caufes fuppofed to be the fources of the diftemper. On extraordinary occafions of this kind, we have nothing for it but to fuppofe, that notwithftand- ing the apparent vigour of the patient, his body has been peculiarly predifpoSed to catch the inSection, and that Some contagion, not Sorcible enough to infect any other perfon, has by fome unobferved means been conveyed to him ; or if fo many fuppofitions difpleafe, we may SuppoSe at once that there is in Some cafes a fouree oSthjs Sever which has not yet been SuSpected, *34 MEDICAL SKETCHES. For although the numtrbus observations that haVe" been made, give us the ftrongeft reaSon to think, that human eiiluvia produces this difeafe, we have no right to infer that it canriOt arife alio frOm fome other fouree*. There is good reafon to believe, from hiftory dnd authentic records, that malignant Severs were former- ly more frequent, more univerfal, and raged With greater violence in Europe in general, and irt this* ifland particularly, than they have done of late. This is generally imputed to the ftreets and hottfes of moft of the cities, and of London in particular, be- ing more Spacious, dry and airy. FrOm * The difficulty of difceweringthe real fpnreek of difeafes, and all their fources, appears greater in proportion to the pain3 which have been beftowed in kiTeftiga'T.i^iiie fubject: If there i:> a dileafd in the world, a certain knowledge of the origin of which is intereft- ingto one part of mankind ;v.oi- than all the red, it is the plague in thole countries where it is fo extremely apt to break out -, >er it appears front the following extract, that the moft c niightened even there are ftill in doubt on that i'ubject. iC M. Michel, phyfician of the hqfpital at Smyrna, appears, ac- cording to a memoir of which he is the author, lent by M. le Baroh de Tott to the Medical Society, to believe ih the Ipontaheity of the plague ; for proof of which he cites the following circumftance ; Atoiitary fhepherd, having no communication with any body, fell fick while he was tending his flocks ; he went into an inhabited part, where he communicated the plague, with which he found that lie was attacked. This urcumle;mce would prove much* if it were certain thai this fhepherd had no communication with others; if it were known how long, and with what precaution he had beenie- fcluded from company; but the proofs of thefe are too diln'cultto b« eftablifhed, to allow of any cor cTifion to be drawn frOiu the fact. We are therefore obliged to acknowledge, that we are equally ig- r.orartt whether it is in facta country which is the cradie of the plague ; v.hr.t country this is, fuppo.vng that fuch an one exifts ; or, finally, whether itfometimes appears fpontaneoufly, and whe- ther the firft who is attacked with it becomes the focus from whence it c.T.an:itC3.M See Hiftory of the Royal Medical Society for the \ears 1777 and 177S, p. 305, MEDICAL SKETCHES. 23$ From their being infinitely more cleanly, in confe* qtience of the new method of paving. From the inhabitants not being fo much crowded to- gether. From their being more cleanly in their houfes and perfons. From the poorer in particular being more comma* diolifly lodged, more falubrioufly nourifhed, and bet- ter taken care of in all refpects. From the difeafe being more judicioufly treated by medical practitioners in general. And, above' all, From our knowledge of the virtues of the Peruvian bark. During the civil Wars in Charles the Firft's time*, this fever raged with deftructive violence in the camps, and degenerated into an abSolute plague in th£ capital and in other parts oS England, Some of the circumftances which have a tendency to fpread this difeafe, and render it more malignant and peftilential, prevail, it will be faid, in a greater degree in Scotland than in England ; yet the latter has been more frequently fubject to peftilential and ma- lignant fevers than the former ; and when this cala- mity laft raged with So much violence in the Southern parts of the ifland, it was little felt in the northern, which naturally may be imputed to the mountainous nature and northerly fituation of Scotland ; the one expofing the atmofphere to a brifker ventilation, and the other bracing the fibres of the inhabitants by frofts of longer duration*. 6 ThU * To prevent the Scots from being too much elated with this or Pny other advantage, they have never wanted good-natured friends, who without grudging them either their ftorms or their frofts, are fond of reminding them ofjevery circumilance that may tend to moderate their pride, and who fail not to remark, that if their z$6 MEDICAL SKETCHES. This fever fometimes creeps on in Such a flow and iufidious manner as fcarcely to be obferved, or wear- ing fuch a mild and innocent afpetit. as to give no alarm for perhaps two or three days. The patient perceives, indeed, alternate fenfations of heat and cold, but fo gentle, that he thinks them of little importance. They are followed by fome degree of uneafinefs in "his head, by want of appetite, liftleffnefs, and dejec- tion of fpirits, to remove which his friends endeavour to drag him into company, or advife him to try to fhake off his liftlefthefs by exercife, to which he generally is extremely averfe. In this condition his pulfe is Some- times a little quicker, at other times about the natural ftandard ; and he himSelf, never quite well, nor appa- rently very ill, remains Several days brooding over uncomfortable ideas, and either does not fleep, or feels little or no refrefliment from his fhort and dis- turbed flumbers, ftarting at the Smalleft noiSe, and Sometimes when there is none, gradually loling ftrength, the uneaSmeSs in his head augmenting to a kind of giddinefs, his limbs and joints, particularly his keees, Seeling weak, and yielding to the weight of his body ; but a kind of tremor of his hands begin- ning to be perceived, and alfo in his tongue, when he is defired to put it out, it is at laft difcovered that the patient, inftead of being difturbed with vapours, is under the influence of a dangerous fever. This fever on other occafions attacks in a more open and avowed manner. The rigour at the beginning being ftronger, the fucceeding heat greater, and the pulfe quicker, but varying in this circumftance every two or three hours, the uneafinefs or confufion of the head their country is lefs fmYjetft to peftilence, it is more expofed to famine than England. This circumftance affords thofe of their neighbours, who are not lefs fond of a joke upon account of its age, a^eat advantage over the Scots in repartee. MEDICAL SKETCHES. 