MONROE (DONALD) LECTURES ON THE PRACTICE OF PHYSICK VOL. I.  (1) 3 By Dr. Donald Monroe Lectures on the Practice of Physick. Lecture the 1st - On the Lax & Rigid Fibre The Animal Body is composed of Fluds & Solids, the Fibre is formed of Forrestrial particles joined by the Fluids afe w:ch fibres the Vessels are formed _ A Fibre itself can’t come under our notice, It is said to be weak when it may be distended or broke by the Actions of A person in [cross out] health, Those that have lax fibres are generally pales, the Blood thinner, & are more lazy & indolent – The Cause besides Constitution, or hereditary Taint, Is the moisture of the Atmosphere. then being lightast & having not so great a pressure , & being more softning by Moisture, 2dly: Whatever prevents Assimulation of raw [cross out] to the Blood or prevents ther Supply; w:ch may be [cross out] on by the great loss of the Vital Fluids, If there is A [cross out] quantity of good blood in the Vessels, so as to bear a greater proportion of Chyle poured into the Subclavian Vein it will be mixed with it, & assimulated, but if the Blood is little & weak the Chyle will not be assimulated, but will dissolve & make thinner the Blood that remains, as after loss of Blood from Wounds Nethay's Patient devours meat wth great Greediness, therefore is necessary to Eat little & often if weak _ The food may be too Glutinous for the Chylopoetic Organs as the crude farinacea. A third Cause is drinking two large A quantity of (2) Thin tipid diluting liquors w:ch melts down the nutritive parts of the Blood & carrying it off in Secretions. The 4t cause is A want of due force to apply the Solids to the fluids owing to the want of Muscular Motion w:ch would give a new force to the blood, & greater density, by w:ch Nutritious particles are applyed w:th sufficient force to the sides of the vessels to supply those that are wasted _ The 5t cause is too great A distraction of the fibres by w:ch they lose their tone and become paralytic, as in the Bladder, & Lig:nt of the joints. The softness of the flesh paleness of the face are natural to those that are lax fibr’d _The shortness of breath upon Exercise is owing to their being unable to circulate the blood thro’ their Lunges fast enough _ The dullness after exercise arises from the Vessels of the Brain being distended, by the rarefaction of the Blood _ The Weak digestion is from the weakness of the Saliva & Succ-Gastric &c. eased from the weakness of the Intestines, sometimes they are Costive from the too lax Vermicular Motion of the Intestines, or to purging from the great flow of their liquors &c. The colours of Urine depends on the Salts & Oils contain’d in it, & when the Vessels don’t act, the fluids & Water is destitute of these principles wch depends on the strong actions of the Vessels & appears clear _ The Lax fibred are little subject to Inflamatory disorders because the Vessels are weak & will distend & the Blood circulates with but little force 4  (3) 5 But from the stagnating Liquors they are subject to Anasarcas, Cold, Indolent, Odematous swellings, Glandular Tumours &c, w:ch must be cured by strengthening the fibres If owing to a moist Atmosphere they should be relieved by removing to a dry one _ If this can’t be done, to defend them from Injuries of the weather _ Patients should be excluded from warm tipid liquors, as Tea, but [cross out] Water Gruel or Milk may be indulged. The food of such must be of easy digestion & nourishing, the 1:st of w:ch is milk prepared by other Animals for the food of their Young, Womans milk is the most digestible of all, & should be from a healthy Young Woman, for there is an instance of a Jaundice being communicated by a Nurse. The Nurse should be properly fed, as what she takes will affect the Child, and the Child has been killd by the Nurses drinking strong Liquor &c. The Milk should be taken at A proper time so as not to be too crude nor too much of the Saline Nature of Blood. About three hours after Meals is the proper time next to Womans _ Asses, Mares, Goats, Cows Milk _ Milk is most nourishing when it comes from the Mamma, as it has lost none of its fine Volatile parts & is well mix’d. o After Milk comes Eggs the white of w:ch is much akin to the Serum of the Blood, & should be mixed w:th Water but not so hot as to coagulate it which makes it indigestible. Broths of Animal flesh are the next for nourishment, w:ch are of Nutritious parts to dissolvd (4) & diluted by Watry liquors, but should not be too Viscid for Weak People. Panada made of well fermented bread is very digestible which good fermentation breaks down the Viscid tenacious parts of the farinosa, this requires stronger digestion, than the others – Weak People should Eat often & little at a time, least the food should not be digested, but stagnating Putrify, wch putrifying process disengages A quantity of Air, & distends the Stomach, & the food distending its too long, likewise weakens its tone. Some gentle stimulant should be mix’d w:th the food of Weak Patients, to help the Tone of the fibres of the Stomach, as Spice, Red Wine, Conal: Rosar: &c or [cross out] Rum w:th Milk. 3dly : The putrescent food may be mixed wth Juice of Lemons &c. to correct their putrescency The Broth of young Animal Food turns Sour, but of Old will putrefy by reason of its greater Animal Nature – Fish of A very putrid Nature therefore seldom allowed to Patients that are Weak, Their drink should be some gentle stimulants as Steel Water, Wine & Water &c When weak the fermented liquor is apt to ferment in the Stomach as Beer, Wine, &c therefore Rum or Brandy may be much more proper, Or Aromatics may help to check the fermenting putrescent process, but Diet will not do unless the Vessels act w:th force enough to assimulate the Chyle, the Action of w:ch Vessels may be helped by Bandage, w:ch forcing the fibres together, & enweaving the force of Cohesion braces,     (5) & strengthens the fibres – Van Swieton tells of A Case of A Lady, who being very Nervously delicate, was cur’d by rolling up by bandage, w:ch remov’d the Irritability of the Fibres _ Dr. Knight gives a Case of An Hydropic Man being cur’d by bandage from the feet to the Breast & Evacuating the Waters by Dovers powder, & Hydragogues, this Encreased the Absorption & prevented A fresh flow of Water into the Cellular Membrane Friction takes away the Viscid Varnish that stops the Cutaneous Vessels, & Encreases the Action of the small Vessels, but too great Friction will hurt by distracting the fibres too much from one another – The next remedy is Exercise w:ch shakes the pendulous Viscera, applys the fibres more closely to one another, & encreases the Secretions by giving the Blood brisker Action, These should not be us’d on A full stomach, least it make them sick or Vomit, or propell the food before Chyle be extracted. The next remedy is the Cold Bath w:ch acts by irritating & stimulating the Solides to contract, & by its pressured on the Vessels _ Weak People should not stay long in the Cold Bath, least the Cold overcome the heat and action of the Heart & Arteries The Cold Bath is not propper for those who have Chronic Abstructions w:ch it will encrease – And now we must Enquire what may be done by Medicines as Assistants - (6) Lecture the 2d: Medicines ought only to us’d as Assistants to Diet Exercise &c. here our first cure must be to strengthen the Digestion w:ch will be affected, by whatever Absorbs watry juices in the first passages as Absorb Earths, Whatever stops fermentation & stimulates the fibres or gives thickness or consistence to the fluids will tend to harden & Brace the fibres. Absorbents Earths do not only absorb but also by Neutralizing the Acid in the Primæ Viæ stop fermentation but also are more or less of an Astringents Nature, & the Bitter Astringents answer their end by strengthening the Bile when become thin & Watery, Boerhaave gives a Case where he gave Ax’s Bile w:t Success – Whatever can carry off the thin Humours w:ch relax the Solids, & thin the fluids & melt down the nutritious particles without weakening the Body will be of Service. For these Thin Humours stagnating in the Cellular Membrane & Cavities of the Body, the thinner parts of the Juices are absorbed & the rest remain Viscid & pituitous. (yet Salivation tho’ it carrys off thin Humours yet as it melts down the Blood it can’t be proper for the Cure of A lose fibre, thus far may be said of Nitre & the other Neutral Salts, as Diuretics & encreases of the Watery Secretions _ Diaphoretics give a brisk stimulus as   (7) 10 they abound w:th Oily Resinous particles such as the Alkalescent Plants. Mustard Horse Radish, Canella Alba &c where the Viscera are strong enough to bear it may answer the present Indications of Cure, but we should be cautious to keep A free perspiration only & not cause sweats. Emetics often give a brisk stimulus, quickens the Pulse, & strengthen the Solids, thus when the Stomach is loaded w:th Mucus, before being cleansed by Emetics, Astringents Stimulants, & Strengtheners can have little or no Effect – 3dly: Whatever condenses the fluids & at the same time hardens the fibres is proper here, as Mineral Acids, Ardent Spirits, & all those Medicines that are calld Astringents. Mineral Acids coagulate the Blood, and restore its native balmyness. Ardent Sp:ts 'tis well known harden & brace the fibres as we see in keeping Anatomical preparations, therefore we should be cautious of too free a use of these Sp:ts: as they'll harden the fibres & render them insensible & thus the Patients will become habitual Drunkards Astringents harden, crisp, draw together the fibres as we see in Tanning Leather. Those Astringents that are the most rough are thought to stop the Mouthes of the Lacteals & prevent their passage into the Blood The Bark & Steal are known to be the most [cross out] Corroborants. He know they are both stimulants & (8) Astringents but their Modus Operandi no Experiment has acquainted us with, The Bark in particular is well known to restore: the balmy consistence of the Blood as we see in Wounds and in Suppurations every day. We should take care that the Medicines should be such as the Viscera of the Patient are able to digest, least they be as a load upon the Stomach or act too much as A stimulus and thereby destroy the tone of the fibres, or render the Juices too acrid & thin, or on the other hand too thick, dense & viscid, but tho’ we treat of these Methods separately, yet they should be employed in conjunction for the cure of the lax Disorders, and we should begin gently, and go on gradually, Encreasing by degrees, the quantity of Exercise, Medicines, & food, & proportion the quantity of Wine &c to their Encreasing strength; during the Cure, care should be given taken to keep the first Passages clean & the Secretions regular – Such A strong hardy state of the fibres as is more then necessary to keep up A proper resistance to the fluids is calld a rigid state, & here the Skin is hard & dry, the Secretions are more plentyfull, & the Blood thicker _ The use of the Medicines in the Cure of the lax fibres are sometimes the cause of the rigid state, & A great quantity of Muscular Motion wch drives   (9) 12 the particles of the Solids & fluids together condenses them & renders them more solid, firm, and rigid, as we see in the feet and hands of the labouring Country man, and Those who by A Custom of Labours have harden’d their fibres, are sooner Mature in their growth & soon grow old. Ardent Sp:ts harden and make the fibres insensible & render them rigid as we see in the lower Class of People by drinking, Gin, Ale &c The too great use of Solid food or too free use of the Cold bath &c will make the fibres too Rigid. 2dly: by continued friction and Attrition the Vessels are forced together & become Rigid, & many of the Vessels become impervious as we see in Injections of Old & young subjects, besides the Vessels become so rigid as to overcome the force of the Heart & Circulation & at length Old Age itself without any disease will put on an End to our Life. By encreasing the Circulation there is also a dissipation of the fine Potable parts, & an Absorption from all cavities of the body, & discharging them insensibly, as fat people grow Lean by A Fiber, & Cattle, by long driving, for [cross out] People with rigid fibres are generally lean and have few stools because the greatest part of the Aliment and Moisture are taken up & perspired, by the stronger action of the Chylopoetic Viscera & the stronger Absorption of the Lacteals, But sometimes when the fibres are become (10) very Rigid, the Absorption & Secretion of the liquors are retarded, because they are too Viscid & the passages become over loaded, w:th Viscid Mucus & stagnating, become Acrid, putrid &c, so as to cause purgings &c. All the Secretions of the blood will be more or less of an Animal nature as the fibres are more less rigid & the Circulation more strong. The hard pulse is owing to the rigidity of the containing Vessels, & the state of the contain’d fluids, & the Heart is obliged to contract oftener because it can’t throw out a sufficient quantity at once by reason of the resistance of the extreme Vessels. In A fainting fit the Blood stagnates or at least its motion is so slow as not to be perceptible; thus these rigid patients after faintings are subject to polypi of the great blood Vessels, because the Blood being very rich and dense will be subject to coagulate in the large Vessels. People of A rigid fibre have their Skins more tense, than the lax. thus A Wound in such a person will have its lips receding far from one another, They are subject to Inflammatory disorders, and all that proceed from A thick dense Blood, and they will be more subject to the Cutaneous disorders, because the Skin is more rigid & Impervious, and to Ruptures of the Vessels from the extreme distention of the Viscid fluids, & the force of the Circulation propelling them w:th great force, The Cure of 13  (11) 14 this Disorder will be in general to relax the fibres by the very contrary Method, to that of the Cure of the Lax fibres, as by a quantity of thin, Watry, tepid Diluting Food by warm emollient Baths & external fomentations, by lying in Bed, & by all methods that can soften & relax the Skin. Lecture the 3d When the fibre is too rigid without disease the Indication is to relax it, by Watry diet that has no stimulus, by little Exercise, Warm tepid Baths, Aleous Linamonts Externally, and by lessening the quantity & Viscidity of the Blood, by lying in Bed &c. People of rigid fibres should take such food as affords a mild Chyle, that will thin the Blood & soften the Fibres: The Vegetables w:th a little Animal food, but the last s:hd be sparingly given, as they thicken the Blood & tend too much to the putrescent, and all these should not be mixed w:th stimulants as they tend to make the fibres more Rigid still. Yet tho’ the Liquors they take should be diluting yet as Water will not easily mix with the Blood, by reason of the Blood being highly Animalized, Oily, & Viscid, therefore Saponaceous & Acid Bodies should be added as Sugar, Honey, Lemon Juice, &c. or they will have this effect, to relax the fibres, to dissolve the Viscid Juices & (12) carry them off by Secretions, By abstaining from Muscular Motion the Blood, is no more drove with that Impetuosity, wch dissipates the fine thin parts that kept the fibres soft & gave greater density to the Blood, but as thick Blood requires A great force to drive it thro’ the Vessels. A strong Man us’d to exercise should not leave it off on asunder least the Blood stagnate & occasion Various disorders, by loss of Secretion; Motion in the Blood &c Warm Water is very relaxing so as to soften most Bodies as Horns &c. thus it penetrates into the living Body & relaxes the Internal parts as well as the Skin, by the force of Absorption. Thus Warm Baths will soften & relax the rigid fibres and restore the skin elasticity, for the Heart is not able to overcome the resistance in the Gradation, & thereby the Blood being not drove w:th its usual projectile force, & the Elasticity of the Vessels is by Degrees lost, Oily substances are well known to soften & relax, the fibres and Emulsions made from oily substances are found usefull internally. 4th Whatever diminishes the Momentum of the Blood will be usefull, thus Bleeding by taking away the thickest part of the Blood makes more room for the remainder to expand itself & for the supply 15  16  (13) 17 of new thin Serum Liquors, w:ch mixing wth the blood render it thinner, abate its force & soften the fibres. Purging may also be usefull but such Medicines as an stimulating should not be us’d, as before they could Operate would prove dangerous, thus far may also be said of Mercury, wch, tho’ it evacuates plentifully yet as it is a Violent stimulus would be improper, neither should Diuretics be of the heating kind, but should be Nitrous & all Salts of the Neutral kind. People of rigid fibres should leave off Exercise, Cold Bath, & Stimulating Diet, but all this ought to be done by degrees, as it may be dangerous to proceed from one Course of life to another. If this Disorder arise from too hot & Dry an Air, it should be changed to A moist temperate Air. From what has been said we may understand why Children & Women are generally so lax, because they are more Sedentery, Eat more relaxing food, &c. Why strong Working Men are so Apt to be of Rigid fibres. Why People in hot countries so soon grow, from the Bloods being more decilerated, the fine Watry parts dissipated and the fibres more tense & rigid. Why the Fœtus in Utero grows so fast in a little time, being constantly in A Warm Bath &c. Why Children are subject to Disorders from Lax’d fibres, & A surplus of this Watry Liquors. Why their Brain & Nerves are so Irritable as Easily (14) to be thrown into Convulsions, & have Excoriations Scales, Sores, St. Anthony’s fire and all Eruptive Disorders, & all from A redundancy of Humours At Puberty A considerable change happens as Bleedings at the Nose &c. Swelling in the Testicles and Penis in the Spermatic Vessels. In Girls there is a Chlorosis &c. And Adults are subject to disorders from A Plethora. Old People to disorders from A pituitous Lentor, & slow Languid Circulations As Asthma’s, Inflammations, Gangrenes &c. Hence we may judge what Diet will be proper for the different Ages, As Milk for Children as their fibres are not firm enough to digest any thing Else & repeated often – And their first Teeth being only thin Shells, are not fit to reduce hard substance, but when the Organs become strong they chuse Diet more nourishing, hard, & Stimulating, & Old People ought to be fed w:th things of A soft relaxing kind, as we see is pointed But by the dropping of the Teeth here Cordials & frictions are sometimes necessary to carry on the Circulation __ Now of the different state of the Blood w:ch is of itself, of A Mild Nature, yet the Blood of Every Animal is much of the same Nature w:th the Food they used. the force & Strength of the Vessels make A great difference, also in the Blood, & thus the the Juices be of A Neutral or Ammoniacal Nature, yet they may be variously affected by 18  (15) 19 the nourishment taken. We shall examine the different states & [cross out] 1st of the too thin when the Blood partakes too much of the Serum, & the fibres lax, and the Bile of consequence digestion, Weak, & watry, & the Blood either turns sour or putrid according to its nature _ hence Stagnations of Serum, and becoming Acrimonious causes Inflammation &c. as In Odematous Swellings & Anasarca’s &c And this state is what Boerhaave calls the Acid state of the Blood, but no Acid can exist in the Blood nor comes from it, by Analysis the Alkaly is forced off w:ch did not naturally exist No Liquor of the body is found to be Acid not even Milk tho’ so Acescent. Yet Blood is sometimes tho’ Neutral more in thn’d to the Acescent wch is A natural state of relax’d Solids, & will arise from ye same Causes, and all the Viscera being relaxed the digestive Juices are insipid & the digested not being well or soon digested turns sour or putrid hence Cardialgias from the Acid of the fermenting process, and from tho putrid process, arise Flatulencies Borboregmi, & putrid Belchings. The Acid sometimes by living on Vegetables Diet (the Bile being Weak) is this the whole tract of the Intestines as is known by Green, & Yellow, Stools, but this chiefly in Children _ The Indolent Tumours we see in (16) Children, and People of a lax Habit w:ch Boerhaave thinks to arise from Obstructions of the Vessels, but Monroe, thinks is always first in the Cellular Membrane w:ch at length press upon, obstruct and rupture the Vessels, and from what is said here ‘tis easy to say what must be the method of Care as Animal food us’d moderately, will help to correct this tendency to the Acid, And Fish as being easy pubescent may be usefull here if their Stomachs can easy digest them, the Bread ought to be well bak’d & in good Measure destroyed, as to its fermentative quality. Some Stimulating Iridecencs should also be mix’d w:th the food to correct the Acescency as we see of the bitter Vegetables, as Hopps, Worm wood &c w:ch stop the Acid fermenting process: when the Bile is weakly use Ox’s Bile or Soap &c are found usefull _ The Absorbent Powders as they Neutralize Acids especially found with stimulating Aromatics, are very useful and Alkalies also Neutralize Acids, & by their Stimulus encrease the Secretions. Soap often promotes Digestion as it scours the Bowels of their Mucus, Absorbs the Acid, & strengthens the Bile, Exercise also thickens the Blood as before observed on the Lax Fibres - 20  (17) 21 Lecture the 4t Another Morbid state of the Blood is when the Juices become too tough & Viscid, wch is generally proceded by lax Solids, whereby the thin parts are run off, & the Viscid parts remain behind in the Cavities. This state is not known by the Blood itself, but by the various fluids discharg’d from the Body, & particularly the Primæ Viæ are overloaded by this Viscid Pituit, the thinner parts being absorbed by the weak absorbent Penis, and this prevails in all the Cavities, as the Lungs, Cellular Membranes &c so as to obstruct Circulation, thro’ the extreme Vessels to break and weaken the red part of the Blood by the slow Circulation, The Intention of Cure here is to attenuate the Fluids & strengthen then the Solids & these must be done both at once, and the first thing must be to cleanse the Stomach by Emetics, w:ch Emetics must be in large Doses, as they are blunted by the Mucus, & there giving the shock and encreasing the Oscillatory Motion of the Vessels squeeze & alternate the Viscid Pituit, & promote the circulation & after this the Warm Moetic Purgers are proper, and sometimes Calomel added to cleanse the Intestinal Canal _ And now we must attenuate the Fluids, by proper Regimen of food & Medicine, and such food as does not generate Viscid Pitiut, but is a Stimulus to Encrease the Oscillatory motion (18) of the Vessels, as Bread well fermented & Aromatics mixed w:th Mild nourishing Diet; the rest of the Cure must be promoted by such Medicines as help Digestion, [cross out] cleanse away the Mucus; strengthen the Bile, Encrease the stimulus & absorption of the Fluids, & strengthens the Solids, as Bark, Bile, Steel, Soap &c. Another Class of Medicines are those Alkalescent Vegetables as Mustard & Horse Radish, w:ch are powerful stimulants & Attenuants, & encrease the Absorption. But Neutral Salts tho’ they Attenuate yet as they weaken the Solids they would prevent Absorption here. Lastly Blisters are found to be very attenuating by reusing a Stimulus & Inflamation & raising the tone of the parts, & draining off, the Liquors not fit for Circulation. Exercise & Friction also are very usefull, as it attenuates the Fluids Strengthens the Viscera & Solids, Encreases the Absorption & reuses the