UNITED  STATES OF AMERICA
ME^q
^ *  .
FOUNDED 1836
WASHINGTON,  D. C.
OPO  16—67244-1 
«b
Surgeon General's Office

cyec^t
cm
.......  --"">"

Atf^ j
;
 
 
 
'•*>S^ ■ Imm»
 
4
O
'  ;
«*   • 
 
        j  FIRST LINES     y



    PRACTICE   OF  PHYSIC.

                     BY

         WILLIAM CULLEN, M. D.
 LATE PROFESSOR OF THE PRACTICE OF PHYSIC, IN THE UNIVERSITY OV
                EDINBURGH, &e. &c.

                    WITH

       NOTES AND OBSERVATIONS,
          PRACTICAL AND EXPLANATORY,

 A  PRELIMINARY DISCOURSE
        IN DEFENCE OF CLASSICAL MEDICINE,
                    AND

              AN APPENDIX,

        By  CHARLES CALDWELL, M. D.
PROFESSOR OF THE  INSTITUTES OF MEDICINE IX TRANSYLVANIA UNIVERSITY.


    SECOND  EDITION,  REVISED AND ENLARGED.


              IN TWO  VOLUMES.
                  VOL. II.  *<
-.7^
      PHILADELPHIA:

PUBLISHED BY EDWARD PARKER,
      No. 178, MARKET-STREET.
        William Brown, Printer,
             1822. 
V %
..♦ \
VIZ 
     CONTENTS

              OF

THE  SECOND VOLUME.
                       BOOK IV.
                                                     PASK
  Chap. VI. Of the Menorrhagia, or the Immoderate Flow
              of the Menses,   -----      t
       VII. Of the Leucorrhoea, Fluor Albus, or Whites,    11
      VIII. Of the Amenorrhoea,  or Interruption of the
              Menses,       -    -    -    -    -    -16
        IX. Of Symptomatic Hsemorrhagies,         -     26
    Sect. I. Of the Hematemesis, or Vomiting of  Blood,     27
        II. Of the Hematuria, or the Voiding of Blood from
              the  Urinary Passage,      -    -    -    -   35

                        BOOK V.
Of Profluvia, or Fluxes, with Pyrexia,      -    -    -     41
   Chap. I. Of the Catarrh,......42
        II. Of the Dysentery,.....52

                        PART II.
Of Neuroses, or Nervous Diseases,      -    -            64 '

                        BOOK I.          ,
Of Comata, or the Loss of Voluntary Motion,  *  -    -     6:5
   Chap. I.  Of Apoplexy,......66
        II. Of Palsy,      ......87

                        BOOK II.
Of Adynamic, or Diseases consisting in a Weakness or Loss
              of Motion in either the vital or natural Func-
              tions,    -    -    -    -    -    -        gg
   Chap. I.  Of Syncope, or Fainting,  -         -    -     99
        II. Of Dyspepsia, or Indigestion,      ...  jo8
       III.  Of Hypochondriasis, or the  Hypochondriac Af-
              fection, commonly called  Vapours or Low
              Spirits,       ......15?4 
CONTENTS
137
139
155
                                                       PAGE

                        BOOK III.

Of Spasmodic Affections without fevek,     -    "
   Sect.  I. Of the Spasmodic Affections of the Animal func-
              tions,   -    -     -    -    -
   Ghap.  I. Of Tetanus,      -
         II. Of Epilepsy,    -
        III. Of the Chorea, or Dance of St. Vitus,  -    -  "y
   Sect. II. Of the Spasmodic Affections of the Vital Func-
              tions,   -......182
   Chap. IV. Of the Palpitation of the Heart,    -    -    -  182
         V. Of Dyspnoea, or Difficult Breathing,  -    -    185
        VI. Of Asthma,......188
       VII. Of the Chincough, or Hooping Cough,    -    199
  Sect. III. Of  the  Spasmodic Affections  in the Natural
              Functions,      -                  -    -  21t
Chap. VIII. Of the Pyrosis, or what is named in Scotland, the
              Water-Brash,     ■»    -    -    -    -    210
        IX. Of the Colic,......214
         X. Of the Cholera,.....22$
        XI. Of Diarrhoea, or Looseness,  -     -    -    -  231
        XII. Of the Diabetes,.....247
       XIII. Of the Hysteria, or the Hysteric Disease,    -  25$
       XIV. Of Canine Madness and Hydrophobia,     -    260

                         BOOK  IV.

Of Vesanije, or of the Disorders of the Intellectual Functions, 264
   Chap. I. Of Vesaniae in general,      -                 264
         II. Of Mania, or Madness,                       280
        III. Of Melancholy, and other forms of Insanity,    290

                         PART  III.
Of Cachexies,    .-.-...-    299

                          BOOK I.
Of Emaciations,    ---_..-.  300

                         BOOK  II.

Of IntumescentijE, or General Swellings,    -    -     -    310
   Chap. I.  Of  Adipose Swellings,.....311
         II.  Of  Flatulent Swellings,    -    -    -     -    315
        III.  Of Watery Swellings, or Dropsies,     -    -  325
    Sect. I.  Of Anasarca,......336
          II.  Of the Hydrothorax, or Dropsy of the Breast,   356
        III.  Of the Ascites, or Dropsy of the Lower Belly,  361
   Chap. IV.  Of General Swellings, arising from an increased
               bulk of the whole substance of particular parts, 366
             Of Rachitis, or Rickets,     ....  357 
CONTENTS.
                                                        PAGE
                         BOOK III.

Of the Impetigines, or Depraved Habit, with Affections of
               the Skin,......379
   Chap. I. Of Scrophula, or the King's Evil,  -    -    -  380
         II. Of Syphilis, or the Venereal Disease,      -    391
        III. Of Scurvy,......404
        IV. Of Jaundice,......414

                       AFPENDIX.

Dysenteria, or Dysentery,     ......       i
Vermes, or Worms,       .......viii
Of Suspended Animation and Resuscitation,  -    -     -    xiii
Frost-bitten,.........xx
The Diseases of Pregnancy,      -----    ibid.
Convulsions,    --------      xxvii
Abortions,........-  xxxiii
Diseases of the Puerperal state,      ...     -       xliii
         After-Pains,.......xliv
         Costiveness,.......ibid.
         Flow of the Lochia,      -----    ibid.
         The Milk Fever,......ibid.
         Inflammation and Tumours in the Breasts,  -    -  xlvi
         Excoriations of the Nipples,    ...    -   xlvii
         Phlegmasia Dolens Puerperarum, -    -     -       xlix
         Hysteritis, or an Inflammation of the Uterus,  -     Ivi
         Feb'ris Puerperarum, or Puerperal Fever,    -       lxvi
         Mania Puerperarum,.....lxxix
         Inversio Uteri,       -...--  ibid.
         Procidentia Uteri,......Ixxx 
 
INDEX
                           TO THE

              TWO  VOLUMES.

X.  B.  THE CIPHERS REFER TO  THE NUMBER OF THE PARAGRAPHS,
ABSCESS,                250
Abscesses and ulcers, the cau-
  ses of their different states, 254
Acids employed in fever,    134
  refrigerant in fever,       ib.
Action of the heart and arteries,
  how increased for preventing
  the recurrences of the parox
  ysms of intermitting fever,  230
Adynamae,                U70
Amenorrhoea,              994
  from retention,            g95
  when occurring,          997
  symptoms of             998
  causes of,         999—1000
  cure of              1001—5
  from suppression,         995
    when recurring,       1007
     symptoms of,         1009
    causes of,          1007__8
    cure of,          1010—11
Amentia,                  1599
Anasarca,                 1669
  the character of,          ib.
  phenomena of,      1669—74
  cure of,            1675—97
  distinguished from Leuco-
    phlegmatia,           1670
St.Anthony'sFire. See Erythema.
Antimonial Emetics,employed
    in fevers,               181
  their different kinds,       ib.
  the administration of them in
     fevers,          183—186
Antiphlogistic Regimen,     129
  how conducted,           130
  when employed in intermit-
    tent fev                234
Antispasmodics, employed in
    fevers,           152—187
Aphtha,                    732
Apoplexy,                 1093
 1     — distinguished from
   . PaIsy>                  ib.
  distinguished from syncope, ib.
  predisponent cause of,    1094
  exciting  causes  of,
                 1097-1114-15
  proximate causes of, 1019__20
  Serosa,proximate cause of, 1113
  prognostic,         1121—22
  frequently ending in hemi-
    plegia.                1121
  prevention of,            1123
  whether sanguine or serous,
  stimulantshurtfulinit, 1135-36
  from powers that destroy the
    mobility  of  the  nervous
    power,                1137
  cure of,             1130—38
Apyrexia,                   «4
Ascites,                   1710
  character of,              j^
  its various seat,     1711—12
  the phenomena of,   1713__14
  its particular seat difficultly
    ascertained,            1715
  the cure of,        1715__13 
INDEX.
Asthma,                  1374
Asthma, phenomena of,    1376
  exciting causes of,       1382
  proximate cause of,      1385
  distinguished  from  other
     kinds of dyspnoea,     1386
  sonic: uv.es occasionsphthisis
     puimonalis,           1387
  frequently ends in hydrotho-
     r:ix,                    ib.
  seldom entirely cured,   1388
Astringents, employed in  in-
     termittent fevers,       231
  joined with aromatics, em-
     ployed  in  intermittent
     fevers,                 ib.
  joined with bitters, employ-
     ed in intermittent fevers, ib.
Atrabilis,                 1028
Atrophia ab alvi fluxu,    1608
  debilium,               1607
  inanitorum,             1608
  infantilis,               1606
  lactantium,                ib.
  lateralis,           1607—12
  a  leucorrhcea,           1608
  nervosa,                1607
  nutricum,               1608
  a  pytalisma,               ib.
  rachitica,               1606
  senilis,             1607—12
AuraEpileptica,           1307
               B
Bitters employed in intermit-
     tent fevers,            231
  joined with astringents, em-
     ployed in intermittents,  ib.
Blistering, its effects,  189—197
  its mode of operation in the
     cure of fevers,   190—194
   when to be employed in
     fevers,                 195
  where tobeapplied infevers,196
 Blood-letting, the employment
     of it in fevers,    138—143
   the circumstances directing
     its use in fevers,        142
   the administration  of  it in
     fevers,                 143
   when employed in intermit-
     tent fevers,             234
              C.
Cachexies, character of the^
    class,
Cachexy, the term how ap-
    plied by  authors,       16U1
Calculis Renalis,           428
Calx nitrataantimomi, its use
    in fevers,         183—185
Canine Madness,           1526
  the cure of,       1526—1528
Cardialgia,                 »428
Carditis,                   383
  of the chronic kind,        ib.
Carus,                     1093
Cataphora,                  ib-
Catarrh,                   1045
  predisposition to,         1046
  symptoms  of,            1047
  remote causes of,         1046
  proximate  cause of,       1056
  cure of,                  1064
  produces phthisis,        1054
  passes into pneumonia,   1053
  produces a peripneumonia
     notha,                 1055
  contagious,              1061
Catarrhus, sutTocativus,     376
Chancre,methqd of treating, 1782
Chicken Pox,              630
  how distinguished from small
     pox,                  631
Chincough,                1403
  contagious,                it).
  frequently accompanied with
     fever,                 1411
  phenomena of,           1405
  prognostic in,           1414
  cure of,                 1415
Chlorosis,                   997
Cholera,                   1454
  symptoms of,        1454—57
  remote causes of,    1559—61
  proximate cause of,      1455
  cure of,             1463—65
Chorea,                   1348
   phenomena of,       1348__54
  cure of,                 1355
Chronic weakness,         1191
Cceliaca,                  1494
Cold, its operations,          g8
   absolute,                  ^ 
INDEX.
Cold, relative,               89
  its  general  effects  on the
    human bodyr        90—91
  its morbid effects,          92
  moderates the  violence of
    reaction in fever,        133
  its tonic power, how to be
    employed in  fevers,    205
Cold drink, an useful tonic in
    fevers,                 206
  the limitation of its use in
    fevers,                 207
  air applied in fevers,      208
  water applied tothesurface
    of the body in fcvers,205-209
Colic,                    1436
  symptoms of,'       1436—39
  proximate cause of,      1440
  cure of,                 1442
  Devonshire,             1452
  of Poitou,                 ib.
  cure of,                 1453
Coma,                    1093
Comata,                  1092
Contagions,                 78
  their supposed  variety,    79
Convulsions,               1253
Corpulency,               1622
Cynanche,                  300
  maligna,                 311
  parotidaea,                332
  pharyngaea,              331
  tonsillaris,                301
  trachealis,                318
  as affecting infants,   322—329
  the cure of it,            330
Cystitis,                   430

              D.
Days, critical, in fevers, 107—124
  noncritical,               113
Death,the causes of,in general,100
  the direct causes of,       ib.
  the indirect causes of,      ib.
  the causes of in fever,     101
Debility in fevers, the symp-
     toms of,                104
  how obviated,            202
Delirium in general,   1530—51
  in fever of two kinds,       45
  or insanity without fever,
                      1551—58
  VOL. n.                     b
Diabetes,                  1500
  symptoms of,        1505—19
  remote causes of,        1505
  proximate cause of,  1511—13
  cure of,                 1514
Diaeta Aquea,              157
Diarrhoea,                 1466
  distinguished  from dysen-
    tery,                  1467
  distinguished fromcholera, 1468
  proximate cause of,      1469
  remote causes of,    1472—94
  cure of,           1495—1504
  biliosa,                  1481
  colliquative,             1502
  mucosa,                 1489
Diathesis phlogistica,   62—247
  how removed,            266
Diluents, their use in fevers,
                      154—158
Diseases, the distinguishing of
    them, how attained,       2
  the prevention of them, on
    what founded,            3
  the cure of them on  what
    founded,                 4
Dropsies,                 1646
  in general the cause of them,
                          1647
  of the breast.  See Hydro-
    thorax.
  of the lower  belly.   See
    Ascites.
Dysentery,                1066
  contagious,              1074
  remote causes of,        1071
  proximate cause of,     1076
  cure of,                 1079
  use of mild cathartics to be
    frequently repeated in it, ib.
  rhubarb improper in it,    ib.
Dysenteria alba,           1069
Dysmenorrhoea,            1013
Dyspepsia,                1190
  remote causes of,        1198
  proximate cause of,     1193
  cure of,                 1201
  flatulence in it, cure of,  12*1
  heartburn in it, cure of,    ib.
  pains of stomach in, cure of, ib.
  vomiting in it, cure of,     ib.
Dyspnoea,                 is 66 
fNDEX.
Effluvia, human,	85
from marshes,	ib.
Emaciations,	1601
causes of,	1603—19
cure of,	1620
Emansio mcnsium,         997
Emetics, suited to  the cure of
    fevers,                 174
  their effects,        176—180
  a mean of removing spasm,170
  the  administration  of in
    fevers,                 175
  their use in intermittent fe-
    vers,             230—233
Emprosthotonos,           1267
Enteritis,                  404
  phlcgmonic or erithematic, ib.
  causes of,                406
  cure of,                  408
Epilepsy,                 1283
  phenomena of,           1284
  proximate cause of,      1285
  remote causes of,        1286
  predisponent causes  of,  1311
  sympathic,              1317
    cure of,               1318
  idiopathic,               1317
    cure of,               1320
Epistaxis,                  805
  the causes of it,           807
  the various circumstances
    of it,             806—871
  the management and cure
    of,                813—828
Erysipelas,                 274
  of the face,               707
  symptoms of,        704—707
prognosis of,                705
  proximate cause of,       696
  cure of,             707—710
  phlegmonodes in different
    parts of the body,       711
  attending putrid  fever,    712
Erythema,                  274
Exanthemata,              584
Exercise, useful in intermit-
  tent fevers,               231
              F.
Fainting. See Syncope.    H70
Fatuity,                   1530
Fear, a remote cause of fever, 97
Fever,
  strictly  so called, the cha-
    racter of,            8  32
  phenomena of,              8
  remote  causes of, are of a
    sedative nature,         36
  proximate cause of,        33
  atony of the extreme vessels,
    a  principal circumstance
    in  the proximate cause of
    it,                  43—44
  spasm, a principal  part  in.
    the proximate cause of it, 40
  general doctrine of,        40
  the causes of death in it,   101
  the prognosis of,           99
  indications of cure in,      126
  differences of,             53
  continent,                 28
  continued,                27
  inflammatory,             67
  miliary. See Miliary Fever.
  nervous,                  67
  bilious,                    71
  scarlet.   See Scarlet Fever.
  putrid,                    72
  named synocha,            67
        synochus,           69
        typhus,             67
  hectic,                    74
  intermittent, the paroxysms
      of,  described,         10
    the cold stage of,        11
    the hot stage of,         ib.
    the sweating stage of,    ib.
    of a tertian peiiod,      25
    of a quartan period,      ib.
    of a quotidian period,    ib.
    caused  by marsh effluvia, 84
    bile not the cause of it,   51
    cure of,                228
    its paroxysms  how pre-
      vented,              22J
    attended  with phlogistic
      diathesis,            234
    attended with congestion in
      the abdominal viscera, ib.
  remittent,                 26
Fluxes, without fever.   See
    Profluvia. 
INDEX.
Fluor albus. See Leucorrhoea.
Fomentation of the  lower ex-
  tremities, its use in fevers, 199
Fomites of contagion,         82
Functions,  intellectual, disor-
    ders of,           1529—30
             G.
Gangrene  of inflamed parts,
    the cause of,      255—256
  marks of the tendency  to, 257
  marks of its having come  on,ib.
Gastritis,                  384
  phlegmonic or erythematic,385
  phlegmonic, the seat of    ib.
    the symptoms of,       386
    the causes of,          387
    the  cure of,       393—397
  erythematic, how discovered,
                           400
    the seat of,             385
    the cure of,            401
Gastrodynia,               1428
Gleet,                    1770
Gonorrhoea,               1766
  phenomena of,       1768—70
  cure of,             1771—79
Gout, the character of,       491
  a hereditary disease,      499
  distinguished from rheuma-
    tism,                  525
  predisponent  causes  of,
                      492—499
  occasional causes of, 501—504
  proximate cause of,  526—532
  not  a morbific matter,     528
  Regular, described,  505—517
    pathology of,           532
    cure of,           563—572
    no effectual or safe reme-
      dy yet  found for the
      cure of it,            538
    medicinesemployed forit,555
    whether  it can be radi-
      cally cured,          539
    treatment  in  the  inter-
       vals of paroxysms,   541
    treatment in  the time  of
      paroxysms,          559
    regimen during the pa-
      roxysms,            560
    external applications,how
       far safe,        567—568
Gout, regular,
    blood-letting in the inter-
       vals of paroxysms,    552
    blood-letting in the time
       of paroxysms,        562
    costiveness hurtful,     558
    laxatives to be employed, ib.
    effects of alkalines,     557
       of Portland powder,  556
Irregular,                  5 17
    Atonic,           573—578
       pathology of,         533
       cure of,         579—581
    Relrocedent,           521
       pathology of,         534
       cure of,         579—581
    Misplaced,             522
       pathology of,         535
       cure of,         582—583
    Translated,two particular
       cases of,             524

              H.
Haematemesis,             1016
  arterial and venous,      1026
  from obstructed  menstrua-
       tion,                1019
  from suppression of the he-
    morrhoidal flux,       1024
  from compression of the vasa
    brevia, by the  spleen,  1026
  obstruction of the liver,   1027
Haematuria,               1032
  idiopathic,  improbable,
                      1032—33
  calculosa,               1036
    cure of,               1037
  violenta,                 1038
  from suppression of accus-
    tomed discharges,      1040
  putrida,                 1042
  spuria et lateritia,        1043
Haemiplegia,               1139
  causes of,               1140
  frequently  occasioned  by
    apoplexy,             1141
  frequently  alternates with
    apoplexy,             1143
  cure of,                 1151
  stimulants,  of ambiguous
    use in,                1159
  stimulants, external,  in,   1160 
INDEX.
Haemoptysis, symptoms of,
                     837—839
Haemoptysis, the causes of,
            759—62—829—835
  how distinguished from other
    spittings of blood,  840—44
  cure of,             845—5 1
Haemorrhagia uteri,        965
Hemorrhagy,
  active or passive,         734
  character of,             735
  arterial,                 743
  venous,                 767
  the causes of  the different
   species appearing at diffe-
   rent periods of life, 749—-772
  general phenomena of,
                     737—742
  the remote causes of,     773
  cure of,                 775
  ----whether to be attempt-
    ed by art,          775—80
  prevention of  the first at-
    tacks, or of the recur-
    rence of,
  treatment,  of
    sent,
  symptomatic,
Hemorrhoides vesicae,
Hemorrhois,
  external and internal,     924
  phenomena of,      924—930
  nature  of the tumours,   931
  causes of,          932—942
  acquire a connexion, with
    the system,      942—943
  particularly  with the sto-
    mach,                945
  cure of,            946—964
Hepatirrhoea,              1482
Hepatitis,                 411
  acute and chronic,          ib.
  acute symptoms of,  412—414
  combined with pneumonic
    inflammation,          415
  remote causes of it,        ib.
    seat  of,                417
  various exit of pus produc-
    ed in,                 420
  cure of,                 421
  chronic, the seat of,      417
    781—788
when  pre-
    788—804
         1014
         1041
Hepatitis,
    how discovered,        ***
Hooping cough.  See  Chin-
    cough,                140j
Horror,  impression  of,  em-
    ployed  in   intermittent
levers,
231
Human effluvia, the  cause of
    fever,                   81
  body, its temperature,      88
  body has a power of gene-
    rating heat,             ib.
Hydrophobia,              1526
Hydrothorax,              1698
  where seated,           1699
  symptoms of,       1702—04
  often combined with univer-
    sal dropsy,'           1705
  proximate cause of,      1707
  cure of,            ,1708—09
  paracentesis, in  it,  when
    proper,               1709
Hypercatharsis,           1478
Hypochondriasis,          1223
  phenomena of,             ib.
  distinguished from dyspep-
    sia,                   1227
  proximate cause of,      1231
  cure of,                 1233
  treatmentof the mind in,  1245
Hysteria,                 1515
  symptoms of,       1516—17
  paroxysm or fit described,  ib.
    rarely appears in males,15l8
  how distinguished from hy-
    pochondriasis,     1519—20
  proximate cause of,      1523
  analogy  between  and  epi-
    lepsy,                1524
  cure of,                 1525
    libidinosa,             I5I8
Hysteric disease.  See Hysteria.
James'  powder,  its  use in
    fever,                  t83
Jaundice,              1316__17
  causes of,           1817__22
  cure of,             1824—30
Icterus.  See Jaundice.
Iliac passion.   See Ileus. 
INDEX.
Ileus,                     1438
Impetigines,               1738
   character of the order,      ib.
Indigestion. See Dyspepsia.
Inflammation, phenomena of, 235
   internal, the maiksof,     236
   the state of the  blood in,  237
   the proximate cause of,   239
   not depending upon a len-
     tor of the blood,        241
   spasm the proximate cause
     of,                243—248
   terminated by resolution,  249
     by  suppuration,        250
     by  gangrene,           255
     by  scirrhus,           258
     by  effusion,            259
     by  blisters,             260
     by  exudation,          261
   the remote causes of,     262
   the cure of in general,    264
     by  resolution,            ib.
   the cure of, when tending to
      suppuration,     268—70
     when tending to gangrene,
                           271
   its general divisions,      273
   more strictly cutaneous,  274
   of the bladder. See Cystitis.
   of the brain. See Phrenitis.
   of the heart.   See Carditis.
   of the intestines.  See  Ente-
     ritis.
   of the  kidneys.  See Ne-
     phritis.
   of the liver.   See Hepatitis.
   of the lungs. See Pneumonia.
   of the pericardium.    See Pe-
     ricarditis.
   of the peritonaeum.  See Pe-
     ritonitis.
   of the spleen.    See Splenitis.
   of  the   stomach.  See  Gas-
     tritis.
   of the uterus,            431
Insanity,                  1536
   causes of,           1551—58
   of different species,      1558
   partial  and  general differ-
     ence  of,               1576
Intemperance in drinking,
  a remote cause of lever,    97
Intermission of fever,        24
Interval ol fever,            ib.
Intumescentiae,            1621
  character of the order,     \b.
King's evil. See Scrophula.
              L.
Leucophlegmatia,          1670
Leucorrhoea,               984
  character of,             985
  appearance of  the  matter
    discharged in,     986—991
  the causes of,            987
  the effects of,             989
  the cure of,              992
Lethargus,                 1093
Lientery,                   1470
Looseness. See Diarrhoea.
              M.
Madness.  See Mania.
  Canine. See Canine.
Mania,                     1559
  the symptoms of,          ib.
  the remote causes,   1560—62
  the treatment of,     1563—75
  occurring in sanguine tem-
    peraments,             1577
  in sanguine temperaments,
    cure of,               1578
Marcores,         •         1601
Marsh effluvia, cause ©ffever, 84
Measles,                   632
  the symptoms of,     636—641
  the nature of             643
  the cure of,         644—649
  of a putrid kind,          642
Medicine, the institutions of,   4
Melaena,                  1016
Melancholia,              1576
  how distinguished  from  hy-
    pochondriasis,     1588—89
  the character of,     1588__90
  the proximate cause of,   1791
  the treatment of,     1593—98
Melancholic temperament,  1230
Melancholy. See Melancholia. 
INDEX.
Menorrhagia,               965
   active or passive,          ib.
   when a disease,       967—74
   effects of,                971
   proximate  causes of,     976
   remote cause of,          977
   cure  of,                  979
Menses, immoderate flow of
   them. See  Menorrnagia.
Metallic tonics, employed in
    intermittent fevers,     231
   salts, refrigerant,          136
Meteorismus,              1634
Miasmata,                   78
Miliary fever,
   the general history of,713—714
   of two kinds, red and whn  715
   white, symptoms of,  716—7 i 8
   the cure of,              719
Morbus caehacus,          1494
   mucosus,                1069
   niger,                   1028

              N.
Nephritis,                  425
   the symptoms of,          ib.
   the remote  causes of,     426
   the cure of,               429
Nervous diseases. See Neuroses.
Neuroses,                 1089
Neutral salts, diaphoretic in
   fevers,              159—161
   refrigerant  in fevers,      135
Nosology, Methodical,         2

              O.
Obesity, when a disease,    1622
Oneirodynia,               1599
Ophthalmia,                278
   membranarum,            ib.
   its different degrees,279—280
   its  remote causes,       280
   the cure of,        288—290
   tarsi,                    278
    the cure of,       288—290
Opiates, employed in the hot
   stage of intermittent fevers, 233
   in the interval of intermit-
    tent fevers,             231
Opisthotonos.  See Tetanus.
Palpitation of the heart,     1356
  the phenomena of,         lD-
  the causes of,            j*


  distinguish.fromapoplexy,1093
  causes of,
Paracentesis in ascites, when ^
    to be attempted,       1718
Paracentesis in hydrothorax,
    when proper,          1709
Paraphrenias,              343
Paroxysm of intermittent fe-
    vers, the recurrence bow
    to be prevented,        229
Pemphigus,                731
Pericarditis,                383
Peiipueumonia notha,       376
  symptoms of,             379
  pathology of,   >•          380
  the curs of,         381—382
  some symptoms explained, 350
Peripneumony,             342
Peritonitis,                 384
Peruvian bark, not a specific, 213
  its tonic power,           214
  when proper in fever,     215
  how effectually employed, 216
  the  administration of it  in
    intermittent fevers,     232
  the tonic chiefly employed
    in intermittent fevers,    ib.
Petechia,                  733
Phlegmasia,               235
Phlegmon,                 374
Phrenitis,                  291
  the character of,          293
  the remote causes of,      294
  the cure of,         295—299
Phrensy. See Phrenitis.
Physic, practice of, how taught,  1
  theory of, how employed,     4
Physconia,                1719
Phthisis pulmonalis, the gene-
    ral character of,        852
  always with an ulceration of
    the lungs,              854
  the pus.coughed up in, how
   distinguished from mucus,855 
INDEX.
Phthisis pulmonalis,
  accompanied with hectic fe-
     ver,                   856
  the various causes of,     862
  from haemoptysis,    863—864
  from pneumonia,     865—868
  from catarrh,        869—872
  from asthma,             874
  from tubercles,      875—881
  from  calcareous matter in
     the lungs,              883
  if contagious,             885
  from tubercles, symptoms, 888
  its different duration,      895
  the prognosis in,          896
  the cure of,         898—928
  the treatment of, when aris-
     ing from tubercles,905—920
  the  palliation  of   symp-
     toms,            921—923
Plague, general character of, 664
  phenomena of,             ib.
  principal symptoms of,    666
  proximate  cause of,       667
  prevention of,        669—684
  cure of,             685—694
Pleurisy                   341
Pleurosthotonos. See Tetanus.
Pneumonia, or Pneumonic In-
     flammation,            334
  general symptoms of, 335-339
  seat of,             340—344
  prognosis of,        352'—360
  cure of,                 361
  the management of blood-
     letting, in the cure of,
                      362—367
  the use of purgatives in,   370
  the use of emetics in-,     371
  the use of blisters in,      372
  the means of promoting
     expectoration in,        373
  the use of sweating in,    374
  the use of opiates in,      375
Polysarcia, when a disease,  1662
  cure of,             1624—26
Profluvia,                 1044
  character of the class,      ib.
Pulse, the  state of the, du-
     ring the paroxysm of an
     intermittent fever,       12
Purging, its use in continued
    fevers,                 144
  intermittent fevers,        234
Pus, how produced,          250
Putrescency of the fluids, in
    fever, the symptoms of,  105
  the  tendency  to, in fever,
    how to be corrected, 222-226
Pylorus, Scirrhous.  See Dys-
      pepsia.
Pyrexiae, character of the class, 6
  orders of the class,          7
Pyrosis,                  1428
  symptoms of,           1432
  proximate cause of,     1434
  remote causes of,        1433
  cure of,                1435
Pyrosis Seucica  of Sauvages,! 429
Quinsy.
    Q-
See Cynanche.