217 head being ftrongly marked from the firft, and is fome- times accompanied with a pain at the bottom of the Orbit of one eye, fometimes with a teafing and con- ftant fenfe of throbbing in the head, which prevents fleep, and haftens delirium. Without either the pain at the Bottom of the orbit, or this throbbing in the arteries, many have from the beginning an increafing confufion in the head, which with a flower pace conducfts to ftupor and mSenfibility, very few retaining their fenfes till death. Exacerbations are obfervable towards night, during which .the delirium feems a little higher, and the pa- tient more reftleSs. His eyes, which generally are from the beginning heavy, and a little inflamed, be- come now more lively, he is apt then to Speak quicker than.ufual, and fhews an uncommon rapidity in all his motions j a fierce anSwer Srom a patient of a mild cha- racter is a bad fymptom, Some nice obServers think they can, in particular Situations of this fever, difcover the ftate oS the brain from the eyes alone. When thefe appear unuSually quick and piercings they imagine delirium is threatened. When fixed and fierce, they indicate ftartings, fub- Sultus and great ftruggling. When half fhut, heavy and bleared with tears, they import the greateft degree of ftupor. When blood feems extravafated in the eyes, the cafe is almoft hopeleSs. But in general when the patient does not get any fleep at the beginning of this fever, his eyes are only half fhut; and when he awakes, he feels not re- frefhed, and often denies that he has been afleep at all. Sicknefs, and even vomiting at the beginning, are not unfrequent fymptoms, though not effential to this fever. Air* 238 MEDICAL SKETCHES. Alfo pains in the loins, and that fenfe of wear}nefs" in the limbs, ufual in all fevers. The tongue is at firft whitifli, and generally moift* as if covered with a t'hin moift white fur, and Some- times it is of a dry, Smooth, gloffy, red, or crimfbn ap4 pearance, which at laft attains a dark-brown colour and horny conftf fence. A Sudden proftration of ftrength Sometimes happensi fo that the patient is in danger of fainting when he is raifed from an horizontal pofture. When this proftra- tion happens early, it may be reckoned the moft di£ tinguifhirtg or the pathognomonic fign of this Sever. There is Sometimes very little thirft through the whole courfe of this difeafe, at other times the tliirft is inceffant; from about the third day there is a deficien- cy of the fecretion of faliva, with a drynefs .and bitter tafte in the mouth. The fymptoms are commonly more various in this than in any other fever ; the urine, though in general varying lefs than in' other fevers, yet fometimes is re- markably pale, and fometimes of a dark-red colour4 When the urine from being thick and high-coloured, becomes thinner and paler, without any great quantity of liquor having been drank to occafon Such an al- teration, it is an indication pf impending or increafing delirium. . "■>■ " A particular eruption of little Spots, like flea-bites^ is the frequent, but not the conftant attendant of this difeafe. Thefe Spots appear generally on the neck, breaft and back, Seldom on the face and limbs ; they are tp be Seen, but not Selt, having no elevation above the Surface of the fkin ; they are feen Sometimes as early as the fifth or fixth day, at other times not till the end of the fecond week; they feldom appfear after that period^ and are never critical ; they are rather a bad fymp- tom, though many recover upon whom they appear: The Spots are generally of a crimfon complexion, and the MEDICAL SKETCHES. 239 the darker the more dangerous. When thefe petc^ cluae are quite black, or when purple vibices, like the wales of a ftripc, appear at the fame time, the fenger is very great. ^ Bleedings at the noSe Sometimes occur at the Same time, which are vcyy feldom ufeful, but rather proe:- nofticate ill. * h It fometimes happens that in the firft two days the patient lofes ftrength to a degree that does not ufually occur till the eighth or ninth day 5 in fuch cafes the pa- tient is in the utmoft danger, in far more than if the fame degree of weaknefs had come on gradually. Sometimes, though rarely, the delirium is of the high land, with a wild frantic look, with unufual quicknefs in the voice and. motions, although all the while the pulfe ^is Ipw; and inftead of a tremor of the hands, there is a ftrong Subfultus tendinum. Such caSes are generally accompanied with wakefulnefs, and often terminate fatally on or before the fevcnth day. But the delirium of this fever much oftener conSrfrS of a low ftate of Stupidity, attended with frequent muttering ; in which the patient, from having been too, acute'qf hearing, becomes almoft perfectly deaf.— This is generally accounted a favourable Symptom, and certainly has a good effect, hindering the patient from being difturbed by any accidental noiSe, or by the whifpers which are apt to go on too conftantly in his bed-chamber. When tins clifeafe lingers, that is, when it paffes the Second we.e]>, the patient is apt to continue for feveral days, v/ith little alteration, in a ftate where the in Sen-- Sibility is greater in appearr.nce than in reality, and feems hi a conildei\ibIe meafure to be owing to cieaf- nefs ; for although he is-net able to combine a number of ideas, yet when a Simple prcpouricn is hallooed in- to his enr, defiring him to put out his tongue, or aik- ingif be choofes to drink, he direcTry fhews that he uuderfbuids 240 MEDICAL SKETCHES. underftands what is defired. And he fhews the fame degree of intelligence When certain figns are made to him, by accommodating himfelf as much as is in his power to what is propofed. When a veffel contain- ing a liquor he relifhes is prefented to his fight, he im- mediately prepares his lips for fucking it in. When he knows that the veffel contains a liquor he diflikes, he fhakes his head or fhuts his mouth and eyes as oSten as it is offered.