Crasis of the Blood, for the Blood is not Viscid here as has been generally Supposed. The Blood some times becomes thin, Acrid, Putrescent, & it is now a mere Gore, not seperating into Serum & Cruor, but being one Uniform Mass, It may be caused by too great heat, exercise, or by fasting too long. Putrescent or Acrid food as well as long exercise will also cause this putrescency, 3dly [cross out] Those who live on too high season’d meats, have the Blood very thin & Acrid, & tending much to the putrescent - 22  (19) 23 Also Alkaline Salts, and Lixivial Medicines, will bring on this putrescency of the Blood. Yet Dr. Pringle says that these Salts are Antiseptic, but this must be in Animal Dead flesh, yet certainly they by this Stimulus on the Blood dissolve & weaken it & it becomes Acrid. Foul Air likewise produces the same effects, for the putrid Miasmata are taken into the Lungs, & by Absorption into the Skin In short whatever may encrease the Motion of the Blood, or convey Putrid Miasmata to the Blood, will dissolve the Blood and make it become Acrid & putrid, tho’ it is hardly ever found that the Blood is Putrid in the Vessel of An Animal. Yet Morton relates A Case of this kind. Yet The Secreted Liquors, by stagnation will become blacks & putrid, and all the Secretions being of the same Nature w:th the Blood, hence the Putrid Collusies of the Stomach & Bowels, Foul Breath, Putrid Stools, Urine &c. The Acrimony of the Blood, brings the Fibres into frequent contractions to throw off: what offends them, hence the Quick Pulse, Pungent Heat & Thirst, & the Fluids being so acrid, and the Blood so thin, & being transfused into the Cellular Membrane, Inflames, Suppurates, Causes Blotches, Sores, Foul Ulcers &c. In the cure Bleeding at first if the Patient is plethoric, but it must not be repeated, as there is always A diseased laxity of the Solids in Putrid Disorders. The Primæ Viæ must also be cleansed (20) by Emetics, & the putrid Sorbarra carried off by A gentle purge, but in the use of all these we must take Care not to sink our patients, unless the Pulse should never rise again, The Diet should be such as affords a Mild Chyle, as Vegetables w:ch will ferment and has so sour, & the farinacea well fermented, w:ch Acescents will correct the putrescency of the fluids, The Drink should be Acid or Acescent, as Lemonade, Cyder, Beer, Wine &c. Pure Water itself does not easily mix with the Blood but is soon washed off: The Mild Saponaceous Medicines here are very proper as Honey, Sugar &c. w:ch are Saponaceous Acids, & Vegetable Acids correct the Putrescent, and Mineral Acids, as they thicken the Blood, & correct the Putrescency, will be very usefull. Some of the Neutral Salts correct the putrescency, as Nitre cools the Blood, but the lowness & laxity w:ch prevails, forbids the use of yem: Sea Salt &c. are Antiputrescent, but not in this little quantity. they can be taken into the Blood according to Dr Pringles experiments, Astringents are sometimes necessary, to prevent the Dissolution of the Fluids, & remove the laxity of the Solids, hence the Infusion of the Red Roses, the Aromatic Astringents, the Bark &c. when it wants A stimulus, the Red Serpent; as very usefull. Warm Baths have been recomended as 24  25  (21) 26 Another Morbid state is that in wch there is too great A number of red Globules, & viscid Crassamentum w:ch is owing to strong Elastic Vessels encreasing the heat & friction, and dissipating the finer fluid Parts, & having the Mass condens’d, heavy, & soon coagulating. It appears (when drawn) cover’d with a thick Buff coat wch is owing to the febrile heat of the Blood, & this change will happen very soon. The cure of this state is much the same w:th that of the rigid fibres, i:e: by gentle evacuations, by softning the fibres, by mild relaxing food, & mild Saponaceous Liquors, w:ch being intimately mix’d w:th the Blood, will abate its velocity, & temper its Crasis. Such Medicines also that dissolve the Blood & abate its heat and Motion. A Plethora is that state in which the Blood is not diseased but in too great quantity, w:ch prevents Secretions & A free Circulation, & the Fluids w:ch should be secreted are retain’d & accumulated in the Vessels, & disorders come on. The Vessels of the Brain are gorged w:th Blood, and the Nerves are so pressed, that these have continual Head Aches, & Dullness. It may be generated by high living, on rich food, that affords A great quantity of Chyle, especially if Exercise is not us’d, It may be generated by ye Suppression of any Natural, or Customary Evacuations, as Menses, Hæmorrhoids, Bleeding, &c. (22) Blood will soon be restored as we see in Van Suoton where in a woman after Bleeding many times her Blood encreased to 100 lb, yet she fell into A Dropsy. Amputation also may cause a Plethora as the Viscera are won’t to prepare the same quantity of Blood. ‘tho’ the Vessels it circulates in are fewer, hence such are frequently subject to disease from Plethora’s - Lecture the 5t- Of Obstructions (and its doctrine) w:ch is ye Stoppage of A Vessel, so as the fluid don’t circulate. The abstracted path is still liable to the Action of the Vessels & the Liquors behind, are stop’d and the thinner parts are carried off, by the colateral branches, & the remainder will become thicker, & a Suppuration will ensue, or Communication being cut off and no Anastomosis to carry on the Circulation, the Parts below the Obstruction will be lost. The Functions of the Parts are lost, & the rest of the Vessels will be Enlarged. In the Serous Vessels there happens An Inflamation of the Serous kind, as in Rheumatic disorders, w:ch cause obstructions of the Returning Blood, & often causes Dropsies, by the lateral branches of the Arteries exhaling into the Cavities, or in obstructions of the Lungs. Obstructions in the Canals pass every Gland causes A swelling of the Gland, & the thin parts are 27  (23) 28 thrown by the lateral branches into the Cellular Membrane as in the Parotid Gland, & A Dropsie of the Womb from An obstructed Os Tincæ, & these may happen in any obstruction, from Tumours, Exostoses, Ligatures &c. Vessels are made less capacious as they are made longer & this may be a cause of Obstructions, or the rigidity of the Vessels itself or the Vasa Vasorum may be thickened as to lessen the diameter of the Vessels, or from A nervous spasm. Or these Obstructions may happen from the diameter of the particles of the fluid, w:ch is the same [cross out] if the diameter of the Vessels were lessened, When the natural cohesion of the fluids is so encreased, as to prevent the contractile powers of the Arteries, dividing & circulating them so that ye: coagulates Exercise also & heat as it dissipates the finer parts & thickens the fluids, & Cold as it condenses the Blood & constricts the Solids, may produce Obstructions, Gangrenes, &c. Mineral Acids or any other Medicine yt: can coagulate the fluids may be the cause. The Blood while it circulates thro’ the Vessels never coagulates ‘till it stagnates, & the Cohesion is encreased & strengthened. In the proper harmony of the Body every Vessel is fitted to admit its proper fluid. All the larger Vessels are reservoirs for the red blood, & the Inferior ones are designed for Serous liquors, but if a change happens, so that any Vessels are so dilated as to admit particles of A larger (21) size, An Inflamation, or Obstruction may happen [cross out] from rarefaction &c. The Action of the Heart & Arteries still being the same & the obstructed fluids reacting on the Blood. they are themselves more condensed or are ruptured & A suppuration ensues. And the parts below if there are not Anastomosing Vessels to supply them, being defrauded of their usual blood, loose their Use, and their Solids grow together, and if this obstructed Vessel be large the other Vessels must transmit A greater quantity of Blood than before, & this partly accounts for the Fever But this Fever is chiefly owing to the Actions & Oscillatory motions of the Vessels & Arteries being encreased to overcome the Obstruction. The Serous liquors are sometimes preternaturally condensed, & will Occasion Obstruction, & Inflamation wch: as cheifly known by pain. The cure of Obstructions must depend on the different causes, thence of from External pressure must be removed, or if from A Steatomas Hydatid, &c these must be remov’d, or if the Obstruction arises from the Vessels being stretched their Diameters Opened, must be cur’d by restoring their figure, as in laxations &c. Those from slow Circulation & tenacity of ye Vessels must be removed by encreasing the Vis Vitæ & fitting the Vessels. If from A rigidity of the Vessels we must treat it as directed in the Cure of the rigid fibre. Contraction of the Vessels from Spasmes must be remedied by the Cure of the Spasms. 29  (25) 30 When Obstructions arise from the Viscid Pituitous state of the Fluids, we must use the Method of Cure before directed. Wherefore the too Viscid sizy state of the Blood & the finer parts being Evaporated, we must lessen the quantity or density of the Blood by bleeding & dilating it by Watry Saponaceous liquors & Nitrous & Dissolving Medicines Obstructions, from Acids or Alkalies may be counteracted by each other, as the Lunar Caustic by the Loss: Infem: & Vice Versa - § And now of Inflamation w:ch is Acrid painfull swelling A burning heat, and the bulk of the part is owing to the great quantity of liquors, & the redness comes ye prescence of red Globules, & in Vessels that were not designed to admit them, & the pain shewing the Difficulty of Circulating the Fluids thro’ these Vessels, & as pain is encreased by touching the Inflamed parts this is owing to the Blood being pressed into the other branches, & their being more stretched. An Inflamation must either be resolved or Suppurate, or Gangrene, or if Glandular parts, A Schirrus will ensue – The Obstruction being form’d & the Elastic Vessels, & the Heart acting mutually on one another, encrease tho Heat Attrition, Concretion Pain, & Fever & the nearer the Vessels are to being distended & ruptured, the more pain, Action of the Vessels, & Heart, Heat Fever &c. encrease, and the Efforts of the Heart Encreased to overcome the Obstructions & the Vessels Obstructed (26) press on the Neighboring Vessels & obstruct them. A Pellicle will be found on the Blood of A person in health by compressing the Vein w:ch A ligature wch shows that the Watry thin parts escape, & leave the rest thicker, & encreased the Akretion, Heat, & thickness, This Pellicle seems to be made up of A Coagulating Serum condensed by the Air, as we see it is always on the Top. If the Patients in good Health has an Inflamation, & finds less Heat Fever, Pain &c. after bleeding. The Inflamation will abor but if the Symptoms encrease, especially after the 4t day, it is reasonable to suppose that there will be a suppuration. If the Humours be very Acrid, the pulse very hard & the Obstruction greatr then there is reason to expect a Gangren And especially in Old People this is observable. If it is A glandular part, as in the Breast of A Woman, A Schirrus will generate, tho’ it often proceeds from other causes - Lecture the 6t Of Inflamation (and its Cure) w:ch may terminate in Resolution, Suppuration, Gangrene, & Schirrhus, to bring on Resolution & Indications are to remove the cause of Obstructions & Inflamation, & make the Obstructed liquors [illegible] for circulation. The cause of Inflamation are such as coagulate, or condense the fluids, so they diminish the capaci of the vessels, as force red blood into Serous Vessels – As by 31  (27) 32 Luxations, Fractures. Application of Acrid Substances externally, or Internally, Acids are counteracted by Alkalie, & vice versa. Ardent Spts, Mineral Acids & Astringents, will also coagulate the Fluids, & harden the Solids, & thus may cause Inflamation. All profuse Evacuations that drain away the finer Fluids, in bigining Inflamatory Disorders, are improper. Whatever can encrease the Momentum of the Blood, may cause Inflamation, al errore Loci, therefore is improper here. The second Indication is to resolve the Obstruction already made, and this maybe done by the Vessels driving on the Fluids into the Corresponding Veins, & thus by Circulation their Cohesion will be broke or the obstructed matter may be broken down by the Actions of the Vessels themselves, by the help of Dilution, & the Matter will be corrected, or let out by some of the Evacuations, hence the Sediments of Urine – 3dly: By long Stagnating in the Vessels for we see that the red globules by standing long will break down into A watry liquor, especially as thin Fluids are constantly carried to it by Circulation. We must begin the Cure by Diminishing the Momentum of the Blood, to diminish the Vis, A Tergo, by w:ch the Obstructed fluids, are still more and more impacted, & Dilation prevented (28) and by Bleeding we give A free play to the Heart and Vessels, the larger Vessels, are emptyed & the Vis a tergœ diminished, and these Vessels acting more freely give repeated strokes to break [cross out] the Obstruction And the Blood is broke down & made more thin & fluid, We also encrease the force of the Absorbents by emptying the Vessels. If they are not too relax’d before, whereby the Obstructed & Extravassated fluids are taken up into the Circulation and in the Primæ Viæ there is a greater absorption of thin Liquors. It is also said, that by telling Blood the Momentum is encreased, to the part, and its Impetus the other way lessen’d and this is call’d Revulsion; but this is not acertain’d. In the beginging of Inflamation there is often A depressed pulse: owing to the Vessels being too full & the Blood too rarifyed, [illegible] will rise upon Bleeding.- After Bleeding we must cleanse the Primæ Viæ of its Putrid, & Inflamatory foulness, least they are absorbed into the Blood, and encrease the Fever, as the power of Absorbents is encreased by the encreased Vis Vitæ, & Circulation, And those purgers must be Antiphlogistic & mild. but we must be cautious not to weaken so as to destroy the Action of the Vessels, as by this it is yt: the Disorder is resolved. The diet ought to be of easy 33  34  (29) 35 digestion, affording A mild Chyle, & diluting Animal food as it has already undergone A series of Circulations is too pubescent therefore Panadas & all Vegetables yt: are mild & Asescent, the drink may be of the same kind as Lemonade, Hydromel &c which will arise wth: the Blood by their Saponaceous quality. All tho’ Watry liquors sould be soon thrown off without mixing. the Blood by its encreased Circulation is too much enclined to the Putrescent therefore the Putrescent food is by no means proper. The Medicines fit for to resolve the Obstruction are those of the Emollient kind, as Decoct Putorale wch: will mix wth: the Blood and delute it. The Nitre & all Neutral Salts as Tartar Solubile, Sal Diuretic, the Saline Drauts or Spts Mindereri: If the Patient is low, A Cordial as Conf: Cardiac, or Pulv Contrery, Comp: may be added. Drinks, must be all Acids, or Acescents as they are Antseptic, & they weaken the fibres, thin the Blood, dilute it, & lessen its heat & Momentum. External Applications, as warm fomentations to relax the Vessels, & allow the obstructed fluids to pass into the Veins, are usefull, & use generally at least get time & eased by it. An Opiate will often be of Service, but this must not be done ‘till necessary Evacuations are premised, the pulse soft and the (30) obstruction abated, for Opium will only conceal the Patent Enemy & make the Disease more obstinate. Cupping Glasses applied to the Neighbouring parts w:ch are served by branches of the same Artery will often times answer the present purpose. And if the Glasses are applyed above the inflamed parts it has frequently resolved the Obstruction. If there supervenes any Evacuation of thin Watry Liquors in the begining as Sweats, Stools, Urine or Spitting, it must be check’d as it is Symptomatical not Critical, & will drain away the fine fluids, if not stop’d [cross out] or the inconveniencies must be supplyed by A quantity of diluting Liquors, if it is supposed they may give relief and prove Critical. If the obstruction does not yet remove we must give A strong Stimulus, to the Vessels, provided there be no danger of new obstructions, & the Vessels are sufficiently Emptyed, & the moment of it lessened. In Inflamations may be call’d Acute, & Chronic, & here they may be helped by a brisk purge, & other stimulants as in the Chronic Ophthalmia, Swell’d Testicle &c but Care must be taken that the Stimulus does not bring on A fever, & consequently Suppuration. Emetics too give A shock to the whole Constitution. Attenuate & dislodge the Obstructed Humours, but these must not be given 36  (31) 37 ‘till proper Evacuations have been premised, & there is no danger from an Encreased Stimulus. Blisters also applyed externally, stimulate the Vessels and drive on the Fluids, & help to break down the Obstruction, & they also discharge, A quantity of morbid matter, & here we must dilute plentifully to supply the thin Liquors wch: the encreased circulation will necessarily, dissipate, and these must be of the Saponaceous kind, as all these Stimulants encrease Absorption; Liquors that dilute will be carefull on this Account. Topical Remedies also may keep up A Stimulus on the fluids, & astringe, & help the Vessels to carry on their contents, Which stagnation often happens from weakness of the parts after Inflamation, And if the Patient is low we must support them, & give powerful stimulating Medicines, to help Nature in the resolution of the Obstruction. Such are all warm and Cordial Medicines. Some have proposed pushing back the obstructed fluids into the large Arteries by friction, whereby they will be broken down & circulated, but this is a Wild & Vague notion. If resolution will not take place we must endeavour to bring on Suppuration wch: is preferable to Gangrene & Schirhus. On Suppuration the Pain, Heat, redness, & Fever encrease, like the Suppuration (32) has actually taken place, & then the Fever abates & the Patient feels cold horrors & shiverings, feels the pain abate & a weight in the part & fluctuations will be sensible if it is external. The pain encreases as the Vessels are nearer to being ruptured, & now the obstructed Fluids being mixed w:th the tender Solids, form A Pus. The Shiverings may be owing to Spasms from the erosions & rupture of the Vessels. In order to promote the formation of good pus we must guard the part against the Injuries of the Air, & relax & soften the Vessels by fomentations & poultices. The mild oily Glutenous Plaisters prevent the thin softning fluids escaping thro’ the Pores, or if any does escape it is returned on the Skin & acts as A warm relaxing, softning fomentation, these will produce good pus. If the Patient is low, he must be supported by Cordial & stimulating food, & if there is not circulation enough in the part, [cross out] Galbanum and such things as inflame the part more are proper, As A certain degree of Fever is necessary to bring on Suppuration. But if the Fever is very high of the Patient plethoric & no veniesectio premised &c. there will be danger of circulation being stopped & A Gangrene taking place in the part, & here we must use bleeding & such things as abate the fever, & circulation and 38  (33) 39 Gentle Purges, as they will by giving A free play to the Heart and Vessels, promote Suppuration. We must not make the Aperture ‘till the Suppuration is perfect, as by that means we let in the Air to harden & Inspissate the Vessels, & let out the matter, w:ch is most Corrosive & the Pain & Inflamation will be removed w:ch are very [cross out] necessary to Suppuration, and the Corrosive matter is necessary to melt down the Indurated parts, but if matter is formed near A Joint or Bone so as to endanger A Joint, or foul the bone, or on the Capsula of A Joint, whereby there would be danger of its eroding the Capsula and getting into the Joint, as in the Paronychia or Inflamation of the Membranes of the bone, or where there is an Impostume on the outside of the Pleura or Peritoneum, where there would be danger of its getting into the Viscera of the Abdomen & breast, we must open as soon as possible The Dr: gives us a Case of Matter being found betwixt the Biles & Pleura w:ch not being Opened, destroyed the patient – Lecture the 7t When once An Abcess is mature, there is then no doubt what is to be done, for if the Matter is not let out it becomes Acrid & Corrosive so as to destroy the neighbouring parts, and the Absorption of it back into the Blood will (34) will bring on An hectic Fever w:th: all its Symptoms Consumptions &c. It has indeed been known that when Matter has been neglected, & in consequence absorbed, it has been evacuated by some natural Outlet, as Stool, Urine &c. But this is very rare & what ought to by no means to be depended upon where the Matter can any way be discharged wth out endangering the Patients Lifes The Dr here gave Several Cases of this kind when Matter has been discharged by A purulent Diarrhea, or A Paralys Evacuation of Urine, & the Patient happily recovered. When by the softness & whiteness of the parts the sensible weight & fluctuation preceded by some degree of Fever & Shiverings we are sensible of the Matter being fully mature, & are then to make an Opening in the most depending part as otherwise where the Integuments are thinnest and the Matter pushes most to A point, provided the Matter can flow off this way, or to avoid the danger there might be from blood Vessels in the other more depending part: and then Bandages & Compress & must supply the disadvantage of this opening: when the Matter is once evacuated our care must be next to cleanse the Abcess w:ch must be helped by A particular Regimen, in order to procure A Mild balmy Pus, & for this purpose Such Food must be administred as afford A mild easy digestible, & Antisceptic Chyle Such are all Vegetable Substances, & Eggs, & the Drinks 40  (35) 41 must be of the same kind as nothing contributes more to the Cure of Sores, than A Mild Thickening, Balsamic Diet, yet this must be varied, according to the Seasons of the Year, the State of the Patient the high or low Pulse the Mild or Acrid state of the Juices &c. The Dr gives A Case of A Gentleman being cured of A Venereal Bubo that had resisted all repeated Mercurials, and other Antivenereal remedies, being cured by giving Balmy Thickening, Diet &c All Patients that have Abcesses should be care full not to encrease by healing stimulating things the Acrimony of the Blood, by any improper regimen, as irregularity of living would make the Blood inclined to the Putrescent, as any little Irregularity in the Non naturals will sometimes bring on A fresh Inflamation & Fever, & encrease the thin Acrid discharge & protract the Cure, & as in resistant to Diet. Some Cordial Medicines & Wine in smaller Quantity may be usefully given to raise the Patient, & make the Sore kindly. In Scorbutic Sores while the Patients are out at Sea, it is found that the Sores will not heal, but when they get on shore & have A quantity of Mild Vegetable diet, they soon heal up. And in those that proceed from A Lues Venerea the Sores will not heal up. Untill the Acrimony be corrected by Mercury & other Antivenereal Medicines. But when the Patient has a good habit of body, the Juices Mild and the belly regular, there need no Medicines Nature herself will work the Cure.