    R.
Rachitis,                  1720
  its origin,               1721
  remote causes of, 1722—1724
  phenomena of,           1725
  proximate causeof,1726—1729
  cure of,          1730—1737
Reaction of the system,       59
  violent  in  fever, symp-
    toms,                  103
  violence  of, how moderat-
    ed,                    127
Refrigerants, the use of them
     in fever,               134
Remedies, table of those em-
    ployed in continued  fe-
    vers,                   227
Remission of fever,          26
Resolution  of inflammation,
    how produced,         249
Respiration, changes,  during
    paroxysm of an intermit-
    tent,                    IS
Revolution, diurnal, in  the hu-
    man body,               55
Rheumatism, acute or chro-
    nic,                   432
  Acute, remote causes of,  435
    proximate cause of,444—459 
INDEX.
Rheumatism, acute, symp-
       toms of,        438—446
    cure of,          460—469
  Chronic, symptoms of,    449
    how distinguished from
       the acute,           450
    proximate cause of,    471
    cure of,          472—475
    how distinguished from
       gout,               525
Rickets.   See Rachitis.
Rose.   See Erythema.

             S.
Scarlet fever,              650
  the  symptoms of,        655
  different from   cynanche
    maligna,         650—654
  the  cure of,        656—663
Scrophula,               1739
  the  phenomena of, 1739—1750
  the  proximate cause of,  1751
  not  contagious,          1752
  not  arising from  the lues
    venerea,             1753
  the  cure of,        1754—60
Mesenterica,             1607
Scurvy,                  1790
  remote causes of, 1793—1803
  cure of,            1805—10
  proximate cause of, 1812—15
Sinapisms, effects of them,   197
Skin,  affections of. See Impe-
    tigines.
Small-Pox, gen. character of, 586
  symptoms of distinct kind, 588
    of confluent kind, 589—592
  general differences between
    distinct and confluent,  593
  causes  of these  differ-
    ences,           594—599
  prognosis in,           •  592
  cure of,            600—629
  inoculation of,             601
    the several  practices of
       which it consists,     602
. importance of several prac-
    tices belonging to, 603—614
  management of small-pox
    received by  infec-
       tion,          615—629
c  ,                       1428
Soda,                  _
Spasm, internal, means ot
    removing in fevers, 152—187
  the proximate cause of in-
    flammation,      243—248
Spasmodic affections without
    fever,                 125'
  of the animal functions,  1254
  of the vital functions,     1356
  of the natural functions,  1428
Sphacelus,                 255
Splenitis,                   424
Stimulants, when to be  em-
    ployed in fevers,        217
  their  use in intermittent
    fevers,                 230
Stomach, its consent with the
    vessels on the surface of
    the body,               44
Sudorifics, arguments for their
    use in fevers,      163—167
  against their use in  fevers, 164
Suppuration of inflamed parts,
    the causes of,          251
  the marks of tendency to,  251
  formed, the marks of,      ib.
Surface of the body, its con-
    sent with the stomach,    44
Swellings, general.  See In-
    tumescentiae.
  adipose,                1622
  flatulent,                1627
  watery.   See Dropsies.
Sweating, when hurtful  in
    continued fevers,       165
  rules for the conduct of in
    continued fevers,       168
  use of  in  intermittent fe-
    vers,                   230
Syncope, phenomena of,    1170
  remote  causes of, 1173—1178
  predisposition to,        1184
  cure of,                 1189
  distinguished  from  apo-
    plexy,                1093
Synocha.  See Fever.
Synochus.   See Fever.
Syphilis,                  1761
  originally from America, 1762
  how propagated,         i 753 
INDEX.
Syphilis and gonorrhoea, how
    distinguished,         1765
    cure of,        1784—1789
T.	
Tabes a hydrope, a sanguifluxu, dorsalis,	1610 1609 1611
glandularis, mesenterica,	1607 ib.
nutncum,	1609
rachialgia, scrophulosa,	1607 ib.
 Tartar Emetic, its use in fe-
     vers,                  185
 Tetanus,                  1257
   remote causes of,        1268
   cure of,                 1270
   pissileum Barbadense, or
     Barbadoes tar, in,     1280
   lateralis,                1268
 Tonic  medicines employed
     in continued fevers,     211
   do. in intermittent fevers,  231
 Toothach,  how far different
     from rheumatism, 476—479
     symptoms  of,          477
   predisposition to,         480
   remote causes of,   480—481
   proximate cause of,       482
   cure of,            484—490
Trismus.   See Tetanus.
   Nascentium.            1282
Tussis.  See Catarrh.
Tympanites, character of,   1628
  different species of,  1629—31
  intestinalis,              1629
  enterophysodes,           ib.
  abdominalis,              ib.
  asciticus,                 ib.
 Tympanites, phenomena of, 1633
   proximate cause of, 1636—37
   cure of, -           1638__45
 Typhus.  See Fever.
   the species of,              70

              V.
 Vapours, or low spirits.  See Hy-
     pochondriasis.
 Venereal Disease.  See Syphilis.
 Venery, excess in, a remote
     cause of fever,           97
 Vesanise, in general,       1529
 Vis medicatrix naturae,        38
 St. Vitus' Dance.  See Chorea.
 Vomiting of blood. See Hemate-
     mesis.
   effects of in continued fe-
     vers,             172—173
   the use of in intermitting
     fevers,            230—34

              U.
Urine, bloody. See Haematuria.
Urticaria, the  history and
     treatment of,           729

              W.
Water-Brash.  See Pyrosis.
Whites.   See Leucorrhoea.
Warm bathing, the effects of
     in fever,                198
  administration of iirfevers, 199
  marks of the good effects, 200
Wine, the most proper stimu-   *
     lant in fevers,           218
  its convenient use in fevers,219
  when  hurtful or useful  in
     fevers,                 220
VOL. II. 
A 
         FIRST LINES

              OF THE

PRACTICE OF  PHYSIC.
BOOK IV.
                   CHAPTER VL

OF THE  MENORRHAGIA, OR  THE IMMODERATE
            FLOW OF THE MENSES.

965. BLOOD discharged from  the  vagina may pro-
ceed from different sources in the internal parts:  but
here I mean to treat of those discharges only, in which
the blood may be presumed to  flow from the same
sources that the menses in their natural state proceed
from; and which discharges alone, are those properly
comprehended under the present  title.  The title of
Metrorrhagia, or hcemorrhagia  uteri, might  compre-
hend a great deal more.
  966. The menorrhagia may be considered as of two
kinds; either as it happens to pregnant and lying-in wo-
men, or as  it  happens to women neither pregnant nor
having recently borne children.  The first kind, as con-
nected with the circumstances of pregnancy and child-
bearing, (which are not to be treated of in the present
  VOL. II.                b 
2
PRACTICE  OF  PHYSIC.
course) I am not to consider here, but shall confine my-
self to the second kind of menorrhagia only.
   967. The flow of the menses is considered as immo-
derate, when it recurs more frequently, when  it con-
tinues longer,  or when, during  the ordinary continu-
ance, it is more abundant than is usual with the same
person at other times*
   968. As the most part of women  are  liable to some
inequality with respect to the period, the duration, and
the quantity of their menses; so it is not every inequa-
lity in these respects that is to be considered as a dis-
ease; but only those deviations, which are excessive in
degree, which  are permanent, and which induce a ma-
nifest state of debility.
   969. The circumstances (967,  968.) are those which
chiefly constitute  the menorrhagia: but it is proper to
observe,  that although  I allow the frequency, duration,
and quantity of the menses to be judged of by  what is
usual with the same individual at other times; yet there
is, in these particulars, so  much uniformity  observable
in the whole of the sex, that in any individual in whom
there occurs a considerable deviation from the common
measure, such a deviation,  if constantly recurring, may
be considered  as at least approaching to a morbid state,
and as requiring most of the precautions which I shall
hereafter mention as necessary  to  be attended to by
those who are actually in such a state.
   970. However we may determine with respect to the
circumstances (967, 968.), it must still be allowed, that
 * The interval of time which, in temperate climates, occurs between the pe-
riods of menstruation in healthy women, is from twenty-seven to twenty-nine
or thirty days- In tropical climates, this interval is shorter, and, in polar ones,
longer. The continuance of the menstrual period varies from two to seven or
eight days ; and the quantity of sanguineous fluid discharged, from three to
eight ounces. Women are themselves competent judges whether this
evacuation be, in any measure, immoderate, and will usually report correctly
to their physician. 
                PRACTICE OF PHYSIC.             g

  the immoderate flow of the menses is especially to be
  determined by those symptoms affecting other  func-
  tions of the body,  which  accompany and follow  the
  discharge.
    When a larger flow than usual  of the menses has
  been preceded by headach, giddiness, or dyspnoea, and
  has been ushered in by a  cold stage, and is attended
  with much pain of the back and loins, with a frequent
  pulse, heat, and thirst, it may then be considered as pre-
  ternaturally large.
    971. When, in  consequence  of the  circumstances
  (967—970.) and the repetition of  these, the  face be-
  comes pale; the pulse grows weak:  an unusual debility
  is felt in exercise; the breathing is hurried by moderate
  exercise; when,  also, the back becomes pained  from
  any continuance in  an erect  posture;  when  the ex-
  tremities become  frequently cold;  and when  in the
  evening the feet appear affected with oedematous swell-
  ing; we may from these symptoms  certainly conclude,
  that the flow of the menses has been immoderate, and
  has already induced  a dangerous state of debility.
   972.  The debility  thus induced does often discover
 itself also by affections of the stomach; as anorexia and
 other symptoms of dyspepsia;  by a palpitation  of the
 heart, and frequent faintings; by a  weakness  of mind
 liable to strong emotions from slight causes, especially
 when suddenly  presented.
   973. That flow of the menses, which is  attended  with
 barrenness in married  women, may generally be  con-
 sidered as immoderate and  morbid.*

  * Every irregularity in menstruation is liable to be the cause or concomi-
tant of barrenness, as proceeding from a morbid condition of some of the fe.
male organs of generation  This is true of a defective no less than of ara
excessive menstrual discharge.
  The reason why irregularity in menstruation produces barrenness, is suffi*
ciently obvious. 
4
PRACTICE  OF PHYSIC.
   974.  Generally, also,  that flow of tRte menses may be

   Conception in  the female is now known to take place in the ovarium,
 and to be the result of a sympathetic process.  It does not arise from the
 actual conveyance of the semen masculinum in propria forma, but trom the
 transition of its specific influence, to one or more of the vesicule ovarii; and
 this transition  is effected  by sympathy.  The  seminal  fluid of the  mule
 need not, and does not, pass beyond the vagina of the female. Brought into
 contact with some portion of that tube, it makes its specific impression there,
 which, by sympathy or consent of parts, is thrown on the ovarian vesicle,
 and excites in it the conceptive process.   For the  completion of this process,
 an entire harmony between all the several parts of the female generative
 system is requisite. The vagina must harmonize with the ovarium, the ova-
 rium with the fallopian tubes, the fallopian tubes with the fundus, body, and
 neck of the uterus, and the whole reciprocally with each part, otherwise
 the generative effort,  however  auspiciously commenced, must prove abor-
 tive.  But, it is scarcely necessary to add, that a very slight disorder or ir-
 regularity in any one of the female organs is sufficient to derange this curi-
 ous and important system of sympathies.
   We well know, that the sympathetic doctrine of generation is by many
 still held in doubt   But, we as well know, that, as far as our information ex-
 tends, it is doubted only by those who have never  studied it; or who  have
 brought to the study of it such inveterate prejudices as amount to a film, or
 a distorting and deceptive medium of vision.
   We repeat, that it is now a conceded fact, that conception takes place in
 the ovarium, and not in the  uterus.   That the semen masculinum does not
 make its way to that glandular body, we are forbidden  to believe, by con-
 siderations that <ie irresistibje.  Nor to the enlightened physiologist does
 it  appear at  all necessary  that it  should.  Such  a physiologist perfectly
 knows, that distant stimulation is as powerfully operative, as that which is
proximate—that stimulation, for example, on the vagina, may operate on the
 ovarium as forcibly as if it were made on the ovarium itself—that stimulation
 on the stomach  acts as powerfully on the liver, and  produces in it as copious
 a secretion of bile, as if it were made on the liver itself—and that concupis-
 cence or lust, which being a meatal affection, acts necessarily on the brain,
 the organ of the mind, gives rise to  a  secretion  of semen masculinum  as
 abundant as if it acted immediately on the testicles.
   The real physiologist also knows, that  the difficulty of explaining the
 modus operandi of a stimulus  on  any organ, is not in the slightest degree
 diminished by bringing it into contact with that organ.   We know just as
 well how and why a blistering plaster placed on the temple or the neck,  or
 an emet.c acting on the stomach, relieves ophthalmia, as we do, how or whv
 a remedy applied to the eye itself relieves it.
  It is the tyro in physiology who alone holds « contact" in such high estima
 hon-who alone believes, that he has removed every obstacle, and solved
 every difficulty, when he has conveyed the agent to the part on which it is
 to act.
   We repeat, that it is just as difficult to explain  the mode in which the se- 
PRACTICE OF PHYSIC.
5
 considered as immoderate, which is preceded and fol-
 lowed by a leucorrhoea.*
   975.1 treat of menorrhagia here as an active haemor-
 rhagy,  because I consider menstruation, in its natural
 state, to be  always of that kind; and although there
 should be cases of menorrhagia which might be consi-
 dered as purely passive, it appears to me that they can-
 not be so properly treated of in any other place.
   976. The menorrhagia (967. etseq.) has for approxi-
 mate cause, either the haemorrhagic effort of the  uterine
 vessels  preternaturally increased,  or a  preternatural
 laxity of the extremities of the uterine arteries, the hae-
 morrhagic effort remaining as in the natural state.f
   977. The remote causes of the menorrhagia may be,
 1st, Those which increase  the plethoric  state of the
 uterine vessels; such as a full and nourishing diet, much
 strong liquor and frequent intoxication.   2dly,  Those
 which determine the blood more copiously and forcibly
 into the uterine vessels; as violent strainings of the whole
 body; violent shocks of the whole body from falls; vio-
 lent strokes or contusions on the lower belly, violent ex-
 ercise, particularly in dancing;  and violent passions of
 the mind.   Sdly, Those which particularly  irritate the

 men masculinum, if conveyed to the ovarium, might excite in that body the
 conceptive process, as it is  to explain the mode in which it does it, when
 acting on the vagina.
  By adopting the sympathetic doctrine, we escape the difficulty, which is
 in itself insuperable, of conducting the male semen to the orarium of the
 female.
  To the thorough-bred physiologist, therefore, such adoption must appear
 imperative.
 * Leucorrhoea, in some cases, precedes or follows menstruation when the
 discharge of the sanguineous fluid is preternaturally scanty.
  | We have already said that we believe the doctrine of haemorrhagy, as
proceeding from a mere laxity of the extremities of arteries, to be erroneous.  It
 is altogether mechanical, is derived from our ideas of the properties of
 dead matter, and ought, therefore, to be rejected in our consideration of the
 properties and laws Qi living matter. 
6
PRACTICE OF  PHYSIC.
 vessels  of the uterus;  as excess  in venery;  the exer-
 cise  of venery  in  the time of menstruation;  a  cos-
 tive habit, giving occasion  to violent straining at stool;
 and cold  applied to the feet.   Uhly,  Those who have
 forcibly overstrained  the extremeties of the uterine ves-
 sels; as frequent abortions; frequent child-bearing with-
 out nursing;  and  difficult tedious labours.   Or, lastly,
 Those which  induce a general  laxity;  as living much
 in warm chambers, and drinking  much  of warm ener-
 vating liquors, such as tea and coffee.*
    978.  The effects of the menorrhagia are pointed out
 in 971,  972, where I  have mentioned the several symp-
 toms accompanying  the disease;  and  from these the


  • Humidity and cold applied to the feet during menstruation, frequently
check the discharge, and produce dangerous obstructions.
  The process of nursing produces on the uterus a twofold effect: it excites
in it, by sympathy, a healthy state of action, and draws from it to the breasts
the blood, which would otherwise oppress it by an unnatural plethora. It
thus affords it time and opportunity to recover its tone, after having been
debilitated by gestation and parturition.
  Hence, the moral duty which binds females, who are competent to the
task, to nurse their offspring, is strongly enforced by its physical advan-
tages.
  We have in this article, again, a repetition of  the erroneous doctrine of
laxity.  We here deliberately bear against  it, wherever it may occur, our
decided testimony.  It is immoderate and morbid action, not laxity, the latter
being, as already stated, a mere  mechanical property, and not, therefore,
predicable of living vessels.
  Our author is correct in enumerating the passions of the mind among the
causes which  are concerned in the production of menorrhagia.  The pas-
sions most powerful in the excitation of this discharge are rage, jealousy,
and terror. The two  latter, in particular, may, perhaps, be said to possess
a specific influence in  producing uterine hsemorrhagy.
  To the agency of terror may be traced more  cases of abortion, than to
that of all the other passions combined. Yet do many physicians pronounce
terror to be a sedative passion !
  Delicate females, therefore, at all times, but especially when in a state
of pregnancy, ought studiously to avoid this passion  To excite it  in them
intentionally,  by way of amusement, as is often done  by mischievous indi-
viduals, is exceedingly culpable.  Sudden death has been sometimes the
issue. 
PRACTICE  OF PHYSIC.             7
consequences  to be apprehended will also readily ap-
pear.
  979.  The treatment and  cure of the menorrhagia
must be different,  according to the  different causes of
the disease.
  In all cases, the first attention  ought  to be given to
avoiding the remote causes, whenever that can be done;
and  by that means the disease  may be  often  entirely
avoided.
  When the remote causes cannot be avoided, or when
the avoiding them has been neglected, and therefore a
copious menstruation has come on,  it should be mode-
rated as much as  possible, by abstaining from all exer-
cise, either at the coming on, or  during the continuance
of the  menstruation; by avoiding even an erect posture
as much as possible;  by shunning  external heat,  and
therefore warm chambers and soft beds; by using a
light and cool diet; by taking cold drink, at least as far
as former habits will allow; by avoiding  venery; by ob-
viating costiveness, or removing it by laxatives that give
little stimulus.
   The sex  are commonly negligent, either in avoiding
the remote causes, or in moderating the first beginnings
of  this disease.  It  is  by such neglect   that it so fre-
quently becomes violent, and  of difficult cure; and the
frequent repetition of  a copious menstruation,  may be
considered  as a cause of great laxity in the extreme
vessels of the uterus.*
   980. When the coming on of the  menstruation has
been preceded by some disorder  in other parts of the
body,  and  is  accompanied with pains of the back, re-
sembling parturient pains, together with  febrile symp-

  * The laxatives most suitable, in such cases, are, manna, magnesia, castor
oil, or some of the mildest of the saline purgatives, as cream of tartar, Ho-
chelle salts, or phosphate of soda. 
8              PRACTICE OF PHYSIC.
toms, and  when at the same time the flow seems to be
copious, then a bleeding at the arm may be proper, but
it is not often necessary;  and  it will in most cases  be
sufficient to employ,  with great attention and diligence,
those means for moderating the discharge which have
been mentioned in the last paragraph*
   981.  When the immoderate flow of the menses shall
seem to be owing to a laxity of the vessels of the uterus,
as may be concluded from the general debility and lax-
ity of the person's habit; from the remote causes that
have occasioned the disease  (977.); from the absence of
the symptoms which denote increased action in the ves-
sels  of the uterus (970.);  from the frequent recurrence
of the disease,  and  particularly from  this, that in the
intervals of menstruation the person is liable to  a leu-
corrhoea; then in  such case the disease is to be treated,
not only by employing all the means mentioned in 979,
for  moderating the  haemorrhagy, but also by avoiding
all irritation, every irritation having  the greater effect
in proportion  as  the vessels have been more  lax and
yielding.   If, in  such a case of laxity, it shall appear
that some degree  of  irritation  concurs,  opiates may be
employed to moderate the discharge; but in using  these,
much caution is requisite.
   If, notwithstanding these  measures  having been  ta-
ken, the discharge shall prove very large,  astringents,
both external and internal, may be employed.   In such
cases, may small doses of emetics be of service?!

  * Digitalis has been found a useful remedy in  the more active states of
this disease. By weakening the action of the heart and arteries, it dimi-
nishes of course the impetus of the blood.
  f The internal astringents most commonly in use are, alum, gum kino,
and catechu, but more especially saccharum saturni.   To these the bark is
added, in some instances, with great advantage.
  The only »xternal astringent which we consider of any moment, is cold.
This may be used in the form of cloths wet with cold water,  or vinegar 
PRACTICE  OF PHYSIC.
9
    982,  When  the menorrhagy depends on the laxity of
 the uterine vessels, it will be  proper, in the intervals of
 menstruation,  to employ tonic  remedies;  as cold bath-

 and water, applied to the lower part of the abdomen, or immediately to the
 pudenda; or, which is better still, to both.
   A sheep's gut, tied at one end, introduced into the vagina, and distended
 with iced water, is still,  perhaps, a more effectual mode of application.  A
 piece of ice, itself, has been sometimes advantageously introduced into the
 vagina.
   The most efficacious local remedy we have ever used, consists in the fol-
 lowing injection : Sacch. saturn. dj.  Opii gr. iij.   Let these be dissolved in
 two ounces of mucilage of gum arabic, rendered sufficiently liquid by a lit-
 tle water, gently thrown up the rectum, and there retained.
   This injection should  be repeated as often as circumstances may require.
   In this complaint emetics are sometimes administered with  great advan-
 tage.
   The emetic most effective in checking  uterine haemorrhagy, is ipecacu*
 anha.
   For the  salutary influence of  that article,  in  this complaint, we are in-
 debted, of course, to its specific agency.  For that, in addition to its power
 to  produce vomiting, it and  every other emetic possesses such an agency,
 is sufficiently obvious.
   Indeed the whole of material nature is composed of specifics; no two arti-
 cles in it being alike.  This is equally true of the causes which  produce,
 and of those which remove disease.
   Hence it is idle to denominate one of nature's productions a specific, as if
 it were, in that respect, contradistinguished from another.  We repeat, they
 are all specifics—ipecacuanha and Glauber's salts as much so as mercury
 and Peruvian;  and marsh miasmata and cold, as much so as the poisons of
 measles and small-pox.
  Given in small nauseating doses, ipecacuanha is, perhaps, even more effi-
 cacious in stopping uterine hxmorrhagy, than  when administered in  such
 quantities as to excite puking.  If the haemorrhagy be accompanied  with
 pain,  opium sufficient in amount to allay  it should  be combined  with the
 ipecacuanha.  If not allayed,  the pain  will keep up the hemorrhagic ac-
tion, in despite of every effort to remove it.
  We are perfectly aware that cold is not usually denominated an astringent,
nor is it applied externally with a view to its acting in that capacity.
  Most physicians deem it a sedative, a term which, as used in medicine, is
self-contradictory and absurd.
  That nothing can  be in its nature a sedative which excites sensation, or
makes an impression, (and every medicinal article must act thus) is a per-
fect truism—a  position so obvious, that nothing but  blindness  or obstinacy
can deny it.  But that cold produces a very powerful impression, mi1 is ex-
ceedingly potent in exciting  sensation,  are equally true.  Hence the  con-
clusion is irresistible that it is a genuine stimulant.
VOL. TT,                      C 
10               PRACTICE OF  PHYSIC.
   ing and chalybeates.   The exercises of gestation, also,
   may be very useful,  both for strengthening  the whole
   system, and for  taking  off  the  determination  of  the

   blood to the internal parts.*
     983. The remedies mentioned  in these two last  pa-
  ragraphs may be employed in all cases of menorrhagia,

    That cold belongs to that class of stimulants denominated astringents, can-
  not be denied.
    It is the nature of those articles to produce, in the capillaries of the body,
  an astriction or tonic contraction, which seems to extend, at times, to some
  of the larger vessels.
    That cold produces such contraction, cannot be denied.
    Of the truth of this, abundant testimony is derived from its action on the
 fingers, in  rendering them pale and bloodless, and diminishing their size.
   To these phenomena it gives rise, not by occasioning a collapse  in the
 vessels of the fingers,, for that could never force the hlood out of them; but
 by exciting in them a strong and continued contraction.  A collapse means
 a cessation of action, which permits'things to remain in their existing condi-
 tion.  But, were the blood-vessels of the fingers to cease from acting, when
 filled with their contents, the fingers, remaining in such  condition  would
 not become bloodless—they would be neither pale in colour ner diminish-
 ed in size.  To produce this effect, nothing but vascular contraction is suf-
 ficient.
   When uterine hamorrhagy has produced  great debility, accompanied by
 fainting and coldness of the skin, the application of cold is a very doubtful
 remedy.  Full doses of laudanum, judiciously repeated,  are much more
 useful.
   In cases of haemorrhagy, a high temperature can alone justify the exten-
 sive and continued application of cold to the surface.
   * An excellent formula, under which chalybeates may be administered,
 consists in  the prepared rust of iron, united  to Peruvian  bark, and a little
 pulverized  ginger or cloves, and made into  boluses with conserve of roses
 The use of chalybeate waters, taken in small quantities, and frequently re-
 peated in the course of the day, is also highly  beneficial.  To many sto-
 machs the chalybeate wine is still more grateful.   Nor is it less salutary, in
 it* operation on the system.
   The pure air, eheerful society, and wholesome exercise, enjoyed at water-
 ing-places,  by revolutionizing the system, and inducing in  it a new state of
 action, contribute, in no small degree, to the benefits thence received.
  In cases of chronic menorrhagia, occurring about the period of the close
 of menstruation, when, in consequence of debility*, blood-letting is inadmis-
 sible, blisters on the wrists, repeatedly renewed, are an important remedy.
 With these  may be advantageously united, a free use of  alum and mucilage
 of gum arabic.
  In this, as in every other chronic complaint, the wearing of flannel next
to the skin should never be neglected. 
PRACTICE OF PHYSIC.
11
from whatever cause it may have proceeded, if the dis-
ease shall have already induced a considerable degree
of debility in the body.
                    CHAPTER VII.'