—From this ftate, after lingering Sor many days with little variation, the patient not unSre- quently recovers. But there is a greater and more dangerous degree of infenfibility, which occurs when the patient lies in this dozing ftate, where he fhews that kind of confufion and want of accuracy of idea, which people have in fome oppreflive dreams. In this ftate the patient evinces a fenSe oS bodily uneafineSs, without being Suf- ficiently diftinct to refer to the part of his body where fhe impreflion is made. Thus patients who are not very attentively looked after, are apt to have painful excoriations, or parti- cular parts greatly inflamed, and even threatening mortification, from the mere preffure of their bodies, by being allowed to lie too conftantly on the Same parts* They difplay a general fenfe of pain, by a frequent moaning, but have not fufficient accuracy to point to the part affecfted. The irritation oS frees in the recftum,- or of urine in the bladder, fometimes occafions much diftrefs to the wretched patient, whoSe oppreffed and bewildered fenSes cannot diftinguifli the cauSe oShis Sufferings, and which nature in particular cafes is tedious in relieving. But that this retention is the caufe of his diftreSs, is Sufficientlv evident Srom his giving over moaning, and acquiring a ftate oS comparative eaSe and calmneSs, im- mediately aSter evacuation. This Medical sk£tch£s. 2-4 i . This circumftance fhould prompt thofe whofe duty it is to watch over the patient, to redouble their at- tention, in endeavouring to diScover the fouree ojf his Sufferings when he fhews fymptoms of un- eafinefs, and to make up for the confufion of his fenfes by the diftinctneSs of theirs. The acutenefs even of a nurfe on fuch occafions may Save a patient whole hours oSdiftreSs, arid pollibly may Save his life. There is a particular Symptom^ which if I am t6 judge from the cafes that have come under my own ob- Servationj I fhould think fully as dangerousj if not more fo, than the laft mentioned. When the patient lying on his back (for that is his cOnftant pofture when this fymptom occurs) with his eyes open, receives with tnarks of eagernefs the drink that, is presented to him, and having taken a mouthful, keeps it in his mouth without attempting to Swallow it, not becauSe he cannot Swallow it; for after he has kept it in his mouth a con- siderable time, if the cup is preferred to his lips again With more drink, he immediately Swallows the firft mouthful, and takes a fecond, which he retains in his mouth in the fame manner as he did the firft. It feems as if the patient, irpon feeing the liquor, has the idea of taking it into his mouth, and immediately forgets that he is to Swallow it, which marks a very great degree oS abSence or confufion of mind ; he will on thefe occafions retain it a very long time in. his mouth, and perhaps Spit it out at laft, or allow it to glide Out imperceptibly, iSno means are ufed to make him Swallow it.—The means are, Simply to fhew him the liquor, and preSent the cup or Spoon to his lips again while he has the Sormer Spoonful in his mouth 5 at fight of a fecond Spoonful he Swallows the firft ; on Seeing a third approach, he Swallows the Second ; and So on, till he has taken the Still quantity intended, or till he fhews averfion to the taking any more. The only precaution neceffary is; to give the different Spoon- Bt fuls 242 medical sketches* fuls at fliort intervals, andnot too rapidly, left a fit of coughing be railed, and the liquor rejected. It may Seem ftrange that the Same degree of recol- lection that prompts the patient to fuck in the liquor, does not alfo prompt him to Swallow it. Whoever thinks So, may account Sor it in any other manner he thinks more Satisfactory ; but thofe who will attentive- ly obferve all the various fymptoms of this fever, will find, that in certain cafes this happens exacftly as above reprefented. I myfelf have been aflured, on entering the patient's bed-chamber, " that he could no longer Swallow j " that he could take indeed a little into his mouth; but u there he would keep it Sor a quarter of an hour per- u haps, and then would allow it to efcape out of his cc mouth again, without fwallowing a drop." On which I have called for fome wine, the fame liquor which Iliad been told the patient could not Swallow, and have given him one SpoonSul after another, in the manner above mentioned, till he had taken the quantity I judged proper. A difficulty of fwallowing, however, is alfo a fymp- tom of the'difeafe, which fometimes proceeds from the drynefs of the throat, and fometimes from aphthae on the tongue and throat ; but the cafe above mentioned is an effentially different fymptom. It is alSo a very bad Symptom, and proceeds Srom the Same cauSe, whcrti the patient, after putting out his tongue, forgets for a confiderable time to draw it in again, or fhews a continual uneafinefs, by fre- quently throwing the bed-clothes from his body, and endeavouring to get out of bed, without giving any reaSon, when afked, for So doing. The patient is Srequently obferved to draw his breath in a laborious or convulfive manner, fetch- ing deep Sighs, or rather Sobs, as if he were under fevere affliction, or felt much, oppreflion about the precordial Medical sketches. 