- (36) It is necessary also that the Patient should breath in A good Air, as we see in crouded Hospitals. Often Sores can’t be healed but will frequently heal of themselves when the Patient enjoys A good Air. As to topical Applications when the Patient is in good health & regular, there needs only A little fine Lint w:ch is better than any of the Balsams kept in the Shops, and the dressings should not be removed ‘till they are ready to drop off of themselves. The French dress often & wash the Sores w:th Sp:ts w:ch frequently kills the Patient by preventing A suppuration, And if A Fungus arises the best Escoratic is the Lunar Caustic & if the Patient be in good habit of body & the Abcess goes on with this method will do of itself. The Sore may be washed at the End w:th Lime Water, Brandy, or Tincture of Myrrh wch removes the flabbyness, hardens the Fibres, & bring the Skin on the part, but this only when there is little Suppuration. But this method will not always do as when the bottom & sides of the Abcess are too rigid & hard, tis necessary to Apply Emollient Ointments & warm Poultices to bring on Suppuration, & granulation of Flesh, such as the Ing Basilic &c. When the Sides & Bottom are too soft & flabby & the discharge too great & thin, we must then apply some hardening Ointment as Ung:t Basilic cum Pracipitat or Arug Ani, or Turpentine as next w:th An Egg. these blunt the Acrimony of the Pus constringe the Fibres, & prevent the flowing off of thin 42  43  (37) 44 Acrid Fluids. The cure of these Sores discharging A thin Acrid Matter, is often retarded by A Fungus which may be removed by Lunar Caustic or Soap mix’t w:th Lap. Infernalis &c: & not using Recip Rubr: - And where An Abcess seems deep, we must take care that it heal not from the bottom, & the Sides not grow together before the bottom is healed, & then a new Abcess might be formed, & the work must be done over again, & this must be done by filling the Sides wth soft Lint instead of Tents, w:ch encreased the Inflamation & prevent the flesh uprouting up at bottom. If it happens that A bandage can compress the Bottom of the Abcess and bring the sides together, so as to heal it, & will then be usefull If A sore run up in one continued Pipe it is called A Fistula. if it has many Sinuses it is called A Sinus Ulcer running up among the Muscles. If the Sore runs deap & lies so that we can compress the Bottom & A depending Before may be a sufficient drain for the Matter, & bandages & compresses apply’d abou and the Orifice kept open wth. Soft Lint will be very usefull and this method is recomended even in bad habits where the Pus is very acrid, together w:th proper food & Medicines. Surgions have advised to lay Fistula’s quite open when the Sides are callous, & to cut away the callous parts or destroy it by Eschoratics, but this Method, when the Fistula runs too high up the Rectum, or other parts so (38) as to endanger Blood Vessels &c. and have the best Method as to cut freely thro’ the Integuments in A straight Line wth the Fistula and by throwing up digestives made thin, as Met: Rosar and not using the Dossils or Tents, but these Fistulas after acute Inflamations will be easily cured, but where there is no Suppuration the Præcip Rubr, may be thrown up to bring on Inflamation &c. but otherwise all Irritation should be avoided especially the probing of the Wound. When there are no hopes of Making the part heal & you can’t cut them, you may throw up Injections of Met Rosar & Aq Calcis. Vitriol Alb & Spts by itself, to dry up the discharge & heal the Fistulas & sometimes the Sore will heal and yet the Fistula remain without any great Inconvenience. Dr Monroe of Edin Sur:y has made use of this method wth Success, but must not be attempted where y:er are any Callous Indurations, or the Fistula can’t be diluted freely, & this Method may be tried in other deep Sinous Fistula’s: as for Example in a large Abcess deep among the Muscles of the Thigh, One thing ought to be observed that where the discharge is become habitual, or by A bad habit proves Salutary we must not Attempt A cure, least its fall on the Lungs or some of the Viscera & Occasion Phtisis Pulmonalis or Fevers &c And here we must endeavor to moderate the drain of humours 45  (39) 46 Yet we must when it is to drain A bad habit & there is danger from the Fistula or Sinus making large Sinous Ulcers, or penetrating into Any of the large cavities the Cure must be attempted, And here we must open Artificial drains to supply the Natural once- Lecture the 8t: Of Seatons, Issues &c all these drains answer the same end, whether Seatons, Issues, or what not, There is one precaution not to make An Issue upon A Muscle whose Action will be incomoded by its asor the sides of the Insertion of the Deltoid Muscle, or in the Interstices of the other, and Care must be taken not to put it near large Blood Vessels or Nerves to hurt them by its pressure [cross out] Another Method of Making Drain’s is by Caustics or Blistering Plaisters & Ointments, The part gangrened by Caustic the Suppuration will seperate – These Discharges remove pains of the Head, Arm &c. and carry off morbid Matter – Dr Monroe & Ruysch give instances of these blisters & Issues on the head curing the most Violent head Achs. In Suppuration [cross out] the Back that communicate w:th the Abdomen, & Thorax, in the Medical Essay we have An Instance of the Pus being discharged by Sætons & the Patient cured. In a Phtisis Pulmonalis A Seton betwixt the Biles near the pain, has (40) has removed it and, the Patient has been cured, & In Chric Opthalmias, & Epilepsies, we see these Setons succeed if long continued. How Issues produce their Effects is not will known, but ‘tis supposed that the gross morbid Matter will pass here w:ch can’t pass off by the common outlets of the body & therefore will carry off the morbid matter, that could not be carried off other ways – Mortification is the stoppage of circulation thro’ an part. A loss of Sense pains - The Gangrene dishg mortification. The Sphacelus is A confused one, when A part moritifies, the Swelling & shining redness dissapears, it becomes hard & Black and the Cuticle is distended into Vesicles, and the Pulse flutters, Sink and Intermitts. When any of the Viscera are gangrened cold Sweats come on, the Pain is quite lost and Deat is at hand, & here the Countenance looks Worn, & Das the causes may be whatever can compress the Vessels & put a stop to Circulation as after Fractures, Luxatio &c. by too strict bandage – 2dly. The Strangulation the Intestines in the Rings of the Muscles, brings on Mortification. Also A Mortification will come on from the Patien lying too long on A Weak Part, as the Serum &c. Ano Cause may be Tumours compressing the returning Veins or Arteries, of w:ch Hildanus gives A Case of A Schirrous Tumour compressing the Vena Cava, above the Heais. 47  48  (49) 49 Then we must dissect it out, by the Cellular Membrane, doing it slowly, and taking care of large blood Vessels & Nerves. The Tumours being removed we must take care to prevent A relapse, by such a regimen, as already prescribed to discuss them. Keeping A part of the Sore open by means of some eschoratic, has been found to prevent it by Dr Monroe of Edinburgh, as he found no relapses happen’d during the Suppuration. The Ointment made use of for this purpose, is Digestive, & Soap, and A little Lap. Infernal, spread as big as A Crown, And wash constantly. Our last Indication is to prevent the Schirrhus being Irritated, as where the Schirrus can’t be resolv’d or the place of it forbids Extirpation, or the Patients Age this must be done by mild Regimen as Alorei Recomends Lecture the 10t: Of Cancers Cancers are hard painfull Tumours which never melt down into Pus, call’d Carcinoma in Greek & Cancer in Latin. It is call’d, Occult, Ulcerating, or Eating, Occult Cancer is known by heat and redness in the part, when it has been along continued Schirrus, then Skin is at first slightly red, next becomes blue, and then Black, and the Vessels shooting out it becomes larger, more rough, & uneven. The neighbouring Vessels swell, and have little black knotts wch is owing to Tumours compressing the Veins and making them turgid. New knotts appear at a distan (50) or in the Neighbourhood. We may suspect, An Internall Cancer, where there has been A long weight and Hardness, & when there is pain or discharges we conclude it is A Cancer When it becomes Ulcerated it is call’d Eating, and the Pain is confined to A particular [cross out] spot, when the Matter pushes and Inflames, and then it Corrodes the Edges w:th An Acrid matter and enlarges the Ulcer. Here is A plentifull discharge of A thin Acrid, Sanies, or Ichor, which tinges the pooles, And the Lips become very indurated, and turned back. There is a burning, pricking Pain in the part, and the roots become more fixed to the Part, and brings on Hæmorhages, Convulsions, Faintings, &c and Death is the consequence of it. Difference in the Habit of the body, and parts affected make A great difference. Cancers are found in all Glandular parts, or parts that approach more nearly to A Gland, as Breast, Scrotum, Uterus, Penis, Testis, Lips, The remote cause of A Schirrhus, may be the remote cause of A Cancer The seat of it seems to be in the Extremities of the Vessel, where the Heart has no influence, and any Acrid matter stagnating here may change the Schirrhus into A Cancer, & this acrimony may happen from a bruise on the Schirrus, or any Irregularity of living, or by improper applications. The Cause then is whatever can make the Fluids acrid & cause obstructions of it, and the Fluids being generally affected. Cancers are very liable to return after Extirpation 50  (51) Cancers have been thought Infectious by Hildanus &c And Gooch found them infectious by the mouth &c Its advances depend on this Habit of the Patient & manner of living, but in Old Age it grows very violent. Women at the time that the Menses have them, are very liable to these, as any other evacuation leaving Persons, would make them liable to them. Old Maids are more subject to them, as their Uterus, soon grows Rigid, & their Menstrua leave them sooner. The Fluor Albus (w:ch is fragrant to Women after their Menstrua) being stopt makes them subject to Cancers & perhaps to other disorders. The burning pain in the Occult Cancer, the Situation near Vessels and Nerves and its largness, are the most dangerous Symptoms. In the Armpits and Groin, it is dangerous from the large Vessels. Cancers from Accidents are more dangerous than from Habit. The knife is the only remedy that can be expected to do anything. Hippocrates and Celsus are against midling w:th Cancers. But the Knife sometimes gains A long truce & now and then cures. We must not attempt ye Extirpation, if the Tumour is not moveable & the whole can be taken away safely, and we must keep of part of it. pres or make a drain near the part to carry off the Acrid Matter In extirpating, the knife is preferable to all other methods, & exceeds Escarotics, as they give the most violent pain immaginable; Yet some superficial Cancers may be treated (52) w:th Escarotics as Lap Infernal. Caustic Common or Lunar, may succeed. We must prepare the patient by a strict regimen & take away Blood if plethoric. If the operation is thought improper, we must endeavor to palliate, 1st by a mild diet, as Milks of all kinds, Broths, Panadas &c. Decoctions of Sarsa & such as make the blood mild are proper, but Mercury and all stimulants must be avoided. The Cancerous part must be defended from external Injuries, by Tars, Skins, &c An Issue near the part may be usefull in the occult Cancer. Emollient, & Warm Applications must not be used, but Tar and Egg mixed have been recomended, w:ch is not too soft and defends the Cancer. Aq Calcis externally has been recommended & a little Sacch Saturn, & pledgitts of Nutritum. But if the Cancer is irritated by any Acrid application it will run like a wild fire. Galen recommended the Solanum, Creata Aquatica for Cancers, & these will sometimes obtund the violence of it externally The Red Cale Wort brought to a poultice by stewing was A medicine made use of by Mc. Dobbs of Dublin. Some have recommended raw meat supposing Worms the cause Emollients makes Cancers furcate, and sprout out, & Astringents often Irritate it, therefore Emollients and strong Astringents are improper. Near the fatal Period there is An intollerable stench, and the pain being excessive recours has been had to Opiates, & tho’ they give ease Dr. Young says that Opiates make the pain return more violent, & having the patient out of the world, the sooner. When A Cancer bleeds we must use 52  53  (53) 54 some gentle Astringents, as Bol Armon: to the small Vessels to the larger the Lunar Caustic must be applied w:ch is the best Escharotic, the pain being sooner over. The Ung e Ric, The common Digestive, Ung Saturnin &c are the most mild & the best Applications. They must be neither too Emollient nor too Astringent, as the first will make the surface spread, the other the Roots. When the discharge is very great, & Fœtid, we must dress it often, and wash w:th Vinegar & Water, or w:th Aq Calcis & Mel. Rosar: - Lecture the :11t: - On Wounds in generall __ A Wound is a forcible division of the flesh by A hard or Sharp Instrument, first we consider the most simple Wound made by A sharp Instrument, where there are no Tendons, Vessels, &c Then where Tendon Vessels, & Extraneous bodies are &c. Immediately as the Wound is made the Mouth of the fibres retract a little owing to ye Natural Spring or sensibility of the Fibres endeavouring to contract on Irritation. The Blood issuing out at length, stops & forms a crust w:ch shuts up the Orifices of the Vessels, unless a large Artery be cut, After that Serous Liquors continue to ouze from the Wound, the Vessels being not stopt so as to prevent it. The Lips swell & grow painfull & the bottom of the Wound Inflames, and there is A distention of the Cellular Membrane from the divided Vessels, w:ch the act still continues to act upon. About the 3d or 4t day A Suppuration comes on (54) or sooner if the Weather is hot or the Juices Acrid, for the Juices in no Cellular Membranes, and the Obstructed cuts Vessels growing Acrid, Corrode and break down the Vessels, & become Pus. Some Wounds Suppurate not, till the 7t: or 8t. day. The redness, Heat, Pain, Swelling, and Fever go off as the Suppuration coming on. The Bloody crust then falls off, and the Wound fills up at the bottom & sides, ‘till it is quite healed, for the edges of the Vessels being Coroded make the Crust fall off easily, and the vessels send out small, Papilla to form A Nexus of Vessels as before, ‘tis disputed when the Vessels are ingrafted on the one another, or are produced so as to unite in the same Manner as before. And it has been urged that the Humours Issuing from the side of the Vessel might be absorbed by the others, and e Contra it has been said that the Vessels do actually unite and the Circulation is carried on by continued trunks as before, as by Haller & Du Hamel’s seems to be true by their Experiments. When A wound is made w:th A sharp Instrument without loss of substance, there is little or no Cicatrix but w:th loss of substance there is a large Cicatrix. The Vessels shooting out and the Cutis not being supplyed, they harden & are covered w:th the Cuticle The new Substance is made by the Elongation of the Vessels from A proper Matter brought out from them, and as this depends on the state of the Juices, we must chiefly have A regard to this in the healing them, for wounds that heal by the first intention want some of this matter to supply 55  (56) 56 their consolidation. We must make use of A mild Cooling Regimon, and what is easily digestible. Assimilated & Antiseptic. Nevertheless there may be Cases where the Vis Vita must be supported. And we must have A great regard to the habit of the Patient & way of Living, The Air ought to be dry and temperate, and not Foul wch makes the Juices Putrid &c Too Hot Air causes large Suppurations and makes the Juices thin, Acrid and Putrescent, therefore Operations are delayed in Summer. Too Cold Air contracts the Vessels and coagulates the Fluids, and makes the Vessels not suppurate and throw out their contents w:ch Encreases the Inflamation, There ought to be free Excretions, as of perspiration, Stool &c, and this must be slowly attended to - Bleeding is often necessary to prevent Inflamation & Fever and encrease the Absorption of the extravassated Blood from Contusions &c.: but this must not be done if the Patient is low especially if Old. If the Pain is so violent as to prevent Sleep , Opiates may be usefull, If Evacuations have preceeded and there is no very great Inflamation The Second Indication is to bring the Edges of the Wounded parts together, and to keep them thus and they will Unite, and this is called first Intention, but this is not without Suppuration, this may be done by Bandage, Plaisters, & Suture And when the Wound is made in the longitudinal direction of the Fibres, wh may be brought together by the suiting bandag made w:th A Slitt in the Middle and is other and drawn thro’ (57) and dressed w:th Lint &c And sometimes compresses where the Wound is deep. When A Wound runs in A cross direction in respect of the Parts, Bandage perhaps cannot bring them to by Plaisters, or by Sutures if the Wound is large. As there these are two the Interrupted and the quill’d wch is chiefly recomended in the Abdomen. When the Wound is small it must be dressed Seldom, but large Wounds being subject to A large Suppuration must be dressed often least. Abcesses are formed, and here we must lessen the stress upon the Stiches, by Compresses, and bandage. When the parts are securely united we must withdraw the threads by cutting cautiously near the knott on one side, Laying your hand to the Wound while you withraw the thread Carefully. Wounds must not be strehed where there is A contusion, Laceration, or loss of substance, for this would Irritate, and in flame the parts more & more. And these we must endeavour to promote A good suppuration, by dressing it with dry lint, and not Opening it till 4 days after and the dressing will remove easily, Spirituous Applications, inflame Wounds and prevent suppurations Ointments soften too much & prevent the cure The best Intention is to bring on A good Cicatrix, and make it as even as the skin, but we must not Apply, drying Medicines too soon ‘till the Wound is filled up w:th flesh, least the Vessels cicatrize too soon and have a hollowness - 57  (41) 58 and preventing the return from the lower Extremeties & brought on Mortification, and whatever suddenly contracts the Vessels and coagulates the Fluids, as in cold Northern Countries, as Lapland, America, &c And frequently happens suddenly to Centenells on duty and other Persons Le Motte tells of Case of A man, who in July by going into A Cold Well had A Gangrene. Another Cause may be Spts: or Mineral Acids applied to An Inflamed part or any thing else that is too Acrid, or Bruses w:ch mush together the sides of the Vessels and prevent Circulation. A 3d Cause may be A want of force in the Vessels to carry on the Circulation as is frequent in old people, to w:ch their Rigid Fibres contribute – A 4t: Cause may be An ossification of the Arteries as in A Case related in the Philosophical Transactions. These Causes producing obstructions by the Vis A tirgo, the Blood is still more & more impacted and Circulation entirely stopt & the Fluids soon become putrid & the Blood of the part black instead of Red. the Sinking of the Pulse is either produced by the same cause as the Gangrene, or the Blood is tainted by the Matter of the Gangrene. The Veins are Empty when the Arteries are compressed and the part Looses that shining red colour - The more Rigid the Vessels and the slower the Circulation the more danger of A Gangrene, and those who have Acrid Juices are more liable to Mortifications. When A Gangrene is threatened, The Indication to prevent it is the same as in A (42) Plethora & Inflamation. We must bleed &c. but when the Gangrene is begun, ‘tis too late then to use Evacuations. Patients under Putrid Fevers, Scurvys &c ought to be put under a Regimen that prevents putrifaction, as Acids, Bitters, Cordials, Barks &c. Gangrenes from Dropsies Pthisis Pulmonalis &c are seldom curable but are forerunners of Death, & the only Method of Cure is to cure the Original Disease. When A Gangrene is from lowness and decay’d Visa Vitæ, we must use Bark and Cordialls and when from O Tumours that compress the returning Veins. the Tumours ought to be [cross out] or dissected away or opened if Suppurated. If it is from the Patient lying on the part we must order the posture to be shifted. Applications too Acid ought to be removed, if they encrease the Pain and Inflamation & Threaten A Gangrene. When A Gangrene is formed we must then try to stop its progress, & when it is stop’d to promote the Seperation of the dead parts, and this Intention must be helped by applying Cupping Glasses to the Parts above to Inorte Circulation that way, and we must make incisions in the part to give An Issue to the Acrid Matter, to prevent its being taken into the Blood, and allow the Efficacies of Topical Applications, and we must cut to the quick. The topicks must be Warm Sp:ts Baths, Digestives w:th Turpentine &c And Warm Antisceptic Cataplasms of Theriaca &c And when we observe A small white Line around the Eschar, or Pus 59  (43) 60 coming thro’ the Incisions, then we conclude there is A Suppuration, & help it by Poultice, Fomentation, &c And we must treat it as A Common Sore, And we must be carefull to use A proper Regimen in Food and Medicines such as Bark, Cordials &c. Gangrenes from frost & Cold have A Diagnosis Peculiar to itself, & requires particular treatments. As the same treatment in other Gangrenes would bring on A Sphacelus, we must then rub the Parts well with Snow, or put them into Cold Water for some time. As by this means we easily dissolve the Icy Spiculæ, and attract them so that they do no harm, thus If A person is found frozen in the field, bringing him to the Fire gives accessive pain. After the Parts have been thus treated, we must bring him in lapp’d in A Blankett by degrees to the fire &c Hildanus gives us A Case of the kind where the Mans benumbed being put into Cold Wat Icy Spiculæ came out from every Pore & cover’d him over w:th A crust of Ice, for it is these Icy Spiculæ that being too quick put in Motion by fire compleat the Mortification & Van Sweiten says that Apples frozen brought to the fire will Rott: but kept in Water will throw out the Icy Spiculæ [cross out] remain as sound as before - (44) Lecture the 9t If the Sphacelus wch is when the parts are entirely Mortified to the Bone, & here we must be pretty free in Culling, tho’ A Gangrene would not allow it. When A Finger, Toe Leg &c: is Sphacelated, Surgeons generally advise to take it off, but this is objected to, of late, as they say that the Operation does not step the Disorder, but A new Operation is required. Experience has not determined the disspute. The Disorder sometimes stopping and sometimes not. When the Disorder arises from A Diathesis of the Blood the Operation is improper, but if it is local, as from Accidents &c I shd think the Operation adviseable. When once lax Gangren is stopt there is then no doubt of ye matter. As it may be performed, or the Seperation left to Nature only. Great Care right to be taken least the Gangrene be mistaken for a Sphacelus for the thickness of the Membrana Cellularis may deceive us & makes us thinks it A Sphacelus when the Muscle and Vessels are sound below When the Sphacelus or Gangrene is dry. When the Parts mortify and instead of falling into liquid Matter, dry & wither as in Old People it perhaps wont be advisable if the Patient is weaks therefore we must support the Patient & use Antisceptics externally to preserve the parts from Putrefaction and as it were keep the Limb in constant pickle Emollients as we see by several Observations know always ne harm in such cases and encrease the Putrefaction 61  62  (45) 63 A Scirrhus is A hard Tumour in parts of Glandular structure after Inflamation, generally rough, tho’ sometimes smooth _ Boerhaave thinks they always proceed from Inflamation, but