OF THE LEUCORRHCEA, FLUOR ALBUS, OR WHITES

984.  EVERY serous or puriform discharge from the
vagina  may be, and has been comprehended under one
or other of the appellations I have prefixed to this chap-
ter.   Such discharges, however, may be various; and
may proceed  from various sources, not yet  well ascer-
tained;  but I  confine myself here to treat  of that dis-
charge  alone which may  be presumed to proceed from
the same vessels, which, in their natural state, pour out
the menses.
   985.  I conclude a discharge from the vagina to be of
this  kind; 1.  From its  happening  to women who are
subject  to an immoderate flow of the menses, and liable
to this from causes weakening the vessels of the uterus.
2. From its appearing chiefly,  and often only,  a little
before,  as well as immediately after,  the flow of the
menses.  3.  From the flow of the menses being dimi-
nished,  in proportion as the leucorrhoea is increased.
4. From the leucorrhoea  continuing  after  the menses
have entirely ceased,  and with some appearance of its
observing a  periodical recurrence.  5. From the leu-
corrhoea being accompanied with the effects of the me-
norrhagia (971—972.)  6. From the discharge having

  •The including of fluor alius within the order hsmorrhagix is a step
which cannot be justified on any principle with which we are acquainted.
With  much more propriety might it be made to fall  within the order pre*
fuvia. 
12
PRACTICE OF PHYSIC.
 been neither preceded by, nor accompanied with, symp-
 toms of any topical affections of the uterus.   7. From
 the Jeucorrhrea not having appeared  soon  after com-
 munication  with  a person who might be suspected  ot
 communicating infection, and from the first appearance
 of the disease not being  accompanied with any inflam-
 matory affection of the pudenda.*
   986.  The appearance of the  matter  discharged  in
 the leucorrhcea, is very various with respect to consist-
 ence and  colour;  but from these appearances, it is not
 always possible to determine concerning  its nature,  or
 the particular source  from whence it proceeds.
   987.  The leucorrhoea. of which I am to treat, as as-
 certained  by the several circumstances (985,) seems to
 proceed from the  same causes as that species of menor-
 rhagia, which I suppose to arise from the laxity of the
 extreme  vessels of the  uterus.   It  accordingly  often
 follows or accompanies such a menorrhagia: but though
 the leucorrhoea depends chiefly upon  the laxity men-
 tioned, it may have proceeded from irritations inducing
 that laxity, and seems to be always increased by any  ir-
 ritations applied to the uterus.
   988.  Some  authors  have alleged,  that a  variety of

  * For practitioners of medicine, who are defective in experience, there
are few points of greater difficulty,  than to discriminate certainly and satis-
factorily to themselves, between leucorrhoea and gonorrhoea.  In addition to
what our author has stated, the following particulars are worthy of atten-
tion :
  In gonorrhoea,  the running, although never very copious, is  somewhat
uniform in quantity, and, therefore,  seldom very small: in leucorrhoea, it is
irregular, being sometimes very profuse,  and, at other times, scarcely per-
ceptible.  In gonorrhoea the symptoms are, in general, much more inflam-
matory than they are in leucorrhcea; the smarting in making water is more
severe, the itching of the pudenda more troublesome, the inclination to ve-
nery greater, the labia more swollen, and the glands in the groin more apt
to be enlarged.
  In addition to all these particulars, the practitioner is oftentimes obliged
to inquire minutely into the character and connexions of the female he is
examining, the better to satisfy himself respecting her disease. 
PRACTICE OF  PHYSIC.
13
circumstances  in  other parts of the body may have a
share in  bringing on and in continuing this affection of
the uterus now under  consideration; but I  cannot dis-
cover  the reality of those causes; and it seems to me,
that this leucorrhoea, excepting in so far as  it depends
upon a general debility of the system, is always prima-
rily an affection of the  uterus; and  the affections of
other  parts of the body  which  may happen to accom-
pany it,  are for the most part to be considered as ef-
fects, rather than as causes*
   989. The  effects of the leucorrhoea  are  much  the
same with those of menorrhagia; inducing a  general
debility,  and in particular, a debility in the functions of
the stomach.  If, however, the leucorrhoea be moderate,
and be not accompanied with any considerable degree
of menorrhagia, it may often continue long without in-
ducing any great degree  of debility, and  it is only when
the discharge has been very copious as well as constant,
that its effects in  that way are very remarkable.
   990. But, even when its effects upon the whole body
are not  very considerable, it may still be supposed to
weaken  the genital  system;  and it  seems sufficiently
probable that this discharge may often have a share in
occasioning  barrenness.f
   991. The  matter  discharged in  the  leucorrhcea is
at  first generally mild: but after some continuance of
the disease,  it sometimes becomes acrid; and  by irri-
tating, or perhaps eroding,  the surfaces over which it
passes, induces various painful disorders.]:
  • We cannot fully concur with our author in the sentiment expressed by
him in this article.  We feel persuaded, on the other hand, that a depraved
state of the stomach is oftentimes the cause of leucorrhoea.  In such cases,
remedies directed to the stomach constitute the only means of cure.
  -j- There can be no doubt that the diseased condition of the uterine sys-
tem, whence leucorrhcea proceeds, is,  in many instances, the cause of bar-
renness.
  * Cases hare occurred in married women of unsuspected virtue, where 
  14                PRACTICE OF PHYSIC.

    992.  As  I have supposed  that the leucorrhoea  pro-
 ceeds from  the same causes  as  that species of menor-

 itae discharge in leucorrhoea was so extremely acrid, as to produce, on com-
 ing in contact with it, severe ulceration on the male organ.
   In  the treatment of this disease,  whatever may  be its original seat, to
 commence with an emetic, is, in general, sound practice.  Ipecacuanha is,
 for the most part, to be preferred.
   In addition to the evacuation of the stomach, that organ is, by this proce-
 dure, so far altered in its condition, as to  be  more readily acted on,  and
 more favourably impressed, by other remedies.
   Owing to the powerful and universal sympathy of the stomach with the
 other parts of the body, the pervasive influence of an emetic is well under-
 stood.  When judiciously administered, the entire system feels its influence
 in the most salutary manner, and in a very high degree.
   The secretions of the body are particularly affected by it.  When healthy,
they are encouraged; and when unhealthy, ameliorated.   This is especially
the case in relation to the bile,  the urine, the cutaneous perspiration, and
the fluids secreted into the cells of the cellular membrane, and the various
larger cavities of the body.
  But leucorrhoea consists essentially in a vitiated secretion, being the con-
verse of menstruation, which  is a healthy one.  In common with other se-
cretions, therefore, it participates in the salutary effects of the emetic pro-
eess.  But no inconsiderable portion of the propitious influence of this pro-
cess arises from its predisposing the stomach to be favourably acted  on by
other remedies.  An emetic acts here as it does in intermitting fever, when
given as introductory to the use of the bark. It prepares the way for what
is to follow.
  In the estimation of many practitioners of great respectability, purgatives
bear, in  the treatment of leucorrhoea, a rank still superior to that of emetics.
  Without attempting to strike a balance between these two classes of re-
medies,  we have no hesitation in testifying to the excellent effects of the
purgative plan in the treatment of leucorrhoea.
   This complaint is often, if not  always, accompanied by more or less de-
rangement, at least in  the functions, if not in the structure,  of the liver.
Hence,  in the alimentary canal  are formed accumulations, at times enor-
mous, of faeces and sordis, exceedingly offensive and no less injurious.  The
removal of  these constitutes a primary object of indication.
  But, in common with emetics, the effect of  purgatives is not limited to
the mere evacuation of the alimentary canal.  It is felt throughout the sys-
tem ; by certain parts, however, more than by others.
   Nor are all purgatives alike in their action. Added to  its evacuant effect,
 each one makes a specific impression.  By a judicious selection of these ar-
 ticles, therefore,  according to the cases in  which  they are exhibited, the
discerning and experienced practitioner shows his skill.
   In  the treatment of leucorrhoea we have derived most benefit from those
 that act  somewhat forcibly on the lower  intestines.  With  that portion of
 the alimentary canal the uterine system more immediately sympathizes*. 
                  PRACTICE  OF PHYSIC.               15

 rhagia which is chiefly owing to a laxity  of the uterine
 vessels, it must be treated,  and  the cure attempted, by
 the same means as delivered in  981, for  the cure of
 menorrhagia, and with less  reserve  in  respect to the
 use of astringents.*
    993. As the leucorrhoea  generally depends upon  a
 great loss of tone in  the vessels of the uterus, the dis-
 ease has  been  relieved, and sometimes cured by certain
 stimulant medicines,  which  are commonly  determined
 to  the urinary passages,  and from the vicinity of these
 are often communicated to the uterus.   Such for ex-
 ample, are cantharides, turpentine, and ether balsams
 of a similar nature.f

   The bowels being first very thoroughly cleansed by calomel combined
 with jalap,  or some of the drastic  gums, sulphur administered, daily or
 twice a day, in moderate doses, and continued for a considerable time, ha*
 contributed not a little to the removal of this complaint.
   So has the blue pill, employed as a laxative, and, at the same time, as an
 alterative.
   Of the good effects of balsam copaiva,  spirits of turpentine, and  other
 terebinthinate substances, judiciously administered, it -would be superflu-
 ous to  speak.
   The way being prepared for them, tonics must complete and perpetuate
 the cure.
   Of these,  the most important are, a well regulated diet, suitable clothing,
 the use of the flesh-brush, pure air, a sufficiency of exercise without fatigue,
 an indulgence in sleep to the extent of entire refreshment, cheerful society,
 and  a subjection to those moral causes, which, while they  moderately ex-
 cite,  tend to harmonize and tranquillize the mind.
   The  more technical tonics are every where detailed, and need not be
 here specified.
   • Astringent injections composed of solutions of alum, saccharum saturni,
 and  vitriolated zinc; also well filtered decoctions of galls and of oak bark
 are advantageously used in this complaint.
  f Of all the balsamic or terebinthinate substances, the balsam capaiva is at
 once the gafest and most efficacious.   From fifteen to twenty drops, taken
 on loaf sugar, or in any convenient vehicle, and repeated three or four times
 a day, we have found to be a remedy  of great value.
  Cantharides and turpentine, when skilfully administered, are both useful.
  In  the treatment of this disease, travelling, during the summer months,
 constitutes a  most important remedy.  So Hoes sea-bathing,  as well as the
 cold  bath locally but frequently applied to the  pudenda, and persevered m
for a  considerable  time, 
16
PRACTICE OF PHYSIC.
                      CHAPTER VIII.
  OF  THE AMENORRHEA, OR INTERRUPTION OF
               THE  MENSTRUAL FLUX.

 994. WHATEVER, in a system of  methodical no-
 sology, may be  the  fittest place for the amenorrhoea, it
 cannot be improper to treat of it here as an object of
 practice, immediately after  having considered  the me-
 norrhagia*
   995.  The interruption of the menstrual flux is to be
 considered as of two  different kinds;  the   one being
 when the menses do not begin to flow at that period of
 life at which they usually appear;  and the other being
 that when, after they  have repeatedly taken place for
 some time, they do,  from other  causes than conception,
 cease to return at their usual  periods.  The former of
 these cases is  named  the retention, and the latter the
 suppression, of  the  menses.
   996.  As the flowing of the menses depends upon the
 force of the   uterine arteries impelling the  blood  into
 their extremities, and  opening  these so as to pour out
 red  blood; so the  interruption of the  menstrual flux
 must depend,  either upon the want of due force in the
 action of the  uterine arteries, or upon some preterna-

  * Our author having himself, in this article, admitted, in  substance, the
impropriety of receiving amenorrhoea into the order hsemorrhagize—in plain
English, a defect of haemorrhagy into the order haemorrhagy—it would be
superfluous in us to dwell on the subject.  Indeed amenorrhoea is so <. ssen-
tially different from all other diseases—it being, in the nature of things, im-
possible for any one to be like it—that it appears impracticable to class it at
all on the principle of similarity.—Consisting, as it does, in the suppression
of a specific function, we perceive not how it can be other than itself &ispe-
cific complaint. Perhaps the best arrangement for Dr.  Cullen would have
been, to have placed it under  the order spasmi, and genus  hysteria__go-
verning himself chiefly by affinity of situation. 
PRACTICE OF PHYSIC.
17
 tural resistance in their  extremities.   The former  I
 suppose to  be the  most usual  cause of retention, the
 latter the most common cause  of suppression;  and  of
 each of these I shall  now  treat more particularly.*
    997.  The retention of the menses, the emansio men-
 sium of Latin writers, is not to be considered as a dis-
 ease merely from the menses not flowing at that period
 which  is usual  with most other  women.   This period
 is so different in different  women,  that no time can be
 precisely assigned as  proper to the sex in general.—In
 this climate, the menses usually appear about the age of
 fourteen, but in many they appear more early, and in
 many not till the sixteenth year:  in which last case it is
 often without any  disorder being  thereby occasioned.
 It is not, therefore, from the age  of the person that the
 retention is to be considered as a disease; and it is only
 to  be   considered as  such,  when  about the time  the
 menses usually appear, some disorders  arise in  other
 parts of the body which may be  imputed to their reten-
 tion ; being such as,  when  arising at this period,  are
 known  from experience to  be removed  by the  flowing
 of the  menses.
    998.  These  disorders are, a  sluggishness, and fre-
 quent   sense of  lassitude and debility,  with  various
 symptoms of dyspepsia; and sometimes with a preter-
   * The doctrine enunciated in this article, as to the cause of amenorrhoea is
 eminently erroneous. Our author speaks of menstruation as if it  were aren/
 hxmorrhagy .• whereas the fact is known to be otherwise. Instead of being
 a  haemorrhagy, it is nothing but a sanguineous secretion.  It does  not consist,
 therefore, in a  mechanical forcing open of the  mouths of the uterine arte-
 ries, by the impetus of the blood thrown into them.  This doctrine is alto-
 gether gross, vulgar, and unfounded. Menstruation consists in a peculiar
 secretory action of the extremities of these arteries, whereby the red glo-
 bules and serum of the blood are separated from the  fibrina—the former
(eiected, and the latter retained.
   As well might our authordeclare  the secretion of urine to be a  mechanical
 forcing open of the mouths of the extremities of the emulgent arteries, as to attempt
 to explain, on a similar ground, the process of menstruation.
    VOL.  IT.                 D 
18            PRACTICE OF PHYSIC.

natural appetite.   At the  same time the face loses its
vivid colour, becomes pale, and sometimes of a yellow-
ish hue; the whole body becomes pale and flaccid; and
the feet, and perhaps also a great part of the body be-
come affected with (edematous swellings.   The breath-
ing is hurried by any quick or laborious motion of the
body, and the heart is liable to palpitation and syncope.
—A headach sometimes  occurs; but more certainly
pains of the back, loins, and haunches*
   999. These symptoms,  when  occurring  in  a high
degree, constitute the chlorosis of authors, hardly ever
appearing separate from  the retention of the menses,
and, attending to these symptoms, the cause of this re
tention may, I think, be perceived.
   These symptoms  manifestly show a considerable lax-
ity and flaccidity of the whole system;  and, therefore,
give reason to conclude, that the retention of the menses
accompanying them, is owing to a weaker action of the
vessels of the uterus; which therefore do not impel the
blood  into  their extremities with a force sufficient to
open these, and  pour out  blood by them.f
   1000.  How it happens that at a certain period of life
a flaccidity of the system  arises  in  young women,  not
originally affected with any such weakness or laxity,
and of which, but a little time before,  they had given
no indication, may be difficult to explain; but I would
attempt it in this way.
   As  a certain state of the ovaria  in females prepares
and disposes them to the  exercise of venery, about the
  *In amenorrhoea, more especially, perhaps, the emansio mensium, a most
extraordinary propensity  oftentimes prevails for the eating of chalk, clay,
lime-plastering, charcoal, and sometimes salt. The same preternatural appe-
tites arise in some women during the period of gestation; thus manifesting «
the ex stence of a sympathy equally singular  and powerful between the '
uterus and stomach.
  f In this article our author pursues his erroneous doctrine touching tbe
proximate cause of menstruation. 
PRACTICE OF  PHYSIC.
19
 very period at which the menses first appear, it is to be
 presumed, that  the state of the ovaria and that of the
 uterine vessels are in some measure connected together;
 and as generally symptoms of  a change in the state of
 the former appear before those of the latter, it may be
 inferred that the state of the ovaria has a great share in
 exciting the  action of the uterine vessels and producing
 the menstrual flux.   But analogous to what happens in
 the  male  sex,  it  may be presumed,  that in females a
 certain state of the genitals is  necessary to give tone
 and tension to the whole system; and, therefore, that, if
 the stimulus  arising from the  genitals be Xvanting, the
 whole system may  fall into  a torpid and flaccid state,
 and from  thence  the chlorosis and retention of the
 menses may arise.*

  * Without making ourselves the advocates of any part of our author's rea-
 soning on this subject, or even pretending fully to comprehend it, we believe
 it to be true, that there exists between a sound state of  the ovaria and the
 process of menstruation an intimate connection.  So essentiaMfcthis con-
 nection, that it may be regarded as the relationship of cause and effect.
  It is perfectly understood, that an entire absence of the ovaria is inconsis-
 tent with the existence of the menstrual secretion. So is any deeply disor-
 dered condition of those organs.  Hence, in a scirrhous, hydatid, dropsical,
 or sarcomatous state of the ovaria, that evacuation is always wanting.  Nor,
 under excision of those bodies, does it ever appear.
  In all real viragos,  or females without menstruation, with narrow hips,
 broad shoulders, and a general masculine  air, voice, and deportment, whose
 bodies have been examined after death, the ovaria have been found wanting.
  To the sound and efficient state of the  genital system of the female, the
 ovaria bear the same relation that the testicles do to that of the genital sys-
 tem of the male.   Without them, menstruation never takes place, nor can
 procreation be effected.
  They  are  the  glandular bodies destined, under proper excitement, to
 secrete the elementary matter of the embryo. That excitement is produced
by the influence of the semen masculinum.
  No more can we expect the foetal rudiments to be secreted without these
 glands, than the bile to be secreted without the liver, the urine without the
 kidneys, or the semen masculinum without the testes.  Hence their impor-
 tance not only to the integrity and health  of the female  system, but to the
 existence of the human race.
  Is any one inclined to question the opinion, that the fetal rudiments are
 the result of a secretory process ? 
20             PRACTICE OF PHYSIC.

   1001.  It appears to me, therefore, that the retention
of the menses is to be referred to a certain  state or af-
fection of the ovaria: but what is precisely the nature
of this affection, or what are the causes of it, I will not
pretend to explain; nor can I explain  in what manner
that primary  cause of retention is to be  removed.  In
this, therefore, as in many other cases, where we cannot
assign  the proximate cause of diseases, our indications
of cure must be formed for obviating and removing the
morbid effects or symptoms which appear.
   100^.  The effects, as has  been said in 999,  consist
in a general'naccidity of  the  system, and consequently
in  a weaker action of  the  vessels  of the  uterus; so
that this debility may be considered as  the more im-
mediate cause of the retention.   This, therefore,  is to
be  cured by restoring the tone of the system in general,
and by exciting the action of the uterine vessels in par-
ticular.
   10d!f The tone of the system  in general is to be re-
stored by exercise, and in the beginning  of the disease,
by  cold bathing.   At the same time,  tonic medicines
may be employed;  and of these the chalybeates have
been chiefly recommended*
  We ask, from what other source can they possibly be derived ? They da
not pre-exist either in the unimpregnated ovarian vesicle, or in the semen
masculinum.  Nor are they to be found in a forma! state in the blood of the
female.  Even admitting  them  to be formed by an  intermixture  and vital
union of a male and a female seminal fluid, those fluids must be the product
of secretion.
  But, in fact, they are not thus formed.  They are the result of a secretory
action altogether sui generis, excited in the female ovarium by the specific
influence of the male semen.
  This peculiar action taking place more especiaatly in one or more of the
ovarian vesicles, produces the foetal elementary mass, which is taken up by
one of the fallopian tubes, and conveyed into the uterus. This mass we
repeat, is as really a matter secreted from the blood of the female as is saliva,
the fluid of perspiration, or the pancreatic juice.
  * Pure bitters,  Peruvian bark, chalybeates, and all the other tonics recom-
mended in menorrhagia  and leucorrhoea, except the astringents, may be 
PRACTICE  OF PHYSIC.             21
  1004.  The action of the vessels of the uterus may
be excited:
  1st,  By determining the blood into them more copi-
ously;  which is to  be done by determining the  blood
into the descending  aorta,  by purging, by the exercise
of walking, by friction, and by warm bathing of the
lower extremities.   It  is also  probable that the  blood
may be determined more copiously into the hypogastric
arteries which go to the uterus, by a compression of the
iliacs;  but the trials of this kind  hitherto made  have
seldom succeeded.*
   100a. 2dly, The action of the  uterine vessels may
be excited by stimulants applied to them.   Thus those
purgatives which  particularly  stimulate the intestinum
rectum, may also prove stimulant to the uterine vessels
connected with those of the rectum.   The exercise of
venery certainly proves a stimulus  to the vessels of the
uterus; and  therefore  may be useful  when,  with pro-
priety, it can be  employed.   The various  medicines
recommended as stimulants of the  uterine vessels, un-
der the title  of Emenagogues, have  never appeared to
me to be effectual; and I cannot  perceive that any of
them are possessed  of  a specific power in this respect.
Mercury, as an universal  stimulant,  may act upon the
uterus, but cannot  be \erv  safely  employed  in chloro-
tic  persons.   One of the most powerful means of ex-
citing  the action  of the vessels in  every part  of the
system is, the electrical shock; and  it has often  been


advantageously employed in the present disease. They may be administered
also under the same formulae.   If preceded by an emetic they will act with
more certainty and higher effect.
  * With a v;ew to the promotion of the object herein  contemplated,
dancing, jumping the rope, and riding on horseback, are important exercises. 
22
PRACTICE  OF PHYSIC.
  employed with success for exciting  the  vessels  of the
  uterus*
     1006.  The remedies (1002— 100f>.) now mentioned,
  are those adapted to the retention of the  menses;  and
  I am  next to  consider the case of suppression.    In en-
  tering upon this, I must observe, that every interruption
  of  the flux, after it  has once  taken  place, is not to be
  considered as  a case of suppression.  For the flux, upon
  its  first appearance, is not always immediately establish-
  ed  in  its regular course; and therefore,  if  an interrup-
  tion happen soon after the first appearance,  or even in


  * The purgatives usually employed for such purposes,  are aloes, scam-
 mony, and gamboge, given in suitable doses, and at such times as the prac-
 titioner may deem necessary   A strong infusion  of senna, stimulating the
 rectum very considerably,  constitutes a  useful remedy in this complaint."'
  For awakening the  action of the uterine vessels, other remedies, not of
 purgative qualities, are highly recommended, and have, we feel persuaded,
 been usefully employed.
  These may be divided into external and internal.
  The external are, blisters on the os sacrum, or on the inside of the thighs,
 as near to the groins as practicable,  and warmth applied to the pudenda in
 the form of steam,  or cloths wet with water, as hot as can be borne without
 pain.  To  this head belongs electricity frequently passed through the re-
 gion  of the uterus,  and the lumbar region generally.
  The internal are  the savin, in powder or tincture,  tincture of  myrrh, the
 radix senekse in powder or decoction, and the clavus or ergot of rye, which,
 in proper doses, is reported to be a safe and very powerful remedy. For in-
 formation as to the effects and mode of exhibition of this latter medicine, the
 reader is referred to a paper by Dr. Bigelow, in No. II. Vol. V. of  the " New
 England Journal of Medicine and Surgery."  Other interesting papers on
 the medicinal qualities of  the same article, have  appeared of late in the
 northern section  of our country.
  Of the specific and powerful action of this  article on the uterine system,
 there no longer remains a doubt.
  Its entire efficiencies and utilities  are not yet known.  When the deve-
lopment shall have been completed, we  feel persuaded that the cicale cor-
 roitum or ergot will be found, in certain affections  of the uterus, one of the
 most efficacious remedies in the materia medica
  Amenorrhoea being sometimes accompanied with hepatic affections, ren-
ders the employment of mercury essential. In other cases of the complaint,
that remedy is of more doubtful promise. 
              PRACTICE OF  PHYSIC.            %$

the course of the first, or perhaps second year after, it
may often be  considered as a case of retention, espe-
cially  when the disease appears with the symptoms pe-
culiar |o that state.
   1007.  Those which may be properly considered as
cases  of suppression, are such as occur  after the flux
has been for some time established in its regular course,
and in which the interruption cannot be referred to the   ^
causes of retention (1001, 1002.) but must be imputed
to some resistance in the extremities  of the  vessels of
the uterus.  Accordingly, we often find the suppression
induced by cold, fear, and other causes which may pro-
duce  a constriction  of these extreme vessels.   Some
physicians have supposed an obstructing lentor of the
fluids to occasion the resistance now mentioned:  but
this is purely hypothetical, without any proper evidence
of the fact;  and it is besides, from other considerations.
improbable.
   1008. There are indeed some cases of suppression
that seem to depend upon a general debility of the sys-
tem, and consequently of the vessels of the uterus.  But
in such cases, the suppression always appears as symp-
tomatic of other affections, and is  therefore not to be
considered here.
   1009. The idiopathic  cases  of suppression (1007.)
seldom continue long without  being attended with va-
rious symptoms or  disorders in different  parts of the
body; very  commonly  arising  from the  blood which
should have passed by the uterus, being determined
more  copiously into other parts, and very often  with
such  force as to produce haemorrhagies in these. Hence
haemorrhagies from the nose, lungs, stomach,  and other
parts, have appeared  in consequence  of suppressed
menses.  Besides these, there are commonly hysteric and 
 24              PRACTICE Ol  PHYSIC.