243 precordial The breath and perfpiration alfo, in particular cafes, have been found ftronger and more offenfive ; and, upon preffing the fkin of the pa- tient, a fenfation of a peculiar penetrating heat re- mains on the hand for fome minutes after ; where- as ""the heat communicated by the fkin of a patient in the inflammatory fever is more tranfient. The heat of the fkin is more moderate at the be- ginning, in this than in other fevers ; and unfor- tunately, this peculiar and permanent heat is not per- ceptible till the difeafe is far advanced. The languor and defpondency of the patient's mind is ftrongly marked from the beginning in the dulnefs and heavinefs of his eyes ; but it is a fatal fymptom when the eyes become blood-fhot and glaffy, which often happens before the termination of this fever. Towards the clofe, when Nature and the efforts of the phyfician prove unable to refill: the maligni- ty of the difeafe, all the diftinguifliing marks oft fevers are obliterated 3 and the concluding fcene is common to all. The ftrength being almoft entirely exhaufted, the patient lies conftantly on his back, with a perpe- tual propenfity to Aide to the bottom oS the bed 5 the hands fhake when they attempt to lay hold of any thing, and a continual twitching is obServed in the tendons oS his wriftj the ^tongue trembles when it is pufhed Sorth Sor the inSpeCtion of the phyfician, or all attempts to pufh it forth are un- SucceSsSul ; a black and glutinous cruft gathers on the lips and teeth, to the increafe and inconvenien- cy of which the patient feems now infenfible. He Seems equally inSenfible to the ardour of thirft ; he mutters to himfelf; he dozes with his mouth half open, the lower jaw falling down as if the mufcles R. 2 were * The region of the heart. 244 MEDICAL SKETCHES, were too much relaxed to refift its own gravity; he fees objects indiftinctly, as if a dark cloud hung before his eyes; fmall black particles, called by phyficians mufchae volitantes, play, as is believed, before his eyes -, for he often catches with his hands at thofe or feme fuch objects of his difordered brain ; he frequently extends his arms before and above his face, feeming to contemplate his nails and fin- gers ; at other times he fumbles with his fingers, and picks the wool from off the bed-clothes ; he lofes the power of retention ; the evacuations pafs involuntarily ; and, as if lamenting his own deplo- rable condition, tears flow down his ghaftly counte- nance ; the pulfe flutters Small as a thread, and on a preffare very little ftronger than common, is not felt at all; his legs and arms become cold ; his nails and fingers blackifh ; his refpiration is inter- rupted by hiccup, and finally by death. It may feem fuperfluous to add, that a general defcription is different from a particular cafe ; in the one all the fymptoms are enumerated, though they cannot be fuppofed to be united in every individual. In this fever it frequently happens that many of the fymptoms now mentioned are prevented, and the duration of the difeafe fhortened, by a fatal diarr- hoea or dyfentery. Some phyficians have^ by Splitting this diSeaSe, maile two diftiifcfc fevers, defcribing the one under the name of the flow nervous, and the other under that of the putrid malignant fever. On comparing the defcriptions, however, or, what is of more importance, on Studying the Symptoms from Nature, it will appear, at leaft fo it feems to me, that the two are effentially the Same, and that the apparent difference depends upon the degree or apon the different conftitutions of the patients. Wc MEDICAL SKETCHES* 245 We are told, " that tlie nervous fever attacks " perfons of weak nerves, thin poor blood, deject- " ed fpirits, and exhaufted habits ; whereas the pu- u trid fever is more likely to appear among thofe 11 af a fuller habit of body, ftronger conftitution, " and who are accuftomed to richer and hotter u diet." The difeafe, I imagine, attacks perfons of all con- ftitutions ; but thoSe oS the firft defeription are moft SuSceptible of it, and the fymptoms are in feme par- ticulars different when it is ingrafted on the one, from what they are on the other. The effential fymptom of great debility and nervous affeciion are common to both. With regard to the opinion that one has its feat in the lymphatic and nervous juice, and the other in the blood itfelf, I have nothing to fay farther, than that before a great deal of trouble is taken to find out what is feated in the nervous juice, it will not be amifs to afcertain that there is fuch a juice ; and even then the reft of the opinion is hypothe- tical, will be difficult to prove, and when proved, will leave the method of cure where it is at pre- fent. Many of the fymptoms of this nervous fever are unqueftionably common to all fevers, and fome of the moft diftinguifhing marks of this do not appear at the beginning, or, perhaps, in many inftances, not till a method of cure has been adopted that would not have been uSed if the nature of the difeafe had been known. It is of great importance therefore to detect this as foon as poifible; which consideration may form an apology for recapitu- lating fuch circumftances and Symptoms as peculiar- ly diftinguifh this Sever ; and although none oS them j taken Singly, can mark with certainty its exiftence, R 3 yet g4a MEDICAL SKETCHES, yet the combination of a few will form that de- gree of.probability which juftifies.a decifive pracftice* i. Inftead of the ftrong hard pulfe which attends the outfet of other fevers, in this it is' fome- times fo little altered," that we are aptto fuSpecl the patient, exaggerates in the account of his com- plaints ; it varies more than other fevers both in -'quicknefs and flawnefs, and alfo in Strength1 and weakneSs:; and Sometimes there are cqnfiderable variations even in the' courSe of. one. day. , . .-> 2. The heat of the fldn is more moderate at the beginning of this than of other fevers ; fprt that penetrating hsat of the fkin, which is peculiar to this fever, is not perceptible at the beginning, g. The fkin, inftead of appearing reddifh, is general- ly pale. .. 4. The pain, or rather heavinefs of the head, is not fo acute as in other Severs, but is attended with more dejection of fpirits, and augments with a flow but Steady pace, Seldom remitting aSter it commences, unleSs it is checked by the bark. 5. When this heavineSs in. the head is attended witfi tremor in the hands, there is little doubt of the fever being of the malignant kind. 6. There is a greater degree of languor and de£ poridency in this than in other fevers. 