this is known to be false as they more generally arise from Chronic Obstructions & however It always has the same Appearance, Glands and other parts like them are ye proper Seat of the Schirrhus, yet as Galen says they may be in Muscular Parts in the Cellular Membrane there are two sorts, the Imperfect & Perfect or Exquisite The first is only the begining of the last, when grown large being attended w:th Inflamation & Pain. They are call’d External and Internal. External is easily judged of. The Internal only by the parts that seem affected. A Schirrhus is A white Indolent Tumour generally rough and in glandular Parts, they often cause Obstructions by pressing upon the Veins or Vessels and thus making Inflamation _ Schirrhous Tumours in the Nose stop respiration and suffocate the Patient, In the Pylorus they cause continual Ejections of the Food and in the Osophagus prevent swallowing. Some have died of ye Illiac Passion by Schirrhous Tumours in the Rectum and others by Schirrhi in the Colon, w:ch would dilate the Intestines above and shorten’d them below, Dropsies sometimes proceed from Schirrhous Livers. these Symptoms may be call’d (46) Accidental and are not the true Pathognomonies of the Schirrhus. They generally prove Cancerous in the End, tho’ sometimes continue long without it. The Causes of Schirrhi may be whatever can render the Fluids too thick to pass thro’ the Vessels and Ducts of the Gland or taken up from the Cellular Membranes. Thes Tumours are Generally in the Cellular Membranes & this makes then different from Inflamation distending the Vessels & giving pain. The Cellular Membranes give no pau ‘till they press so much on the Vessels as to cause Inflamation. The Cause may also be from the Diameters of the Vessels being lessen’d as in Womens Breas after blows &c causing Inflamation & Schirrhus. Th Heart not being able here to overcome the Obstruction Milk Tumours may also produce these Tumours by repelling Medicines that contract the Vessels and Coagulate the Fluids, Or A thick dense Crasis of the Blood w:th out any Accident, or A small one may produce Schirrhi. The Passions as Grief, Fear, Sudden Freights, has been found to Occasion these Tumours, and all these Tumours on the Breasts of Women [cross out] frequent at the Time the Menses leaving them. But the Schirrotic often proceed from Habit and Hereditary Taint. These are said by Hoffman to be more dangerous as they are nearer the 64  (47) 65 Heart. A Schirrhous from constitution is difficult of cure, if It has no pain it is still more difficult, & it is tho’ A true Schirrhous hardly ever resolved. But we ought to Attempt [cross out] its Schirrhi are more dangerous According to their Situation, and when Extirpated often return. The Intention of Cure 1st: is to resolve it, if recent, by correcting Vitiated state of the Fluids. If Sizy by Attenuants & Venesectio, & keep the mind quiet, as the passions hurt much and make the Juices Acrid. Applications w:ch relax and Attenuate the Schirrhus substance, but must not be Irritating so as to bring it to A Cancer very soon. Medicines stimulating and heating & violent have the same Effect. We may expose it to the steams of Water twice a day, gently chaff’d and Plaisters applied Van Sweiten recomends it much, and Empt: ea Cicutae Ammoniac, or Soap dissolved in Milk, to bath it. Some have recommended Vinegar applyed, by A Sponge and the steams of it warm, & Poultices w:th Gum Ammoniac, & Vinegar &c, have done great things. Others have recomeded Mercurials, & Spt Mindereri, as Attenuants. The Body ought to be kept cool, by A Mild light cooling Diet, and the belly might to be kept loose. Sea Water given often so as to purge and Sponge burnt w:th Nitre, is said to succeed in these Cases Repeated Doses of the Laxative Mercurial Pills have been recommended, as Purges, and as Allterative. But we must take (48) care of this, as All Violent Medicine must do either good or harm, as in A case of [cross out] Scirrhus on the Rectus Muscle of the Abdomen that the Dr gives us. Others have recommended the Juices of Herbs in the Spring, as Succory, Dandelion, Lettuce &c. Others the Decoction of the Woods and Sarsaparilla, & others the Neutral Salts made w:th the Vegetable Acid. The Sarsaparilla says the Dr: has succeeded in A Schirrhus Testicle when other things failed. A Modd Diet, Laxative Medicines, Gentle Discutients, as steams of Vinegar, or Solution of Gum Ammoniac in Vinegar & discutient Cataplasms. The Decoction of the Sarsa, or Woods internally, & such Medicines often varied. If one method does not succeed we must try others. If the Schirrhus is so situated that the Patients Life is in danger, by Extirpation, as to blood Vessels Nerves, &c. as in the Axilla or fore part of the Throat, or when they be deep on the Vessels. But if they are moveable by Cellular Membrane at all, they may be extirpated. 2dly: If it can be taken away at once, (or the remainder will be Irritated and Spread the faster) 3dly: Whether more than one Schirrhus, as the others will be Irritated by the extirpation of the one, the Circulation being encreased and Inflamation brought on, 4thy: Whether it has encreased lately and what the state of it is, 5thy: The state of the Patients, Age, &c whether they have sufficient strength to undergoe the Operation, If the disease be recent from external Injury and the Patient in good Health, then it is most favourab for the Extirpation & the nearer it is to this, the more favorable (50) 66 Lecture the 12th: In the different Accidents Attending Wounds, as Bleeding from cut Vessels, Aneurisms, Pain & Convulsions, from Cut or Wounded Nerves, Tendons &c. Contusions, Extraneous Bodies &c. These depend on the Nature of the part wounded, and the wounding Instrument, If any large Vessel near the Heart be wounded, the Patient bleeds till he faint or dyes, or if A large Artery w:ch only supply A limb be divided, the Wett or dry Gangrene takes place below of An Artery is cut tho’ it bleeds & Sallum, and this weakens ’till by degrees it stops, if it is only wounded it will be more difficult to stop it. When An Artery is wounded, the Patient Coat is ruptured and the rest distended, ‘tis called an Encysted Aneurism, that wherein the Blood is diffused into the Cellular Membranes is called the diffused Aneurism – The common Method of stopping the Blood is to tye up the Vessel w:th A needle and thread first used by Ambrose Parey. Tho’ Celsus seems to mention such a thing. When an Artery is wounded and so deep seated and the wound so small that we can’t come at it, and Bandages & Compresses will not do, then we must dilate the Wound to come at the Vessel and stich it as before, When A large Artery is wounded that has large Anastomoses going to it, we must make A ligature below, as ell as above to prevent the Bloods flowing back. The next method is by Styptic Medicines w:ch are of little use, as they (59) only stop small Vessels, w:ch may be done by Lint as well, when compression can be used. If compression can’t be us’d we may apply those Astringents w:ch absorb the Blood and harden it on the Orifices of the Vessels. The Fungus Agarica has been recommended by some as proper to stop bleeding Vessels, keeping A Tournequet applied some time after. The Puff Balls have been recommended formerly. The Cautery or red hot Iron has been used by the Old Surgeons before Pareys introducing the Sutures, but when the Suppuration came on the Eschar fell off and the Vessels bledd anew Therefore only to be used when the Artery Lies so deep, that it can’t be come at by dilating, to stich it. It may be usefull also when the Arteries are just entering the bone, and it can’t Colapse. The Potential Cautery are such Caustics as eat and dry the parts in the same manner, as the actual Cautery. They are now not much used, yet the Caustic Lunar may be used where there is Ouzing of Blood from small Vessels. The last method is A compress and strait bandage w:ch can be only where there is A bone to make a counter pressure, on the Artery and press its sides together, and here we must avoid making so general A Compression as to stop the Circulation entirely, by including ye pressure on the Wounded Vessels only by means of your Compresses, but where the Vessels are smal the Blood coagulating, & the Vessels contracting, the bleeding will stop of itself. When the Blood is poured out into the Cellular Membrane or Aponeurosis, and has distended it 67  (60) 68 It is called An Aneurism. We must make use of A Tournequet here, and cut directly into the Sack and evacuate all the Blood, wiping it away w:th A Sponge, you’ll find the Artery at the bottom of the Sack and bending the Elbow a little, you may bunch it up A little be twixt the finger or Thumb, or introduce A probe into the Artery and making your Nails meet behind ye Vessels take up the Vessels above and below. In the diffused Aneurism the blood is Extravassated in the Cellular Membranes all over the limb, and here we must use the same method as the last. The true Aneurism is generally at the curvature of the Aorta. When A Nerve is cut, the Lips of the Wound and end of the nerves retract and make A tension upon the lateral branches, and the part looses the use and Sense. And when it is partly divided only, the Fibres not divided, are stretched, & cause great pain, Acrid Substances to Wound, or Extraneous substances Oft in Wounds, cause great pain & Inflamation, When A Nerve is quite divided we must treat the Wound as A simple one, and in time perhaps the part will recover its sensation, tho’ we don’t know whether the cut nerves will ever grow together or not, or Whether it is by means of the lateral branches, being enlarged to carry a greater quantity of Fluid, The pain on cut or Wounded Nerves is to be venx’d by Emollients, Vinæ Sectio &c. to prevent the greater Inflamation & Tension & by blunting the Sensation by Opiates wch often remove pain & Convulsion but this must be done after previous Evacuations, and it may be done (61) very freely in the lockt Jaw & Excruciating Convulsions. Where there are Extraneous bodies or Irritating Substances they must be removed. The best method is to destroy the Nerve or cut it thro’, if it is small and does not endanger the loss of the Limb &c: This may be practice in the Tooth Ach, & in some small parts of the body – Lecture the 13th The last Accident considered is Aneurisms And now we come to consider Convulsions, w:ch arise from A struggle in Nature to cast off some Irritating cause, or from An Irritation of the Brain, or Unequal distribution of the Nervous Influence, or from An Effort of Nature, to carry on the Circulations & the pain attending these Convulsions, arise from An Irritating Cause, It must be removed: If from Exinanition we must supply the Patients w:th Foods, & Cordials, as fast as possible. The next Accident is a Contusion or Solution of the Vessels of the part without dividing them, w:ch Occasions Echymosis & Aneurisms, or if the part is glandular, it may prove Schirrhus, The method of Cure is by resolution, the Liquors being absorbed, and the Vessels consolidated, without Suppuration, or it may be cured by Suppuration breaking down the Vessels. Or by letting out Extravassated Liquors by Incision & healing it as A Common Wound. The most Eligible Cure is resolution, w:ch is to be effected by Attenuating the Fluids, by Encreasing the power of the Absorbing Vessels, And this 69  70  (62) 71 is done by Evacuations w:th the Lancett, and Mild Purges and Attenuating Neutral Medicines, Attenuating, Resolving, Discutient, Fomentations, and Poultices, as Sps: Mindereri, Vinegar and Water, or mixed w:th Sal Ammoniac, &c &c: And such Poultices as are discutient as Stale Beer, Vinegar, and Jars of Wine &c. as all these Acids are discutient by their Stimulus. Yet the Bread and Milk Poultices is perhaps more proper where there is A great tension. The Patient in the mean time must be suppl’d w:th thin Liquors, and the Antiphlogistic Regimen, and Diet. Thus [cross out] Contusions are cured without Suppuration, where there is no External Wound. And Where there is A Wound the Suppuration of it will frequently help the Resolution of the bruise. In contusion of the Face and head, but especially of the Brain we must be free w:th Evacuations as there is a great danger from Suppuration. Where resolution can’t take place, we must endeavor to bring on A Mild Suppuration, by Emollient and relaxing Poultices and Fomentations, And where there is A Great Effusion of Liquors, below the Skin it is proper, sometimes to make Incisions, to let it out least it occasion great Tension, Gangrene or Sphacelus. The last Accident is that of Extraneous bodies, by w:ch we mean whatever will not unite with our solids, as Metals Shop, Bone, or Sloughs &c., The Instruments used are Forceps of different Forms Scoops, Trepan, Screws in Canulas, Tonics to dilate where the bodies can’t be come at and Direction to cut on - (63) We must first consider if the Patient has strength to bear the Extractions, Of what Nature the Body is and what will be the Consequence of it, As for Instance, If by drawing it out you must wound some larger Vessel or other. We must have all the Instruments ready that may be wanted when we go about to extract any body. And we must put the Patient in the Posture he received the Wound. In order to make the direction of Extraction the same as that it enter’d by. If the Wound is large enough we must extract it by loosening it gently and then extracting it carefully for fear of Lacerations. If the Extraneous body is deep and the External Wound is small ‘tis proper to dilute the Wound freely of it can be done safely, for we must consider, if An Artery, Nerve, Tendon, or any other Organ will be cut by dilating and by our director in cutting to avoid them. We must cut on the body as nearly as we can. Making the Orifice larger than the confined body, and then laying hold of it to extract it. The most proper time for Extraction is immediately after the Wound is inflicted, before the Inflamation is come on, -tho’ it is genereally adviseable to take the body out the same way it came in. [illegible] there are many Exceptions, as it may be dangerous from Vessels or Nerves, or it may be more convenient for extraction, on the Opposite side. Or if the body is of such a shape as to lacerate the Wound in drawing it out forwards, we must then draw it out 72  (64) 73 backwards as in the barbed Arrow. Yet there are some Cases where it is improper to extract, as where an Instrument fills up the cavity of a blood Vessel, and the extraction of it brings on immediate death, as in Epimanondas of Thebes, or where the body, is so deep, that we can’t tell where to cut on it. He must leave it to suppuration, w:ch will make it come out easily. Especially if the Patient is low, & the bleeding already stopt, least we bring on a fresh bleeding, and endangers the Patients life, Or when the Body is deep, the Inflamation already come on, great Fever &c. we must use Evacuations &c., and not extract the body ‘till the Symptoms are abated, and the part suppurated. If the body is lodged so deep, that it can’t be extracted w:th out great force, and laceration, we must then leave the Case to time & Suppuration w:ch will bring it to the Orifice of the Wound, especially if the body be near large Vessels or Nerves, or in the Viscera. When An extraneous body can not be felt we must not put the Patient to pain and danger, by searching often, & cutting to dilate the Wound, but encourage Suppuration, by Poultices, Warm Plaisters, &c: For Nature always makes efforts to free herself from any Irritating Cause, and will not let the Sore heal till the Body is extracted, thus in Batletts Foul Bones &c (65) Of the Wounds of the Head that may injure the outward Integuments only, as the Periosteum, Cranium, Meninges, or Brain. And these we judge of (from the Instrument that gave the Wound, and from the figure of the Wound itself.) by the Finger or probe, and lastly by the Symptoms that come on in consequence. When A Wound is made wth. A Sharp Instrument, and there are no Symptoms but what attend A common Wound, then we must bring the Lips together, and treat it, as A common Wound, least by keeping it open too long, we bring on A Caries of The Skull. When the Wound is inflicted w:th a sharp Instrument, below the Skull and Encaphalon may be hurt. The tables may be depressed, The External parts of the bone may be bruised w:ch will bring on a slight Caries, and Suppuration of the Bone, and the Liquors may be Extravassated, betwixt the two internal Membranes, or betwixt these & the Brain, wch is call’d A concussion. Sometimes when the External bone is slightly hurt, the Bone comes away insensibly, w:th the Pus, and this happens where the bone has not been injured, but laid bare by the Surgeon &c. When the Cranium is broken, Head Aches, Stupors, Delirium, Convulsions, Lethargy, Palsy &c, may be the consequence. If the Bone is not much displaced, the Symptoms at first will only be slight, but if Neglected by the Surgeon, any cause Extravasation, Suppuration &c. In all these Wounds, the first thing is to be prevent the effects of 74  (66) 75 Inflamation, Suppuration &c, by bleeding, & Attenuating Medicines, Purgings &c. so as to prevent Fever, & Inflamation and Encrease the Power of ye Absorbents, The first thing to be done is to examine the Extent of the Wound, by shaving away ye hair, and washing ye part wth: A Sponge and Warm Water. But if the External Wound is not penetrated to the Bone we must dilate the wound, making Use of the Edge of the knife for Fear of hurting the Brain wth: the Point, and if we find the Bone injured, we must then dilate on that part by A Crusial Incision, or by taking out a piece of the Integuments, but if the best way of the a mining is by first making A longitudinal Incision, and not cut out more them is necessary, and not to make the Circular Incision ‘till you are sure there is A fracture. The Periostium must be suppurated, and the Vessels stitched before we proceed. Lecture the 14t – The Bone being bare then, we must proceed to A cure, and if the bone as bruised we must use dressings to cleanse the Bones, wch either insensibly, or Sensibly Exfoliating, Oily Dressing are apt to promote Fungus, by relaxing, & to foul the Bone. Fine Lint is the best dressing after cleansing the Wound. Where there is A great Degree of Corruption, Pledgetts w:th Digestives, as Tin:r of Myrrh, are proper, Surgeons us’d to advise keeping of the bone Scrap by Caustics, but this always brings on a fresh contusion (67) Inflamation, & Exfoliation, Belloste recommends the perforating the Bone into the Diploe, that Granulating Flesh may come from the surface of the Wound & heal without Exfoliations, but this can only afford A fungus w:ch must be cut off afterwards, in order to make A Cure, for the true flesh arises not only from some parts of the Bone, but from all the surface, in order to form A good Cicatrix. Where one or both Tables of the Skull are fractur’d or Fissured, The pieces must be removed to suffer the Extravassated Fluids to flow out, and if there are any loose bone shattered, it must be Taken away w:th the Scalpel or Pinchers, and the depressed bones must be raised up, by a Elevator. We must Trepan at the side of the fractured part of the bone depressed (& if it is strong enough to bear the Trepan), to give a free exit to the matter and give free room for An Elevator to raise up the depressed part. When one table only is injured, it is necessary to trepan only into the Diploe, but this seldom can be distinguished. When both Tables are fractured, we must trepan thro’ both, & must not trust to the common Masks of the Diploe, (because in many places there is no Deploe) but must go on cautiously. There are some parts w:ch must avoid, as the Longitudinal & Lateral Sinuses as the Patient would be in danger of bleeding to death. 3dly ye Frontal Sinusses ought to be avoided as these have heard some Cases where rushing into these Sinusses have had bad consequences 76  (68) 77 We ought not to Trepan where An Artery has its course into the Brain, as in ye holes of the Ossa Panitalia where there is A Branch of the Temporal Artery going in. And we ought to avoid trepanning on the Artery of the Dura Mater as it some times forms a deep furrow within ye Bone. The Temporal Muscle of the Fracture [cross out] his immediately under it, ought to be avoided as much as possible, or at least cut longitudinally & divide as few fibres as possible. These are to be avoided if it be in our power and we must apply the Trepan so often ‘till we can get away all the pieces of the Bone. The reason that so few Patients recover is from ye injury of the Brain, not from the Operation. When this is done if there is any suspicion of extravassated Fluids, below ye Dura Mater, and there are Symptoms of An oppressed Brain & not relieved by the Opperation, then we must cut thro’ ye Dura Mater, & Mo Sharp advises when there are Symptoms of A Suppurated Brain, to run A lancett into the substance of the Brain. And now we must dress w:th dry Lint, wch will absorb the Matter, if too great a discharge, & be a mild, gentle defence against the Air, and we must stress it often or seldom according to the discharge. We should apply a Plate of Tin, or Silver covered w:th Leather to keep the dressings on, & defend the part, for some time after, as it is weak some time The worst Accident from the cutting of the Dura Mater, is A fungus proceding from ye Brain itself, owing to the (69) owing to the Under Vessels of the Brain being extended, these must be taken away by the knife or ligature & by keeping A Gentle pressure upon the Brain w:th Lint, Compress and Bandage, or using some gentle Astringent, as Mel Rosor Tinct Myrrhe &c: but we must be careful not to use too strong Astringents, or too great A compression least we bring on suppuration, or Gangrene by stopping ye Circulation, and we must Bleed &c. to diminish the force of the Circulation in the Brain, wch distends its Vessels _ When there are no external marks, of the part of the head that is hurt, and the Symptoms of an Oppressed brain are come on, we must Bleed, & shave the head & engrave when the Patient had the Blow, or where he feels the Pain, or often puts his hand to; and ‘tis advis’d to put An Emollient Plaister all over the head, and ‘tis said the injured part will thus discover itself, by a redness & humour, but if this does not do we must make several Incisions into different parts of the Skull, scarefing out the place, and if we can’t find the part, and the Symptoms still encrease we must Trepan at the most probable part, now on one side, now on another, in order to let free the extravassated Matter _ When there is An External Wound, and the Bones broke, & not depressed, or only fissur’d, Hippocrates advises taking some Ink on the part w:ch will mark out the hurt by the black line, but this deceived the Old Man 78  79  70 80 once & made him take A suture for a fissure. Many doubt of the Contra fissure, or fracture made by A blow on the opposite side, and it is difficult to conceive that A Blow can break the inner Table without breaking the outermost. Yet Ambrose Perrey tells us that this was ye case w:th A Gentleman, by a Bullett, and many Cases of both kinds are said to have happen’d, thus if on the External Wound there be found no fracture we may apply on the opposite side, and so an as before directed. Some mention A depress’d Skull without A fracture, but this can be only in Young Children, whose Bones are soft, but we must be cautious here as there are frequent One as an orifice on the Skulls of Children. We must bleed here and use discutient Fomentations &c. before we proceed to cut, especially on the forehead. On the kind head we may be more ventrous - Some have proposed raising the Skull by sticking Plaister, by A Screw, & by Cupping Glasses, _ but these