 dyspeptic symptoms produced by the same cause: and

 frequently colic pains, with a bound belly*
   1010. In the idiopathic cases of suppression, (1007.)
 the  indication of cure is  to remove  the constriction af-
 fecting the extreme vessels of the uterus;  and for this
 purpose the chief remedy is warm bathing applied to the
 region  of the  uterus.  This, however, is not always
 effectual, and I do not know of any other remedy adapt-
 ed to the indication.   Besides  this, we have  perhaps
 no other means of removing the constriction in  fault,
 but  that of incrcasit-'.  t'te action and  force of the vessels
 of the uterus,  m» as  thereby to overcome the  resistance
 or constriction of the extremities.   This,  therefore, is
 to be attempted by the same remedies in  the case  of
 suppression, as those prescribed  in the cases of reten-
 tion  (1003,  1005.)   The  tonics, however,  and  cold
 bathing (1003.") seem  to be less properly adapted to the
 cases of suppression,  and have appeared to me of am-
 biguous effect.f

  * In cases of suppressed menses, vicarious hjemorrhagies have appeared
not only from the parts herein stated, but from the kidneys, the hemorrhoidal
vessels, the fingers, the eye, and from warts and the surfaces of ulcers.
  f In the treatment of this disease; vomiting, and blood-letting, when skil-
fully directed, are important remedies. So is the warm bath,  both local and
general.
  In other respects the practice here does not  differ materially from that
recommended in a suppression of the menses
  In difficult and painful menstruation, the warm bath, well timed blood-let
ting, ii:id opiates, constitute the usual and most important remedies.
  In divid;ng amenorrhoea  into idiopathic and symptomatic, our author hM
only fallen into the common error of medical writers.  Against the division
we enter our protest.
  If by an idiopathic complaint, we are to understand ^.general disease, nei-
ther preceded nor accompanied by a local affection, we declare our convic-
tion that no such disease ever did or ever can exist.
  Dsease consists  essentially in broken or unbalanced excitement__excite-
ment no longer equable and uniform. But excitement cannot long be broken,
 without a similar derangement in the circulation.  Hence congestion, either
 venous, or arterial, or both, occurs.
  Those forms of amenorrhoea which our author denominates idiopathic such, 
PRACTICE OF PHYSIC.
25
    1011. It commonly happens in the case of suppress
 sion, that though the menses do not flow at their usual
 periods, (here are often at those periods some marks of
 an effort having a tendency to  produce  the discharge.
 It is, therefore, at those times especially when the efforts
 of the system  are concurring, that we ought to employ
 the remedies for curing a suppression;  and it is com-
 monly fruitless to employ them at  other times,  unless
 they be such as require some continuance in their use
 to produce their effects.
    1012. Nearly similar to the cases of suppression, are
 those cases in which the menses flow after long inter-
 vals, and in lesser quantity  than usual; and when these
 cases  are  attended  with the disorders  in the system
 (1009.) they are to be cured by the same remedies as
 the cases of entire suppression.
    1013, It may be proper in this place  to take notice
 of the dysmenorrhoea, or cases of menstruation in which
 the menses seem to flow with difficulty, and are accom-
 panied with much pain  in  the back, loins, and lower
 belly.   We impute this disorder partly to some weaker
 action of the vessels of the  uterus, and partly, perhaps
 more especially, to a spasm of its extreme vessels.  We
 have commonly found the disease relieved by employ-

for example, as arise from " cold and fear,"  are, in their commencement, ob-
viously local.
  In producing amenorrhoea, cold acts only on the skin ; for the most part
only on the skin of the feet, and is, therefore, in its original impression, ex-
ceedingly circumscribed.
  Being a passion of the mind, fear acts originally on the brain, which is a
very limited organ.  Diseases, then, resulting from the influence of this pag>
sion, as well as from that of cold, must be in their commencement local.
  Indeed, to speak of a disease, general in its beginning, or of & general dis-
ease unaccompanied by a local affection, is, we repeat, to speak of that '
which has never been seen.  As well may you contend for the existence of
a living tree without a root,  or of  a running stream without a ibuntain tn
feed it.
   VOL. II.                  £ 
2H           PRACTICE OF PHYSIC.
ing some of the remedies of suppression  immediately
before the approach of the period, and at the same time
employing opiates.
                    CHAPTER IX.

       OF SYMPTOMATIC HAEMORRHAGIES.

1014. I HAVE thought it very improper, in this worl£
to treat of those morbid affections that are almost always
symptomatic of other more primary diseases; and this
for several reasons, particularly because it introduces a
great deal of confusion in directing practice, and leads
physicians to employ palliative measures only.   I shall
here, however,  deviate  a little  from my general  plan,
to make some reflections upon symptomatic haemorrha-
gies.
  1015. The haemorrhagies of this kind that especially
deserve our  notice,  are the Hematemesis, or Vomiting
of Blood; and the Hematuria, or the Voiding of Blood
from the  urinary passage.   Upon  these I am  here to
make some remarks; because, though they are very ge-
nerally symptomatic, it is possible they may be some-
times primary and  idiopathic  affections; and  because
they have been treated of as primary diseases in almost
every system of the practice of physic. 
PRACTICE OF  PHYSIC.
21
                     SECTION I.

 OF THE HEMATEMESIS, OR VOMITING OF BLOOD


   1016. I have  said above  in 994, in what manner
 blood  thrown out from  the  mouth may be known to
 proceed from the stomach, and not from the lungs; but
 it may be proper here to say more particularly, that this
 may be certainly  known,  when the blood is  brought up
 manifestly  by vomiting without any coughing; when
 this vomiting has been preceded by some sense of weight,
 anxiety, and pain, in the  region of the stomach; when
 the blood brought up is of a black and grumous ap-
 pearance, and when it is manifestly mixed  with other
 contents of the stomach; we  can  seldom  have  any
 doubt  of the source from whence the blood proceeds,
 and therefore of the existence of the disease we treat of.
   1017. We must allow it to be possible that a  ple-
 thoric  state of  the body  from general  causes may be
 accompanied with causes of  a  peculiar  determination
 and afflux of blood to the stomach, so as to occasion an
 hasmorrhagy there, and thence a vomiting of blood; and
 in such a case this appearance might be considered as a
 primary disease.  But the history of diseases in the re-
 cords of physic, affords little foundation for such a sup-
 position; and on  the contrary, the whole  of the in-
 stances of  a vomiting of blood which  have been re-
 corded, are pretty manifestly symptomatic of a more
primary affection.
   Of such  symptomatic vomitings of blood,  the chief
instances are the following:
   1018. One of the most frequent is that which appears 
28
PRACTICE OF  PHYSIC.
 in consequence  of a suppression of an evacuation of
 blood, which had been for some time before established
 in another part of the body, particularly that of the men-
 strual flux in women.
   1019. There  are  instances of a vomiting of blood
 happening from  the retention of  the menses: but such
 instances are very uncommon; as retention of the menses
 rarely happens in consequence of, or even with a ple-
 thoric state of the body;  and as  rarely does it produce
 that, or the haemorrhagy in question.
   There are instances of a vomiting of blood  happen-
 ing to pregnant women; that might therefore  also be
 imputed to the suppression of  the menses, which hap-
 pens to  women in that state.  There have indeed been
 more instances of this than of the former case; but the
 latter are still very rare:  for although  the blood which
 used to flow monthly  before  impregnation,  is, upon
 this taking place, retained, it is  commonly so entirely
 employed  in  dilating, the uterine vessels, and* in  the
 growth of the foetus, that it is seldom found to produce
 a plethoric state  of the body, requiring a vicarious out-
 let.
  The vomiting  of blood, therefore,  that is vicarious of
the menstrual flux, is that which  commonly and almost
only happens upon a suppression of that  flux, after it
had been for some time established.
   1020. When such a suppression happens, it may be
supposed to operate by inducing1 a plethoric state of the
whole body, and  thereby occasioning haemorrhagy from
other parts of it; and haemorrhagies from many differ-
ent parts of the body have been observed by physicians
as occurring in consequence of the suppression we speak
of.   It is,  however, the great variety of such haemor-
rhagies, that leads me to  think, that with the plethoric
state of the whole body there must always be some pe- 
               PRACTICE OF  PHYSIC.            £8

culiar circumstances in the part from which the blood
flows, that determines its afflux to that particular, often
singularly odd, part;  and therefore,  that such haemor-
rhagies may from these circumstances occur without
any considerable plethora at the same time prevailing
in the whole system.
   1021. It is to be observed, that if we are to  expect
art haemorrhagy in consequence of  the suppression of
the menses inducing a plethoric state of the system, we
should expect especially an haemoptysis, or haemorrhagy
from the lungs, as a plethora might be expected to show
its effects especially there; and  accordingly, upon occa-
sion of suppressed menses, that haemorrhagy  occurs
more frequently than any other; but  even this,  when
it does happen,  neither in  its circumstances nor  its
consequences, leads us to suppose, that at the same time
any considerable or dangerous  plethora prevails in the
body.
   1022. These considerations  (in 1020, 1021.) will, I
apprehend, apply to our present subject; and I would
therefore allege,  that a hematemesis  may perhaps de-
pend upon particular circumstances  of the  stomach de-
termining  an afflux of blood to that organ; and may,
therefore, occur without any considerable or dangerous
plethora prevailing in the  system.   What are the cir-
cumstances of the stomach,  which  upon the  occasion
mentioned, may  determine an afflux  of blood to it, I
cannot certainly or clearly explain;  but presume that it
depends upon the connection  and  consent which we
know to subsist between the uterus and the whole of the
alimentary canal, and especially that principal part of it,
the stomach.*

  * Besides the powerful sympathy known to subsist between the uterus
and stomach, a preternatural determination of blood to the latter organ ap-
pears to be oftentimes groduced by an imtnaderate use of wine, ardent spi 
 30            PRACTICE OF PHYSIC.

    10^3.  From these reflections, we may, I think, draw
 the following conclusions:
   I. That the hematemesis we speak of, is hardly ever
 a dangerous disease.
   II.  That it will hardly ever require the remedies suit-
 ed to the cure of active haemorrhagy; and at least that it
 will require these only in those unusual cases in which
 there appear strong marks of a general plethora, an*in
 which the vomiting of blood appears to be considerably
 active, very profuse, and  frequently recurring.
   III. That a vomiting of blood from suppressed menses,
 ought seldom  to prevent the use of  these remedies of
 amenorrhoea, which might be 1 -nproper in the case of
 active idiopathic haemorrhagy.
   1024. Another case of  symptomatic  hematemesis
 quite analogous to that already mentioned, is the hema-
 temesis following, and seemingly depending upon, the
 suppression of an haemorrhoidal  flux,  which had been
 established and frequent for some time before.
   This may perhaps be explained by a general plethoric
 state induced  by such  a  suppression; and indeed some
 degree of a plethoric state must in such a case be sup-
 posed to take place; but that supposition alone will not
 explain the whole of the  case; for a general plethora
 would lead us to expect an haemoptysis (1021.) rather
 than an hematemesis; and there is therefore something
 still  wanting, as in the former case, to explain the par-
 ticular determination to the stomach.
   Whether such an explanation  can  be got from the
 connexion between the different parts of the sanguife-
 rous vessels of the alimentary canal,  or from the con-

rits, vinegar, or some other strongly stimulating beverage.  Most of the
serious cases of hematemesis roe have had occasion to witness, have occurred
in the persons of habitual drunkards—at least, of individuals addicted to
intemperance 
                  PRACTICE OF PHYSIC.               31-

nexion of the whole of these vessels with the vena por-
tarum,  I  shall  not venture  to determine.   But in  the
mean  time  I imagine,  that the explanation  required  is
rather to  be obtained  from that  connexion  of the sto-
mach  with the haemorrhoidal affection that I  have taken
notice of in 945.*

  * Hematemesis arising from a suppression of the haemorrhoidal flux,  is by
no means a rare occurrence.
  As we.know of no remedies or modes of practice that belong in a parti-
cular manner to this disease, we have but little to say on the subject  of its
treatment.  As a general rule, what is applicable in other cases of haemor-
rhagy, will be found equally applicable and useful here.  Perfect quietude
of both body and mind should be strictly enjoined.  If the habit' be plethoric
and the symptoms inflammatory, blood-letting will be  requisite  Owing,
however, to the powerful influence of  affections of the stomach, in mode-
rating the action of the heart and arteries, this remedy can rarely be carried
to any considerable extent.  We have occasionally repeated it two or three
times: but  such cases seldom occur. Here, however, as in all other instances
of disease,  the pulse and the state of the system must direct.
  In hematemesis, as in haemoptysis, it is particularly necessary that the
drinks be cool.  Perhaps even iced water swallowed in small quantities, and
frequently  repeated, might be found useful, by acting as an astringent on the
ruptured vessel.  Drinks of a mucilaginous qualin, as flax-seed tea, barley
water, or a solution of gum  arabic in water, are also  productive of salutary
effects.  *
  In the treatment of haemoptysis, culinary salt is a useful remedy:  what
would be its effects in that of hematemesis ?
  In addition to the use of astringents, as symptoms may indicate, the appli-
cation of cups and blisters to the abdomen will prove  advantageous.  So will
the frequent emptying of the bowels by means of injections.  Should pur-
gatives be found necessary, as they sometimes are, the mild  saline ones will
be most  suitable.  Castor oil is also, at times, exhibited with  advantage.
  Cases  of hematemesis that had obstinately  resisted  other means,  have
yielded, at Jength, to copious purging*
  When this disease is to be regarded as a translation of hxmorrhois to the
stomach, the application of leeches to the hxhorrhoidal  vessels is a promis-
ing remedy.
  As a styptic in it, the tinctura ferri muriatis,  in doses of  from twenty to
thirty drops, exhibited every two hours, in cold water, is recommended as
useful.
  Should pain or irritation render opium necessary, its exhibition by injec-
tion will be entitled to a preference
  Although spermaceti is favourably spoken of by European practitioners,
we acknowledge oi-rselves  at a loss as to the grounds of the prescription,
We do not consider it a very promising remedy. 
$2            PRACTICE OF PHYSIC.
    1025. How we may explain the hematemesis occa-
 sioned by a suppression of the haemorrhois,  the consi-
 derations in 1020, 1021, will apply here as in the ana-
 logous case of hematemesis from suppressed menses;
 and will, therefore, allow us also to conclude here, that
 the disease we now treat of will seldom be dangerous,
 and will seldom require the same remedies that idiopa-
 thic and active haemorrhagy does.
    1026.  The cases of hematemesis already mentioned,
 may be properly supposed to be haemorrhagies of  the
 arterial kind; but it is probable that the stomach is also
 liable  to haemorrhagies of the venous kind (767.)
   In the records of physic there are many instances of
 vomiting blood, which were accompanied with a tume-
 fied spleen, which  had compressed the  vas breve, and
 thereby prevented  the free return of venous blood from
 the stomach.   How such an interruption of the venous
 blood  may occasion an haemorrhagy from either the ex-
 tremities of the veins themselves, or from the extremi-
 ties of their correspondent arteries, we  have  explained
 above in 768; and the histories of tumefied spleens
 compressing the vasa  brevia, afford an  excellent illus-
 tration and confirmation of our doctrine on that sub-
 ject, and render  it sufficiently probable that  vomitings
 of blood often arise from such a cause.
   1027. It is also  possible, that an obstruction of  the
 liver resisting the free motion of the blood in the vena
 portarum, may sometimes interrupt the  free  return of
 the venous blood from the vessels  of the stomach, and
 thereby occasion a vomiting of blood; but the instances

  If hematemesis arise from an obstruction or enlargement of the liver or
fipleen.its cure will depend on a removal of these affections by mercury and!
 Other suitable remedies
  In obstinate cases of it, arising from common causes, repeated injection's
 of cold water have been found efficacious. 
              PRACTICE OF PHYSIC.            gg

 of this are neither so frequent nor so clearly explained
 as those of the former case.
   1028. Besides these cases depending  on the state
 of the liver or spleen, it is very probable that other hae-
 morrhagies of the stomach are frequently of the venous
 kind.
   The disease  named  by Sauvages, Melaena, and by
 other  writers commonly  termed  the  Morbus  Niger
 (771.), consisting in an evacuation either by vomiting or
 by stool, and sometimes in both  ways, of a black and
 grumous  blood,  can  hardly  be otherwise occasioned,
 than  by a venous haemorrhagy from some part of the
 internal surface  of the alimentary canal.
   It is, indeed,  possible, that the  bile  may  sometimes
 put on a black and viscid appearance, and give a real
 foundation for the appellation of an Atra Bilis: but it is
 certain, that instances of this are very rare; and it is
 highly probable  that what gave occasion to the notion
 of an atra bilis among the ancients, was truly the ap-
 pearance of blood poured into the alimentary  canal in
 the manner I have mentioned; and which appearance,
 we know, the blood always puts on when it has stagnat-
 ed there for any  length of time.   I suppose it is now
 generally thought, that  Boerhaave's  notion of such a
 matter existing  in the mass  of blood,  is  without any
 foundation;' whilst, by dissections in modern times, it
 appears very clearly, that  the morbus niger presenting
 such an appearance of blood,  always depends upon the
 effusion and stagnation I have mentioned.
   1029. From this account of the melaena it will appear
that vomiting of blood may  arise in consequence  of
blood  being poured out in the  manner I have mentioned,
either into the cavity of the stomach itself, or  into the
superior portions of the intestines, from whence  mat-
ters often pass into the stomach.
   VOL. II.                F 
U           PRACTICE OI  PHYSIC

   1030.  Both in the case of the  melaena,  and ;n tiit-
analogous cases from affections of the spleen or liver, it
will appear, that the vomitings of blood occurring must
be considered as symptomatic affections, not at all to be
treated as a primary active haemorrhagy, but by reme-
dies, if any such be known, that may resolve  the pri-
mary obstructions.
   1031.  I believe  I  have now mentioned  almost the
whole of the causes producing an hematemesis; and cer-
tainly the causes mentioned, are those which most com-
monly give occasion to that symptom.  Possibly, how-
ever, there may be some other causes of it, such as that
singular one mentioned by Sauvages of  an aneurism of
the aorto bursting  into the stomach; and  it  is possible,
that some diseases of other contiguous parts, which  have
become  closely adhering to the  stomach, may some-
times, by a rupture into the cavity of the stomach,  pour
blood into it, which is afterwards rejected by vomiting.
It is possible also, that abscesses and  ulcerations of the
stomach  itself, may sometimes pour blood into its cavity
to be thrown  up by vomiting.
   I did not think it necessary, among the symptomatic
vomitings of blood, to  enumerate those from external
violence, nor, what is analogous to it, that which arises
from violent straining to vomit; which last, however, is
much more rare than might be expected.   In either of
these cases the nature of the disease cannot be doubtful;
and the  management of it will be readily  understood
from what has  been delivered above with respect to
moderating and restraining hemorrhagy in general 
PRACTICE OF  PHYSIC.
                            SECTION  11.»


  OF THE HEMATURIA, OR THE  VOIDING OF BLOOD
              FROM THE URINARY PASSAGE.


     1032.  It is alleged, that an  hematuria has occurred
  without any other symptom of an affection of the kid-
  neys  or  urinary  passages  being  present  at  the  same
  time; and  as this happened to plethoric  persons, and
  recurred at fixed periods, such  a case has been supposed

   * Practitioners of medicine-are frequently at a loss as to the cause of the
  vitiated condition  of urine.   The following circumstances may serve, at
  times, as discriminating marks of hematuria.
   The blood, which may have become black and grumous, being specifically
  heavier than the urine, falls to the lower part of the bladder. It is conse-
  quently discharged  in larger quantities, in the beginning, than towards the
  end of making water.  Hence the urine  first evacuated is deep coloured
  and muddy ;  but, as it continues to flow, becomes lighter coloured by de-
  grees, until it assumes, at length, its natural appearance.
   Besides the antihxmurrhagic remedies, already recommended in hema-
  temesis and elsewhere, ura ursi is said to  be peculiarly useful in hematuria.
  Digitalis is also very highly recommended.  Cold applications to the scro-
 tum in men and the  pudenda in women, are found to  be productive of bene-
 ficial effects. So also is the employment of emetics
   By means of injections the bowels should  be  kept free from irritating
 contents.
   If the disease continue obstinate, let cups be applied to the  region of the
 kidneys.  Nor would we withhold blisters  from the same part,  from any ap-
 prehension of the production of strangury.  Should that affection  occur, it
 may even prove useful on the principle of revulsion; which is but another
 term for that of sympathy.
   The carbonate of soda is recommended here as an efficacious remedy.
   In a paper contained in the  8th volume  of Medical Tracts and Observa-
 tions, a case of hematuria, of great obstinacy, is reported to  have been cured
 by a decoction of peach leaves.  The decoction was prepared by boiling an
 ounce of the dried leaves in a quart of water, until it  was reduced to a pint
 and a half.  Of this the patient  drank a pint in the course of the day.
  In this complaint, nauseating doses of tartarized antimony constitute a  re-
 medy of fair promise.   So does vitriolated zinc, exhibited in such quantities,
and at such intervals, as to produce on the stomach a similar effect. 
36            PRACTICE OF PHYSIC.

to be an instance of idiopathic hematuria, and ot the
nature of those active haemorrhagies I have treated of
before.
   1033. I .cannot positively deny the existence of such
a case;  but must observe, that there are very few in-
stances  of such upon the records of physic; that none
have ever occurred to my observation,  or to that of my
friends; and that the observations adduced  may be fal-
lacious, as I have  frequently observed  an hematuria
■without symptoms of other affection of  the kidney or
urinary  passages being,  for the time,  present; whilst,
however,  fits of a nephralgia calculosa having, before,
or soon  after, happened, rendered it to me sufficiently
probable,  that  the  hematuria was  owing to a wound
made by a stone present in some  part of the  urinary
passages.
   1034. The existence of an idiopathic hematuria is
further Improbable,  as a general plethora  is  more likely
to produce an haemoptysis (1021.), and as we do not well
know of any circumstance which might  determine  more
particularly to the kidneys.   An idiopathic hematuria,
therefore,  must certainly be  a rare occurrence; and in-
stances of symptomatic  affections of the same kind are
very frequent.
  1035. One of the most frequent is,  that  hematuria
which attends the nephralgia calculosa, and seems ma-
nifestly to be owing to a stone  wounding the  internal
surface of the pelvis of the kidney or of the ureter. In
such cases, the  blood discharged with the  urine is some-
times of a pretty florid  colour,  but for the  most part
is of a dark hue:  the whole of it is sometimes diffused
or dissolved, and, therefore,  entirely suspended in the
urine; but if it is in any large quantity, a portion of it
is deposited to the bottom of the vessel containing the
voided blood and urine.  On different occasions the 
PRACTICE OF PHYSIC.
blood voided puts on different appearances.  If the blood
poured out in the kidney has  happened to stagnate for
some time in the ureters or bladder, it is sometimes co-
agulated, and the coagulated part is afterwards broken
down into a grumous mass of a black or dark colour,
and therefore gives the same colour to the urine voided;
or if the quantity of  broken  down  blood is  small, it
gives only a brownish urine resembling coffee.  It some-
times also happens, that the blood stagnating  and coa-
gulating in the  ureters, takes  the form of these vessels,
and is therefore voided under the appeaiance of a worm;
and  if the  coagulated blood happens to have, as it may
sometimes  have, the gluten separated from the red glo-
bules, these worm-like  appearances have their exter-
nal surface whitish, and the  whole seemingly forming
a tube containing a red  liquor.   I have  sometimes ob-
served the  blood which had seemingly been coagulated
in the ureter, come away in an  almost dry state resem-
bling the half-burnt wick of a candle.
   1036.  These are the several appearances of the blood
voided in the  hematuria calculosa, when it  proceeds
especially from the kidneys or ureter; and  many of the
same appearances are observed when the blood  pro-
ceeds only from the bladder when a stone is lodged
there; but the attending  symptoms will commonly point
out the different seat of the disease.
   In one case, when a quantity of blood from the kid-
ney or ureter is coagulated in  the bladder, and is, there-
fore, difficultly thrown out from this, the pain and un-
easiness on such an occasion  may appear chiefly to be
in the bladder,  though it contains no stone; but the an-
tecedent  symptoms will  commonly discover the nature
of the disease.
   1037.  In any of the cases of the hematuria calculosa,
it will hardly be necessary to employ the remedies suit- 
 38            PRAC1ICE OF PHYSIC