7. Greater mufcular debility. If a Hidden and unexpeCred debility take place, there can be no doubt with regard to thg nature of the difeafe *. .;. \ The * Monf. Tifl'ot, when treating of malignant fevers, obfervts, that they are more dangerous than they feem, like a do«j vrho bites without barking; and then proceeds to inform us, that " The charadteriftic of malignant fevers is, the total " lofs of ftrength from the beginning." This however I fliould conlider as barking very loud ; but th!s decilive fymptom does not L'.hvu'ys appear till the fever his exifted fome days. MEDICAL SKETCHES. 247 The malignity of this fever is generally in pro- portion to the debility at the beginning. To inveftigate the nature of the fever from the appearance of the blood, is equally uncertain and inexpedient, both becaufe at the beginning even of this fever it fhews fome fhare of inflammatory buff, and becaufe to determine whether we ought to bleed or no, is1 one chief reafon of our wifhing in th£ firft place to be certain of the nature of the fever. The Weaknefs that immediately follows. bleeding, fhews at once the nature of the fever and the im- propriety of the evacuation. When the fymptoms are fo oiibure or ambigu- ous that we cannot form a decided opinion refpeCl- ing the nature of the fever, the obfcurity may be difpelled, or at leaft Some light may be derived from the Sollowing circumftances : Whether putrid Severs prevail. ^ Although no Such epidemic does prevail, whether any connection or communication can be traced be- tween a Single perSon in this kind of fever, and the patient. Whether the patient has lately been weakened by exceffes, by difeafe, by hemorrhage from wounds or otherwife. Wmether he has been long under ' the influence of the depreffing paflions, or of dejection of fpirit, independent of a known caufe. Having paid due attention to every fouree of in- formation, and after weighing every circumftance, being at length fatisfied that the fever is of the malignant kind, we proceed to the cure. As confined air, particularly that which is load- ed with human effluvia, . feems fo intimately con- nected with the peculiar malignity of this fever, the expediency of a free ventilation through the pa- tient's chamber is obvious, and perhaps, if not of & 4 itfelf 248 MEDICAL SKETCHES, itfelf the moft effectual curative meafure that can' be taken, is at leaft that upon which the fuccefs of all the others feems moft to depend. To thoSe whoSe circumftances afford the comSort of a Spacious well-aired bed-chamber, all the bene- fit that can flow Srom this meafure, will be obtain- ed by occafionally throwing open the doors and windows, and allowing the room to be refrefhed by a current of frefh air. WThen the chamber is fmall, if the weather is mild, and the patient can with tolerable conveniens cy be carried into the open fields or into a garden, and allowed to fo there a few hours, it ought to be done ; for Hiis ^aCtice has been found highly re- frefhing and cordial. When from various circumftances this cannot be done, every means in our power to procure a free ventilation muft be ufed, and the chamber fhould be frequently refrefhed by fprinkling it with vi- negar. Confining the patient conftantly to his bed, under a load of bed-clothes, by which means his body is always Surrounded by a kind of vapour-bath of his own effluvia, is exhaufting and pernicious. The bed-clothes ought to be in no greater quanti- ty than is agreeable to his own SenSation; and when he can fit up in an elbow-chair with his clothes looSely put on, it is often a refrefhing change of pofture and Situation. There are inftances of patients in this fever, who while lying in bed thought their ftrength So much exhaufted, that they could not poflibly fit in an ereCt pollute even for a few minutes ; yet upon be- ing carried on a-eouch into the open air, and re- maining there for two or three hours, have been fQmuch refrefhed, g,nd have acquired fuch an acceflion of MEDICAfc SKETCHES. 249 of Strength or Spirits as not only to fit up, but even to ftand and walk a little. In caSes where the patient can eafily be moved into the open air, it is not impoflible that the cheer- ing verdure of the fields and rural objeCts, with the refrefhing fmell of plants, at particular feafons of the year, may contribute to the cordial effect which a free cool atmofphere is Sound to produce. ThoSe who have been long teazed and harraffed for want of reft, while confined under a load of bed-clothes, have obtained refrefhuig flumbers after their bodies have been cooled by the reftorative influence of the open air ; and af^wards find their beds more comfortable, particularly when furnifhed with clean fheets and cool frefh covers. With changes in this laft article, thofe who can afford it fhould frequently be furnifhed. Whatever benefit is derived from the ufe of a ftrong- er and more effectual ventilation in this fever than was formerly allowed, or from the open atmof- phere, when the patient can with fafety and con- veniency be carried into it, the honour is due to thofe who firft adviSed and introduced this judi- cious and SucceSsful practice in the inoculation of the fmall-pox. After its falutary effects were ma- nifeft in the one difeafe, its application to the other was obvious ; and indeed when we recollect that putrid fevers often originate in places where a per- fectly free ventilation cannot be obtained, its ap- plication to this difeafe feems more natural than to the other. As in the high inflammatory fever the fymptoms Seem to ariSe Srom the heart being ftimulated to ftronger exertions than are confiftent with health, and therefore we look Sor the cure in Such means as we know have a tendency to abate theSe vio- lent exertions j So in this Sever, whofe Sinking fea- ture .250 MEDIC A L 'Sf K* T;C HE S. lure is debility, in which the nervous energy feemsc' impaired, and the action of the heart is weaker*1 than is confiftent with health, we look Sor the cure in inch means as give vigour to the vital powers. Evacuants which