can’t do except the Screw may sometimes in Children that are very young _ Extravasations of Matter in the Diploe & lecht can ye Membranes of the Brain, will often bring on bad Symptoms, When there is no fracture, & it is often long after the Blow that the Symptoms appear, as in the Case that the Dr mentions where the Patient had violent head achs for 9 years & (71) the whole Frontal Bone, was taken away, being Caries by Matter in the Diploe, and the inner table being melted down into a kind of fœtid clay’y Matter. And in A Case at St. Georges, where the Matter was extravasated in the Diploe, & the whole Brain was Suppurated without a fracture, and sometimes Death has been caused by the obstruction of such fine Vessels, as can’t come under the notice of the Inspector, after death- Lecture the 15t- Of Wounds of the Breast or Thorax which if they go no deeper than the Integuments are simple Wounds, but they may penetrate into the Cavity, & not wound the Viscera, or they may wound the Heart or Lungs &c. In order to discover the Nature of the Wound we must examine if it penetrated into the cavity, by examining the Instrument and putting the Patient in the posture that he received the wound & by using the probe, we may know if it penetrates or not if it does not run in a very oblique direction. If it meets w.th no resistance we conclude it penetrates, & Vice Versa We must be very cautious how we use the probe least we make A Supperation of the Cellular Membrane. It is adviseable, if we can’t find it out by this method, and the Wound is oblique by the skin, and Cellular Membrane’s changing its situation, and covering the Orifice, to inject Warm Water wch. if it goes in readily, we conclude the Wound penetrates 81  (72) 82 but if no bad Symptoms intervenes, we need not care whether the Wound Penetrates or not. When the Water is in the Thorax we may let it run out at the Wound or else it will be taken up by the Absorbents, & we must be carefull not to inject too much Water for fear of A Hydrops Pectoris or Asthma Another method is to hold A Candle to the Wound and if it penetrates the Air will blow the Candle backward & forwards, and more if the Lungs are wounded. And if the Wound is oblique, & the Skin has covered the Orifice, and the Air can’t find an exit as it comes from the wounded Lungs it will get into the Cellular Membrane, and distend the whole body w:th An Emphysema. Wounds of the Thorax have the same Symptoms, & require the same treatment as other Wounds, only the Action of the Chest, sometimes gives pain, & must be impeded by A gentle compression, & Wounds must not be probed, nor must Fonts or Dossils prevent the free egress of Matter, least there come on A Caries of ye Ribs, by the Matters becoming Acrid. A little soft Lint (w:th a string tied to it to prevent its growing in too far) is ye best dressing of the Natural Orifice is at the top of the Wound we should make A depending Orifice to let out the Matter. There is frequently An Asthmas from the Air getting in & pressing the Lungs & preventing Circulation. Thus Van Swton found an orifice larger than ye Glottis will let in, so much Air will counteract the Air from above, & overcome Respiration. When (73) A Wound penetrates into the Cavity without further mischief, we are to Cure it as soon as possible, and endeavor to evacuate the Air by making A full Inspiration, when the Wound is covered & then expiring w:th the Wound open & this repeated till the Air is evacuated. And we must take care to let the Dressings be so large as not to be drawn in wth Inspiration into the Cavity, or A String put thro’ some Linnen to draw it out if it should happen. It is advised to hold near the Wound Warm Water while you are dressing to rarefy ye external Air. And we must dress as fast as we can the Patient making but little Inspiration. Sometimes Blood flows into the Cavity of the Thorax, as in the Case of the Intercostal Artery wound’d, It will be known from Blood flowing at the wound when the Patient is in A proper posture, And it may be known by lying Active a load upon the Diaphragm in An Erect posture, or when he Lies he is easiest on his back because if he lay on his side it pressis on one side of the Mediastinum & Lungs. Sometimes he feels A fluctuation [cross out] and if it is not discharged it putrifies & becomes Acrid Erroding the Neighbouring parts & Suppurating the Lungs. The first Indication is to stop the further Effusion of Blood into ye Thorax, w:ch is done by abating the force of ye Circulation by bleeding & Emptying the Vessels to make them more fit to receive the absorbed extravassated Fluids & by keeping the Body soluble & give a low Diet. - 83  (74) 84 And 2dly: we must evacuate the Blood already extravasated, but first we must be sure the Bleeding inwardly is stopt, & this will be known by an equal Pulse, & Strength. no Hiccups &c. & no loosing strength. The most simple Method is to lay the Patient so that the Wound may be depending, then the blood may run out at the Wound if it is large enough. If the Wound is not large Enough we must dilate it, least the long pressure impede the Action of the Lungs, and bring on Death _ These Evacuations may be helped by binding the belly w.th A belt; to press up the Viscera on the Diaphragm, & to make strong Inspiration. It has been proposed to throw in A Mild, Saponaceous Injection, to dilute and mix w:th the Blood by the Action of the Lungs, As A Mild Decoction of Mallows, w:th Nitres Soap &c. Where the Orifice is oblique and the Wound can’t be dilated, it has been proposed to introduce A pipe round at the end w:th holes to suck out the extravasated Fluids. If none of these will do, The Operation of the Empyema must be recommended to let out the Matter or Blood, It has been said, we should make the Orifice between the 2d, or 3d false ribs reckoning upwards, but the Diaphragm is often connected here, therefore between ye 5t: & 6t Rib is most advisable, see Sharps Surgery who discommends this Operation, because it may occasion A dangerous bleeding by unstopping the Wound or that Blood will (75) be spitt up by the Trachea, or be absorbed & carried by some other way. Yet when the Patient is much oppressed & the Lungs much impeded. Especially if the wound is obliq the Operation is adviseable; least the Matter grow Acrid, & Corrode the Viscera. Or is absorbed & causes A true Phtisis without previous ulcerating the Lungs. When the Operation is made & the Blood begin to be evacuated, (or Pus) we must make A pressure on the Abdomen, to press up the Diaphragm & Lungs, least the immediate loss of pressure, should cause A Syncope; & it may even be adviseable to evacuate the fluid, at 2 or 3 times, & This reduces the Case, to that of A simple Wound. In order to know if the Thoracic Vicera are wounded we must examine ye Instrument, & it may be known by A Candle at the Wound, or by the Patients spitting blood, that the Lungs are wounded. Wounds of the Heart and large Vessels are generally Mortal, and Wounds of the Thoracic Duct will cause an Extravasation of Chyle into the Thorax w:ch will be known by Chylee flowing from the Wound, but this can hardly happen without death, as it lies so close to the Aorta, Vena Cava &c. Yet some instances are given as in Bonetus, where this has happened. We must endeavor to prevent Fever, & bleeding, by Venae Sectio &c and keep open the Orifice freely, ‘till the internal Wound is healed & discharges no Matter or else we shall have A Collection of Pus in the Thorax w:ch will require the Operation for Empyema, if the discharge 85  (74) 86 is very foetid, we may make use of some digestive, or Antisceptic Injection, of T.r Myrrhee: Bals: Copaivi, wth Mel Rosar &c. but we must not inject; unless there is A free depending Orifice, to let it return. A gentle Astringent may be used if the discharge is too great. Wounds of the Œsophagus are known by the Meat & drink being discharged into the Cavity of the Thorax. The cure must be trusted to Nature & the Patient must be Nourished by Broths & Clysters. Such Broths as will not irritate the Lungs if extravasated. It may happen that the Patient may recover- Lecture the 16th. Of Wounds of the Abdomen which are simple, only dividing the Integuments. 2dly: Those that penetrate into the Peritoneum & 3dly: such as wound the Viscera, & the Kidneys may be wounded without going into the Cavity of Abdomen. And the Nature of these Wounds must be judged of by the Instrument that made it, & by this looke of the Wound dilating w:th the Finger, & searching w:th the Probe and injecting Warm Water, in short the same Methods nearly as recommended in treating of the Wounds of the Thorax. We know by the sight of the Wound & Viscera being seen through or coming out, and by ye resistance to the probe, Injection &c: We know also if any particular Liquors of the Viscera, come thro’ ye Wound that the parts within are hurt. As by Galls Blood, Faces, Urines Chyles &c We must judge also (75) from ye Symptoms. External Wounds of ye Teguments are merely Simple, & all of these Wounds that do penetrate or not require Care & Bandage, least ye Teguments be weakened & tho’ the Peritoneum be not cut. Some of the Intestines will come thro’. Wounds that do penetrate, and wound no Viscus have the same Symptoms as the simple only that the Intestines will protrude, & we must immediately return, reducing the Air with the hand or pricking the intestine w:th a fine needle, but if there is A Strangulation we must enlarg the Wound to remove the stricture & return the Intestines taking great care not to wound the Gut, using A grooved director or your finger to guide your Bistory. The Omentum must be reduced in the same manner. And of this or the Intestines are mortified we must cut them away, but we must never be in A hurry to take them off, as the Warm Fotus of the belly when the Gutt is returned has often recover’d them when tho’ to be mortified. When the Intestine is replaced, sew up the external wound w:th the Interupted or quill’d Suture w:ch is prefered, & heal as fast as possible, & always make the Patient wear A Bandage ‘till the part is firm as before, Le Dran says we ought to deviate from the Common way when the wound is above ye Musculi Rect. Abdom, & open the sheath at its upper part whether the Viscera are wounded or not, as he says Cases have happen’d where the Intestine has been strangulated, betwix the Peritoneum, & Rectum in its sheath after the Wound has been outwardly healed. 87  88  (76) 89 We must bleed freely for fear of Inflamation in these Cases. Wounds of the different Viscera are generally known from ye knowledge of the Anatomy of the part, the direction of ye Wound being known. Yet there are same particular Symptoms. As the diaphragm being wounded gives great pain, by its notion inflaming the part, & brings on Hiccups, and as Le Dran says Risus Sardonicus. And perhaps by the action of this Muscle, ye Stomach or other Viscus is forced up into ye Thorax, oppressing the Lungs and hindering Respiration & having many other bad Effects. This Dr Monroe has seen thro’ A Natural hole in Diaphragm in Foetusses. Wounds of the Liver have A little peculiar, The Liver is not very Sensible and Patients have often recovered after a loss of its substance A Wound into any of its large Vessels will occasion A fatal Hœmorrhage & if the Gall Ducts are wounded the Blood may flow into the Duodenum & so pass by the Anus. The Gall may come thro’ the External Wound & the Duodenum being deprived of it, the Patient has dyed for want of Digestion _ Wounds of the Spleen are not dangerous except from Inflamation & Hœmorrhage, it being sometimes taken away w:th out any Inconvenience from Brutes. The Pancreas can be known to be wounded only by its Situation. In wounds of the Kidney there may be A great flow of Blood into the Abdomen, but if the Wound is given backwards and does not penetrate into the Peritoneum the Blood will be transfused into the (77) Cellular Membrane at the External Wound. An Ischuria generally happens from these Wounds. Wounds of the Mysentery give great pain by its great number of Nerves, ye the Lacteals are cut the Chyle flows thro’ the Wound &c. Wounds of the Bladder are known by ye grain in making Water, & by its coming thro’ arterial Wound. Wounds of the Stomach, are known by the Aliment coming thro’ the Wound. Wound of the Intestines are known only by their protruding, or by Blood coming thro’ the Anus, & Wounds of the Uterus are known by the Blood coming from the Vagina, in these Wounds we must bleed freely to prevent A large Inflamation & Suppuration, &c use A Mild Diet &c. And this is the chief we can do in the Wounds of these Viscera, & to keep the orifice open for the exit of Blood & Matter ‘till the parts below are quite heal’d and Clear. Yet in Wounds of the Intestines, or Alimentary Canal some what more may be done, giving the Patient A little or no nourishment by the Mouth & giving Glysters to Nourish &c. And when the Stomach is wounded we must enlarge the external Wound so much as to come as to come stit, & stich it up by the Glovors Stich, & sow it to the side of the External Orifice, ‘till the wounded Stomach adheres to the Integuments & then the Thread may be drawn out, and the same Method must be used where the Intestines are wounded without loss of Substance, when there is 90  (78) 91 loss of Substance from A Wound or Mortification by strangulation, we must put the upper Gutt within ye lower & stich them together, or Cherrington has proposed putting Tallow, or what will melt in the Abdomen within the Intestine & sowing it in that manner to keep them distended. Where there is no hopes of the Gutt uniting then the upper Orifice of it must be sewed to the External Wound, to serve as An Artificial Anus, w:ch will do only where there is length of Intestine above, enough to take up the Chyle but this must not be done where the other end of the Gutt can be got at. Wounds of the Bladder may be sew’d to the External Wound in the same manner as the Intestines, but we see them heal every day w:thout this Suture after Lithotomy – Diseases of the Bones - The Bones serve as Sutures to ye soft parts, & are compos’d of regular Lamellæ, ye exterior are firm, ye Interior A kind of Lattice Work call’d Cancelli. Bones are affected with Inflammation from internal or external Causes, either in their own substances or Periosteum, they have the same Symptoms, as Inflamation of the soft parts, & requires the same regimen, & Evacuation ought to be us’d more freely here, as Suppuration would here be of very bad consequence, as Suppuration always brings on A Caries, wch Suppuration is known by Pain (79) Throbbing, & Inflamation, & by the Pain abating by sense of weight, & cold shiverings, as in other Suppurations, & Incision ought to be made directly into the pa before the Caries is large & the Sore may be healed were without any sensible Evacuations of Pus, as in the Inten Paronychia, where the Matter has rendered ye Bone Caries it must be treated accordingly. Where the Oily Liquors or extravasated, it grows rancid & fœtid & discolours the Bone brown, black & yellow, & the Matter that flows too the Vis & smells fœtid and is greasy. While the Bone is Can. the external Wound will not heal, or at least will brea out frequent ‘till the Bone is cleansed - Lecture the 17t - The Caries of Bones are of two kinds, the Dry & the Worm Eaten. the first is firm & without Matter, The Second rough & spongy & has Matter. When the bone is firm & smo & has no matter as in ye dry, the Exfoliation soon comes on & a a sign of exfoliating you see matter ouzing on ye sides of ye Bones, and you hear A hollow sound by strikeing wth A probe and at length on the sides & bottom flesh granulates & thru out the carious plate. It is observable that the true Cure of Caries is when flesh grows out from all the bare surface of the bone, & that wch shoots over & meets from ye sides as perforations as in Belloslys Leaves the bone adhering loosely to ye flesh & there is no cure made 92  (79) 93 When the Caries is Cavernulous as worm eaten & swelled out & runs a good deal, as in the Worm eaten, here there is no Exfoliation comes away but insensibley, unless you break away ye fungus of the Bones that is hard & reduce to ye former Caries, A deep seated suppuration of the Bone is not known of for some time, as in the Jaw after tooth Aches & whole Jaw is corrupted before the matter points outwards, as they are more Spongy its spreads faster thro’ the Cells of the bone & makes the whole carious to the Joint. We must enquire whether these Suppurations arise from A Topical cause, or from the habit of the Juices in generall. We must make use of A proper mild diet. We must 1st. endeavour to leave A free Externa opening into the Bone. If in the Dry Caries by the foresaid mark if we see no Exfoliation coming on, Nature itself will do the business, w:th Mild dressings. If the Pus be of too small quantity we must use digestives. But where there is no sign of Exfoliation coming on it may be adviseable to apply A Caustic, or Cautery to make A complete Gangrene of the Bone, whereby the rotten Vessels will seperate from the Sound. If the Caries is quite thro’ so that A Caustic can have no Effect, then we may strike w.th A Mallet or make use of A Chisel or Trepan sometimes the cure has been made by taking away all the middle of A long bone, & sprouting flesh from the two ends fill’d up its place & hardened so as to suffer the Patient to recover & walk, where the Tibia had been affected (80) but for the most part when the Bone is wholly affected, Hectic Symptoms come on from Absorption & the bone is [cross out] affected taken away, nor can we wait for an Exfoliation, we must then we can take off the Limb. We see then the Intention is to give free exit to the Matter to prevent the Disorder spreading, to bring on Exfoliation &c, and if the Caries as Worm eaten, we must distroy or remove the fungus or Honey comb like substance before there can be Exfoliation. Where there is A Caries liqur in the Canca if you make an aperture into it, for Natare to give A free exit to the Matter it will sometimes run itself off, by the external Orifice & a Cure will be made. Where the Cells of the Worm eaten Caries are filled w:th Spongy flesh we must destroy it with Caustics, Cauterys, Chesils &c and finding the surface affected below, an Exfoliation will come on. Caries from Lues, or Scurvy must be treated in the same manner, at the same time curing the original disease. There are Schirrhous & Cancero Caries w.ch must be cured by Amputating, as like the Schirrhous & Cancer in ye softer parts & if they can’t be brought to Suppuration we must use the same precaution against the return of the disorder as in the soft parts. The Cancelli of the Bone resemble Cellular Membrane & therefore Suppuratio between the Lamina will make one Tube seem inclosed in another & Cancelli will be seen in the Bone that is naturally Solid. And A pulsation in Bones will be seen from A little Artery creeping into the Bone. And A Hœmorrhage 94  (81) 95 may proceed from cutting Bones & their fungi, as they are very vascular and may require the Actual Cautery or at least strong Caustic Sp.ts - Inflamations in the Frontal & Maxillary Sinuses – Inflamations of the Frontal Sinuses, cause great pain from the sensibility of the Membrane lining them The usual Antiphlogistic method must be used, and A warm steam of A fotus by the Nose. Where the Bone is carious we must trust the Cure to nature. The disorder has been cured by Sneazing & discharging Blood & Pus by the Nose. Worms or Insects sometimes get into These Cavities and almost make the Patient mad, w:ch have been discharged by sneezing. The length of the Disease distinguishes it from Acute Inflamation, & we may suspect that there is Suppuration or Insects &c Littor in the Memoir of the Academy of Sciences proposes to pour Oil into these Sinuses to kill the Worm &c and it will putrify and come away. We ought not to lay open the Cavity, if we can avoid it, but must do it if it is the only chance left, but must take care to keep the Air from the Membranes, Inflamations of the Maxillary Antrum acquire the same treatment as all Inflamations. These frequently terminate in Suppuration but are often mistaken for the Tooth Ach, & to distinguish, if there is no Carious Tooth we may suspect the Antrum (82) and by its schiation we may conjecture, and it is A sure sign if by ye head Matter flows into the Nose. But if we can’t determine by this we may examine if the bone is swelled on the pain’d side, and if there is A Suppuration on the Teguments by the passing A probe into the Sinus. We must endeavor to cure this disorder by Compress Method, i.e. by drawing the 3d Dens Molaris & penetrating quite into the Cavity w:ch will give A free exit, to the matter and Inject Mel Rosar, & Aq Calus; or some mild Digestive. The Teeth are very often Carious & when there is an Inflamation without any external Injury we ought to use the Antiphlogistic Method tho’ generally neglected, Some make use of Lead to stop the hollow of the Teeth, Others burn the Tooth, or use Warm Aromatics but without Success, Burning ye Lobe of the Air w:th A red hot Iron if it freghts the Patien it cures the pain, Carious Teeth will breed Ulcers unless they are pull’d out - Lecture the 18 Of the Diseases of the Bones – They may grow soft and this is from A Cause that weakens the whole body & takes away their hardness and firmness. When this proceeds from any Disease, you must apply to the original disease & make use of all Medicines proper in relaxed Solids, when the original Taint is removed. 