 cd to an active: hfvmorrhagy.  It will be proper only to
 employ the regimen fit for moderating haemorrhagy in
 general, and particularly here  to avoid every thing or
 circumatance that  might irritate the kidneys or  ure-
 ters.   Of such cases of irritation there  is none  more
 frequent or  more considerable  than the presence of
 hardened faeces in the colon: and these, therefore, are
 to be frequently removed by the frequent use of gentle
 laxatives.
   1038. The hematuria calculosa may be properly con-
 sidered as a case  of the hematuria violenta: and, there-
 fore, I subjoin  to that the other instances of hematu-
 ria from external violence;  such as that  from external
 contusion on the region of the kidney,  and that  from
 the violence or long continued exercise of the muscles
 incumbent on the kidneys.  An instance of the latter
 cause occurs especially in riding.
   1039. It may also be considered as a case of the lie-
 matura violenta,  when  the disease occurs in conse-
 quence of the  taking  in of certain  acrid  substances,
 which pass again especially by the urinary passages; and
 by inflaming and swelling the neck of the bladder, bring
 on a rupture of the over-distended blood-vessels,  and
 give occasion to a bloody urine.  The most noted in-
 stance of this is in the effect of cantharides in a certain
 quantity, any way introduced into the body.  And  pos-
 sibly some other acrids may have the same effect.
   1040. Beside these most frequent instances of hema-
 turia, which cannot be considered as  idiopathic haemor-
 rhagies, there are some  other instances of  hematuria
 mentioned by authors, that are still, however, manifest-
ly symptomatic; such as  a discharge  of blood from the
urinary passages,  in consequence of a suppression of
 either the menstrual or haemorrhoidal flux. These may
be considered as analogous to the hematemisis produc- 
PRACTICE OF PHYSIC.
39
ed by the like causes; and the several reflections made
above on that subject, will, I think, apply here, and par-
ticularly the conclusions formed in 1023.  Instances,
however, of either of these cases, and especially of the
first, have been extremely rare.
   1011. Of such symptomatic hematuria there is, how-
ever, one  instance deserving notice;  and that is, when
a suppression of the haemorrhoidal  flux,  either by a
communication of vessels,  or  merely by  the vicinity
of parts,  occasions a determination  of blood  into the
vessels of the neck  of  the bladder,  which, in conse-
quence  of a  rixis or anastomosis, pour out blood to be
voided either with or without urine.   This case is what
has been named the  Ilaemorrhoides  Vesicae;  and with
some propriety, when it is manifestly an evacuation vi-
carious  of what had before been usually made from the
rectum.   With respect to the management of  the hae-
morrhoides  vesicae,  I would apply  the whole of the
doctrines that I have delivered  above,  with respect to
the cure of the proper haemorrhoidal affection.
   1042. There remains still to be mentioned one other
instance of symptomatic hematuria, which is that which
happens in the case  of confluent and putrid small-pox,
as well  as in several  other instances of putrid diseases.
The  blood,  in such cases, may be presumed to come
from the kidneys; and I apprehend that it comes from
thence  in consequence of that fluidity which is always
produced in the blood  approaching to a  putrid state.
Such hematuria, therefore, is not to be considered as a
symptom of any affection of the kidneys, but merely as
a mark of the putrescent state of the blood.
   1043. In certain diseases the urine  is discharged of
such a  deep red colour, as to give a suspicion of its
being tinged by blood present in it;  and this has given
occasion to  Sauvages, amongst the other species of he- 
40             PRACTICE OF PHYSIC

maturia, to mark the hematuria spuria, and the hema-
turia latertia;  both of which,  however, he supposes to
be without any blood present in the urine.   In many
cases it is of importance,  in ascertaining the nature of
the disease, to determine whether  the red colour of
urine be from  blood present in it, or from a certain state
of the salts and oils which are always in greater or
lesser proportion constituent parts of the urine; and the
question may be commonly determined by the following
considerations.
  It has been  observed  above, that when any consider-
able quantity of blood is voided with the urine, there is
always a portion of it deposited at the  bottom of the
vessel containing the voided blood  and urine: and  in
such a case there will  be no  doubt  in attributing  the
colour of  the  urine floating above to some part of the
blood diffused  in it.  The question,  therefore, with re-
spect  to the presence of blood in the  urine can only oc-
cur when no such deposition  as 1 have  mentioned ap-
pears; and when the blood that may be supposed to be
present is dissolved or diffused, and therefore entirely
suspended in the urine.   In this case the  presence of
the blood may be commonly known.  1st, By the colour,
which blood gives, different  from  any urine  without
blood that I have ever seen; and I think a little expe-
rience will enable most persons to make this distinction.
2dly, By this,  that the presence of blood always dimi-
nishes the transparency of the urine with which it is
mixed;  and it is very seldom that urine,  though very
high coloured, loses its transparency; at least this hardly
ever appears,  if the urine is  examined when recently
voided.   3dly, When urine has blood mixed with it, it
tinges a piece  of linen dipped into it with a red colour,
which the highest coloured urine without blood  never
does.   4thly, High coloured urine without  blood, upon 
PRACTICE  OF  PHYSIC.
41
cooling, and remaining at  rest in a vessel,  almost al-
ways deposits a lateritious sediment;  and if upon any
occasion bloody urine should deposit a sediment that
may be of a portion of the blood formerly diffused  in
it, the difference, however,  may be discerned by this,
that the sediment  deposited by urine without  blood,
upon the  urine's being  again  heated, will be entirely
redissolved, which  will  not happen  to any sediment
from blood.  Lastly, we know no state of urine  with-
out blood, which shows any portion of it, coagulable by
a heat equal to that of boiling water; but blood diffused
in urine is still coagulable by such a heat; and by this
test, therefore,  the presence  of blood  in urine may be
commonly ascertained.
                       BOOK V.


   OF PROFLUVIA,* OR FLUXES, WITH PYREXIA.


 1044. FORMER nosologists have established a class
 of diseases under the title of Fluxes, or Profluvia; but
 as in this class they have brought together a great num-
 ber of diseases,  which  have nothing  in  common ex-
 cepting  the single  circumstance of an  increased dis-
 charge of fluids, and which also are, in other respects,
 very different from one another;  I have avoided so im-
 proper an arrangement, and have  distributed most of

  * We have already observed, and, therefore, need not repeat, that both
the diseases included by our author under the order profluvia, belong of
right to that of phlegmasiae. They are febrile complaints marked by an in
flammatory topical affection.
   VOL. II.                 « 
k>           PRACTICE OF PHYSIC

the diseases comprehended  in such a class by the no-
sologists, into places more natural and proper for them.
I have,  indeed, still  employed  here the general title;
but I confine it to such fluxes only as are constantly
attended with pyrexia, and  which therefore necessarily
belong to the class of diseases of which I am now treat-
ing.
   Of the fluxes which may be considered as being
very constantly febrile diseases, there are only two, the
catarrh  and dysentery; and of  these, therefore, I new
proceed to treat.
                     CHAPTER I.

                OF THE CATARRH.

1045. THE catarrh  is an increased excretion of mu-
cus from the mucous membrane of the nose, fauces,
and bronchiae, attended with pyrexia.
  Practical  writers and nosologists have distinguished
the disease  by different appellations,  according as it
happens to affect those different parts of  the mucous
membrane,  the  one part more or less than the other:
but I am of opinion, that the disease,  although  affect-
ing different parts,  is always of the  same  nature, and
proceeds from the same cause.  Very commonly,  in-
deed, those different parts are affected, at the same time;
and therefore  there can be little room for the distinc-
tion  mentioned.
  The disease has been frequently treated of under the
title  of Tussis, or Cough; and  a cough, indeed,  always
attends the chief form of catarrh, that  is, the increased
excretion from the bronchiae; but a cough is so often a 
PRACTICE  OF PHYSIC.
43
 symptom of many other affections,  which are very dif-
 ferent  from one another, that it is improperly employed
 as a generic title.
    1046. The remote cause of catarrh is most commonly
 cold  applied  to the body.   This application  of  cold
 producing catarrh, can in many cases be distinctly ob-
 served; and I believe it would always be  so, were  men
 acquainted  with, and  attentive  to,  the   circumstances
 which  determine  cold  to  act tipon the body.   (See
 94—96.)
    From  the same  paragraphs we  may learn what in
 some persons gives a predisposition  to catarrh.*


   * The opinion here asserted  we believe to be erroneous.  So strong is,
 at times, the predisposition to  catarrh, in consequence of  certain corbific
 conditions of the atmosphere, that exposure and other  causes too slight to
 be noticed,  will produce the disease.
   That catarrh, in all its diversified forms, is an atmospheric disease, no one
 is at present inclined to deny.   It is not, however, at all times derivable
 from the sensible qualities of the atmosphere.  It arises, very generally, from
 that peculiar undefined condition of the atmosphere denominated a consti-
 tution.  This is not the case merely when that form of catarrh which we call
 influenza prevails.  It is equally true  of what is termed  a common cold,
 when that  complaint attacks  numbers, as it  generally does, at the same
 time. Rarely, if ever, can such a form of catarrh be correctly traced to any
 of the sensible qualities of the atmosphere.
   On this topic we well know, that we differ materially from general be-
 lief.  Common  observers attribute common colds to changes in the atmos-
 phere from  a hot to a cold, or from a dry to a humid condition.
  The representation is incorrect.  Were these changes alone sufficient to
 produce catarrh, independently of an auxiliary predisposition in the human
 system, they would always do it, as often as they occur.  But we need
 scarcely remark that this is not the case. A very large  majority of our
 greatest and most sudden vicissitudes in the sensible qualitieb of the atmos-
 phere produce no disease.
  That catarrh may arise, predisposition must exist: and this predisposition
 can be the  offspring  of nothing, as we believe, but a  peculiar and secret
 constitution of the  atmosphere.
  In  further confirmation of this, we will be permitted  to observe, that
when vicissitudes in the atmosphere do excite disease, that disease is not al-
 ways catarrh.  It is often peripneumony, pleurisy, or rheumatibin.  But the
nature and  character of a complaint are always determined by  predisposi-
tion.  To render any disease either endemic or  epidemic, a common pre- 
44
PRACTICE OF PHYSIC.
     1017. The disease, of which I am now to treat, ge-
  nerally begins with some difficulty of breathing through
  the nose, and with a sense of some fulness stopping up
  that passage.   This  is also often attended with  some
  dull pain and a sense of weight in the forehead, as well
  as  some stiffness in the  motion  of  the eyes.  These
  feelings,  sometimes at their very first beginning, and
  always soon after, are attended with the distillation from
  the  nose; and sometimes from the eyes, of a thin  fluid,
  which is often found to be somewhat acrid, both by its
  taste, and by its fretting the parts over which it passes.
    1048.  These  symptoms  constitute  the coryza and
 gravedo of medical authors, and are  commonly attend-
 ed  with  a  sense of  lassitude  over  the whole body.
 Sometimes cold shit erings are felt, at least the body is
 more sensible than usual to the coldness of the air; and
 with all this the pulse becomes,  especially in the even-
 ings, more frequent than ordinary.
    1049.  These symptoms seldom continue long before
 they  are accompanied  with  some hoarseness,  and a
 sense of roughness and  soreness in  the trachea,  and
 with some difficulty of breathing, attributed to a sense
 of straitness of  the chest, and  attended with a cough,

disposition must prevail.  But the atmosphere, being the only medium com-
mon to every one, must be regarded as the source of common affections.
  There scarcely exists a febrile disease, that is not marked, at times, by
something like an epidemic prevalence.  This is true even  of apoplexy,
pajsv, and hysteria.  We have, in sundry instances, witnessed such a spread
of those complaints, as to justify the remark.
  Referring, then, to certain atmospheric constitutions, the predispositions
to general diseases, which bestow on them their character, we regard vicis-
«tudes,n the sens.ble qualities of the atmosphere,  as nothing more than
exciting causes.                                   °
  When, for example, other more latent causes have produced predisposi-
tions to catarrh, to peripneumony, to rheumat.sm, or to any of the forms of
^Z  tLTZK-Vici8SitudeS CXCke those base's -to actual ex-
istence  Th- remark ., dilated, and its truth confirmed, by all correct
observations on epidemics.                            3  ^or1^' 
PRACTICE OF PHYSIC.            45
which seems  to arise from some irritation felt  at the
glottis.   The  cough  is generally at first dry, occasion-
ing pains about the chest, and more especially  in the
breast.    Sometimes,  together with  these symptoms,
pains resembling those of the rheumatism are felt in se-
veral parts of the body, particularly about the neck and
head.   While these symptoms take place, the appetite
is impaired, some thirst arises, and a general lassitude
is felt over all the body.
   1050.  These symptoms (1047—1049.)  mark the
violence  and  height  of the disease; which, however,
does not commonly  continue long.   By degrees the
cough becomes attended with a copious excretion  of
mucus;  which is at  first thin, but gradually becoming
thicker,  is brought up with less frequent and less labo-
rious coughing.  The hoarseness and  soreness  of the
trachea likewise  going off, the febrile symptoms abat-
ing, the cough becoming less frequent, and with less
expectoration, the disease soon after ceases altogether.*
   1051.  Such is generally the course of this disease,
which is commonly neither tedious nor dangerous; but,
upon some occasions, it is in both respects otherwise.
A person affected with catarrh seems to  be more than
usually liable to be affected by cold air; and in that con-
dition, if exposed to cold, the disease, which seemed  to
be yielding, is often brought back with greater violence
than before;  and  is rendered not only  more  tedious
than otherwise it  would have been, but also more dan-
gerous by the supervening of other diseases.
   1052.  Some degree of the cynanche tonsillaris, often
accompanies the catarrh; and, when the latter  is aggra-

  • 1047—43—49—50.  The description of catarrh herein given is accurate
and excellent. It may be truly denominated, a picture of the disease. The
sensation in the chest, however, excited by coughing, is, for the most part,
a soreness or an uneasiness, rather than a pain. 
 to"           PRACTICE OF  PHYSIC

vated by a fresh application of  cold, the  cynanche also
becomes more  violent and  dangerous, in consequence
of the cough which is present at the same time.
   1053. When a catarrh  has been occasioned by a
violent cause; when  it has  been aggravated by impro-
per management; and especially when it has been ren-
dered  more violent by fresh and repeated applications
of cold, it often passes into a pneumonic inflammation
attended with the utmost danger.
   1054. Unless, however,  such accidents as those of
1051—1053, happen, a catarrh, in sound  persons not
far advanced in  life, is, I  think, always a slight disease,
and  attended with little danger.  But, in persons of a
phthisical disposition, a catarrh may readily produce an
haemoptysis,  or perhaps form   tubercles in the  lungs;
and  more certainly, in persons who have tubercles al-
ready formed in the  lungs, an accidental catarrh may
occasion  the inflammation of  these tubercles, and in
consequence produce a phthisis pulmonalis.
   1055. In elderly persons, a catarrh sometimes proves
a dangerous  disease.  Many persons, as they advance
in life, and especially after they have arrived at old age,
have the natural  mucus of the lungs  poured  out in
greater quantity, and consequently  requiring a frequent
expectoration.   If therefore a catarrh happen to such
persons, and increase the influx of fluids to the lungs,
with some degree of  inflammation, it may produce the
peripneumonia notha, which in such cases is very often
fatal.  (See  376. 382).*
   1056. The proximate cause of  catarrh seems to be
an increased afflux of fluids to the mucous membrane

  * 1054—5. The sentiments expressed  in these articles are equally im-
portant and true. They, therefore, merit the utmost attention, and should
be made the foundation of great precaution on the part of physicians as weM
as of patients. 
PRACTICE OF PHYSIC.
47
 of the nose, fauces and bronchiae, along with some de-
 gree of inflammation affecting these parts.   The latter'
 circumstance is confirmed by this, that in  the case of
 catarrh, the blood  drawn from a vein commonly exhi-
 bits the same inflammatory crust which  appears in the
 case of phlegmasiae.*
    1057. The application of cold which occasions a ca-
 tarrh, probably operates  by diminishing  the perspira-
 tion  usually made by the skin, and which is therefore
 determined to the mucous membrane of the parts above
 mentioned.  As a part of the weight which  the body
 daily loses by insensible evacuation, is owing to an ex-
 halation from the lungs, there is probably a  connexion
 between this exhalation and the cutaneous perspiration,
 so that the one  may be increased in  proportion as the
 other is diminished: and  therefore we may understand
 how the diminution of cutaneous perspiration,  in con-
 sequence of the application of  cold, may increase  the
 afflux of fluids to the lungs,  and thereby produce a ca-
 tarrh, f
    1058. There are  some observations  made by Dr.
 James   Keil  which  may  seem to  render this  matter
 doubtful; but there is fallacy in his observations.  The
 evident  effects of cold in  producing coryza, leave the
 matter  in general without  doubt; and there are  several
 other circumstances which show a connexion between
 the lungs and the surface of the  body.

  • Catarrh consists in an inflammatory affection of this membrane, accom-
panied with fever.  Of such affection an increased secretion is the natural
consequence
  f The explanation herein attempted is too mechanical to apply to living
matter. Like all other febrile complaints, catarrh is a disease of association.
It begins at a point, and becomes general on principles of sympathy. With-
out the influence of such principles, how could a mere check or diminution
of cutaneous perspiration determine an immoderate afflux of fluids to the
schneiderian membrane ? Such determination can arise only  from the sym-
pathy which exists between that membrane and the skin. 
48
PRACTICE OF PHYSIC.
    1059. Whether from the suppression of perspiration,
 a catarrh  be produced merely  by an  increased afflux
 of fluids,  or whether the  matter of perspiration be at
 the same time determined  to the  mucous glands, and
 there excite a particular irritation, may be uncertain;
 but the latter supposition is sufficiently probable.*
    1060.  Although,  in the case of a common  catarrh,
 which is in  many instances sporadic, it may be doubt-
 ful whether any morbific matter be applied to the mu-
 cous glands; it is, however, certain, that the symptoms
 of catarrh do  frequently depend  upon such  a matter
 being applied to these glands; as appears from the case
 of measles, chin-cough, and especially from the frequent
 occurrence  of contagious and epidemical catarrh.
   1061. The mention of this last leads me  to observe,
 that there are two species of catarrh, as I  have marked
 in my  Synopsis of Nosology.    One of these, as I  sup-
 pose,  is produced by  cold alone, as has been explained

  * The supposition herein stated, we think extremely improbable.  There
exists in physiology no principle on  which it can be maintained.
  The matter of perspiration is a secretion formed from the blood by glandu-
lar action, but does not exist in the blood  in a formal state, any more than
bile, saliva, or the liquor of the pancreas.  How, then, can it be determined
to the " mucous  glands" to excite irritation in them ? The process is impos-
sible. Until formed, by the action of the cutaneous capillaries, the perspir*
ble matter as  such,  is a non-entity, in common with every thing else that
has not yet received a formal existence.
  To find applied to living organized beings such coarse mechanical doc-
trines as appertain only to dead matter, is humiliating to the medical pro-
fession.
  The absurdity of our author's hypothesis, as here enunciated, is equalled
only by that  which maintains that  a superabundance of carbon floating
loosely and formally in the venous blood, constitutes the distinction between
it and arterial  blood, and that this carbon passes either mechanically orbj
chemical attraction  through  the coats of the pulmonary vessels, to unite
with the oxygen  of the air inspired, and form carbonic acid gas.
  Neither the matter of perspiration thrown off by the skin, nor the carbon
evacuated through the lungs, exists in the blood in a formal state.  They
are both real secretions from  that fluid, as is every other healthy discharge
from the living body, the faces alone excepted. 
PRACTICE OF PHYSIC.             49
 above, and the other seems manifestly to be produced
 by a specific contagion.
   Of such contagious  catarrhs, I  have pointed out in
 the Synopsis  many  instances  occurring from the 14th
 century down to the present day.   In all these instances
 the phenomena have been much the same; and the dis-
 ease has  always been  particularly remarkable in this,
 that it has been the most widely and generally spread-
 ing epidemic  known.   It has seldom  appeared in any
 one country of Europe, without appearing successively
 in every other part of  it; and in some instances, it has
 been even transferred  to America, and has been spread
 over that continent, so far as we have had opportunities
 of being informed.
    1062.  The catarrh  from  contagion appears  with
 nearly the same symptoms as those mentioned (1047—
 1049.)   It  seems often  to come on in consequence of
 the application of cold.  It comes on with  more cold
 shivering than the catarrh arising from cold  alone, and
 sooner shows febrile symptoms, and these likewise in a
 more considerable degree. Accordingly, it more speedily
 runs its  course, which is commonly finished in  a few
 days.  It sometimes terminates by a spontaneous sweat;
 and this in some persons, produces  a  miliary eruption.
 It is, however, the frebile state of this disease  especially,
 that is finished in a few days; for the cough, and other
 catarrhal symptoms, do frequently continue longer;
 and often, when they appear to be going off, they are
 renewed by any fresh application of cold.*

  * 1060—1—2. By his observations contained in these three articles, it is
our author's intention to designate influenza.  That disease, although al-
ways epidemic, is never contagious. It  arises, we apprehend, from a mor-
bific matter diffused throughout the atmosphere; but that matter is utterly
incapable of specific propagation.  The  view of it  herein given, although
brief, is accurate, and communicates a faithful picture of the complaint; al-
though somewhat, it must be acknowledged, of a miniature size.
   VOL.  II                II 
 50             PRACTICE OF PHYSIC.

   1063. Considering  the number of persons who are
 affected with catarrh, of either the one species or the
 other, and escape from it quickly without any hurt, it
 may be allowed to be a disease very free from danger;
 but it is  not  always to  be considered as such; for in
 some persons  it is  accompanied with pneumonic  in-
 flammation.   In the phthisically disposed, it often ac-
 celerates the coming on of phthisis; and in elderly per-
 sons, it frequently proves fatal in the manner explained
 above, (1053 and 1055.)*
   1064.  The cure of catarrh is  nearly the same,  whe-
 ther it proceed from cold or contagion; with  this differ-
 ence, that in the latter case,  remedies are commonly
 more necessary than in the former.
   In the cases of a moderate disease, it  is  commonly
 sufficient  to  avoid  cold,  and  to  abstain  from  animal
 food for  some  days; or perhaps  to lie a-bed,  and, by
 taking frequently of some mild and diluent drink  a lit-
 tle warmed, to promote a very gentle sweat; and after
 these to take care to return very gradually only, to the
 use  of the free air.f
   1065.  When the disease is more violent, not  only
 the  antiphlogistic regimen must be  exactly  observed,
 but  various remedies also become necessary.
   To take off the phlogistic diathesis which  always at-
 tends this disease, blood-letting, in a larger or smaller

  ' The statement given in this article is not only true, but of great moment.
 No disease is so powerful as influenza in ripening the seeds of pulmonary
 consumption. Nor does any one prove so fatal—certainly none more fatal—
 to persons who are far advanced in years. Let such persons, therefore, as
 well as those predisposed to consumption, most vigilantly guard against the
 disease.
  f Instead of a mere avoidance of animal food, the patient should avoid solid
food of every description.  H1S only aliment ought to be, barley water, bran
 tea, flax-seed tea, gum arabic dissolved in water, and other farinaceous and
 mucilaginous drinks. 
PRACTICE OF  PHYSIC.
51
 quantity, and repeated according as the symptoms shall
 require, is the proper remedy.
   For restoring the determination  of the  fluids to the
 surface of the body, and at the same time for expeding
 the secretion of  mucus in  the lungs,  which may take
 off the inflammation of its membrane, vomiting is the
 most effectual means.
   For the latter purpose, it has been supposed, that
 squills,  gum ammoniac, the volatile  alkali,  and some
 other medicines,  might be useful: but their efficacy has
 never appeared to me to be considerable; and, if squills
 have  ever been  very useful, it seems  to have been
 rather by their emetic than by their expectorant powers.
 When the inflammatory affections of the lungs seem
 to be considerable, it is  proper, besides blood-letting,
 to apply blisters on some part of the thorax.
   As a cough is often  the  most troublesome circum-
 stance  of  this disease, so demulcents may be employed
 to alleviate it. See 373.
   But after the inflammatory  symptoms have much
 abated, if the cough should still continue, opiates afford
 the  most effectual means of relieving it; and in the cir-
 cumstances just  now mentioned,  they  may be very
 safely employed.  See 375.
   After the inflammatory and febrile  states of this dis-
 ease are almost entirely gone, the most effectual means
 of discussing all  remains of the catarrhal affection,  is
 by some exercise of gestation diligently employed.*
  * For determining to the surface and promoting expectoration, nauseat-
ing doses of tartarized antimony, combined with nitre, is a useful remedy.  So
is a combination of ipecacuanha and opium, when there exists an irritating,
troublesome cough.
  To the excellent plan of treatment  herein proposed and sufficiently de-
tailed by our author, we shall only further add, that we have seen many
cases of influenza, in which a determination to the abdominal viscera was so
strong, as to render copious purging a  necessary remedy: and that, in other
instances, the disease having a predominant determination to the skin, 
52
PRACTICE OF PHYSIC.
                      CHAPTER II.

                OF THE DYSENTERY.