diminifh the quantity of the blood and humours, and refrigerants which'are thought to abate their heat,- are therefore -thought "proper-in the firft cafe 5 cordials and ftrehgtheners in the fe- cond. * :j ' -1 ' It has been thought that bleeding may 'be neceffa- ry at the beginning of this difeafej to prevent "the fever from running too high,' and producing inflam- mation^ of the i^rain, lungSj or other vital parts. But all the obfervations i have been able to make, and the knowledge I have otherwife been able to acquire, convince me That we have much more certainty of the bad effects of blood-letting in this* fever, than we have of the evils it prevents ; part of this conviction I have received from the writings of two very eminent and very learned phy- ficians, neither of whom feem themfelves however to have been fo fully convinced of the bad effects of this evacuation. Dr. Huxham, after defcribing the cafe of a pa- tient, with the ftrongeft Symptoms of a putrid fe- ver, adds, " He was bled to about ^xii. from his " anil, but this gave him no manner of relief; the " oppreflion, fighing, fainting and anxiety, continu- c; ing as bad as ever, nay rather increafing; a vio- *■'• lent hemorrhage alSo broke Sorth from his nofe ; cc which continuing from both noftrils, he was bled u again to ^x. about twelve hours after the former '" bleeding: Neither did this five him any relief, ■li but iiicrcafed his weaknefs co?ifiderably, and he con- u tinued as anxious, reftleis and oppreflcd, as ever, " without even the leaft fleep*." The * Vide Iluxham's Efjay on Fevers, pages 6 < and 64. MEDICAL SKETCHES. 251 The Doctor continues to relate'the low ftate to which his patient was reduced, and the dreadful fymptoms which accompanied it ; that he avcvued giving hinr.the hot, alexipharmic and vol t:!e cordial medicines, which it was too much the practice of that time To adminiftcr in Such caSes ; mat-he alio declined the application of blifters, but that having experimentally and repeatedly known the gre?t ufe of the bark, in preventing and flopping the advance of gangrenes, he 'ordered that medicine with elixir vi- trioli ; and by the continued ufe of thefe and feme other reftoratives the • patient recovered. This ingenuoufnefs difplayed in the recital oS this caSe, muft ftrike every body ; few will be fur- prized that the two bleedings afforded fo little re- lief, and many will be of opinion, that if the learn- ed phyfician had treated his patient from the be- ginning as he did at the end, the difeafe would fboner have come to a happy termination. Indeed he feems afterwards to lean to this opinion himfelf ; for in a fubfequent part of his book he expreffes himfelf in thefe words: " In truth, bleed- u ing in a contagious difeafe, as arifing merely from " contagion, feems not indicated, becaufe the con- " tagion is intimately mixed with the humours, and u by drawing off a fmall part of the blood, you very ■" little leffen the whole contagion, which will have " its effect whether you bleed or bleed not*." The reafon afligned for bleeding not being indi- cated, is unqueftionably very ingenious ; but the rea- Son which makes the greateft impreflion upon my mind for not bleeding in this fever, is fimply be- caufe it feems generally to do harm. Thofe who ftill are of opinion that bleeding is neceffary in this fever, conline it to thofe cafes in which the pulfe is ftrong and full. It has been al- ready * Vide Huxham's Eflay on Fcwr.-?, page ico. 252 MEDICAL S KETCHE S. ready obServed, that the pulfe is generally not ftrong and full in this difeafe ; and when the pulfe is in this ftate, we are apt to imagine that a difeafe of ^>a different nature is impending; this, to btffure, may lerve as an apology Sor the evacuation, which, if we bad been certain of the nature of the fever, the fulnefs of the pulfe, in my opinion, would not have done. The other work above alluded to, which helped to give me an early imprelfion of the inexpedien- cy of bleeding in this fever, is the Obfervations on the Gaol or Hofpital Fever, by the late Sir John Pringle :—This learned gentleman's words are, " But in the Second ftate, when the fever was " rnaniSeft, iS the pulfe was Suil, I generally took " away Some blood, if that had not been done * Vide Dr. Monro's Account of Difeafes in the Military Kof- piti;ls, &c. pages 7 and 8. MEDICAL SKETCHES. 25* t]iat oppreffion about the precordia which fo commonly attends this difeafe. . If this medicine fliould, fome hours after operating as an emetic, alfo ad effectually as a purgative, which is oSten the cafe, no other purgative will be necef-v Sary. But iS it only proves emetic, the contents of the in- teftines fhould be entirely evacuated the following day by a proper cathartic medicine. The evacuation by a cathartic undoubtedly weakens in fome degree, as well as that by venefeClion; but this is more than compen fated by the benefit refulting from cleanfing the bowels oS their.impure contents j whereas veneSeCtion, without producing any certain benefit, is apt to occafion greater debility, and of a nature not fo eafily to be remedied. Befides, a cathartic exhibited in proper time often prevents the bad effects of too fevere purging, by car- rying off the fouree of an impending diarrhoea, which might foon take place in confequence of bilious matter and other impurities being pent up in the bowels. And in cafe a diarrhoea has actually come on be- fore we fee the patient, the firft thing to be done is to give a purgative, whofe operation fhould be affifted by drinking plentiSully oS imperial, or oS water gruel, or barley-water, with Some cream of tartar diflblved in them ; and iS the patient Seems much Satigued and exhaufted by the preceding loofeneSs and the opera- tion oSthe purgative, eight or ten drops oS Thebaic tinClure maybe given in a fpoonSul of fimple cinnamon water. It was obferved before, and ought to be kept conftantly in remembrance, that the danger of this fever is in proportion to the debility. If it be doubtful whether in the common remitting Sever it is always prudent to delay giving the bark, and t® 2y5 ME DICAL SKETCHES, to confine our treatment to antimonial alteratives^ Saline mixtures, and neutral falts, in expectation of a more complete remiflion ; it may eafily be con- ceived how much more improper it would be to delay that powerful medicine in this infidious dif- temper, where the force of the circulation feema impaired from the beginning, and the moft dangerous proftration of ftrength is apt to come Soon after the firft perception of any ailment. When a malignant fever happens to be epidemic^ the flighteft appearance of complaint fhould give an alarm, and forms a good reafon for ordering an emetic and purgative; if to the head-ach is joined dejection of Spirits, flight chills and heats, and the Smalleft tendency to tremor in the hands, the alarm fhould be taken independent of any reign- ing epidemic, and in both cafes the bark fhould be given immediately after thofe evacuations.