96  97  (83) 98 these Cases seldom admit of A cure because the disorder is so far advanced when the bones are thus soft. Bones are very brittle in Old People by their natural decay of Moisture. The Lues Venerea or Scurvy &c will also make the Bones very Brittle, these are subject to break their bones by the least Accident. The Brittleness in younger People is owing to Diseases that waste the Marrow and make it thin and Acrid. We must in the Cure first remove the Original Disease & then we must use the same Method nearly as in the Cure of the Rigid Fibre. Bones have Excrescences from their Surfaces when the Tumour is shooting out from the Bone itself it is call’d Exostosis, when it’s like A knot it is call’d Nodes, When like A Chalks tone, Tophes and when Inspissated Extravassation, Gummas. The harder Tumours are the bony fibres them selves, but they Softer are owing to the Liquors extravasated between the Periosteum & Bone, or in the Periosteum itself. Accidents will give rise to these Tumours, tho’ they generally arise from the Lues. When they come from Accidents we ought to use Discutients &c as in the fleshy Tumours, it is soft & recent it may be thus overcome. If it can’t be got the better of we must then take it off by Amputation & treat it as A Bone that is wounded. If it is of A softer kind it must be opened Immediately on feeling the fluctuation & we must treat it as An Ulcer w.th A Caries. When the Tumour is small & does not increase & is no (84) Inconvenience, especially if it is An Exostosis of the bony fibres we mush like a bone. When they proceed from Diseases the Cure of the disease often cures them, but if not as in the Lues Venerea we must break them in the Manner as above. Fractures are either Simple or Compound & these other transverse, Oblique; or Longitudinal. The Effects of all Fractures are Contusion & Laceration of the Neighbouring parts &c When A Suppuration comes on you have An Ulcer w:th A Caries complicated wth A Broken Bone, Splinters of Bones when shatter’d are to be taken away if loose, or cut w.th A Saw if they are not loose. When great pain & Convulsions attend fractures &c After bleeding &c we must give great Doses of Opium, of wch 1 g:n in 2 hours has abated even the Lockt Jaw. When A fracture is near A Joint we should take care least when the Callous has begun to unite, it should shoot out & make An Anchylosis, by moving the Joint & using Emollients to it to keep the Motion easy. This may be judged of by feeling the Callus & the Situation of the Joint. Young People are in danger of too soft and luxuriant A Callus & therefore require dry Drick, & Spirituous Fomentations & tight bandage. To Old People who are liable to have too Little Callus, we must give nourishing Moist Diet & gentle bandage, & Emollients. Women pregnant it is said by reason of the pressure of the Uterus retarding the free return of the Blood, have not so ready A Union of the broken bones, as we see they have Œdematous swelling of their legs- 99  (85) 100 Lecture the 19:h – On Luxations – A Luxation is when the extremity of A bone receds from its place by some External Agent. Luxations break or extend & relax ye Ligaments, they bring on Inflamations, Palsies, Aneurisms, & Convulsions. The Prognosis is different according to the situation of the bone luxated. The first thing to be done is to remove the head of the bone into its place. In the Os Humeri: we are sometimes obliged to use Petetts Machine to make sufficient Extension. In some The Os Humeri after often replacing is apt to slip out again by the luxaty of the Ligaments: We must be careful not to let an Anchylosis form for Want of motion, Pumping Warm Water on the part will soften & at the same time strengthen the Ligaments; When the Bone is out for two Months or above the Prognostic is bad, as the Cavity is filled, & the Extremity of the luxated bone has shot out into Angles, & roughness w:ch prevents its return. Of Curvatures of the Spine wch often happens to children, yet if recent may be cured. It depends on whatever can make the Cartilages, Intervertebrates, or the Vertebræ thicker on one side than on the other. Owing to Habits of pressure, thinning the Cartilages on one side & thickening on the other. And we see that Children (86) who are curved on one side, are so on the other, as they endeavour to keep the body in ballance. Sometimes when the Spine is much curved it presses on the Spinal Marrow, and destroys all Sensation below & the Spinal processes, may be so destroyed as to form A kind of Luxation & greatly hurt the Integuments. We must make A pressure upon the convex part w:th Compresses & bandage, or by A counter pressure from the posture, & the Concave part may be kept free. The Typhoid Cartilage when it rises outward may irritate the Teguments & cause An Ulcer & Caries It may proceed from An Original Disease [cross out] or it may arise from A Tumour Dropsy &c w.ch must be apply’d hardy it has made its way so far that it can’t be brought back by pressure it may be cut away. When it is drawn inwards, Especially if it is Ossified, it occasions A difficulty of Breathing, from the Diaphragm not being stretched, & it may irritate the Liver & Stomach & cause great pain & death. We may relieve this disorder by pressing of the Abdominal Viscera w:th A Bath: if it comes from A fractu or reluxation, the Ligaments are subject to Inflamation & these generally turn out bad when they come to Suppuration, for when the Capsula is spread there flows out A Sinovia & the Air makes the Bone carious or at least makes it shoot out & form an Anchylosis - 101  (87) 102 In Opening these Capsulæ we must make A very gentle and carefull Opening & take care not to let the Patient move his Limb. We must be careful in taking out the moveable Cartilages that we do not hurt the Lig.ts more than is necessary, as it has much Endangered the Patient, & in all Openings of capsular Ligaments. The Method of treating these Inflamations, is like the rest, but the Opening must always be made very small & Rest must be prescribed. If there is not A flow for the Matter by reason it can’t be got at, it will cause An Incurable Hectic. Internal Diseases are of the same kind to External only they can’t come under the notice of the Senses - Of Fevers - A Fever is an accelerated Motion of the Blood according to Sydenham to preserve health, & throw off something noxious. It begins w:th Cold & Shiverings, suceeded by heat and evaporates the fine fluid parts. The Fluids by their quick motion tend much to the putrescent. Fevers may obstruct Vessels or may dilate others & so bring on many Symptoms. Fevers may prove fatal by unfitting the Blood for Circulation or by obstructing or distroying principal Vessels. They may terminate by matter falling on some particular parts, or Eruption on the Skin, or swelling of the Parotid Gland - Van Sweiten thinks by the sudden formation of these abcesses that Fever (88) forms something in the Blood like Pus. Fevers end by the Circulation assimulating the Febrile Matter or by taking up the Obstructed Matter & making it fluid & throwing it out sensibly or insensibly. A Fever may spring from infinite causes. Ex Gratia: such as may cause A greater Velocity of the Blood as the Passions, Exercises &c without any Fault in the Solids & Fluids. 2:oly Such as can stimulate the Fibres & encrease the Oscillatory Motions of the Vessels, As Blisters, Acrid Substances of the Primee Viæ. And by Such Acrid Fluids as are taken into Blood & are unfit to circulate whether taken Externally or Internally. These stimulate the Vessels to A Fever ‘till they are either thrown out or deposited or render the Fluids unfit for Circulation. The last Class is Obstruction w:ch encreases the Motion of the Neighbouring Vessels to overcome it. The first Intention is to remove the heat & prevent the too rapid Motion vitiating the Fluids & destroying the Vessels so as to bring Death. Lecture the 20t - Secondly to remove the Cause 3:dly to assist Nature to throw it off. 4:thy to obviate any occurring Symptoms The first Intention must be answered by supporting the Patient w:th food that does not tend to the putrescent as Panadas &c. If the Fever has emissions &c it is best to eat at that time. The Drink should be oft Saponacious Nature to wise w:th the Oily Fluids & Anteputrescent. The Fat is observed in Fevers to blunt the 103  (89) 104 Acrimony of the febrile Matter & mitigates the disease. Such are Hydromel, Lemonade, Sugar Liquors & Apple Water, mixable wth the Juices. People in Fevers ought not to be kept too Warm, as it encreases the Acrimony, Heat, Velocity, & Thickness of the Blood by dissepating the fine Juices & we must not expose the Patient to A great degree of Cold w:ch condenses the Fluids and contracts the Vessels. Violent Passions & Motions of the Blood encrease its Momentum, and encrease the Fever, In the begining of Fevers it is mostly necessary to bleed, as the encreased heat & Moment of ye blood, rarify’s & fills the Vessels, so that the Vessels of Absorption can’t act freely & the fluid particles are dissipated, & There is no Room in the Vessels, for food & dilution by this we prevent the Vessels bursting & give them liberty to break down the obstructions by their free Action. We should lways cleanse the first passages in the begining of Fevers least the putrid particles be taken up by the Lacteals & ther Absorbents, & this must be done by Emetics & Purgatives, but this requires the same Caution as the Lancets :ly to remove the Cause if known tho’ this seldom known. The cure of Fevers from Motion requires rest: & from Passions, Calmness, & sometimes Anodynes & Opiates. If it proceed from Heat, by diluting the Heat w:th cooling Medicines bring the Air &c. If proceeding from Acrid stimulating tings whether externally applyed, or lodged en ye Intestinal (90) Canal must be removed. Aloes applyed to the Leg has caused purgings, Opodeldoc, & Blisters have sometimes encreased the Symptoms in low Fevers, & Caustics will for a long time keep up the Fever perhaps, but this must be other taken away or counteracted by Acids, if Alkalies & Vice Versa The effects of A Debauch of Wine &c is best convey’d off by diluting & lying in bed to soak it out, or give A Vomit & Purge if this don’t do – Sharp Resinous Particles should be sheathed & blunted by Oleaginous Drinks or Glysters of if not Purgative, it may be carried off by A Purge _ Mineral Poisons should be counteracted wth Oil both to make them Vomit & prevent the Saline Spicula, Vitiating the Fibres and after this some gentle solutive to evacuate the remains- If Narcotic Plants are taken down soon give A Stimulating Emetic as Ipecacuan, Vitriol: Alb: &c & Stimulating Purgers. When Particles are mixed with the Blood, as by Absorption from Foul Air w:ch would vitiate it & destroy the Vessels, we must remove the Patient into A clear Air, & we must purify the Air & make it as clean as possible, by opening Windows & washing w:th Vinegar & burning Aromatic. The low Effects of the Absorbed particles must be counteracted by cooling Antiputrescents, both as food & Medicines _ Fibre is A Cause of Particular disorders in Some Particular temperatures of the Air w:ch can’t account for as it sometimes generates ye Small Pox, Sometimes Measles, Malignant Sore throats &c When Putrid Food has generated 105  106  (91) 107 Disorders it must be left off, and the Passages cleansed _ A Fever from [cross out] the Absorption of [cross out] Acrid Matter or Pus situated in any part of the body must be let out. If Fevers arise from any habitual Evacuation being stopt as Perspiration &c. must be cured by bringing on these Evacuations, but Sweats forced out in the begining of Fevers &c only dissipate the fine Fluids & waste the Patient_ A Suppression of Urine must be cured by Warm Fomentations & Warm Baths & diluting, Warm, Liquors & all Medicines that promote this Secretion, but when it depends on Inflamation of the Kidneys, we must use Antiphlogistics. All our Fluids by Circulating become Acrid therefore need A Supply of new Juices – We must keep A due degree of Fever to assist nature to do her Work, but we must take care not to let it rise too high – Lecture the 21 - The first Symptoms that attends a fever is Cold, with A Pale countenance & Urine, this Cold can’t be accounted for, unless from some Acrid Particles obstructing the extreme Vessels ‘till the Arteries overcome it, but it seems rather to be A Spasm or Contraction upon the Vessels, by new particles mixed with it, as we see after A full Meal on the Chyle being absorbed. And we see something like this before (92) the Crisis of A fever & the pale Urine seems to confirm this by the Vessels being constricted so as not to suffer the grosser parts to run off. And the Blood not circulating freely by reason of this Spasm A sense of general rigour & Cold is generated, there is frequently an Intermitting Pulse or Slow because the Heart finds difficulty to overcome the rigidity of the constricted Vessels. The colour of ye Skin depends upon the constriction of ye Vessels not admitting red blood so freely. The shivering & Rigor is said to be owing to the irregular determination of the Nervous Influence but it rather seems an Effort of Nature to carry on the Circulation w:ch is now in danger of being stopp’d, for Nature always acts thus Involuntarily, as in dying. Animals we see the most powerfull Convulsions. The greater the Shiverings are the more are the Particles unfit for Circulation & the Spasms & Rigors are greater. Hot Medicines & Stimulants are not masses as they drive forwards the Blood into the small Vessels & often cause obstructions, & do not dilute the Febrile Matter & carry it off & often bring on Acute Inflamatory disorders. It is proper therefore to dilute the Blood w:th thin Liquors & gently Warm, so as to relax them when the Cold Fitt is violent, & Frictions to promote the Circulation. But if there is also depressed pulse & a Pethora, then we must bleed to empty the Vessels & encrease the force of the heart. When at the end of A fever Nature makes An effort to throw off, the febrile matter by A cold fit & Spasms &c, we must then encourage the Vis Vitie w:th Cordials &c. But when 108  (93) 109 it proceeds from weakness & A lowness after A Fever, it must be cured by Cordials, Nourishing Food &c. The Cold in the begining is succeeded by A quick pulse & heat above ye general degree of the Body’s heat w:ch attends thro’ the whole fever, & this seems to be from the Obstruction of the smaller Vessels the Irritation of the Acrid particles stimulating the Heart & Vessels more strongly to overcome the Obstruction & the Blood is carried very quick thro’ the Arteries & so on by the returning Veins & then the heart continues. The Heart will be greater as it tends the more to the putrescent, & the greater the Obstruction & Spasms are the greater is the heat and Vice Versa, & the greater the heat is the more the Blood tends to putrefaction. And the Oils are taken up & the Fluids are dissipated, & the Blood becomes more thick, & the Serum is so coagulated as to be ahead of Jelly when not circulating, hence we understand how the Urine is sord’d during the encreased force of the Heart &c. Why A great inward heat about the Pericardia is reckoned A bad Symptom, when the External parts are cold, because it argues an Obstruction there w.ch will probably bring on death. Bleeding in the beginning of Fevers is the first thing to abate the heat & Circulation & give room for Dilution & prevent dissipation of the fine Fluids, Density of the Blood & Obstruction of the Vessels And Diluters are necessary to overcome the Acrimony of the Fluids & relax the Vessels to enlarge their diameters &c And Medicines w:ch make the Blood thinner & abate the heat are 94 proper as Neutral Salts & Acids w:th the Saponacious diluting Liquors. And A gentle Purge to evacuate ye Saburra of Acrid Bile & Putrid [cross out] Flows &c. w:ch would be absorbed. Warm Baths tho’ they encrease the Heat & [cross out] Circulation for the time yet they relax the Fibres much & weaken afterwards therefore recommended by Boerhaave but seldom practiced. Opiate are generally prejudicial in the begining of Fevers, but if there is extreme restlessness after Evacuations, we may then venture to give it. A Thirst generally attends Fevers either from ye Obstructions of the fine Vessels of the mouth or by A mixture of Acrid stimulating particles w:th the Blood for in health tho Vessels exhale A thin Liquor to moisten the mouth &c. And the Diluters carry off the vitiated Fomes w:ch by its ferment would Assimulate the Blood, & make it Acrid & Putrid. There is a constriction of the Vessels in Fevers w:ch lessens the diameter of the Exhaling Vessels of the Mouth. In Putrid Disorders, the Patient may be indulged w:th Cold Liquors, rather than in Inflammatory. Cold Liquors by Gangaryzing, & the Steam of Warm Water will soften the Vessels of the Trachea. When the Patient can’t or won’t drink, Warm Water may be given as Glysters so as to be absorbed, & dilute the Blood Fomentations & Baths furnish A diluting Liquor by the mes Bibulous Veins of the Skin. Thence A Warm Bath when the Patient will not dilute, may be of great use 110  (95) 111 And sometimes Thirst requires A stimulating Drinks to encrease the flow thro’ the exhaling Vessels. The Pain in Fevers is owing to either some Obstruction of the Vessels w:ch encrease according as the Vessels are nearer being ruptured. Or it is owing to the Encreased Heat, Rarefaction & Circulation of the Blood, & as the Nerves, Spinal Marrow & Brain are composed by the most Sensible fibres we must frequently find these are affected w:th Pain. Opiates as they do not diminish the cause of Pain in Fevers, can’t be proper in Fevers 'till after plentifull Evacuations. Weakness is another Symptom owing to the Vessels being over stretched & the Brains & Nerves are compressed & all the Vital Organs, & Functions are injured. And A foul putred Stomach will produce great Weakness & Langour. And the Chylopoetic Organs are weakened & the Diet is low, & Evacuations are all much encreased, w:ch is the Cause of increase of Weakness. The first Cure of this weakness is to cure the Fever by Evacuations &c but must always keep up the Strength so as to encourage A due degree of fever when it wanting - (96) Lecture the 22d - Anxiety, or the Uneasiness of the Breast w:th A Sense of Suffocation from the Obstruction of the Lungs from the too quick Motion of the Blood thro’ them, from Obstructions of the Lungs, or thickness of the Blood or from Spasms as in the Nervous Asthma. This Anxiety is said by Boerhaave to arise from the Blood being stopt in the Vena Porta, or its extreme branches instead of its returning to the Cava. Polypi may be formed in the large Vessels, or Obstructions in the smaller. When the disease continues long, the Cause has been removed. The Obstruction in the Lungs themselves is more dangerous than the thickness of the Blood, or Spasms of the Lungs. Boerhaave says A tension will be felt about the Region of the Liver, where the Aorta is obstructed, & this is not so dangerous, & the Suffocation not so great, as when the Lungs are primarily affected. The Cure must be according to the cause if it is owing to the quick Motion of the Blood, we must lessen the Momentum of the Blood, by bleeding &c. but when too thick Blood, is almost obstructed in the Lungs, it is more difficult of Cure but bleeding in this sizy state of the Blood is likewise necessary & plentifull Dilution w:th Saponacious Liquors, but when the Pulse is low & the Extremities cold, it is then generally too late for remedies, but the depressed Pulse will rise w:th bleeding. The Steams of Warm Water are usefull on those Obstructions to Moisten & relax ye Trachea & Vessels 112  (97) 113 of the Lungs & Cause A Secretion into them, the Water may be mixed w:th Spt. Mindereri & Vinegar. But when the Anxiety arises from an Accumulation of Pituit in the Cellular Membranes or Bronchii, then A Vomit will be of use by only we using them and encrease their Absorption, if the Lungs are not so Stuffed as to endanger Suffocation, & bleeding ought to be premised. And the stimulating Medicines as Squills & Ammoniac are proper here, & Blisters when the Pulse is sufficiently soft w:ch may act as stimulants, attenuation & Encriasers of Absorption. A Contraction of the Vessels or Spasms from acrid Matter may be helped by Warm Baths & Fomentations & diluents. Spasms in the Lungs in Hysteric Women or Hypochondriac Men ought to be treated according to the Cause as by removing any disagreeable Scent or Calming the Anxiety of the Mind or by ye Nervous Medicines. Stimulating Application externally & Opiates internally are usefull here. Anxiety may proceed from putrid Sordes in the Primæ Viæ irritating And affecting the Nerves. And here Emetics & Purges are proper. Nausea is a Symptom of Fevers & also Vomiting, the Cause of them are too great A fullness & load of the Stomach as Phlegm & Mucus, undulating in the stomach, & Bile or other Putrid Sordes irritating & distending, or relaxing the Stomach. Vomiting is A bad Symptom in an Inflammation of the Stomach. Affection of the Brain & Nervous System will bring A Nausea on ye Stomach, owing to the Nerves being effected at their Origin (98) & continuing the Sensation to the distinct branches. The Stomach may be affected by morbid Air taken in, or by the Juices, & Mucus being secreted into ye Stomach & stagnating & Putrefying these. The Cure must then be different accord.g to the Cause. If by overloading of the Stomach An Emetic & Purge. If they don’t increase too much the velocity of the blood in Fevers & endanger rupture of the small tender Vessels of the Lungs & Brain will be of Service. The same Method is to be pursued when the Stomach is filled w:th Mucus, & Phlegm, but ye Emetic must be stronger & the Purge of the warmer kind. And the Bilious & Putrid Sordes require the same Method, only that we must dilute w:th Acid & other Antiputrescent Medicines such as Cort. Peruv. or Serpent. The evacuating such Matter in the begining has often put A stop to Fevers as Sydenham observes in Epidemics _ so says Dr Pringle. When this Symptom proceeds from the flow of Morbid Matter that way, then whatever can abate the fevers will relieve this Symptom, as we see in the Small Pox coming out, the Nausea goes off, & in Epidemical Fevers a Sweat frequently carrys off the Nausea & Vomiting, but when it proceeds from Inflammation the Antiphlogistic Method must be pursued, & Medicines & Nutrements must be given hypsay of Glyster, or at least Cochloatine, least the Vomiting increase the Inflammation & bring on Death soon. In Schirrhi nothing can be done ‘till Death itself puts an end to this Symptom. 