1066. THE dysentery is a disease in which the patient
has  frequent  stools  accompanied with  much  griping,
and  followed by a tenesmus.   The stools, though fre-
quent, are generally  in small quantity; and the matter
voided is chiefly mucus, sometimes  mixed with  blood.
At the same time the natural faeces seldom appear, and,
when they do, it is generally in a compact and hardened %
form.
   1067.  This disease occurs especially in summer and
autumn,  at the  same time with  autumnal intermittent
and  remittent fevers;  and with these it  is sometimes
combined or complicated.*
   1068.  The disease comes  on  sometimes with cold
shiverings,  and other symptoms  of pyrexia; but more
commonly the symptoms of the topical affection appear
 first.  The belly is  costive, with an unusual flatulence

yielded most readily to plentiful sweating—so diversified is its character on
different occasions.
  Purging to a great extent is necessary more especially in that form of in-
fluenza which prevails in the summer and  autumnal seasons, in southern
climates, and in low marshy tracts of country  Under these circumstances,
the complaint is marked by a gastric and abdominal character, and calls for a
mode of treatment similar to that of bilious fever.
  In influenza, and every  other epidemic disease, let the physician mark
well the leading indications, and  the  steps which nature is pursuing to ac-
complish them, and these will be, in practice, his safest guides. With bea-
cons so sure and palpable to direct him, he can scarcely err, or prove unsuc-
cessful.
  * Dysentery is a disease very incidental to armies, when, after or during
 warm weather, they are long exposed to heavy rains, or lie in low swampy
 grounds. 
PRACTICE OF  PHYSIC.            53
in the bowels. Sometimes, though more rarely, some de-
gree of diarrhoea is the first appearance. In most cases
the disease begins with griping, and a frequent inclina-
tion to go to stool.   In indulging this,  little is voided;
but some tenesmus attends it.  By degrees, the stools
become more frequent,  the griping more severe,  and
the  tenesmus more  considerable.   Along  with these
symptoms  there is a loss of appetite;  and frequently
sickness, nausea, and vomiting, also affecting the pa-
tient.  At the  same time there is  always more or less
of pyrexia present, which is sometimes of the remittent
kind,  and observes a tertian period.  Sometimes the
fever  is  manifestly inflammatory, and  very often of a
putrid kind.   These febrile states continue to  accom-
pany the disease during  its whole course, especially
when it terminates soon in a fatal manner.  In other
cases, the febrile state almost entirely disappears, while
the proper dysenteric symptoms remain for a longtime
after.*
   1069. In  the course of the  disease, whether of a
shorter  or  longer duration, the matter voided by stool
is  very  various.  Sometimes it is  merely a mucous
matter,  without  any blood,  exhibiting that  disease
which Dr. Roderer has named the morbus mucoms, and
others the dysenteria alba.   For the most part,  how-
ever, the mucus discharged is more or less  mixed with
blood. This sometimes appears only in  streaks amongst
the mucus;  but at other times is more  copious, tinging

  * In consequence of the offensiveness of the alvine discharges, we are
less surprised at the application of the term "putrid" to dysentery, than to
most other diseases.  Still, however, the epithet is incorrect in relation
even to this complaint.
  If the reader wishes to lie thoroughly convinced of the absurdity of the
term putrid, as applied to the living body, whether in health or disease, we
beg leave to refer him to Dr. Seybert's Inaugural Dissertation, contained in
the volume for 1805 of select " Medical Theses," published by Thomas and
William Bradford. 
54
PRACTICE OF PHYSIC.
the whole of the matter discharged; and upon some oc-
casions a pure and unmixed blood is voided in consider-
able quantity.  In  other respects  the matter voided
is variously changed in colour and consistence,  and is
commonly of a strong and unusually foetid odour. It is
probable that sometimes  a genuine pus is voided; and
frequently a putrid sanies, proceeding from gangrenous
parts. There are very often mixed with the liquid mat-
ter some films of a membranous appearance, and fre-
quently some small masses of a seemingly  sebacious
matter.
   1070.  While the stools consisting of these various
matters are,  in many instances,  exceedingly frequent,
it is seldom  that natural faeces appear  in them;  and
when they do appear, it is, as I have mentioned,  in the
form  of scybala, that is,  in somewhat hardened, sepa-
rate  balls.   When these are voided,  whether by the
efforts of nature, or solicited by art, they procure a re-
mission of all the symptoms, and more especially of the
frequent stools, griping, and tenesmus.
   1071.  Accompanied with these circumstances, the
disease proceeds for a longer or a  shorter time.  When
the pyrexia attending it is of a violent inflammatory
kind, and  more especially when it is of a very putrid
nature, it  often terminates fatally in a very  few days,
with all the marks of a supervening gangrene.   When
the febrile state is more moderate, or disappears alto-
gether,  the disease is often protracted for weeks, and
even for months; but even then, after a various dura-
tion, it often  terminates fatally, and generally in  conse-
quence of a return and considerable aggravation of the
inflammatory and putrid states.   In some cases the dis-
ease ceases spontaneously; the frequency of stools, the
griping, and tenesmus, gradually diminishing, while na-
tural stools return.   In other cases, the disease with 
              PRACTICE OF PHYSIC.             55

 moderate symptoms, continues long, and ends in a diar-
 rhoea, sometimes accompanied with lienteric symptoms.
   107^. The remote causes of this disease have been
 variously judged of  It generally arises in summer or
 autumn  after  considerable  heats, have prevailed for
 some time,  and especially after very  warm, and at the
 same time very  dry states of the weather;  and the dis-
 ease is more frequent in warm, than in cooler climates.
 It happens,  therefore,  in the same circumstances and
 seasons  which considerably affect the state of the bile
 in the human body; but as the cholera is often without
 any dysenteric  symptoms, and  copious discharges of
 bile have been found to relieve the s) mptoms of dysen-
 tery, it  is difficult to determine  what connexion this
 disease has with the state of the bile.
   1073. It has been observed,  that  the effluvia  from
 very  putrid  animal substances, readily affect the ali-
 mentary canal; and upon some occasions they certainly
 produce a diarrhoea; but, whether they ever produce a
 genuine dysentery, I have not been able to learn with
 certainty.
   1074.  The  dysentery  does  often manifestly arise
 from the application of  cold, but the disease is always
 contagious: and, by the propagation of such contagion,
 independent of cold,  or other  exciting causes,  it be-
 comes epidemic in  camps and other places. It is, there-
 fore, to be doubted if the application of cold does ever
 produce the disease, unless  where the specific conta-
 gion  has been previously received into the body: and,
 upon the whole, it  is probable that a  specific contagion
 is to be considered as always the  remote cause of this
 disease.*

  * From what we have already repeatedly said, it is well known that we do
not believe in the contagious nature of dysentery. That disease prevails
often as an epidemic, spreading rapidly from a common origin.  But it is 
5G
PRACTICE OF  PHYSIC.
    1075. Whether this contagion, like many others, be
 of a  permanent  nature,  and  only  shows  its effects in
 certain  circumstances which render it active,  or if it be
 occasionally produced, I cannot determine.  Neither, if
 the latter  supposition be received,  can I say by what
 means it may  be generated.   As little do we know any
 thing of its nature considered in itself;  or at most this
 only,  that,  in  common with many other contagions, it
 appears to  be commonly of a putrid  nature, and capable
 of inducing a putrescent tendency in the  human  body.
 This, however, does  not at all explain its peculiar power
 in inducing those symptoms which  properly and essen-
 tially constitute the disease of dysentery.   (1066.)*

never, we think, propagated from the sick to the well.  In this respect it
stands on a footing with the other phlegmasiae, with which, of right, it ought $
to be associated.
  * We do not understand the strange doctrine, which maintains, that a con-
tagion may  be in its nature  "permanent," and yet  " show its effects" only
" in certain circumstances."
  Contagion is a poison. If, therefore, its nature be permanent, its effects or
action will be equally permanent—at least as often as it meets with a subject
on which it may act.
  As well might we maintain that fire will burn or water drown only occa-
sionally, as become the advocates of the hypothesis  herein  set forth. A
poison is, in its nature, something potential.  It will act as long as it exists.
The  idea of a poison with  its powers suspended or annihilated, amounts to
an absurdity.
  In his exposition of the nature of this disease, we think our author exceed-
ingly visionary: in that of its treatment,  he is no less defective.  Without,
therefore, considering ourselves bound to follow in the track which he has
marked out, or to assume as our text what he has written, we shall,  somewhat
briefly, but as comprehensively as we can, deliver our sentiments on these
two subjects.—
  Although ultimately an intestinal, dysentery is, at its commencement,  a
srastric disease.  Like other complaints arising from an aeriform poison, it
originates in the stomach, but is soon thrown on the bowels, which then be-
come its permanent scat; whence it extends itself throughout the system.
  Dysentery, then, we consider as an inflammatory affection of the lower in-
testines—more especially of their interior coats—accompanied with fever.
It might be denominated, perhaps, not incorrectly, a catarrhal or rheumatic
affection of these parts.  That in consequence of its inflammatory condition,
there is a peculiar and very obstinate spasm of the colon, impeding its peri-
staltic motion, and preventing the expulsion of iufscal contents, is also true 
PRACTICE  OF  PHYSIC.
57
      1076.  Of  these symptoms,  the proximate  cause is
   still obscure.    The common opinion has been, that the

  This spasm, however,  is an effect, not the original cause, of the disease.
  Remove entirely the inflammatory state of the part, and the morbid irritabi-
  lity attending it, with the spasm of the colon, will cease to exist.
    The pathology of dysentery we believe to be the same with that of perip-
  neumony, hepatitis, gastritis, or nephritis.  The difference of the disease
  arises from the difference of the part inflamed, added to that of the morbific
  eause.  Like most other'febrile affections, this complaint is also accompa-
  nied with a stricture, or want of healthy action on the surface of the body.
  The cutaneous secretion is, therefore, in a defective state—in more common
  language, perspiration is suppressed.—From  this general morbid state of
  things arise the nature and severity of the pain that is felt.
    If this view of the pathology of dysentery be correct, the indications of
  cure are sufficiently obvious.  They are,  to remove inflammation, with the
  morbid irritation and spasm attending it, to procure a free discharge of the
  oontents of the bowels, and to restore the healthy action of the skin.   The
  relief of pain is a subordinate indication, and its completion follows, of course,
  when the principal ones are accomplished.
    Thus analyzed, the practice, we think, becomes plain and easy.
    If the inflammatory symptoms be high, and the patient plethoric and vigor-
  ous—and sometimes even independently of the existence of this latter con-
  dition—blood-letting is essential; and the operation must be repeated as
  often as circumstances  may require.  In some cases,  blood must be taken
  away to a considerable amount.
    The early exhibition of an emetic, either accompanied, or speedily follow-
  ed, by  a cathartic, is, in  most instances, important.  Besides discharging from
  the stomach such matters as  might be morbidly irritating-, the operation of
  tbe'emetic aids in resolving the spasm of  the intestines,  and in effecting a
  free evacuation of their  contents.
   If an emetic be given alone, tartarized antimony is most suitable; and, as
 a cathartic to succeed it, nothing is preferable to castor.oil, or  Glauber's,
 Rochelle, or Epsom salts. If an emetic and cathartic be given in combination,
 a solution of tartarized antimony and Glauber's salts is an  excellent prepara-
 tion. The usual effect of it is a free and copious evacuation of the alimentary
 canal.
   If the bowels cannot be moved by the oily or saline purgatives, a trial must
 be made with some of the more active.   Of these,  calomel and jalap, jalap
 and cream of tartar,  a strong decoction of senna holding Glauber's salts in
 solution, or a purgative preparation composed of balsam copaiva, mucilage
 of gum arabic, and lavender water, will be found to be highly efficacious and
 useful.  Large and repeated doses of calomel, combined with opium, have
 sometimes succeeded in procuring a passage when other things had failed.
  These purgatives must be repeated daily, changes being made from one
to another of them, as circumstances may require, as long as the disease shall
continue violent.  To aid their operation, injections will  be requisite, and,
perhaps the most powerful injection that can be employed, will consist of
    VOL. II.                     I 
68
PRACTICE  OF PHYSIC.
 disease depends upon an acrid matter received  into, or
 generated  in  the  intestines  themselves,  exciting their

 from fifteen to twenty grains of tartarized antimony, dissolved in about three
 gills or tepid water, with the addition of two or three table spoonfuls of sweet
 oil.  This, if well administered, and retained for a time in the rectum, sel-
 dom fails to produce a discharge of faecal contents.
   By the  action of the tartarized antimony,  whether it be exhibited by the
 mouth, or by injection, but especially when given in the former mode, some
 thing wii! be done towards a restoration of the healthy action of the skin-
 This object may be still further promoted, by giving the same article occa-
 sionally in nauseating doses, accompanied by the use of diluting drinks.  For
 the same purpose,  ipecacuanha,  combined with opium, is sometimes exhi-
 bited with the happiest effect.—Such is the practice  necessary  to be pur-
 sued during the first, or most inflammatory stage of dysentery.
   When the febrile symptoms have been  considerably subdued, and the
 bowels freely evacuated,  opiates  must be administered for the twofold pur-
 pose of relieving pain, and procuring sleep.  When exhibited in the evening
 they are most useful; sleep during the night being more salutary and resto-
 rative, than that which is enjoyed in the course of the day.  Anodyne injec-
 tions, consisting of opium dissolved in mucilage of gum arabic or flax-seed
 tea, are sometimes better retained and prove more efficacious, than opiate!
 by the mouth.  These points, however,  must be regulated entirely by the
judgment  of the practitioner.  In relation to them, no abstract and binding
 rule can possibly be laid down. We shall only observe, that opiates in some
 form should be  administered, as often as they are called for by the severity
 of the pain, provided their operations do not too much interfere with the eva-
 cuation of the bowels.
  After the bowels have been sufficiently evacuated, an excellent remedy
 to allay irritation and tenesmus, is an injection composed of from half a pint
 Jo three gills of melted butter, free from salt.  This may be repeated every
 three or four hours ; or oftener,  should circumstances require it.  It is im-
 portant that the butter be free from rancidity as well as salt.
  If the pain continue obstinate,  and  the abdomen be tumefied, hard an»l
 sore to the touch, in addition to fomentations and anodyne liniments, the
 application of cups or leeches and blisters to it, will be found indispensable.
 In the  treatment of such a case, a gentle mercurial ptyalism has  sometimes
 been induced with the happiest effect.
  In every case, where the disease is likely to assume a chronic form, more
 especially if there be reason to apprehend the existence of a hepatic affec-
 tion, a  moderate salivation is  the most promising remedy.
  On various occasions, throughout the course of the disease, mucilaginous
 injections  will be useful and necessary.  They may  consist of flax-seed te»,
 bailey water, a solution of gum  arabic in water, or a decoction of starch.
 The proper time of their administration the judgment of the practitioner
 alone can direct.  An important object to be attained by them is an allevia-
 tion of tenesmus.
  From the commencement to the close of the complaint, the drinks in gene 
                     PRACTICE  OF PHYSIC.               59

  peristaltic motion,  and  thereby producing the frequent
  stools  which occur in this disease.   But this supposi-

 ral  should be diluting,  mucilaginous, and mild  In the latter stages, when
 fever and inflammation have disappeared, and debility is  considerable,  a
 small quantity of wine may be advantageously allowed. So may light broths
 and animal jellies.  But, until a considerable progress shall have been made
 in convalescence, solid animal food is totally inadmissible.
   When a great disposition to acescency prevails in the stomach, preparations
 of rice, crackers, and well baked bread, are highly useful as articles of diet.
   When solid animal food  lias  become  admissible,  salted  meat is usually
 found to be preferable to fresh.
   In the treatment of dysentery, the article of clothing is of no small impor-
 tance.  Flannel should be worn next to the skin in general, with one or two
 additional folds of it over the abdomen. Certain late writers recommend the
 use of a broad flannel roller, passed  several times around the abdomen, with
 some degree of tightness.  This answers the twofold purpose of promoting
 perspiration, and giving the necessary support to the weakened intestines.
   A strong solution of muriate of soda in vinegar, has been given in this dis-
 ease ; and, as report represents, with very salutary effects.   We  tried the
 preparation once, in the case of a boy about nine years old,  and thought it
 useful.  Pain  and tenesmus appeared certainly to be relieved by it: the
 bowels,  moreover, were kindly  opened.  We simply state  the fact; but
 shall not attempt its explanation.   Nor can we venture to recommend the
 remedy on a single trial.
   When the convalescence proves lingering and unsteady, accompanied by
 a constant or occasional diarrhoea, opiates, astringents, and mild tonics may
 be given with advantage.  A very valuable astringent is a decoction of log-
 wood.  But the chief reliance must be placed on regimen ; and, in the more
 obstinate cases, on a change of climate.
   When dysentery degenerates  into a chronic state,  a grain or two of ipe-
 cacuanha, combined with a little opium, may be given several times  a day, to
 suspend irritation and determine to the skin.  To this add a steady use of an
 infusion ofcolombo, and riding on horseback, if the patient be possessed of suf-
 ficient strength. From this practice great benefit has been oftentimes derived.
   Of late pulverized charcoal has been recommended in dysentery, in the
 quantity of a table spoonful three or four times a day.
   Dr. Moseley, a very respectable West India writer, concurs with Dr. Sy-
 denham in considering dysentery as the fever of the season thro-wn on the bowels,
 by means of a great and sudden suppression of perspiration.  The restora-
 tion  of perspiration, therefore, constitutes his leading, indeed almost his sole
 object, in the treatment of the disease   Hence, after preparing the way for
 them by blood-letting, if requisite, and cleansing the bowels of their irritat-
 ing contents;  he places his  reliance almost exclusively on the employment
of sudonfics.   We apprehend that he pushes his theory too far.
  For much learned, curious, and interesting matter on the subject of dysen-
tery, the reader is referred to the last edition of Dr.  Moseley's " Treatise on
Tropical Diseases."   Those who are  desirous of still further information, 
60            PRACTICE OI  PHYSIC.
tion cannot be admitted; for in all the instances known
of acrid substances applied to the intestines and produc-
ing frequent stools,  they at the same time produce co-
pious  stools,  as might  be expected  from  acrid  sub-
stances applied to any length of  the intestines.  This,
however,  is not the case  in dysentery; in  which the
stools, however  frequent,  are  generally in very small
quantity, and such as may be supposed to proceed  from
the lower  parts of  the  rectum only.  With respect to
the superior portions of the intestines,  and particularly
those of the colon, it is  probable they are under a pre-
ternatural  and considerable degree of constriction:  for,
as I have observed above, the natural faeces are seldom
voided; and when they are, it is  in a form which gives
reason to suppose, they have been long retained in the
cells of the colon, and consequently that the colon had
been affected with a preternatural constriction.    This
is confirmed by almost  all  the dissections which  have
been made of the bodies of dysenteric patients, in which,
when  gangrene had not entirely  destroyed the texture
and form of the parts, considerable portions of the great
guts have  been found affected with a very considerate
constriction.
   1077. I  appprehend,   therefore, that the proximate
cause  of dysentery, or  at least the chief part of the
proximate cause, consists in a preternatural constriction
of the colon, occasioning at the  same time  those spas-
modic efforts which are felt in severe gripings, and which
efforts, propagated downwards to the rectum, occasion
there  the frequent mucous stools and tenesmus.   But,
may consult, with advantage, the following writers:—Pringle Dis. Arm.
Huxham de aere—Cleghorn Minor.  Hillary Barbad.  Akenside de  Dysen-
teria. Monro  Dis. Arm.  Stark Historic Dysenteria. Wardrop de Dysen-
teria contagiosa  Rollo on acute Dysentery, with various valuable papers in
the periodical publications of Europe, and  the Medical Repository of thii
country. 
              PRACTICE OF  PHYSIC.            61

whether  this explanation shall be admitted  or not, it
will still remain certain, that hardened faeces retained
in the colon are the cause of the griping,  frequent
stools, and tenesmus; for the evacuation of these faeces,
whether by nature or by art, gives relief from the symp-
toms mentioned; and it will be more fully and usefully
confirmed by this, that the most immediate and success-
ful cure of dysentery is obtained  by an early and con-
staut attention to  the preventing the constriction, and
the frequent stagnation of faeces in the colon.
   1078.  In this  manner I have endeavoured to as-
certain the proximate cause of dysentery, and therefore
to point out also the principal part of the cure, which,
from want of the proper view of the nature of the dis-
ease,  seems to have been in  several respects fluctu-
ating  and undetermined among practitioners.
   1079.  The  most eminent of our late  practitioners.
and of the greatest experience in this disease, seem to
be of opinion,  that the disease is to be cured most effec-
tually by purging  assiduously  employed.   The means
may be various; but the most gentle laxatives are usu-
ally sufficient; and as they must be frequently repeated.
the most gentle are the most safe; the more  especially
as an  inflammatory state so frequently accompanies the
disease.  Whatever  laxatives  produce an  evacuation
of natural  faeces,  and  a  consequent remission of the
symptoms, will be sufficient to effectuate the cure. But
if gentle laxatives shall  not produce the evacuation now
mentioned, some more powerful medicines must be em-
ployed; and I have found nothing more proper or con-
venient than tartar emetic, given in small doses, and
at such intervals as may  determine their operation  to
be chiefly by stool.  Rhubarb, so frequently  employed,
is in several respects amongst  the most improper pur-
gatives. 
t)2            PRACTICE OF  PHYSIC.
   10S0. Vomiting has been held a  principal remedy
 in this disease:  and may be usefully employed in the
 beginning of it, with a view to both  the state  of the
 stomach and of the fever; but it is not necessary to re-
 peat it often; and unless the  emetics employed operate
 also by stool they are of little service.   Ipecacuanha
 seems to possess no specific power : and  it proves  Duly
 useful when so managed as to operate chiefly by stool.
   1081. For relieving the constriction  of the colon,*
 and evacuating the retained faeces,  glysters  may some-
 times be useful; but  they are seldom so effectual as
 laxatives given by the mouth; and acrid glysters, if  they
 be  not  effectual in  evacuating the colon, may prove
 hurtful by stimulating the rectum too  much.
   1082.  The frequent and  severe griping  attending
 this disease, leads almost necessarily to the use of  opi-
 ates, and they are very effectual for the purpose of re-
 lieving from the  gripes; but by occasioning an inter-
 ruption  of the action of the small guts, they favour the
 constriction of the colon, and thereBy  sometimes aggra-
 vate the disease; and if at the same time the use of them
 supersede in any measure the employing  of purgatives,
 it commonly does  much mischief; I believe  it indeed
 to be  only  the neglect of purging that renders the use
of opiates very necessary.
   1083. When the gripes are both frequent and severe, 4
 they may sometimes  be relieved by the employment of
 a semicupium, or by  a fomentation  of the abdomen,
continued for some time.  In the same case, the pains
may be relieved, and, as I think, the constriction of the
colon  may be taken off, by blisters applied to the lower
belly.
  1084. At the beginning of this disease, when the fe-
ver is  any way considerable,  blood-letting, in  patients
af tolerable vigour, may be proper and necessary; and, 
              PRACTICE  OF PHYSIC.           * 63

 when  the pulse is full and hard, with other symptoms
 of an  inflammatory  disposition, blood-letting ought  to
 be repeated.  But, as the  fever attending dysentery is
 often of a putrid kind, or does, in the course of the dis-
 ease, become soon of that  nature,  blood-letting must
 be employed with great caution.
   1085. From the account now given of the nature of
 this disease, it will be sufficiently obvious, that the use
 of astringents in the beginning of it must be absolutely
 pernicious.
   1086. Whether an acrid matter be the original cause
 of this disease,  may be uncertain; but from the  indi-
 gestion and the stagnation of  fluids  in  the  stomach
 which attend the disease,  it  may be presumed,  that
 some acrid matters  are constantly present in the sto-
 mach  and intestines, and therefore that demulcents may-
 be always usefully employed.  At the same time, from
'this consideration that mild oily  matters thrown  into
4he  intestines in considerable  quantity  always prove
 laxative.   I am of opinion that the oleaginous demul-
 cents are the most useful.                           *
   1087. As this disease is so;often of an inflammatory
 or of a putrid nature,  it is evident that  the diet em-
 ployed in it should  be vegetable and acescent.   Milk
 in its  entire state is of doubtful utility in many cases;
 but  some poition of the cream is often allowable, and
 whey is always  proper.
   Iu the first stages of the  disease, the sweet and sub-
 acid fruits are allowable, and  even proper.  It is in the
 more  advanced stages only  that any morbid acidity
 seems to prevail in  the stomach,  and to require some
 reserve in the use of acescents.  At the beginning of
 the  disease, absorbents seem to  be  superfluous; and by
 their astringent and  septic  powers they may be hurtful.
   1088. When this  disease is complicated with an in- 
04             PRACTICE OF  PHYSIC.
termittent fever,  and  is  protracted  from  that  circum-
stance  chiefly, it is to be treated as  an intermittent, by
administering the Peruvian  bark, which, however,  in
the  earlier periods of the disease, is hardly to be ad-
mitted.
                         PART II.

      OF NEUROSES,*  OR NERVOUS DISEASES.

 1089. IN a certain view, almost the whole of the dis-
 eases of  the  human body might be called nervous:
 but there would be no  use for such a general appella-
 tion; and on the other  hand, it seems improper to limit
 the term, in the loose  inaccurate manner in  which it
 has been hitherto applied, to hysteric or hypochondria-
 cal disorders, which are themselves hardly to be defined
 with sufficient precision.
    1090. In this place I propose to comprehend,  under
 the title of neuroses, all those  preternatural affections
 of sense or motion which are without pyrexia, as  a part
 of the primary disease; and  all those which do not de-
 pend upon a topical affection of the organs, but upon a
  * We have already stated as our opinion, which we beg leave to repeat^
that the whole, or at least  the greater part, of our author's class of neuj
roses or nervous diseases, have their seat in the stomach.  Nor is thjs to be
regarded as a mere speculative notion.  It is a point which we consideremj^
nently important in the practice of medicine.  It is calculated to give our
attention, in the treatment of those diseases, the proper direction.  It points,
in a particular manner, to the stomach and  bowels, as the organs to which
we should apply our remedies.  It presses on us a truth, of which practition-
ers of physic are becoming daily more and more convinced, that emetics,
cathartics, and tonics, constitute the remedies on which we must chiefly
rely, in the cure of what are denominated nervous diseases.  Such diseased
are most certainly induced  by  whatever disorders and debilitates the sto-1
mach, and removed by those things which restore to it its healthy action. 
              PRACTICE OF PHYSIC.            65

more  general affection of the  nervous system, and of
those  powers of the system upon which sense and mo-
tion more especially depend.
  1091. Of  such  diseases I  have established a class,
under the title of neuroses or nervous diseases.
These I again  distinguish, as they consist, either in the
interruption  and debility of  thq powers of sense and
motion, or in the irregularity with which these powers
are exercised;  and have accordingly arranged them un-
der the four  orders of Comata, Jldynamice, Spasmi, and
Vesanice, to  be defined as we proceed  to treat of  them
more  particularly.
                     BOOK I.

OF COMATA, OR THE LOSS OF VOLUNTARY MO-
                      TION.

1092. UNDER this title  are comprehended those af-
fections which have been  commonly called the  Sopo-
rose diseases; but they are most properly distinguished
by their consisting in some interruption or suppression
of the powers of sense and voluntary motion,  or of
what are called  the animal  functions.   These are in-
deed  usually suspended in the time  of natural sleep:
but of all the diseases to be comprehended under our
title, sleep, or even the appearance of it, is not con-
stantly a symptom.  Of such diseases I can mark and
properly explain  two genera only, which come  under
the title of Apoplexy and Palsy.
VOL. II.                K 
 66             PRACTICE  OF  PHYSIC.
                                   *,


                       CHAPTER 1.

                    OF APOPLEXY.