—What$ while the fkin is dry ? When there is little or no per- fpiration ? During the Spafin ? Yes, during any thing. Theoretical opinions muft in Such an emergency have no weight: A dangerous debility, and a train of malignant Symptoms, are threatened ; the bark i$ found the moft powerful means of preventing thefe ; and notwithstanding its aftringent quality, frequent- ly promotes a Salutary diaphorefis more effectually than any of the medicines which enjoy from pre- scription the title of diaphoretics. When the pa- tient is out of danger, you may account for this in the beft manner you can, and fettle the point at leifure, whether in producing thefe effects it has aCled in the character of a tonic, a diaphoretic, or an antifeptic. In the circumftances that have been deScribed, the nature of* the difeaSe being aScertained, and the alimentary canal entirely cleanfed, the bark fhould be given without waiting for very diftinCt remifc fions» MEDICAL S'KfiTCHE S. 257 fions. To wait for fuch when the difeafe appears from the beginning to be the nervous malignant fe- ver, is to wait for what will not happen; depriving the patient of a probable chahce of the fever be- ing carried off at once, and allowing him to incur a rifkj which might have been prevented, of finking Suddenly into fuch a ftate of weaknefs and infenfi- bility, as will fender the bark and all Other me- dicines of no avail. Having refolved then on giving the bark, our next care fhould be to avoid the very common er- ror of underdofing it. One ounce or an ounce and a half of this medicine may be given to an adult in the Space of twenty-four hours ; or if it is dif- agreeable to the patient in fubftance, what is equi- valent to this quantity may be given in decoction;' Some patients can take the powder in the decoClion as eafily as in any other vehicle. A much larger quantity has been recommended by Some authors in the Same Space of time, but there are very few pa- tients Whofe ftomachs can bear a greater quan- tity, and many who cannot take fo much. The expediency of increafing or diminifhing the dofes muft depend upon, circumftances. Whether this medicine be given in Subftance or in decoction, the addition of a few drops of elixir of vitriol is of- ten found to render it lighter and more agreeable, perhaps, in fome cafes, more effectual J If the pulfe is particularly fmall, and the patient complains of great weaknefs, a little wine may be given occafionally even at this period Of the fever ; ii may be added to panado or water-gruel, if the patient can take any fuch nourifliment; or a little may be mixed with each dofe of bark, which fome- times is found to remain eafier on the ftomach by fhis addition. But the propriety oS giving or con- S tinuing 2*3 MEDICAL SKETCHES. tinuing wine at this period, depends on the ftrength of the pulfe, and the effect of the cordial. • It is not improbable that the bark itfelf, exhibit- ed in this manner, will prove opening in fuch a degree as to fuperfede the ufe of any other means for that purpofe ; but if the body continues bound, it will be expedient to procure one motion daily by clyfters. If, on the contrary, the bark excites a purging, this effeCl may be reftrained by giving two or three drops of laudanum in each dofe, or every fecond dofe of bark. After the medicine has been continued in this man- ner for two or three days, we often have the Sa- tisfaction to find the fever entirely thrown off, or abated in a confiderable degree. In either cafe it will be proper to continue the ufe of the bark, but in a much fmaller quantity, for two or three days more, at the end of which the fever is generally gone, and the pulfe flower than before it began. It fometimes happens in this fever, that a quick and weak pulfe is accompanied with difficult respira- tion and confufion in the head, and that both fymp- toms proceed principally from debility ; in fuch cafes the bark renders the pulfe fuller and ftronger, and in proportion as it becomes fuller, it becomes alfo flower; the oppreffive breathing abates, the threat- ened delirium is removed, the fkin, which was be- fore dry, is perceived to be moift, with a warm and gentle perfpiration, and a fediment is foon after per- ceived in the urine. But if after a fair trial for two or three days, the difeafe feems to have repelled the powers of the medi- cine, ftill there is no harm done, the fever will run its courfe, but the patient has as good, perhaps a bet- ter chance of recovering at laft, than if the trial had pot been made ; for although the bark has not been able to prevent the progrefs of the fever, it may tend t». MEftlCAL SKETCHES. 