114  115  (99) 116 If it proceeds from the disorder of the Fauces, or Œsophagus, it may be treated as these diseases themselves & when it proceeds from Affections of the Brain & Nerves, we must apply to this Disorder in Nervous Nausea’s & Vomitings. Opiates are generally of the greatest Use. When A Nausea remains after A Fever, Aromatics & Bitters w:th Opium are the best Remedies, or Anodyne & Aromatic Plaisters to the Stomach, as Theriaca & Ol. Macia, Linums Saponac &c and Spt. Sal Aromatic &c and Riverius recommends the Saline Draughts even while they are fermenting, but if the Stomach will bear nothing, we must not irritate its Fibres, but leave them to recover their tone, by rest & have recourse to Glysters of Milk, Broth, Wine &c And sometimes after ale. The Patient perhaps has had A desire for some particular thing however seemingly disagreeable, & this As Oysters, Snail &c has cured the Patient - Lecture the 23 Sometimes there is An occasional distention of the Stomach & Intestines wth Air by its recovering its Elasticity, this may arise from A Sedentary life, or from Diseases of the Alimentary Canal, & its Liquors but sometimes without any Disease of these Organs, the Stomach may be distended by particular Food that contains it, Elastic it may be also from Spasms contracting the Intestines, and confining the Air in great quantities (100) This Distention of the Air causes Spasms of the Alimentary Canal, & where the air is confined, there arise Borboregmi. The Air is not sufficient to produce these Symptoms of itself. It must distend the Gutts & force out A passage. Air distending the Gutts often causes Anxiety & pain by over stretching after the Fibres. and they feel A Tumour at the Stomach especially after fermenting Liquors. A Fever weakens the Body, vitiates the Fluids & weakens the process of digestion & there is an Acrid Matter w:ch occasions Spasms &c therefore we have frequent distentions in Fevers. When this Symptom proceeds from bad Digestion & fermenting & putrid Sordes, w:ch serve as A ferment in the first passages, to assimulate other Bodyes, we must cleanse w:th Emetics & Purges & restore the Tone of the Fibres & healthy state of the Gastric Liquors, by strengtheners & Food that is nourishing & Light in small quantities. When the Bile is weak & effate by being vitiated, the Ox’s Bile w:th Soap is the best Medicine. In giving these Medicines in Fevers we must have a regard to the concomitant Symptoms. If the Fever be gone off, Exercise will greatly help the cure. When Unripe Fruits have caus’d this Spasm & Distention, we must endeavor to evacuate them by stool, or correct their fermentation by Bitters or Absorbents. When putrid Sordes are the cause, we must evacuate them & correct ye remaining Acrimony by Mineral Acids & other Anteputrescents. Spasms from Inflammation must have the Antiphlogistic Method. This Distention occasions A Spasm above & below the distended part 117  (101) 118 And therefore where we can’t perform the cure by Emetics & Purges & Bitters we must use Antispasmodics of w:ch Opium is the best. And stimulating Glysters as they encrease the peristaltic Motion downwards & remove the Spasm & Excrite the Fæces, are usefull. And Warm Baths & Fomentations & Skins of New Kill’d Lambs or Sheep to the Belly may be tried & Galen recommends Cupping Glasses to the Belly, Others Warm Plasters & Blisters After these disorders case must be had of A relapse, when this Symptom happens in Inflamatory Fevers we must not use stimulants. Some Foods will generate this Air, because they contain more Air & when the Fibres are weak, & the Bile & other Gastric Liquors are weak & Effate, the Food not being well digested ferments in the Stomach, or becomes putrid & lets loose A quantity of Air, w:ch distends the Intestinal Canals – We are said to be delirious when we form Ideas w:ch have no just Existance & act in consequence regardless of the Ideas [illegible] around us, & all Ideas are formed in the Brain. This Disease arises from the Brain or the Nerves being irritated, that communicate with it. Phlogosis of the Brain occasions Delirium but of this presently - Sometimes it arises from Pain in a particular part, or from Pus confin’d in the part w:ch irritate & distract the Fibres, & convey the sensation to ye Sensorium Commune, and the Matter may at ye same time be absorb’d to irritate ye Brain more. We must have regard here to the original disease cheifly we must endeavor to ease the pain (102) or we must discharge the Pus When it comes from A quick motion of the Blood, & its acrid febrile particles irritating ye Brain, as in Inflammatory Disorders, we must bleed freely & use gentle Evacuations of the Bowels &c. It matters not what part we bleed in. In this or any other case, so we do but take A sufficient quantity. Sydenham recommends shaving the head to encrease the perspiration, thro’ the Cutaneous Vessels. Blisters on the Head when the Patient is low & Warm fomentations have been usefull. Bathing the Feet has been said to encrease the flow of Blood, & Cause A greater dirivation of Humours, but this is hardly safe in A great degree of Fever, as it rarefys the Blood & gives it A greater Momentum. Cupping wthout Scarefication has been said to be of Service. Blisters tho’ good where Stimulants are wanted, yet encrease the Delirium when the Pulse is any thing hard, & pale, & Bleed:g has not been premised, they often stimulate & Attenuate the Morbid Matter & encrease the Actions of the Vessels to discharge it & themselves discharge the Morbid Matter. Opiates, tho’ much recommended yet in the beginings of Fevers are certainly hurtfull, but in the end when the Patient is restless may be used. In low Nervous Fevers the Delirium is obviated by Wine & Cordials w:ch encrease the Vis Vitæ, keep used Action of the Vessels & discharge the Acrid Matter by encreasing & helping the Secretions- Sinapisms & Blisters here are proper. When A Critical Sweat comes on we must 119  (103) 120 encourage it, & keep up the Patient, or when A gentle Purging that gives relief comes on, we must not check it perhaps give Rhubarb w:th Cordials &c. And when ye Urine deposits A sediment we must endeavor to wash the Urinary passages. When this Symptom arises from the stop of A Natural or Artificial Evacuation we must restore them or supply their places by others. Sometimes the diverting the Patients attention by Musick &c from ye present Ideas, has cured the Delirium. In generall the Patients Chamber should be kept Dark, but sometimes this will encrease the Disorder Wakefullness arising from the quick flow of ye Blood irritating the Brain & Nerves is often attendant on Fevers. If the pulse is quick & full we must bleed & use the Antiphlogistic method, but in the low Nervous Fevers & Putrid we must not be too free w:th the Lancet &c when this happens in the second stage of Fevers. Such Medicines as dilute & blunt the Acrid Circulating febrile particles are proper & all mild Liquors, and sometimes the fœtid Medicines. The Volatile Salts prove Anodyne, but we know not how they act whether by rarifying the Blood & lulling the Senses as by alaying the Irritability of the Nerves. Opiates towards the latter end as the 9th or 10t day are very successfull. Gaulinus recommends the Sal Sedativum gr & ii & it has been usefull. Blisters frequently are the best remedies & prove Anodyne either by removing Spasms Obstructions or encreasing the Vis Vitæ. Epethems of Camphor (104) & Wine & Cloths w:th cold Water to the new shaved head, & the smell of Saffron & Henbane & Poppies &c. Frictions may be used when the Vis Vitæ is low. Some have recommended ye tying Ligatures on the Extremities to divert the Humours to the Brain, & Boerhaave recommends the fall of Water in ye Patients Chamber - Lecture the 24th - The Coma or dosing sometimes w:th A real sleep, sometime without from the compression of the Brain or fullness of the Vessels & Obstructions, or from Emptyness of the Vessels where they are unable to carry on their Circulation thro’ ye extreme Vessels. The Cure must be very different as it proceeds from weakness or Plethora. In all Inflammatory Cases ye Antiphlogistic Method must be pursued, or if there is A plethora without great Inflammation, we must there use bleeding, & give A brisk purge to Empty the Intestines, to purge the Humours that way by its Stimulus, & Strong Glysters where the Load of Fœces obstructs free Circulation in these Vessels & keeps A constant Irritation are usefull. An Emetic sometimes after these means will by its shock propel the viscid Humours, & promote by its stimulus the various Secretions. A Patient w:th A Coma whose pulse beat only 80 so that the Fever was small was roused by An Emetic for sometime yet falling Comatous again & low Volate 121  (106) 122 Salts & Blisters & All Nervous Medicines signifying little An Emetic was repeated and he became better soon lost his Disorder. After Evacuations Such Medicines as stimulate & Attenuate viscid humours & promote the secretions, the Hausts Salin in: Conf Cardiac, The Sps. Minderei The Vol. Alkaline Salts, ye Antimonial Medicines &c The Dilutions made more or less Cordials should be given, to be taken up & intimately mixed w:th the Blood. Blisters as Stimulants & Resolvents are useful here after Evacuations. An Emetic may first be adminstred to cleanse the Intestinal Canals & lenitive purges. The Dr in Coma’s from Weakness, & Emptyness, after Blisters & Stimulants us’d for 8 days, found use from ye Extract of the Bark. A Coma from Weakness in the latter end of the Fever must be relieved by Blisters, Sinapisms & Cordials - Convulsions being An effort of Nature to carry on the Circulation, are owing to Irritation of the Brain or Nerves either from too great fullness or Emptyness, & to various causes as Acrid Matter, Inflammation Pain Suppuration, &c Convulsions are more dangerous in strong Men because it requires A greater Cause to procure them, less Dangerous in Hysteric Women, Hypochondriac Men & Children. Convulsions from Inflammation of the Brain are very dangerous & also from too great Emptyness. It is a bad Sign when the (106) Patient makes A very fine settling Urine & after that A Pale Urine without any settling, owing to A Universal Spasm retaining the Morbid particles & throwing them upon the Brain & Nerves & raising Convulsions, if these continu long the Patient may recover by Fevers’ continuing long to concoct the Matter. When A Topical Inflammation of y Brain or Spinal Marrow is the Cause we must use the Antiphlogistic Method. When from A Plethora we must bleed & empty the Bowels by A gentle Purgatives or Glysters. When there is An Acrimony of the Fluids, A Mild sheathing Diet will be usefull. And after Evacuations All stimulants as Camphor, Crocus, &c w:ch break down Obstructions & rarefy the Blood. Opium as it is A powerfull Medicine to deaden the Sensations of the Nerves & prevent Irritations is useful at the end of Fevers especially join’d w:th the fœted or other Stimulants. And Blisters are usefull to attenuate the sluggish humours & stimulate the Vessels & discharge any Circulating morbid Matter, Slight Convulsions of the face in Fractures &c generally proceed the worst Symptoms, as the lock’t Jaw w:ch is generally followed by death. A Stimulus to some particular part will often [illegible] A Convulsion when nothing else will, as A Cautery to the Ear cured A Convulsion of ye face Convulsions from weakness must be cured by supporting the Patient w:th Nourishing Diet, Cordials, Wine &c to fill his Vessels & strengthen him. Sweats either from too rapid 123  124  (107) 125 motion of the Blood, or from weakness of the Capillary Vessels, or from too easy Seperation of the fluid parts of the Blood from its constituent parts – Sweats in the begining of Fevers thicken the Blood and bring on Obstructions & other bad Symptoms & heating Medicines [cross out] should never be given to procure them in the begining. If this Symptom is accompanyed w:th Inflammation or Plethora we must bleed to abate ye Rapid force of the Fever & the Patient may sit up A little in ye day & ye Air cool’d in the Room, but this with caution & gradually. Heating things should not be drank & the Liquors should be in little quantity. When Sweats to proceed from Weakness & thinness of the Blood & Astringent Bitters [cross outs] Juleps w:th the Mineral Acid & Bark &c such as strengthen ye Fibres & restore ye balmy Consistence & Mildness of the blood. Malagal Wine says Sydenham taken morning & Evening has put a stop to Sweats in the night after Fevers – But where Sweating in Fevers gives relief & may prove Critical, we must then encourage it, by Cordials, Diluters &c _ and it is even - sometimes proper to force out Sweats by loads of bed clothes where there is A Nausea or Purging &c - A Diarrhea may be owing to acrid or putrid Sordes, as Mucus, & Matter absorbed from other parts & thrown into them, as in the Phtisis Pulmonalis, & frequently from Inflammation of the bowells & Intestines, or an overflow of Bile to stimulate the Intestines – If this happens in the begining (108) of fevers w:th A quick full pulse, we must bleed & not confine ye: pabulum Morbi by Astringents & Opiates, but discharge the Febrile matter by gentle purgatives & Emetics w:ch squeaze ye whole Abdominal Viscera & promote their Secretions & Diluters should be given to wash away ye Acrid purulent particles & this Symptom will generally cure itself by its continuance. Glysters will empty ye great Gutts when the Purges do not. The Vitr: Corat Antimonii & other violent Purges will empty the Intestines when others do not therefore so much esteem’d in Diarrhœas & Dyssenteries, but in Fevers ye mild Purges are the more proper. Van Sweiton says A Vomit given two or three days, even when the stomac is not foul, has cured A Diarrhœa, And after the Diarrhea is abated we must strengthen & appease the Stomach & Intestines by Mild Emollient Mucilaginous Medicines & gentle Astringents & Opiates & Anodynes. Dr Pringle says that the Absorbent powders in putrid Dyssenterys rather assist putrefaction & therefore improper. Dr Mead recommends Milk loaded w:th Balaustines, Rosen & Cort Granator - Cinnamon, & Lac Ferratum is likewise good. Absorbent Earths & Wax & Ipecacuan &c have been recommended, Glysters smooth & Emollient defend the Intestines & Involve the Acrid Matter better than Medicines by ye Mouth, during ye Use of Astringents & Opiates. Rhubarb should be often administered to cleanse away the remaining foullness 126  (109) 127 and putridity least the worst Symptoms are brought on as Apthæ & the Immediate forerunners of Death, We may check A Diarrhea by promoting A sweat _ but Diarrhea is often critical & carrys off ye Fever, yet when these become too violent & endanger ye Patient, we must y.en check it _ When it proceeds from An overflow of Bile or Inflammation & Suppuration we must encrease ye original Disease – Lecture the 25th - By the different Appearances of Urine we judge of the state of the Blood. A thin pale Water shews An easy seperation of ye Watry parts of ye ye Blood, or arising to much drinking, or to A too great cohesion of ye Oily & ye Oily & Saline particles of ye Blood, or from A Spasm of ye renal Vessels. The red high, coloured Urine is A Symptom of well mix’d Urine & of A great heat & attrition of ye Blood, when it deposits A brick like Sediment, it shews ye Spasm is gone off & is a good Symptom. Urine of A healthy Colour & depositing A white Sediment is A Symptom of A Crisis as ye Blood is no hotter than health, & the morbid Matter is throwing off - Yellow Urine shews A mixture of Bile as in ye Jaundice & bilious Fever- Bloody Urine, is either owing to ye great heat of ye Blood, as, to ye Renal Vessels emitting their contents, & is A lead Symptom. A Black Sediment like [cross out] (110) Coffee grounds without smell, from A relaxation of the Renal Vessels suffering ye Grumous parts to flow off, & generally brings on A wasting. Black fœtid Urine is A bad Symptom if putrid blood or A Gangrene in any part Urine w:th Pus shews an Abcess in ye bladder, Kidney or Urethra, tho’ sometimes it is absorbed from other parts. Urine w:ch when shaked keeps a foam atop, shews the blood to be of An Oily Saponaceous terrestrial Nature & shews A great degree of Fever. In judging from these Symptoms we must always compare them w:th the rest before we judge, As there is great variation in these Symptoms & no certain prognosis can be made from this alone. The Patients food & Medicines give the Urine A colour, as Saffron, Rhubarb, & Rhubarb is said to make An Intermission in the pulse. Tamarinds give it a greenish cast. And Ol. Amygd gives it A purulent Appearance. Asparagus & Cassia make ye Urine fœtid as in Gangrenes - Eruptions are an obstruction of ye Cutaneous Vessels & owing to an effort of Nature to unload ye Morbid Matter The Petechiæ are little Spotts w:ch appear on ye Skin, sometimes smaller, are reder or blacker & as they are more livid the more putrescent is ye blood. The Milliary are small little red, or white pustules, like pin heads, on ye Head or Necks, back of ye hands, or feet &c The white are more dangerous than ye red & both attended with profuse sweats - 128  (111) 129 Large Bladders on ye back or neck &c are not dangerous. Before these eruptions, ye patient finds some Anxiety especially in Malignant Fevers. Here it is proper to dilute w:th Cordial Liquors to wash ye pores of ye skin & let ye morbid Matter pass thro’. If the Fever is too high we must use gentle Evacuations _ We must not expose ye patient to Cold, so as not to drive in these Eruptions. Eruptive Fevers are to be treated in the same manner, as ye other. Sometimes after Eating ye poisonous Muscle Fish; a particular Eruption, is thrown out, w.ch goes off, in vomiting ye fish up: and after Crabs, Lobsters, or Butter Milk, when hot; such things have happened - Fevers are Epidemic, Pandemic, & Singular, they have been call’d Acute, or slow as they continue 20 days or more. The Antients had their critical ye 7th: & ye 14th day, 21st & so on, & on ye 4th: & 11th: & so on, The Modern Practice of bleeding, & purging, has made these Critical days uncertain, & the Uncertainty & differance of our Climate, Van Sweiton has often found their Critical days to be true, tho’ as often ye contrary - The most simple Fever is the Ephemera where ye Blood is not vitiated owing to too Violent Motion &c. or A quantity of Spirituous Liquors, or from A Cold. All required here is rest & diluting Liquors, Emetics & Purgatives tho’ sometimes bleeding is necessary. The continuance (112) more than A day, makes no change in their treatment- A Putrid Malignant Fever is when ye Crasis as broken down & ye blood tends to ye putriscent, it begins w.th shiverings & heat w:ch grows greater & has particular pungency when felt, attended w.th Pains of the Head, Back, &c Lassitude & Faintness, Vomitings & Poraceous Bile – the Eyes look heavy & after a little inflamed, & A Bloated Countenance. Their respiration is laboring & hot w.th A sighing. The head is soon affected w:th A Delerium, especially in an Evening. The Subsultus Tendinum is not so great as in ye low Nervous, ye Tongue is white at first, but grows blacker & blacker, w.th a great thirst, tho’ sometimes the Patient has none, wch is A bad Symptom of Insensibility, the Skin is generally dry & parched, tho’ there has been A bloody Sweat from ye Acille &c The Urine at first is generally crude & pale but grows higher coloured, & as if tinged w:th Blood, & at last towards ye Crisis it becomes black & fœtid. The Stools are generally very fœtid & green & A purging frequently comes on. Blood from these Patients tho’ florid, appear of A very loose Texture & much dissolved & black of ye height of ye Fever, & does not seperate but is quite A Gore, at ye 11t day or thereabouts Spots Appear on the Skin, the more florid the more faborable, than if they are variegated like Marble w:ch is A very dangerous Symptom The livid Blotches w:th Nausea, Bleeding from ye Gums, Anus &c running thro’ ye Secretory Vessels are of ye last Symptoms 130  (113) 131 At last ye Pulse flutters, Hiccups, Cold Sweats & Delirium encrease. A Coma comes on & death. But A Crisis may come on by A Diarrhea or Purging, or Urine, Rash &c. The Eruption about ye Nose & Lips, is a very good Symptom. The Sweats followed w:th Milliary Eruptions, are no good Sign: but such as are gentle & prove Critical, are a very good Symptom; tho’ they frequently prove violent, & sink the Patient. Foul Air, Putrid Water, & Food, generally give rise to these disorders; & it is generally propogated by A fever. The Liquors secreted from A vitiated Blood, & stagnating on ye Stomach, will encrease the disease. When the Crasis of ye Blood, is broke down; the reguritating Bile flows into ye Stomach, & causes A Vomiting: tho’ this sometimes proceeds from Inflammation. The Delirium & Wakefullness, owing to ye Irritation, of ye Acrid particles of ye Blood, on the Nerves & Brain, & the Heart being irritated, encreases ye motion of ye Blood. The Violent heat is owing to ye putrescency, & ye foulness of ye Skin, gums & is owing to ye grumous part of ye Blood, passing thro' ye Excretory Organs. The Anxiety is owing to debility. The Petechiæ are owing to ye Corosion of ye smaller Vessels; or to ye secretory tubes being lax. The Indication of cure; is to prevent A new Fomes, & to remove ye disorder, by free Air & proper Food, & Drink, to keep the Fever to A due degree, & bring on A favourable Crisis. After bleeding, (if Necessary) we must proceed, to cleanse ye first passages, (as ye Colluvies would encrease the Disease) by Emetics & Purgatives w:th (114) may prevent A fatal Dysentery: And this must be repeated, if there is A nasty taste, & Nausea; And Costiveness, or Griping, if ye Patient is not too low. If the Nausea does not go off by t:is method, we must use further Methods. The Purging is A very bad Symptom & sinks ye Patient. The Elix Vit. Tinct: Rosarum Saline Draughts wth Mithridate or Laudanum. Or A Cataplasm of Spec: Aromatic & Theriac & ye Ol Macis has succeeded, when others have failed, & also ye throwing up thin Liquors by the Anus, but if the Purging continues so as to weaken ye Patient we must use Astringents, After Rubarb has been given, but we must not treat ye Critical Diarrhea w:ch happens at ye decline of ye disease, & ye Patient becomes better by it. The Critical discharge is generally made by ye Skin, & when Nature seems to push this way, we ought to encourage her but not force them too Soon in ye disease by hot Medicines & bed cloths w:ch would weaken the Patient when ye Fever is low & ye Patient sinks fast & ye Blood is more dissolved. And we ought to keep up ye Vis Vitæ & prevent the pubescency by the Bark especially if there is A remission & ye more Cordial Remedies, as ye Rad Serpent ye Conf. Cardiac, Castor, Valerian or volatile Salts, Tinctura Rosar, Acids, Red Wine &c as Antepubescents The Food & drink should be frequently given, & in Tremors & Convulsions we must keep up ye Vis Vitæ w:th Cordials & the fœtids w:ch are Antiputrescent & Antspasmodic, but if ye pulse sinks we must apply blisters & Sinapisms. And as Blisters 132  133  (115) 134 by their absorption of ye Saline Spiculæ dissolve the Blood we should guard against this, especially w:th Camphor w:ch is supposed to prevent this, & as it is a good Nervous Medicine. And ye Volat: Alkal Salts, tho’ they correct ye putrescency in dead bodies, yet break ye living blood therefore ought if possible to be avoided if ye Pulse can be kept up without them Lecture the 26t On Low Nervous Fevers - This Fever is different in different People it generally begins w:th stiches ye first days, the Pulse is A little quick, ye Patient is not very bad for some days, has A heaviness rather than Natural asleep, they are better in ye Morning, & the Urine has a brick-like Sedemint, at Evening there an Aguish Paroxysm, & soon there begins A Stupor & Delirium. Sometimes it begins w.th Symptoms of Inflammation & ye Pulse is high & ye heat pretty great, but in A few days they become ascue before described stupid & Delerius, & by A Spasm on ye Vessels ye Urine becomes pale & ye Pulse is Soft & ye Heat is not great. In ye first stage they are very apprehensive of Noise or Light, but are presently deaf & quite stupid, they feel an Anxiety & Load on the precordia, & waste without any Evacuation, they have profuse Sweats about ye 10t. or 12t. day- They have sometimes A Looseness, but this sinks ye Patient generally. (116) The Tongue turns red & dry, & at last black & dry, & by their Delirium have no thirst. Now if there is no Crisis, the Symptoms, Subsultus Tendinum. the Pulse flutters & Intermitts, the Delirium becomes A Coma, & at last ye Convulsions carry them off, or A Coma becomes Death, when ye Crisis begins: there is perhaps A kindly Moisture over ye Skin, or A slight Purging. The Tongue moist & ye Urine settling or after 12, or 14 days, the Fever begins to be worn out, & the Patient recovers without any sensible Crisis. This Fever is generally in low Nervous People, who live low, it seems to depend on A viscidity & Siziness of ye Blood by w:ch they don’t circulate thro’ ye Extreme fine Vessels of ye Brain &c. There seems to be A struggle between Nature & ye Disease, by ye Several continued Sediments of Urine in ye 1st: days, w:ch is A kind of Aguish Paroxysm, when ye fine Vessels of ye head & Brain are affected it brings on by its Irritation A constant attention & Sensibility, ‘till ye Brain is so much Affected as to bring on A general Spasm, w:ch Causes A Delirium & pale Urine - this does not dissipate ye fine Fluids so fast as ye Inflammatory, or make the Tongue dry so soon, because ye small Vessels only are obstructed, the Anxiety is owing to ye debilitated Circulation thro’ ye Lungs – The Indications of Cure are to keep ye Fevers within due bounds & to attenuate & discharge ye Morbid Matter. If the Patient has Inflammatory Symptoms, we must bleed, but not if ye Patients is of A low Constitution. After Bleeding an 135  (117) 136 Emetic should be given to cleanse the stomach & give A shock to ye whole Nervous Symptom, but we must take Care it is not rough, or lies too Long on ye Stomach so as to act, as A Rough Hydragogue purge. After ye Vomit A gentle Purge should be given to cleanse ye Bowells, & Glysters in ye Course of ye Fever, made of Soap & Sugar – The Food ought to be in the beginning, Antiphlogistic, but in ye Course of ye Disease more Cordial w:th Wine & Spices – Temperate Cordials wch promote perspiration & rather encrease than diminish ye Vis Vitæ, such as Saline Draught, w:th Conf. Cardiac, Pulv Contrayer, Boluses wth Castor & Saffron & Volatile Salts if ye Patient is low, Mixtures w.th Sp.t Menderer, & Tinct Serpentar – The fœted Gumms & Camphor are of very great use, where here is great Confusion & Convulsions of ye Nerves – The Drink tho’ not so great as in ye Inflammatory or Malignant, yet should be sufficient to dilute, but we must be carefull of profuse Sweats, & not force them With a View of Milliary Eruptions w:ch tho’ sometimes Critical when not forced, yet when forc’d do no good, but rather much harm The best way to restrain Sweats is to make ye Patient sit up if he can without Sincope, & not overload w:th bed Cloths give Decoct. Cortic: wth Cordials, Elix Vitriol, & Red Wine, & keep ye body open by