 1093. APOPLEXY  is  that  disease  in  which  the
 whole of the  external  and  internal senses, and  the
 whole  of the  voluntary motions,  are in some  degree
 abolished; while respiration and the action of the heart
 continue to be performed. » By its being an affection of
 the  whole of the powers of sense and of voluntary  mo-
 tion, we distinguish it from JJalsy: and by its being with
 the  continuance of  respiration and  the action  of the
 heart, it is distinguished from Syncope.   I have furthffr
 added to the ordinary definition of Apoplexy, that the
 abolition of the powers of sense and motion  is in some
 degree only;  meaning by this  to imply, that  under the
 title of Apoplexy,  are  here  comprehended  those dis-
 eases which,  as differing from it in degree only, cannot,
 with a view either to pathology or practice, be properly
 distinguished from it: such are the diseases sometimes
 treated  of under  the  names  of   Cams,  Cataphora,
 Coma, and Lethargus*
   1094.  Apoplexy,  in  all its  different degrees, most
 commonly affects persons advanced in  life, and espedk'
 ally  those above sixty years of  age.  It  most usually af-
 fects persons of  large heads and  short necks, persons

  * Apoplexy sometimes resembles  very  strongly a  profound sleep.. But
the process of discrimination  is easy. A  person may be certainly roused
from natural sleep, by the application of powerful stimulants to the organs
of sense—volatiles to the nose, loud and sharp sounds, a strong£ght, or se-
vere pinching.  But in a case of apoplexy, such applications have no effect.
  The smeU of the liqi.or being perceptible in the breath, constitutes the
most certain mark of discrimination  between apoplexy and deep intoxica-
tion.
► 
               PRACTICE OF PHYSIC.            67  -

 of a corpulent habit, persons who have passed an indo-
 lent life and  useif a full diet, and especially those who   <
 have indulged in frequent intoxication.  Men who have
 long laboured under a frequent and copious discharge
 of blood from the haemorrhoidal vessels,  upon either
 the suppression or spontaneous  ceasing of that dis-
 charge, are particularly liable to be affected with apo-
 plexy.
    1095.  This  disease  frequently comes on very sud-
 denly:  but in  many cases  it  is  preceded  by  various
 symptoms, such as frequent fits of  giddiness, frequent
 headachs, a hasmorrhagy from the nose, some transitory
 interruption  of  seeing and  hearing, some false vision
 and hearing, some transitory degree of numbness  or
 loss of motion  in  the extremities,  some  faltering  of
 the tongue in speaking,  a loss  of memory, a frequent
 drowsiness, and frequent fits of incubus.*
    1096.  An  attention  to these  symptoms,  and to the
 predisponent circumstances  (1094.) will often' enable
 us to foresee the more violent attacks of this disease.
    1097.  When the disease comes  on suddenly  to  a
 considerable  degree, it has been frequently observed to
 have been immediately induced by violent  exercise, by
 a full and long continued inspiration; by a fit of anger;
 by much external  heat, especially that arising  from  a
 crowded  assembly  of people; by warm bathing; by in-
 toxication;  by long stooping  with the head down; and
 by a tight ligature  about the neck.   The  disease has
 been remarked  to make its  attacks most frequently  in

  * Incubus is an affection of the stomach.  Its being, therefore, a precur-
sor of apoplexy, shows the latter to be a gastric disease.  When this com-
plaint is induced by a "long continued inspiration, violent exercise, or long
stooping with the head down," its exciting cause is altogether mechanical.
Still, however, even here, we believe the stomach concerned in creating
the predisposition.
♦ 
08            PRACTICE OF PHYSIC.

the spring season, and especially when the vernal heat
suddenly succeeds  to the winter cold*
   1098.  The symptoms denoting the presence of this
disease will  be sufficiently known  from the definition
given 1093.   Although the whole of the body is affect-
ed with the loss of sense and  motion, it sometimes takes
place more  upon one side of the body than the other;
and  in that  case the  side least affected with palsy is
sometimes  affected" with convulsions.   In this disease
there is often a stertorous breathing: and this has been
said to be a mark of the most violent state of th ■ dis-
ease: but it is not always present even in the most com-
plete form or most violent degree of the disease.
   1099. The proximate cause of this disease may he,
in general, whatever interrupts the  motion of the nerv-
ous  power from the brain to the muscles, from volun-
tary motion; onn so far as sense is affected, whatever
interrupts the motion of  the nervous power from the
sentient  extremities of the nerves to the brain.
   1100. Such an interruption of  the motions of the
nervous  power may be occasioned,  either by some com-
pression of  the origin of the nerves, or by something de-
stroying the mobility of the nervous power.  Both these
causes we  must treat of more particularly; and, first,
that of compression, seemingly the  most frequent occa-
sion of apoplexy, and perhaps the occasion of all those
apoplexies arising from internal causes.
   1101. The loss of sense  and motion in particular
parts of the body,  may be occasioned by a compression,
either of the origin  of certain  nerves only, or of the
same  nerves  in  some  part of their  course from the
brain to the organs of sense and motion.   Such cases
of partial compression will be more properly consider-
  * Facts, we think, are wanting to establish the position, that apoplexy is
particularly a vernal disease. 
PRACTICE OF  PHYSIC.            69
ed hereafter; and the affection I am now to treat of
being general, it must depend upon a very general com-
pression of the origin of the nerves, or medullary por-
tion of the brain; and therefore, this more general com-
pression only is to be considered here.
   1102.  This compression of the origin of the nerves,
or medullary portion of the brain, may be produced in
different ways; as,
   I. By external violence fracturing and pressing in a
part of the cranium.
   2. By tumours, sometimes soft,  sometimes  bony,
formed in different parts  of  the brain, or in its mem-
branes, and becoming of  such a bulk  as  to compress
the medullary substance of the brain.
   3. By the blood being accumulated in the blood-ves-
sels of the brain, and distending them to such a degree
as to compress the medullary portion of the  same.
   4. By fluids effused in different parts of the brain, or
 into the cavity of the cranium, and accumulated in such
 a quantity as to occasion the compression  we treat of.
   And as to this last, it  is to be remarked  here, that
 the fluids effused  may be of two kinds;  that is, they
 may be either a portion of the common mass of blood,
 poured out from red vessels; or a portion of serum or
 colourless fluid poured out chiefly by exhalants.
   1103. Of these several causes of compression, the
 first is not to be considered here, because  the removing
 it does not belong to our  province; and the considera-
 tion of the second maybe omitted, as in most instances
 it is neither to be discerned nor cured by any means
 yet known.   The third and fourth causes of compres-
 sion, as they are the most frequent, and are also most
 properly the subjects of our art, so they are those which
 deserve our particular attention: and we shall therefore 
4
70           PRACTICE  OF PHYSIC.

endeavour to trace them further back in  the series of
causes which may produce them.
   1104. Both the states of  over-distention  and of ef-
fusion may be produced by  whatever increases the afflux
and impetus of  the blood  in the arteries  of the head;
such  as violent exercise, a violent fit of anger, external
heat applied, or any strong pressure upon the- descend-
ing aorta.
   1105. But  both these states of over-distention and
of effusion, may also, and  seem to be more  frequently
produced by causes that operate by preventing the free
return of the venous  blood from the vessels of the head
to the right ventricle  of the heart.
   1106. The venous vessels of the brain are of a con-
formation and distribution  so peculiar, as to  lead us to
believe, that nature intended  to retard the motion of the
blood, and accumulate it in these vessels; and therefore,
even  very small  additional  resistances to the motion of
the blood from these  towards the right ventricle of the
heart, may still more  readily accumulate the blood in
them.  Such accumulation will most readily  happen in
advanced life, when the venous system in general is in
a plethoric state, and  when this plethora takes place es-
pecially in the venous vessels of the brain.   It will, in
like  manner, be most apt to occur in persons  whose
heads are large  with respect to the rest of  the body;
and in persons of a short neck, which is unfavourable
to the return of the venous blood from the head. The
accumulation of blood in  the venous vessels  of the
brain, will also be most likely to occur in persons of a
corpulent habit,  either because these may be consider-
ed to  be in a plethoric state, or because obesity,  by oc-
casioning a compression  of the blood-vessels in other
parts  of the body, more readily fills those of  the brain,
which are entirely free from any such compression. 
PRACTICE OF PHYSIC.
71
   1107. These are the circumstances in the consti-
 tution of the body, which, producing a slower motion
 and return of the venous blood from the vessels of the
 head, favour-an accumulation and distention in  them;
 and we now proceed to mention the several occasional
 causes,  which, in every person,  may  glirectly prevent
 the free return of the blood from the vessels of the head
 towards the heart.  Such are,
   1.  Stooping down with the head, or other situations
 of the body, in which the head is long kept in a depend-
 ing state, and in which the gravity of the blood increases
 the afflux of it by the arteries, and opposes the return
 of it by the veins.
  2. A  tight ligature about the neck, which compresses
 the veins more strongly than  the arteries.
   3. Any obstruction  of a considerable number of the
 veins carrying  the blood from the head, and more espe-
 cially any considerable obstruction of the ascending
 vena  cava.
   4. Any considerable impediment  of the free passage
 of the  blood from the veins into the right ventricle of
 the heart; and it is'commonly by this,  and the imme-
 diately  preceding circumstances, that polypous  con-
 cretions in the cava, or right ventricle, are found to oc-
 casion apoplexy.
  5.  The return  of blood from the veins of the head
 towards the  heart, is  especially  interrupted by every
 circumstance that produces a more difficult  transmis-
 sion of  the blood through the vessels of the lungs.  It
 is well  known, that,  at the  end of every expiration,
 some interruption is  given to the free transmission of
 the blood  through the lungs;  and that  this at the same
 time gives an interruption to  the  motion  of the blood
in the veins into the right ventricle of the heart.  This
clearly appears from that regurgitation of  the blood in 
12            PRACTICE OF PHYSIC.
 the veins which occasions the alternate heaving and sub-
 siding that  is perceived  in the brain  of living animals
 when the cranium is removed, and which is observed
 to be synchronous with the alternate motions of respi-
 ration.   From this we readily perceive, that whatever
 occasions a difficulty in the transmission of the blood
 through the lungs, must also interrupt  the free return
 of the venous blood from the vessels of the  head; and
 must therefore favour, and perhaps produce, an accu-
 mulation of blood, and an over-distention  in these ves-
 sels.
   It is  further to be observed, that as a very full inspi-
 ration, continued for any length of time, occasions such
 an interruption  of the free transmission of  the blood
 through the lungs, as produces a suffusion of face, and
 a manifest turgescence of  the blood-vessels of the head
 and neck; so every full and long continued inspiration
 may occasion an accumulation of blood in the vessels
 of the head, to a very considerable degree.  Thus, as
 every strong exertion of the muscular force of the body
 requires, and is  attended with, a very full and long con-
 tinued inspiration, we thence learn why the violent ex-
 ertions  of muscular force have been so often the imme-
 diate  or exciting causes of apoplexy.
  It may also be remarked,  that corpulency and obe-
 sity seem to operate  very much, by occasioning a more
 difficult transmission of the blood through the vessels
 of the lungs.  It appears,  that in fat  persons, from the
 compression of  the blood-vessels in many  parts of the
 body, the  vessels of the  lungs are thereby kept very
 full;  so that upon the least increase of bodily motion,
which sends the blood  faster info the lungs, a more
frequent and laborious respiration becomes in such per-
sons immediately necessary.  This shows, that, in such
persons, the blood is not  freely transmitted through the 
PRACTICE OF PHYSIC.
73
lungs; a circumstance which,  as  in  other instances,
must give a constant resistance to the return of blood
from the vessels of the head,  and therefore favour or
occasion on accumulation of blood in them.
  Is the motion of the blood in the vessels of the head
rendered slower by study, care, and anxiety?
  1108. It is to be observed further, that these several
causes (1104.—1107.) of a preternatural fulness in the
blood-vessels of the brain, may produce  apoplexy in
different ways,  according as the fulness takes place in
the arteries or in the veins.
   1109.  Accordingly, first,  the  increased  afflux of
blood into the arteries of the brain,  and  an increased
action in these,  may either occasion  a rupture of their
extremities, and thereby an effusion  of red blood pro-
ducing compression; or  the same afflux and increased
action may occasion an increased exhalation from their
extremities, of a serous  fluid, which, if not as quickly
re-absorbed,  may soon accumulate in such quantity as
to produce compression.
  1110. Secondly, The plethoric state of the venous
vessels  of the  brain, may operate in three different
ways,
  1. The fulness of the veins may give such resistance
to the blood flowing into them from the arteries, as to
determine the impetus of the blood to be so much greater
upon the extremities of the  arteries as  to occasion a
rupture of these,  and consequently  an effusion of red
blood, or the Hcemorrhagia  cerebriy  which Hoffman
considers as a frequent cause of apoplexy, and which
we have before  explained in 771.
  2. Whilst  the same resistance to  the blood flowing
from the arteries into the veins, increases the impetus
of the blood to the former, this may,  without occasion-
ing  rupture,  increase  the exhalation from their  ex-
  VOL. II.                L 
74            PRACTICE OF PHYSIC.
halant  extremities, and  produce an  effusion of a  se-
rous fluid; in the same manner as such resistance in  the
veins produces hydropic effusions in other parts of the
body.
   3. If we may suppose,  as  no lymphatics  have been
yet  discovered  in  the brain, that the  ordinary absor-
bents are not present there, and that the exhaled fluids
are  absorbed or taken up by the extremities of the veins;
this will show still more  clearly that a resistance to  the
motion of the blood in the veins of the brain, may rea-
dily produce an accumulation  of serous fluid in  its
cavities, and consequently a compression  producing
apoplexy.*
   1111. Besides these causes of apoplexy from afflux
in the arteries, or resistance in the veins, an  effusion of
serum may happen from two other causes.   The one
is a relaxation of the exhalants, as in other cases of  hy-
dropic  diathesis prevailing in  the body;  and it is  not
unusual for a general dropsy  to end in apoplexy.  The
second is an over proportion of watery parts in the mass
of blood, which is therefore ready to run off by the  ex-
halants, as in  the  case  of an ischuria renalis; which,
when it proves  incurable, very commonly terminates in
apoplexy.
   1112. We have now mentioned the several causes of
apoplexy depending upon compression; and from  the
whole it will appear, that the  most frequent of all these
causes is a plethoric state, or an accumulation and con-
gestion of blood in  the venous vessels of the  head, ope-

  * We cannot refrain from expressing our astonishment at our author's ad-
nutting the possibility that veins can, under any circumstances, perform the
office of absorbents.'  Nor is it, indeed, less astonishing, that he should doubt
the existence of absorbents in the brain. These vessels are  as essential to
the processes of nutrition and growth, as the arteries themselves  It can be
proved, therefore, to the perfect satisfaction of every physiologist, that what-
ever part of the body grows and is nourished, possesses absorbents 
                 PRACTICE OF PHYSIC.             75

 rating,  according to its degree,  in  producing over-dis-
 tention or effusion.  The frequent operation of such  a
 cause will especially appear from a consideration of the
 predisponent circumstances (1094.) and from the ante-
 cedent symptoms,  (1095.)*
    1113.  From the view I have now given of the causes
 of apoplexy arising from compression, it will readily
 appear that there  is a foundation for the common dis-
 tinction of this disease into the  two kinds of Sanguine
 and Serous.   But this distinction cannot be very use-
 fully applied  in practice,  as both kinds  may often de-
 pend on the same cause, that is, a venous plethora, and
 therefore requiring very nearly the same method of cure.
 The only distinction that can be properly made of apo-
 plexies from compression,  is perhaps the distinction of
 serous apoplexy, into  that depending on  the plethora
 mentioned, (11 \2.) and that depending on hydropic dia-
 thesis,  or an  over proportion of water in  the blood;
 (1111.) the  former causes giving a proper idiopathic,
 the latter only a symptomatic disease.
    1114.  Beside the causes now mentioned, occasion-
 ing apoplexy by compression, I allege there are other
 causes producing the same disease, by directly  destroy-

  * Notwithstanding the extensive and formidable  array of the causes  of
apoplexy,  which our author has presented to us, in some of the foregoing
articles, we venture to assert, that a gouty affection, which is only another
term for a gastric affection, produces the disease more frequently than the
whole of them combined.  We have seen but very few cases of apoplexy,
which we could not trace, in part,  at least, to some kind of morbid impres-
sion on the stomach—a full meal, improper food,  a debauch in drinking, or
some cause of a similar description.
  Most of the causes assigned by our author, being gross and mechanical  in
their nature, are such, we think, as but rarely occur.
  We pretend to no knowledge of that particular affection which our author
denominates " an immobility of the nervous power."  But no physician, we
think, can be ignorant of the fact, that a strong impression on the stomach
produces an immobility of the whole system. In proof of this, we could ad-
duce, were it necessary, innumerable instances. 
76           PRACTICE  OF PHYSIC.
 ing the mobility of the nervous power.   Such causes
 seem to be the mephitic,  arising  from fermenting li-
 quors, and from many other sources; the fumes arising
 from burning charcoal; the fumes of mercury, of lead,
 and of some other metallic substances; opium, alcohol,
 and many other narcotic poisons: to all which I would
 add the power of cold, of concussion, of electricity, and
 of certain passions of the mind.
   1115. None of these poisons or noxious powers seem
 to kill by acting first upon  the organs of respiration, or
 upon the sanguiferous system; and I believe their im-
 mediate and direct action to be upon the nervous power,
 destroying its mobility, because the same poisons show
 their power in destroying the irritability of muscles  and
 of the nerves connected with them, when both these
 are entirely separated from the rest of the, body.
   1116.  It appears to me probable, that the apoplectic
 state in some degree accompanying, and almost always
 succeeding,  an epileptic paroxysm, does not depend
 upon compression, but upon a certain state of immobi-
 lity of the nervous power, produced by certain  cir-
 cumstances  in the nervous system itself, which some-
 times seem to be communicated  from one part of  the
 body to another, and at length to the brain.
   1117.  The same observation may be made with re-
 spect to many instances  of  hysteric paroxysm; and the
 circumstances, both of epileptic and hysteric paroxysms,
 ending in coma,  or a  degree of apoplexy, lead me to
 think, that also the apoplexy proceeding from retroce-
 dent or atonic gout is of the same kind,  or that it de-
pends upon an immobility of the nervous power, rather
than upon compression.
   1118. It may indeed happen, that as the apoplectic
and gouty predispositions do often  concur in the same
person; so it may consequently happen,  that  the apo- 
              PRACTICE OF PHYSIC.            77

plexy coming upon gouty persons,  may sometimes de-
pend upon compression; and dissections may, according-
ly, discover that the circumstances of such a cause had
preceded.   But, in many cases of the apoplexy follow-
ing a retrocedent or atonic gout, no such antecedent or
concomitant circumstances, as commonly occur in cases
of compression!) do distinctly or clearly appear; while
others present themselves, which point out an affection
of the nervous power alone.
   1119.  With respect, however, to the circumstances
which may appear upon the dissection of persons dead
of apoplexy, there may  be some fallacy in judging,
from those circumstances, of the cause of the disease.
Whatever takes off or diminishes  the mobility of the
nervous power,  may  very much retard the motion of
the blood in the vessels of the brain; and that perhaps
to the degree of increasing exhalation, or even of occa-
sioning rupture and effusion: so that, in such cases, the
marks of compression may appear, upon  dissection,
though the  disease had truly depended on causes de-
stroying  the mobility of the  nervous  power.   This
seems to be illustrated and confirmed from what occurs
in many cases of epilepsy.   In  some of these,  after a
repetition of fits,  recovered from in the  usual manner,
a fatuity is induced, which commonly depends upon a
watery inundation of the brain:  and in other cases of
epilepsy,  when fits have been often repeated without
any permanent consequence, there happens at length a
fatal paroxysm; and upon dissection it appears, that an
effusion of blood had happened.   This, I think, is to
be considered as a cause of death, not as a cause of the
disease: for, in such cases, I suppose that the disease
had diminished the action of the  vessels of the brain,
and thereby given occasion to a stagnation,  which pro-
duced the appearances  mentioned.  And I apprehend 
78
PRACTICE OF PHYSIC
  the same reasoning will apply to the cases of retroce-
  dent gout, which, by destroying the energy of the brain,
  may occasion such  a stagnation  as will produce rup-
  ture, effusion, and  death; and in such a case,  the ap-
  pearances upon  dissection might  lead us to think that
  the apoplexy had depended entirely upon compression.
    1120. The several causes mentioned in 1114, are
  often of such power as to  occasion immediate death;
  and therefore have not commonly been taken notice of
  as affording instances of apoplexy; but, as the operation
  of the  whole of  these causes is similar and analogous,
  and as in most instances of the operation of these causes
 an apoplectic state is manifestly produced, there can be
 little doubt in considering most of the instances of their
 effects as cases of apoplexy, and therefore such as fall
 properly under our consideration here.
   1121. This disease of apoplexy is sometimes entire-
 ly recovered from; but more frequently it ends in death,
 or in a  hemiplegia.   Even when an attack of  the dis-
 ease is recovered from, we generally find it  disposed to
 return;  and the  repeated attacks of it almost always,
 sooner or later, bring on the events we have  mentioned.
   1122. The several events of  this  disease, in health,
 death, or another disease, may be expected and foreseen
 from a consideration of the predisponent circumstances
 (1094.) of the antecedent symptoms, (1095.) of the ex-
 citing causes,  (1097.) of the violence and degree of the
 symptoms when the disease has come on, (1093.) of the
 duration of the disease; and the effects of the remedies
 employed.
   1123.  From the great danger attending this  disease
when it  has come on, (1121.) it will readily appear, that
our care should be chiefly directed to the prevention of
it.  This, I  think, may be often done by avoiding the
remote and exciting  causes; and how this may be ac- 
PRACTICE OF PHYSIC.
79
 complished, will  be obvious  from the enumeration of
 those causes given above, (1097.)  But it will also ap-
 pear from what is said above, that the prevention of this
 disease will especially depend upon obviating the pre-
 disponent cause; which,  in most cases, seems to be a
 plethoric state of the blood-vessels of the brain.   This,
 I think, may be obviated by different means; and,  in the
 first place, by a proper management of exercise and diet.*
   1124. The exercise ought to be such as may support
 the perspiration,  without heating the body or hurrying
 respiration; and, therefore,  commonly by some  mode
vof gestation.   In persons not liable to frequent fits of
 giddiness, and who are accustomed to riding on horse-
 back, this exercise is, of all others, the best.   Walking,
 and some other modes of bodily exercise, may be em-
 ployed  with the  restrictions just now mentioned; but
 in old men, and in men of corpulent habits, bodily ex-
 ercise ought always to be very moderate.
   1125.  In persons who pretty early in life show the
 predisposition  to apoplexy, it is probable that a low
 diet, with a good deal of exercise, might entirely pre-
 vent the disease; but,  in persons who are advanced in
 life before they think of taking precautions, and are at
 the same time of a corpulent habit, which generally sup-
 poses their having  been  accustomed  to full  living, it
 might not be safe to put them upon a low diet;  and it
 may  be enough that their diet may be rendered more
 moderate than usual; especially  with respect  to animal
 food; and that, at supper, such food should be abstain-
 ed from altogether.!

  * Let those who are predisposed to apoplexy, and are anxious to escape
an attack, avoid intemperance of every description, and avail themselves of
the enjoyment of free air and moderate exercise.
  f Our author is perfectly correct in forbidding the use of suppers of animal
food.   To persons of apoplectic habits, they are peculiarly dangerous, and
should be, therefore, avoided with firmness and resolution. 
80            PRACTICE OF PHYSIC.

  In drinking, all heating liquors are to  be abstained
from, a.s  much as former habits  will allow, and  the
smallest  approach to  intoxication is to be  carefully
shunned.   For ordinary draught, small beer is  to be
preferred to plain water, as  the latter is more ready to
occasion  costiveness, which in apoplectic habits is to
be carefully  avoided.    The  large use  of tobacco in
any shape may be hurtful; and, except in cases where
it has been accustomed to occasion a  copious  excre-
tion from the head, the interruption of which might not
be safe, the use of tobacco should be avoided; and even
in the  circumstance mentioned,  where it may  be in
some measure necessary, the use of it should at least
be rendered as moderate as possible.
  1126.  Evacuations by stool may certainly contribute
to relieve the plethoric state of the vessels of the head;
and, upon an appearance of any unusual turgescence in
these,  purging will  be  very properly employed: but,
when no such turgescence appears, the frequent repeti-
tion of large purging might weaken the body too much;
and, for preventing apoplexy,  it may for  the most part
be enough  to keep the belly regular, and rather open,
by gentle laxatives.  In the summer season, it may be
useful  to drink, every morning, of a gentle laxative mi-
neral water, but never in large quantity.*
   1127.  In the case of a plethoric state of the system,
it might  be supposed  that blood-letting  would  be  the
most effectual means of diminishing the plethora,  and
of preventing its  consequences; and, when an attack of
apoplexy is  immediately  threatened blood-letting is
certainly the remedy to be depended upon:  and blood'
should be taken largely, if it can be done, from the ju-
gular vein, or.temporal artery.  But when no threaten-
  * The keeping of the bowels regularly free, is highly important to apoplec-
tic patients, and cannot be neglected without jeopardy, even for a day. 
                PRACTICE  OF PHYSIC.            81

 ing turgescence  appears, the obviating plethora is not
 judiciously attempted by blood-letting, as we have en-
 deavoured to demonstrate  above, (786.)   In doubtful
 circumstances, leeches applied to the temples, or scari-
 fications of the hind-head, may be more safe  than ge-
 neral bleedings.*
    1128. When there are manifest symptoms-of a ple-
 thoric state in the vessels of the head, a seton, or pea-
 issue, near the head,  may  be very useful in obviating
 any turgescence of the blood.
    1129. These are the means to be employed for pre-
 venting the apoplexy which might arise from a plethoric
 state of the vessels of the  brain; and ifj at the  same
 time,  great care is taken to  avoid the exciting causes
 (1097.) these means will be generally successful.
   In the cases proceeding  from other causes (1114.) as
 their  application is so immediately  succeeded by  the
 disease, they hardly allow any opportunity for preven-
 tion.
    1130. For the  cure  of  apoplexies from internal
 causes, and which  I  suppose to be chiefly  those  from
 compression, the usual violence and fatality of it require
 that  the proper remedies  be immediately and largely
 employed.
   The  patient is to  be kept as much as  possible in
 somewhat of an  erect posture,  and  in cool air;  and
 therefore neither in a warm chamber, nor covered with
 bed-clothesjjta^urrounded with a crowd of people.f

  • When an attack of apoplexy is seriously threatened, we know of nothing
that can be safely relied on as a substitute for venesection.  That remedy
offers by far the best security from immediate danger, until other means can
be brought into operation to break the strength of predisposition for the
time.
  f If muscular debility be very great, the keeping of the patient in an
erect posture will prove  injurious,  by inducing fatigue and further ex-
haustion.  In such a case, therefore, the body of the diseased should be suf-
   VOL.  II.               M 
82
PRACTICE OF PHYSIC
    1131.  In all cases of a full habit, and where the dis-
 ease has been  preceded by marks of a plethoric state,
 blood-letting is to be immediately employed, and  very
 largely.   In my opinion, it will be most effectual when
 the blood is taken from the jugular  vein; but, if  that
 cannot be properly done, it may be taken from the arm.
 The opening  of the temporal artery,  when  a large
 branch can  be opened,  so  as suddenly to pour out a
 considerable quantity of blood, may also be an effectual
 remedy;  but in  execution,  it is more  uncertain,  and
 may be inconvenient.  It  may be in some  measure sup-
 plied, by cupping  and scarifying on the temples or hind-
 head.   This,  indeed, should seldom  be  omitted;  and
 these scarifications are  always preferable to the  appli-
 cation of leeches.
   With respect  to every mode of blood-letting, this is


fered to recline, while his head is kept as erect as convenient, by pillows
or otherwise.  Care ought to be taken, however, that the head be not bent
too much forward, as, by such a  posture, the free return of blood from the
vessels of the brain will be somewhat impeded. As a general rule, the
drawing of blood from the arm or the jugular vein, is preferable to the open-
ing of the temporal artery.
  When  the apoplectic stroke has expended its force chiefly on one side,
it usually appears on dissection, that the congestion of the brain, when any
exists, is on the  opposite side.  Hence the propriety of  our author's direc-
tion in relation  more  particularly to  topical blood-letting.  The side on
which the operation of general blood-letting is performed, is of less mo-
ment.  Nor ought we,  even in  topical blood-letting, to confine our opera-
tion exclusively to one  side.  If the system be  plethoric, and the case se-
vere, cups may be applied to all parts  of the head—not  only on the sides;
but on the back and front.
  To our author's directions for  the treatment of apoplexy, which are judi-
cious, full, and forcible, we have but little to add.   If complied with
promptly, and pursued to the proper extent, they are, perhaps, calculated
to do all that is practicable in the disease.
  When the patient is capable of swallowing, we have found Glauber's salts
alone, or a solution of them in an infusion of senna, to be  a very valuable re-
medy.  Besides operating speedily, and removing from the bowels their fe-
cal contents, these purgative preparations evacuate a larger  portion of li-
quid matter, than,  perhaps, any others.  Hence their effect in unloading
the  blood-vessels. 
PRACTICE OF PHYSIC.
83
 to be observed, that when  in any case of apoplexy, it
 can be perceived that one side of the body is more af-
 fected with the loss of motion than the other, the blood-
 letting, if possible, should be made on the side opposite
 to that most affected.