259 to obviate or leffen in fome degree that exceflive pro& tration of ftrength which is its moft alarming Symptom. It is difficult, if not impoffible to prove, that what does not happen, or happens only in a certain degree-, would have happened in a greater degree, if a different method had been followed. Yet in certain cafes where the bark has failed in throwing off the fever, it feemed to me that the medicine had ftill contributed to Support the patient's ftrengthj and to prevent the exceflive de- bility. When however this powerful febrifuge fails in the iprincipal objeCt of flopping the-progrefs of the fever, and when the patient perhaps naufeates any farther ufe of the medicine, our next care muft be to fupport his ftrength by light nourifliment and more agreeable cor- dials, during the continuation oS the diSeaSe ; taking care at the Same time by laxative clyfters, feaSonably adminiftered, to obviate that tenfion and Swelling oSthe belly, difficulty oS making water, and other inconveni- ences, which are the confequence of conftipation ; and if clyfters are not found effectual in preventing or removing thefe, a gentle dofe of rhubarb*, or fome Other mild purgative, muft be occafionally given^ which in this Situation will prove, in effect, a resto- rative, and not a weakener, by throwing out of the bo* dy the fouree of many teazing and exhaufting fymp- toms : A few grains of James' powder, given twice or thrice in twenty-four hours, often proves the moft beneficial laxative that can be given. Although the fever has eluded the firft attempt of removing it by the bark, and although the patient, difigufted with the quantity he has Swallowed during the trial, has reSuSed to take any more, yet if af- terwards in the courfe of the difeafe this difguft" wears off, and the patient can be perfuaded to take two or three dofes in the twenty-four hours ; even this fmall quantity has often feemed to me to fup- S 2 port 260 MEDICAL SKETCHES". port the patient againft that dangerous debility, whicfi feems ever impending in this Sever. The reputation oSthe bark is independent of theo- retical opinions. Thofe who believe in a prutrefcency of the blood and humours, give it as an antifeptic; thofe who believe in no fuch matter, give it as a tonic : For my own part, I recommend it as a medicine that does good, without pretending to know, and be- ing little folicitous about the particular character in which it aCls. It is not uncommon in the practice of medicine for phyficians to follow the fame plan on different, or perhaps oppofite principles. Thus one may re- commend ripe fruit, vegetable juices, and acidulat- ed drinks, in this fever, with a view to correct the putrid tendency of the humours ; another who knows it is impodible for thefe fruits and drinks to correct what he thinks does not exift, may ftill pre- scribe them with a view to their deterging the ex- cretory veffels, by their Sudorific and diuretic qua- lities ; and each may be confirmed in his Supposi- tion -ky the benefit the patient receives Srom the prescription. Some people may doubt either fuppofi- tion, but nobody can doubt the agreeable and re- frefhing effeCls of fuch fruits and juices on the parch- ed, thirfty, and languid patient. Sometimes ripe fruits, particularly Strawberries and wine, are the only nourifhment he will take ; which circumftance of itfelf forms a preSumption,. that they are the propereft for him. At other times, when he refufes panado, fa go, rice, when pre- pared without wine, he will take them in confider- able quantity mixed with wine and fuga'r ;■ and when he takes fuch nourifhment with any degree of relifh, they feldom fail of being beneficial. They enable him to bear the open air and a free ventilation for a longer MEDICAL SKETCHES. 261 a longer time, which always tends to haften his recovery. When that proftration of ftrength, So often men- tioned, has taken place, and is followed by ftu- por, low delirium, twitching of the tendons, and other fymptoms ; however proper we may think the bark would be, and however eager we are to give it, this is no longer in our power. In this ftate the patient generally rejeCls it in all its forms, or will only take it in Such Small quantity as can be oS no Service. Yet the caSe is not entirely hopeleSs ; for even in this Situation, iS the lips are moiftened with a little warm wine, Sweetened with Sugar, he will fhew a relifh Sor it, and when given in Spoon- fuls, will fuck it into his mouth, with figns of Sa- tisfaction, after rejecting every medicine with dif- guft, and refufing every other kind of nourifhment whatever. In one particular cafe of this nature, which I well remember, after a certain quantity of wine. (perhaps near a pint) had been given in the fpace of an hour, 1 perceived the patient's pulfe acquire ftrength, and become flower, while the infenfibility Seemed to wear gradually away ; but the relations taking an alarm at this quantity of wine, notwith- standing thoSe flattering appearances, withheld it, and offered the patient Some other drink, which in their opinion was more Suitable to his caSe. Not- .withftanding his again and again rejecting every thing they offered, it was not till after they plain- ly perceived the pulfe begin to fink, and the deli- rium to return, that they could be prevailed on to vrive more wine, which, upon my returning to vi- sit the patient, I perSuaded them to do, and with the Same SucceSs as before. I have known inftances alSo, where the phyfician not being convinced that the filling of the pulfe and S 3 removal 252 MEDICAL SKETCHES. removal of delirium was owing to the wine, has fet afide the ufe of it in the fame manner, till the return of the bad fymptoms obliged him to refume it, not without remorfe for having made an experiment which had like to have proved fatal to the patient. It is generally neceffary, in Such caSes, to begin by giving the wine warm with Sugar,-to induce the pa- tient to take three or Sour Spoonfuls ; but afterwards he takes it freely cold, and without fugar. The reader might he aftonifhed were I to, mention the quantity of wine I have known fome patients take in this fever, and in fome cafes of the confluent Small-pox, where the weakneSs, inSenfibility and other Symptoms., were the Same, and where the re- covery of the patient was evidently owing to that cordial alone. The proper rule is to give the wine till the pulfe fills, the delirium abates, and a great* er degree of warmth returns ^to the extremities.— Upon the fmallefl appearance of the ftupor coming back, the pulSe quickening and finking, for they .*^-'< &-p 3»s 1rM£^ •''•••'•"l4'#--.;.''' ,;V;:/* *TM