gentle Glysters toward ye end of ye Disease, & now if ye Patient is very restless, & Confused, A Gentle Opiate maybe given tho’ it would be very hurtfull at ye begining, & hurry on ye Symptoms Gaubius here recommends ye Sal Sedalin: w:ch is safer. When, ye Symptoms are much aggravated, Blisters must be applied (118) as A Stimulus & to attenuate & discharge ye Morbid Matter Blisters should not be applyed while there is A hardness in the Pulse especially to ye more sensible parts, as ye Arms & Back. They should be apply’d to ye head in ye begining as A less sensible part, & during ye Operation of ye Blister, we should make ye Patient drink plentifully & be carefull that they don’t run too much, as ye Scrum will sometimes weaken them greatly. Sinapisms may be applied, when Blisters would rank, ye Patient, Epithems of Wine & Camphor, to ye Arms when the Patient is low, by the Stimulus, & gratefull Smell, raise the Patient. If there is a Colliquative Diarrhea, we must check it by gentle Opiates internally or by Glysters. The Chalk Inless & Decoct Alb, & all cordial Warm Medicines. In the Subsultus Tindinum we give the Castor, Musk, Camphor, Fœtid Gums Volatile Salts, & supports ye Patient well w.th Wine, & w.th Spices & that plentifully if ye Patient is low - Ague or Intermittent is A Fever wth an evident apurexia or absence of Fever. The Paroxysm begins w:th Coldness Shivering & lividness of ye Nails, Pale Skin &c. The Urine is pale &c. The Patient turns warmer by degrees & the heat encreases, the Pulse is full & the Head Aches & the Urine is high coloured & at least A plentifull Sweat breaks out & ye Fever goes off. This Answers to ye several stages of A continual Fever. If this Fitt is not repeated it is not an Ague but Ephimera. They are Quotidian, Tertian, or Quartan, Quintan, & Sextan – These often change into the 137  (119) 138 Topical Inflammatory, or ye Low Nervous & again remitt, & at length Harm itt & become regular. People who have had Agues, are subject to them & Sweats that weaken. They are subject to windy Swellings in the Belly & to Obstructions & indolent Tumours, & obstructions in ye Several parts of the Body. The Antecedent Cause of this Disease is said to be A Viscid Indegestible Food as Crude, Farinacea, Accescant weakening Food is said to weaken the Body & dispose it to Agues And A moist Cool Air as well known to dispose to Agues. All these Causes vitiate the Fluids, some say by A viscid Pituit seperated in the Stomach w:ch is too Gross to circulate & acquires An Acrimony. Some have said it lies in ye Small Vessels of the Encephalon, but none of these seem to account for it. As they continue thro’ A Salivation & are so easily stop’d by ye Bark wth out A Sensible Evacuation. The hot Fitt breaks down the peccant Matter, & fits it to pass thro’ the Emunctories. If all the Morbid Matter passes off at once the Fever is cured. But if any remains, its serves as A Fomes to Assimulate A sufficient quantity so as to bring on A fresh Paroxysm, & this will be Quotidian, Tertian, or Quartans, & as there is more or less of A Fomes left. When there is no Excretion of A Morbid Matter by a regular Paroxysm. The Fever will be changed into an Inflammatory, or A Continued Fever. If the Capillary Vessels are large Enough, there may be A hot Fitt without A Cold one. Agues melt down ye Blood & leave great weakness even after ye Morbid Matter is evacuated (120) but if the Morbid Matter as impacted any where it will cause Obstructions, as Dropsy’s Tumours, Ague Cakes Phtisis Pulmonalis _ People in funny places have A Fever less violent but continue long & are difficult of Cure & bring on subsequent Diseases. Agues w:th short Intervalls are easiest of Cure & require ye Saline Draughts & cooling Remedies - [cross out] Lecture the 27t - Indications of Cure, is to avoid every thing that will encrease the disease A 2dly: to assist Nature in throwing off ye disease 3dly: assist Nature in altering ye Matter of ye Disease – 4tly: to remove or prevent any bad consequence that may follow them. We must be sure of Moist Air & Evacuate ye viscid Pituit in ye Stomach & not give viscid Austere indigestible Food in order to bring about ye 1st: Intention. 2d: Bleeding in ye begining of ye disease if ye Blood as of an Inflammatory nature & ye Saline Draughts are proper, for ye Bark in this case will make A continual Feverishness’, but ye Chief thing in this intention is to give plenty of diluting Liquors in the Fitts, to break down ye febrile matter & supply matter for Sweats & Urine. Some have attempted to cure ye Paroxysm by preventing ye Cold Fitt, by viscating before ye Cold Fitt comes on w:ch will frequently cure the Ague, giving Saline Draughts & Sp:s Mindereri Some give Sp.s CC – Castor -Serpentar & Boerhaave thinks that Opium added would bring 139  (121) 140 their Effects to ye Skin. Emetics have succeeded by their shock on ye Fibres, squeazing & breaking down ye Morbid Matter, & squeazing the Viscera, & evacuating their Viscid Pituit, & from ye Stomach & Intestines & prepares for A gentle Purge. The Cort. Peruv: when ye Fever begins to turn Calm, is ye Antidote Specific _ Sometimes ye Secretions of the Viscera are stop’d up & obstructions come on after ye use of ye Bark & ye Ague is apt to return _ But this may not happen if ye Ague is regular, & there is A sediment in ye Urine between ye Paroxysms, & in Quotidians bordering on the Inflammatory, it is not convenient to give ye Bark at first and even when it is given, give Nitre or ye Saline Draughts w:th it. We ought to be carefull of giving Bark to such as have A sallow Countenance & tense Abdomen & are Costive and when we do give it we must give Saponaceous & deobstruent Medicines wth it as ye Tartar Solubil, Sapo Venet & Rhubarb _ If we find that Agues are ready to carry off any Disorder, As Inveterate Pains & Head Aches, we must not then stop it with ye Bark as many Diseases have been cured by Agues – Purgatives should not be given after ye Use of ye Barks. The Jamaica Bark, or ye New Bark has been said to cure Agues, but does not succeed well. Blisters Epithems & Stimulating Medicines to ye Stomach, Breast, & Arms have been recommended – The 4t: Indication is to Mannage any Symptoms that may Intervene, if from A Pethora as Convulsions Pains &c then we must bleed & leave off (122) the Bark, & if ye Patient is too low, we must give Cordials & if ye cold Fitt is very severe we may Expose ye Patient to ye steams of Warm Water. If ye Patient makes but little Water during ye Ague & endangers A Dropsy, there we must stop ye Ague as soon as possible & Join ye Diuretics & Saponaceous Medicines w:th it - Lecture the 28 - Of the Consequence of Agues - The Aguish disposition that remains after the disease must be removed by all bracers, Strengtheners & proper Food & all that are proper for A Lax Fibre. The tendency to Sweat must not be stopt at once, but be cured as ye Aguish disposition goes off. If after the Use of the Bark, there is A weight about ye Precordia. A Yellow Water & Tunica Adnata of ye Eye, we must then leave off the Bark & give Saponaceous Medicines, & the Ague returning may perhaps carry off the Jaundice, And in all obstructions of ye Abdominal Viscera, we must neglect the Ague. Obstructions & Tumours of ye Abdominal Viscera often follow an Ague, & these must be treated w:th Saponaceous & resolvent Medicines & Neutral Salts w:th ye Juices of Succulent Plants, these Obstructions & Swellings of ye Spleen, Omentum, & Mesentery & are Schirrous, This is called 141  142  (123) 143 the Ague Cake & sometimes produced Dropsies, Jaundice &c tho’ it is sometimes without Pain, or any disadvantage. Another Consequence as the Inflation of ye Small Gutts w.ch generally goes off by strengthening Diet, Purges &c. A Madness says Sydenham follows Quartan Agues, curable by Strengtheners only. Dropsies &c after Agues must be treated as Dropsies having regard to ye Ague & stopping it as soon as possible. Some periodical Pains will be cured in ye same manner as Intermittents of w:ch ye Dr give several Cases - Ardent Fever is A violent one w:th Intense heat especially about the Precordia, Cold Extremities, An Anxiety, A slight Cough w:th A hollow Voice, A dry Black Tongue. The Urine at first high Coloured but at last Fœtid & black. Sometime the Vessels of ye Lungs are burst & we have an Hameptoe. Sometimes it ends in A topical Inflammation especially of the Lungs &. It is not so violent in this Country as described in ye Antients, probably owing to our bloodletting & diluting. We find the Blood to have an Inflammatory buff & this happens generally in the heat of Summer. The Delirium is owing to the rigid Motion of ye thick Blood w.ch disturbs the function of all the Vital Organs. We must endeavour to diminish the heat & Moment of ye Blood & dilute well w:th Saponaceous Liquors such as will mix w:th ye oily Inflamed Juices, or ye Liquors will be excreted by Urine colourless, & this Pale Urine may be also owing to A Spasm of ye Renal Vessels. A pure (124) fresh Air often renewed cools the Blood, as it passes thro’ ye Lungs, therefore A Cool fresh Air is necessary to be had in this Fever, After bleeding we must empty ye Gutts of ye putrid fomes that would encrease the disease, such use ye mild purgers, & Emetics may be proper if ye the Pulse is sufficiently abated. Whatever softens ye Vessels so as to enlarge their diameters, such as Warm Baths & Fomentations to ye Extremities & Belly - Of the Phrenitis. The Symptoms are Violent Pain in ye Head, (within ye Encephalon, Weak quick Pulse, Small Alienation of Mind, The Eyes fierce & stern, & the tears are frequently in ye Eyes, the Face is red, turgid & terrible, the Eyes look red at ye bottom and A general fullness of the vessels about the head. Sometimes the Fever ceases & leaves A Delirium & madness that is incurable. The Brain & its Membranes have been found Inflamed & Suppurated & found Gangren’d in dead Bodies. The Coup de Soleil, is an Inflammation of the Brain, by being exposed to ye heat of ye Sun in Italy & ye south of France. This Disorder here is often brought on by External Injury or by A Metastasis of ye morbid Matter & is very seldom Original. All our Ideas depending on ye impression of ye Brain & Nerves, no wonder 144  (125) 145 that ye turgid vessels, rapid motion of ye Blood cause disorderly Ideas, & we see that the Patient is apt to catch at the bed cloths, there being something of Inflammation of ye Retina, or some obstruction of ye Optic Nerves The breathing is here much freeer, & there is less Anxiety in the Pleuritis, Peripneumony &c Œruginous Vomitings, are agreed upon by all to be A Symptom of ye disorder. As Suppuration, or Gangrene of ye Brain must be fatal we must use our Efforts to bring about a resolution: & to this purpose the Air of ye Chamber must be cool, & the Blood must be let from A large Orifice in a large Vein – Some have thought Blood from ye temporal Artery & Jugular Vein has been more usefull than other bleedings, but this is not determined, yet some trifling. Cupping in ye Neck is also recommended but it will not have so good an effect. A Spontaneous Hæmerrhage from ye Nose has cured the disorder, & this ought not to be stopped too soon, but must be [cross out] encouraged by warm steams & Fomentations. The Hœmorrhoedal Flux is said to have a better effect than blood from other Veins. In all Disorders of ye Brain shavg: the head may be of use, or at least will make room for A large Blister on ye head, but this must not be till late when ye Vessels are emptyed & ye Pulse is soft, Baths & Fomentations, when there is A dryness & rigidity of ye Skin (126) are usefull here as will as in other Disorders, And the Obstinate wakefullness may be helped by Laudanum if ye Fever is gone off, or by laying A Cloth moist wth cold Rose Water to ye Temples - The Chamber ought to be dark, or light according as ye Patient finds agreeable to him - Lecture the 29 Of the Angina - A difficulty of breathing or swallowing arising from ye swelling or Inflammation of the parts above ye Stomach & Diaphragm, is call’d An Angina, & distinguished by Inflammation from the Maligna - when the Trachea or Glottis is affected they breath wth difficulty, & when the Pharyna is affected alone) Swallowing is affected, & when both are affected then breathing & Swallowing are both Laborious, the Least swelling in the Glottis is very dangerous, as it shutts up ye passage from ye Lungs, & the Air being rarifyed within, brings on pressure & suffocation. When the Tonsills, & Velum Pendulum are inflam’d there is a secretion of Mucus & Cough more than ordinary & all the parts within the mouth are considerably Inflam’d. It sometimes kills the Patient by Suffocation, sometimes it suppurates & sometimes it ends in A Gangrene. It requires copious Evacuations, especially when the Larynx & Glottis are affected - 146  (127) 147 and we must give Antiphlogistic Purges & Glysters frequently & we must use ye mild diluting liquors, wth ye Vegetable Acid, & give Neutral Salts & Saline Draughts _ The Patient must gargle the mouths w:th warm liquors to moisten & soften ye inflamed parts, Acescent Gargles if not too irritable, or else Mel Rosar, & Decoct Pectorall _ The drawing up ye steams of Warm Water & Sp:s Menderer, or Veget. Acids very often reach further than the Gargles, Emollient Poultices wth Camphor & Fomentations w:th S:ps Menderer & Vegetable Acid, or Wool w.th A little Camphorated Oil supplys the Poultice better __ Cupping Immediately above the part may be very usefull by unloading the Neighboring Vessels, & Blisters may resolve the Inflammation of ye Neighboring parts, but we must dilute when they are apply’d, As they encrease the Vis Vitæ & raise Fever. If at last Suffocation be absolutely threatned we may perform Tracheotomy in order to relieve the Patient see Phil:Trans: No: 416 – Inflammations of ye Tonsils & Uvula have been relieved by Scarification when ye parts were releived by nothing else & this may be done by Petits Scareficator – see Medical Essays. The Account of ye Angina Inflammatoria Epedemica - The Watry Angina wherein the Tonsils & Uvula are red & watry, without great pain & tension, it seems to be A small degree of ye last disease, the Tonsils being surcharged wth Lymph & appearing Adematous, & the Glands are changd (128) w:th A mucilaginous liquor very thick in ye morning. The Cure is nearly the same as the above, perspiration being more encreased by diluting Liquors - Our next Intention must be to bring on A Suppuration, & this by Emollient Gargles & Poultices, & as soon as we find any part softer than the rest we must open the Abcess w:th A Lancett & give A purgative Ptisan to carry off the dreggs of the Disease _ When An Abcess here by its pressure brings on An Inflammation & endangers Suffocation, we must bleed, notwithstanding it is contrary to ye intention of Nature. It seldom happens that Inflammation of ye Trachea comes to Suppuration, by reason it either suffocates or is resolved soon unless we perform Bronchotomy - When it comes to A Gangrene, Cold Sweats, Low Pulse & loss of Pain declare it or if we see the parts, by their livid Appearance. The Event is here very precareous & generally fatal, the Cure must be by the Seperation of ye Sound parts, from ye rotten as taught on Gangrene in general – Mead recommends deep Scarifications & Ung: Ægyptiac &c - 148  (129) 149 Lecture the 30th: Of the Malignant Sore throat, w:ch partakes of the Inflammatory Gangrenous, & yet differs from both in many things, it has Apthæ in the throat: It begins w:th Gedyness of the head, Shiverings succeeded by heat like other Fevers, Pain in the head, & Soreness of the Throat &c, when looked into it appears reddish _ there is a Nausea & Vomiting, before ye Soreness of the throat it is attended, wth A redness of the Face, often & Swelling. If the Mouth is examined the parts about the throat appear florid & sometimes A very livid red, & white spotts up & down on ye Tonsils & Uvula, & seem as if suppurating. A Diarrhea seems to have been very constant at first but not now, The Face & hands &c has an Errisepelatous colour & swelling often, & the Parotid Gland swells & is hard, & the parts about the throat are Œdematous, About the 3d day A Delirium comes on tho’ this is not constant, yet Sometimes turns to A Coma, & the Patient is quite stupid – Towards morning there is often A Sweat w:ch relieves for some hours – Towards Death the Symptoms encrease the Pulse sinks, flutters & intermitts, & is very quick during the whole course, tho’ soft & flaccid as in putrid fevers When the Disease is favorable about the 4th: or 5t: day ye Symptoms all abate, Heat, Quickness of Pulse &c (130) The Urine is at first pale, then Yellow & when ye Disorder goes off it has a farinaceous Sediment. The Blood is at first very florid & much as in other putrid Fevers. the Fauces appear much ye same thro’ the Disease only ye Apthæ become opake, & that Crust wch seem’d ye covering of A Suppurating Tumour is really A Mortified part of ye parts themselves & conceals An Ulcer, These Sloughs seperating frequently impure the Voice, as the Venereal Disease itself would. The Matter discharged from the Ulcer brings on Inflammation, by the Nose & Mouth & is so Acrid as perhaps to occasion faintness when swallowed, & Ulceration in the Bowells of Children. these Sloughs have frequently been found to continue even quite down the Trachea & there is frequently Hæmorrhage from ye Nose & Mouth, either owing to ye putridity of ye Blood, or to ye Acrid Matter coroding the Arteries, this generally found to affect Lax habits, & Women & Children especially, & it is highly infectious like other putrid Disorders – The Indications of Cure – 1st: to keep ye Fever in due bounds, to lessen it by Evacuation if necessary at first & keep it up by Cordials if too low - tho’ Fothergill thinks bleeding at all times improper in this Disease It is dangerous to give even the slightest Ecoprotics in this Disorder say Fothergill & Wall for fear of a Diarrhea w:ch will carry off the Patient however Monroe, thinks, A gentle 150  151  (131) 152 purging Apozem or Glyster may be administer’d safely if there is no fear of A Diarrhea, & tho’ Nitrous Medicines have been said to be very dangerous, yet Monroe thinks ye Antiphlogistic Method has been of use, when the Pulse was full & the Skin very red, & great heat & Fever in Plethoric People at the beginning of the Disease, the Patient should be kept in bed for fear of faintness & A little gentle Emetic should be given to remove the Nausea, & then A gentle laxative by ye Mouth or by Glyster & somewhat cooling remedies, but if the Nausea continues the Cordial Aromatics & warm Medicines are proper & if there is A Diarrhea, we must carefully attend to them, & give the gentle Astringents to prevent it. 2d Indication is to prevent the putrescency of the humours, & seperate the Sloughs that are formed. Subacid Liquors w:th Generous Wine, & all the Cordials & Warm Aromatics, & above all the Barks, as it promotes Suppuration & prevents putrefaction & makes a kindly Seperation of ye Mortify’d parts. The Saline Draughts may be added to ye Barks if the Fevers & Heat are great, but if ye Patient is low, the Cordial Confection, The Aromatics & the T: Myrrh, & Dec: Myrrh w:th the Barks, & Dr Fothergill says the Cordials should be given freely. Ulcers of ye Throat demand our care, as the thin Schor if not washed away will excoriate the parts, & being swallowed, will occasion bad Symptoms. It must be washed often w:th Vinegar & Honey (132) or Barley Water, or Pectoral Decoction w:th T: Myrrh, or Sp.t Vitriol. The steams of warm Liquors are sometimes usefull as they soften & relax the parts of ye Trachea - New Sloughs will generate if ye Sloughs are removed by force, it is best therefore to let them come away of themselves, by ye Internal Remedies. Some propose scarifying wth Petits Scarificator but this is hazardous says Fothergill, & is better let alone, Yet perhaps it may not be amiss when there is an Ulcer below to scarify ye Slough gently - The Schirous of ye Tonsils & Velum Pendulum, tho’ call’d by Boerhaave & others A particular Disorder, yet differs not from ye Schirrhus of ye other parts tho’ ye Tonsils may often require extirpation, There have been two Disorders meant by the Watry Angina, w:ch is A Symptom of ye Leucophlegmatea, & may be chiefly removed by brisk Purges & Diuretecs, the other Watry Angina is treated of already, the Water may be let out by Scarefication or Blisters &c Encysted Watry Angina, must be treated as the common Encysted Tumours after letting out the Water __ Paralytic Angina w:ch is an Inability of swallowing without swelling to occasion it owing to Nervous Disorders, or A general Decay of Nature, & some come on very suddenly _ The Cure requires all such Diet & Medicines as strengthen ye Body in general – The Convulsive Angina wch is A Spasm on ye Parts So as to stop ye breath, it is sometimes 153  (133) 154 sudden & violent, tho’ there is frequently some Slight Convulsions from Hysteric & Hypochondriac Disorders, there is frequently suffocation from A Vomica Pulmonum bursting & this has been mistaken for ye Convulsive Angina _ A Dislocation of ye 2d Vertebra of ye Neck is said to bring on A kind of Angina The Peripneumonia Vera begins like other true Inflammatory Disorders, w:th Shivering &c. owing to the Obstruction of ye Blood in the Lungs, w:th great Opression, Anxiety & Difficulty of Breathing & Pains They are often inclined to sleep by the free return of ye Blood from the Brain being prevented, The Pulse is at first quick, & hard, or else opressed, it very soon sinks, & at last flutters & intermits, the Cough is very great & the Patient rears A yellow Mucus somewhat like Pus, w:ch when tinged wch. Blood is A good sign of A Crisis is because it shews that ye Vessels of ye Lungs are relaxed, by the Discharge The pain is not intense here, but the Anxiety is very great when there is A Crisis there is A Sedement of ye Urine, where there is A Suppuration, there is Shivering without any Manifest Cause, & the pain abates & the Lungs feel heavy & the Hectics & Night Sweats &c come on, the Gangrene is known by the Pain’s being stopt & the Pulse low &c The Prognosis is according to ye difference of ye Disease sometimes the Blood is so impacted in the Lungs as to make it A kind of tough hard flesh. If there is an Anxiety &c a Rutting in (134) in the Throat as if the Lungs are full of Pus, then it is A bad sign. Expectoration is a good Sign & A proper Urine, but if the Urine tho’ well Concocted at first length grows pale then we have little hopes, But we are always in hopes as long as the Pulse holds up, & the [cross out] Blood has an Inflammatory Buff, & Evacuations ought to be made freely if this is ye Case, but if the Blood does not put on A buffy appearance & the Pulse sinks, we mus then desist from further Bleeding _ but if after ye first Bleed the Pulse still throbbs, we must bleed again, ‘till an Expectoration comes on freely, but then we must beware of further Bleeding, least we prevent this Crisis of Nature’s own determining _ We must be carefull not to be deceived by weakness & an opress’d Pulse _ We must give A Gentle Purge in the begining, after Bleeding, & give Cooling, & diluting Saponaceous Liquors Acidulated, & Medicines w:th Spt: Mindereri _ Nitre, & Saline Draughts, but if ye Lungs are much obstructed the Oxymel Scillitic should be given w:th the Neutra Salts, & Warm steams & Fomentations should be us’d to soften & relax the Lungs & Trachea & bring on a free Expectoration, wch is the best & most natural Crisis, & if ting’d with Blood, light & Yellowish, the Symptom is good, when the Discharge is thick & in no great quantity the Oxymel & Ammoniac ought to be us’d, but if too thin & Acrid, we must use the Oleaginous & Balsamic Medicines, Blister’s are recommended after Bleeding & Purging & even Vomits 155  156