    1132.  Another remedy to be employed is purging, to
 be immediately attempted by acrid glysters; and, at the
 same time, if any power of swallowing remain, by dras-
 tic  purgatives given by the  mouth.  These, however,
 lest they  may excite vomiting, should  be given in  di-
 vided portions at proper intervals.
    1133.  Vomiting has been commended  by some prac-
 titioners and writers: but, apprehending that this might
 impel the blood with too much violence into  the vessels
 of the head, I have never employed it.*

  * In like manner with our author, and, for the same reason, we have never
 employed emetics as a remedy in apoplexy.  Yet, from a spontaneous vo-
 miting, we have oftentimes witnessed  the happiest effects.  Hence, vene-
 section in apoplexy does most good, when it procures an evacuation of the
 contents of the stomach.  Still, however, if employed at all, emetics should
 be exhibited  with the utmost caution.  Purging is certainly the safer re-
 medy ; and, unless under very peculiar circumstances, should be always pre-
 ferred.
  If apoplexy appear to have been induced by a suppression of hsmorrhois
 or epistaxis, the application of leeches to the nostrils or hemorrhoidal ves-
 sels should not be neglected.
  Sternutatories, although strongly recommended by some, we consider as
 a remedy of no efficacy.
  Since the publication of the first edition of this work, we have, in seve-
 ral cases of apoplexy, employed emetics with the most salutary effects.  But
 to prevent mischief, we have always antecedently had recourse to venesec-
 tion.   By thus unloading the blood-vessels, emetics are rendered perfectly
 safe.
  When apoplexy occurs  soon after a plentiful meal, as it usually does, to
 evacuate the stomach becomes indispensable.  The malign impression of
 food  and drink on that organ excites the disease. To  aid in the cure, the
removal of this impression is essential. But, by a judicious administration
of emetics, such removal is most speedily effected.
  When the object is simply to evacuate the stomach, ipecacuanha is to be
preferred to every other emetic. Its impression on the stomach being com-
paratively transient, it strains the system less, than other  articles of the same
class, and, therefore, less endangers the safety of the brain. 
84
PRACTICE OF PHYSIC.
   1134.  Another remedy to be immediately employed
is blistering; and  I  judge  that this  is  more effectual
when applied to the head, or near to it, than when it is
applied to  the lower extremities.   This remedy I do
not consider as a stimulant, or capable of making any
considerable revulsion; but, applied to the head,I sup-
pose is useful in taking off the hasmorrhagic disposition
so often prevailing there.
   1135.  It has been usual with practitioners, together
with the remedies already mentioned, to employ stimu-
lants of various kinds; but I am disposed to think them
generally hurtful;  and they must be so, wherever the
fulness of the vessels, and  the impetus of the blood in
these,  is to be diminished.   Upon this principle it is
therefore agreed, that stimulants are absolutely impro?1*
per in what is supposed to bte a sanguine apoplexy; but
they are commonly supposed to be  proper in the se-
rous.   If, however,  we  be right in  alleging  that this
also commonly depends upon a  plethoric state of the
blood-vessels of the  brain, stimulants must be equally
improper in the one  case as in the other.
   1136.  It may be  urged  from  the almost  universal
employment of stimulants,  and sometimes with seem-
ing advantage, that they may not be so hurtful as my
notions of the causes of apoplexy lead  me to suppose.
But this argument is,  in several respects,  fallacious;
and particularly in this, that in a disease which, under
every management, often proceeds so quickly to a fatal
termination, the effects of remedies are not to be easily
ascertained.
   1137.  I  have now mentioned the several remedies
which  I think adapted to the cure of apoplexy arising
from compression, and should next proceed  to treat of
the cure of apoplexy arising from those  causes that di-
rectly destroy the mobility of the nervous power.  But 
PRACTICE OF PHYSIC.
85
  many of those causes are often so powerful, and there-
  by so suddenly fatal in their effects, as  hardly to allow
  of time for the use of remedies;  and such cases, there-
  fore, have been so seldom the subjects of practice,  that
  the  proper  remedies are  not so  well ascertained as to
  enable me to say much of them here*
    1138. When, however, the application of the causes,
  (1114.) is not so  powerful as immediately to kill,  and
  induces only an apoplectic state,  some efforts are to be
  made to obviate the consequences, and  to recover  the
  patient; and  even in some cases where the causes re-
  ferred to from the ceasing of the pulse  and of respira-
  tion, and from a coldness coming upon  the body, have
  induced an appearance of death; yet, if these appear-
  ances have not continued  long, there may be means of
  recovering the person to life and  health.   I cannot, in-
  deed, treat this subject completely;  but for the cure of
  apoplexy from several of the causes mentioned (1114.)
  shall offer the following general directions.
    1.  When  a  poison capable of producing apoplexy
 has been recently taken into the stomach, if a vomiting
 spontaneously arises, it is to  be encouraged;  or, if it
 does  not spontaneously come on, a vomiting  is to  be
 immediately  excited  by art, in order that the  poison
 may  be  thrown out  as# quickly as  possible.  If, how-
 ever, the poison has been taken into the  stomach long
  * The affections treated of in this and the following article, are not to be
considered as cases of apoplexy, but of suspended animation. Some of the
remedies proposed for them by our author are sufficiently judicious. From
the stimulating effects of  the external use of cold water in them, much be-
nefit has been oftentimes derived.  We feel persuaded, however, that, for
the purposes of revival, in cases of suspended animation, remedies judici-
ously and perseveringly directed to the alimentary canal, will be ultimately
found to be most efficacious.  But this is not the proper place for the con-
sideration of this subject.
  Those who wish to inquire further on the subject of apoplexy, are refer-
red to the writings of Ballonius—Willis— Bellini—Lancisi—Hoffman—Bag-
livi—Morgagni—and De Haen. 
86
PRACTICE OF PHYSIC.
before its effects have appeared, we judge that,  upon
their appearance, the exciting of vomiting will be use-
less, and may perhaps be hurtful.
   2. When the poison taken into the stomach, or other-
wise applied to the body, Ijas already induced  an apo-
plectic state, as those causes  do commonly at the same
time occasion a stagnation  or  slower motion of the
blood in the vessels of the brain and of the lungs, so it
will  generally be proper to relieve this congestion by
taking some blood  from the  jugular vein, or from the
veins of the arm.
   3. Upon the same supposition of a congestion in the .
brain or lungs, it will generally be  proper to relieve it
by means of acrid glysters producing some evacuation
from the intestines.
   4. When these evacuations  by blood-letting  and purg-
ing have been  made, the various stimulants which
have been commonly proposed in other cases of apo-
plexy, may be employed here  with more probability and
safety.   One of the  most  effectual means of rousing
apoplectics of this kind, seems to be throwing cold wa-
ter on  several parts of the body, or washing the body
all over with it.
   5. Although the poison producing apoplexy happens
to be so  powerful as very soon to occasion the appear-
ances of death  above-mentioned; yet if this  state has
not continued long,  the patient may often be  recovera-
ble;  and  the recovery is to be attempted by the  same
means that are directed to be employed for  the  reco-
very of drowned persons', and  which are now commonly
known. 
PRACTICE  OF PHYSIC.
87
                           CHAPTER II.


                           OF PALSY.*


 1139.  PALSY is a disease consisting in a  loss of  the
 power of voluntary motion, but affecting certain  parts


   * Palsy and apoplexy appear to be the same disease, differing only in de-
 gree.  Palsy is partial  apoplexy;  and  apoplexy,  universal palsy.  The
 same proximate cause, therefore, must be regarded as giving rise to both;
 except that in one case it is more, in the other less extended and powerful.
   Apoplexy is  more of  an  acute disease than  palsy ; and from this circum-
 stance arises the  principal difference in their treatment.
   Palsy, however, has also an  acute stage, during which it requires to  be      %
 reated precisely like apoplexy.  Bleeding, topical and general,  purging,
 and blistering, constitute now  the  principal remedies.  The active, warm,
 and terebinthinate purges are those from which most advantage is derived.
   After the termination of its acute or febrile character, the practitioner
 must place his chief reliance on regimen, exercise, and external stimulants.
   The diet ought to be  nutritious,  but not stimulating; and  great caution
 should be observed in the use of distilled  and fermented liquors.  In the
 direction of these matters, former and long established habits should be al-
 lowed to have some influence ; but, in the case of a paralytic patient, no-
 thing can justify high living. That which has been instrumental in the pro-
 duction of a disease, can never  be expected to contribute to  its removal.
   If the patient possess sufficient strength, the exercise of  walking or rid-
 ing on horseback or in  a carriage, ought to be practised with  constancy,
 but in  moderation.  Such exercise, in  particular,  as the diseased portion of
 the body is capable of taking, ought, on no account, to be omitted.
   The external stimulants,  from  the employment of which much benefit
 has been  derived,  are  numerous and  diversified.  Blisters and sinapisms,
 with the warm and cold bath, applied immediately to the part affected, are
 among the most powerful.
   To these must  be added warm clothing, consisting of flannel or fleecy
 hosiery worn next the skin, daily and long continued frictions with flannel
 or the flesh brush, and the application of various dry and liquid articles of a
 stimulating character.
   Of these we may mention, as amongst the  most active and  promising,
 tincture of cantharides,  prepared with distilled spirits, or spirits of turpen-
 tine;  the saponaceous, camphorated, and volatile liniments; spirits of tur-
 pentine alone, spirits of camphor alone, or a mixture of the  two, forming
 what has been denominated essence of mustard;  essential oil of cloves, of
juniper, of sassafras, of thyme, and other fragrant and stimulating substances; 
88
PRACTICE OF PHYSIC.
  of  the  body only, and by this  it is  distinguished from
  apoplexy, (1093.)   One of the most frequent forms of
  palsy is when it affects the whole of the  muscles on one
  side of  the body; and  then the  disease is named a He-

  miplegia.

 black pepper alone, powdered mustard alone, black pepper in brandy, mus-
 tard in vinegar, and sundry other irritating  articles.
   Electricity and galvanism are remedies from which much benefit is occa-
 sionally derived in the treatment of paralysis.  But to render them efficient,
 their application must  be  frequent and long continued.  The reason of
 their often failing even to afford relief, is  the injudicious manner in which
 they are employed.  The effect of each shock or single application of Ihem
 is exceedingly evanescent.  To be  productive of good,  therefore, the re-
 petition  of these shocks should be in some  measure  proportioned to the.
 brevity of their time of action.
   Unless  the part affected be kept under  the  influence of these subtle
 agents from three to six hours each day; and this course be pursued forte.
 veral months, the trial cannot be considered as a fair one.  For  it ought
 never to be forgotten, that the remedy should be always as chronic as the
 disease.
   The vapour bath, both dry and moist, has been  found very useful in the
 treatment of palsy.  So has bathing in  salt water, more especially in the
 water of the ocean.
   Urtication, or stinging  with  nettles, has  been recommended  not a little
 in this disease.  Travelling and change of climate, especially the exchange
 of a colder for a warmer climate, have proved useful.
   Various internal remedies have  been used with advantage.   When not
 forbidden by the existence of  fever: the most active of these are, Peruvian
 bark, combined with certain aromatic substances, chalybeates, mustard seed,
 garlic, flowers of zinc, and some of the most stimulating of the essential oils
 —such as, oil of cloves, of mint, of rosemary, of thyme, of sassafras, and of
 juniper; to which may be added, the spirits of turpentine.
  What has been  said of electricity and  galvanism is equally applicable to
 all other remedies in  relation  to the treatment of palsy.  To prove effica-
 cious, their exhibition must be long continued.
  When other means had failed, a gentle  ptyalism, kept up for a considera-
 ble time; or suffered to decline, and again renewed through several repeti-
 tions, has effected a cure.—On the whole, we think we have seen most good
 effected in chronic palsy, by flannel and friction, moderate exercise, and a
 well regulated diet.
  In cases of palsy, where blisters are employed, they will be, perhaps,
 most advantageously applied to the back of the neck.  This is a  point of
 practice which ought  not be  neglected. It is of much more importance
 than has been usually supposed.         «
  For further information on  this disease,  see  Willis—Morgagni—Monre
Dis. Arm.—Home—De Haen—Wardrobe—and Chandler. 
PRACTICE OF PHYSIC.
89
   1140.  THe loss  of  the  power of voluntary motion
may be owing either to a morbid affection of the mus-
cles or organs of motion,  by which they are rendered
unfit for motion; or to an  interruption of the influx of
the nervous power into them, which is always necessa-
ry to the motions of those that are under the power of
the will.   The disease, from the first of these causes,
as consisting in an  organic and local affection, we refer
entirely to the  class of local diseases.   I am here to
consider  that disease only  which depends upon the in-
terrupted influx of the nervous power;  and it is to this
disease alone I would give the appellation of Palsy.  A
disease depending on an interrupted influx of  the nerv-
ous power, may indeed often appear as merely a local
affection; but as it dependsiupon  an affection  of the
most general powers  of the system, it cannot be  pro-
perly separated from the systematic affections.
   1141.  In palsy,  the loss of motion is  often accompa-
nied with the loss of sense; but as this is not constantly
the case, and  as therefore the loss of sense is not an
essential symptom  of palsy, I have not taken it into my
definition (1139.)/and I shall not think  it necessary to
take any further notice of it in this treatise; because, in
so far  as it is in any case a part of the paralytic affec-
tion, it must depend upon  the same causes, and will be
cured  also by the  very same remedies, as the loss of
motion.                               •
   1142.  The palsy then or l6ss of motion, which is to
be  treated of here, may  be distinguished  as of  two
kinds;  one of them depending upon an affection of the
origin  of the nerves in the  brain, and the other depend-
ing upon an  affection of the nenes in some part of
their course between the  brain and the organs of  mo-
tion.   Of the latter, as appearing in a  very  partial af-
fection, I am  not to speak particularly here;  I shall
   VOL. II.                N 
90
PRACTICE OF  PHYSIC.
only treat of the more general paralytic affections, and
especially of the hemiplegia (1139.).  At the same time
I expect, that what I shall say upon this subject will
readily apply to both the pathology and practice in the
cases of affections more limited.
   1143.  The  hemiplegia (1139.) usually begins with.
or follows, a paroxysm of apoplexy;  and when the he-
miplegia, after subsisting for some time, becomes fatal,
it is commonlj by passing again into the state of apo-
plexy.   The relation therefore or affinity between the
two diseases,  is  sufficiently evident;  and is further
strongly confirmed by this, that the  hemiplegia comes
upon persons of the same constitution (1094.) and is
preceded by the same symptoms (1097.) that have beeo ^
taken notice of with respect to apoplexy.             ^
   1144. When a fit of apoplexy has gone off, and there
remains a state of palsy appearing as a partial affection
only, it  might  perhaps  be supposed  that the  origin of
the nerves is in a great  measure relieved; but in so far
as commonly there  still remain the  symptoms  of the
loss of memory, and of some degree  of fatuity, these, I
think, show that the organ of intellect, or the common
origin of the nerves, is still considerably affected.
   1145. Thus, the  hemiplegia, from its  evident con-
nexion with and near relation to apoplexy, may be pro-
perly  considered as depending upon like causes; and
consequentlyieither upon a compression preventing the
flow of the nervous power from the  brain into  the or-
gans of motion, or upon the  application of narcotic  or
other powers (1114.) rendering the nervous power un-
fit to flow in the usual and proper, manner.
   1146.  We begin-with considering  the cases depend-
ing upon compression.
   The compression occasioning hemiplegia may be  of
the same kind, and of all the different kinds that pro- 
PRACTICE OF  PHYSIC.
91
 duce apoplexy; and therefore either from tumour, over-
 distention, or effusion.  The existence of tumour giving
 compression, may often be better discerned in the case
 of palsy than in that of apoplexy, as its effects often ap-
 pear at first in a very partial affection.
   1147.  The other  modes of compression,  that is, of
 over-distention and effusion,  may, and commonly do,
 take place, in hemiplegia: and when they do, their ope-
 ration here differs from that producing apoplexy, by its
 effects being partial, and on one side of the body only.
   It may seem difficult to conceive that an over-disten-
 tion can take place  in the vessels on  one side of the
 brain only: but it may be understood:  and in the case
 of a palsy which is both partial and transitory, it is per-
 haps the only condition of the vessels of the brain that
 can be supposed.   In a hemiplegia, indeed, which sub-
 sists  for any length  of time, there is  probably always
 an effusion,  either sanguine or serous: but it is likely
 that even the latter must be supported by  a  remaining
 congestion in the blood-vessels.
   1148.  That a sanguine effusion can  happen without
 becoming very soon general, and thereby  occasioning
 apoplexy and death, may also seem doubtful: but dis-
sections prove that in fact it does  happen,  occasion-
 ing  palsy only; though it is true, that  this more com-
 monly depends upon an effusion  of serous  fluid, and of
 this only.
   1149. Can a palsy, occasioned by a compression, re-
 main, though the compression be removed?
   1150.  From what has been said, (1143.) it will be
obvious, that the hemiplegia may be prevented by all
the several means proposed (1124. el. seq.) for the pre-
vention of apoplexy.
   1151. Upon the same  grounds, the  cure  of palsy-
must be  very much the  same with that of apoplexy 
92           PRACTICE gF PHYSIC.
 (1129. et.  seq.), and when palsy has begun as an apo-
 plexy, it is presumed, that, before it is to be considered
 as palsy, all those several remedies have been employed.
 Indeed, even when it happens that on  the first  attack
 of the disease the apoplectic state is not very complete,
 and that the  very first appearance of the  disease is as
 a  hemiplegia, the  affinity  between  the two  diseases
 (1143.) is such as to lead to the same remedies in both
 cases.  This is certainly proper in all  those cases in
 which we can with much probability impute the disease
 to compression; and it  is indeed seldom that a hemiple-
 gia from internal causes comes on but with a considera-
 ble affection of the  internal, and even of the external
 senses, together with other marks of a compression of
 the origin of the nerves.
- ■  1152.  Not only,  however, where the  disease can be
 imputed  to compression, but even where it can be im-
 puted to  the application of narcotic powers, if the dis-
 ease come on with the appearances mentioned  at the
 end of the last paragraph, it is to be treated in the same
 manner as  an apoplexy by 1130—1138.
   1153.  The cure of hemiplegia, therefore, on its first
 attack, is the same, or nearly the same, with that of apo-
 plexy: and  it seems requisite that it should  be different
 only, 1. When the disease'has subsisted  for some time;
 2.  When the apoplectic symptoms, or those marking a
 considerable compression of  the origin  of the nerves,
 are removed; and particularly, 3.  When there are no
 evident marks  of  compression, and it  is  at the same
 time known that narcotic powers have been applied.
   1154.  In all these cases, the question arises,  Whe-
 ther stimulants may be employed, or how  far the cure
 may be entirely  trusted to  such remedies? Upon this
 question, with respect to  apoplexy, I have  offered my
 opinion in 1135.   And, with respect to hemiplegia, I 
PRACTICE OF PHYSIC.            93
 am of opinion, that stimulants are almost always equally
 dengerous as in the cases  of complete  apoplexy; and
 particularly, 1. In all the cases of hemiplegia succeeding
 to a paroxysm of complete apoplexy; 2. In all the cases
 coming upon persons of the temperament mentioned
 in 1094, and after the same antecedents as those of apo-
 plexy (1115.), and 3.  In all  the cases coming on with
 symptoms of apoplexy from compression.
   1155. It is, therefore, in the cases 1153  only, that
 stimulants are properly admissible: and even  in the two
 first of these cases, in which a plethoric state of the
 blood-vessels of. the  brain  may have brought on  the
 disease; in which a disposition to that  state may still
 continue; and in which even some degree of congestion
 may still remain, the use of stimulants must  be an am-
 biguous remedy; so  that perhaps it is in the third  of
 these cases only that stimulants are clearly indicated
 and admissible.
   1156. These doubts with respect to the use of stimu-
 lants, may perhaps be overlooked or disregarded by
 those who  allege that  stimulants have been  employed
 with advantage even in those cases (1154.), in  which I
 have said they ought to be avoided.
   1157. To  compromise this contrariety of  opinion, I
 must observe, that  even the  cases  of hemiplegia de-
pending upon compression, although the origin of the
 nerves be so much compressed as to prevent so full a
 flow of the nervous power as is necessary <o muscular
 motion, yet it appears from the power of sense still re-
maining, that the nerves are,  to a certain  degree, still
pervious; and therefore it is possible that stimulants ap-
plied, may excite the energy of the brain  so much, as
in some measure to force open the compressed nerves,
and to show  some return of motion in  paralytic mus-
cles.  Nay, further, it may be allowed, that if these 
91            PRACTICE OF PHYSIC.
 stimulants be such as act more upon  the nervous than
 upon the sanguiferous system they may possibly be em-
 ployed without any very hurtful consequence.
   1158. But still it will be obvious, that although cer-
 tain stimulants act chiefly upon the nervous system, yet
 they also act always in  some measure upon the sangui-
 ferous; so  that, when they happen to have the latter ef-
 fect in any considerable degree, they may certainly do
 much harm; and in a disease which they do not entirely
 cure, the mischief arising from them may not be dis-
 cerned.
   1159. Whilst the employment of stimulants is so of-
 ten  an ambiguous practice, we may perhaps go  some
 length towards ascertaining the matter, by considering
 the  nature of the several stimulants which may be em-
 ployed, and some of the circumstances of their adminis-
 tration.  With this  view,  therefore, I shall now men-
 tion the several stimulants  that  have been commonly
 employed,  and offer some remarks upon their nature and
 use.
   1160. They are in the first place to be distinguished
 as external or  internal.   Of the  first kind, we again
 distinguish them as they are applied to particular parts
 of the body only, or as they are more  generally applied
 to the whole system.  Of the first kind are,
   1. The concentrated  acids of vitriol or nitre; involv-
 ed however, in oily or unctuous substances, which may
 obviate  their corrosive,  without destroying their stimu-
 lant power.
  2. The  volatile alkaline spirits,  especially in  their
 caustic state; but involved also in oils, for the  purpose
just  now mentioned.
  3. The same volatile spirits are frequently employed
by being held to the nose, when they prove a powerful
stimulus to the nervous system; but it is at the same 
PRACTICE OF PHYSIC.           95
time probable, that they may also prove a strong stimu-
lant to the blood-vessels of the brain.
  4. A brine or strong solution of sea-salt.
  5. The essential oils of aromatic plants,  or of their
parts.
  6. The essential oils of turpentine, or of  other such
resinous substances.
  7. The distilled oils of amber,  or of other bitumi-
nous fossils.
  8. The rectified empyreumatic oils of animal or vege-
table substances.
   9. Various vegetable acrids, particularly mustard.
   10. The acrid matter found in several insects, parti-
cularly cantharides.
  Some of these stimulants may be either applied in
substance; or may  be dissolved in ardent spirits, by
which their stimulant power may be increased, or more
conveniently applied.
   1161. The greater part of the substances now enu-
merated show their stimulant power by inflaming the
skin of the part to which they are applied; and  when
their application is so long continued as to produce this
effect, it interrupts the continuance of their use; and
the inflammation of the part  does not seem to do so
much good as the frequent repetition of a more mode-
rate stimulus.
 * 1162. Analogous to these stimulants  is the stinging
of nettles, which has been frequently commended.
  Among the external stimulants,  the mechanical one
of friction with the naked hand, the flesh-brush, or flan-
nel, is justly to be reckoned.  Can  the impregnation of
the  flannels to be employed, with the fumes of burning
mastic,  olibanum, &c. be of any service?
  1163. With respect to the whole of these external
stimulants, it  is to be ob&erved, that they affect the part 
96
PRACTICE OF PHYSIC.
to which they are applied much more than they do the
whole system, and they are therefore indeed safer in am-
biguous cases; but for the same reason, they are of less
efficacy in curing a general affection.
   1164. The external applications which may be ap-
plied  to affect the whole system, are the powers of heat
and cold, and of electricity.
   Heat, as one of the most powerful stimulants of the
animal economy, has been often employed in  palsies,
especially by warm bathing.   But as, both by stimulat-
ing the solids and rarefying  the  fluids,  this proves a
strong stimulus to the sanguiferous  system, it  is  often
an ambiguous remedy; and has frequently been mani-
festly hurtful in palsies depending upon a congestion of
blood in the vessels of the brain.   The  most certain,
and therefore the most proper use of warm bathing/in
palsies, seems to be in those that have been occasioned
by the application of narcotic powers.  Are the  natural
baths more useful by the matters with which they may
be naturally impregnated?
   1165. Cold applied to the body for any length of time,
is always hurtful to the paralytic persons;  but if  it be
not very intense, nor the application long continued, and
if at the same time the body be capable of a brisk re-
action, such an application of cold  is a  powerful sti-
mulant of the whole system, and has often been useful
in curing palsy.   But,  if the power of reaction in the
body be weak, any application  of cold may prove very
hurtful.
   1166. Electricity, in a certain manner applied, is
certainly one of the most powerful stimulants that can
be employed to act upon the nervous system of animals;
and therefore much has been expected from it in the
cure of palsy. But, as it stimulates the sanguiferous as
well as the nervous system, it  has been often hurtful in 
PRACTICE OF PHYSIC.
97
palsies depending upon a compression of the brain; and
especially when it has  been so applied as to act upon
the vessels of the head.  It is safer when its operation
is confined to particular parts somewhat remote from
the head; and, further, as the operation of electricity,
when very strong, can destroy the mobility of the nerv-
ous power, I am of opinion, that it is always to be em-
ployed with  caution, and that it is only safe when ap-
plied with moderate force, and when confined to certain
parts of  the body remote from the head.   It is also my
opinion,  that its good  effects are to be expected from
its repetition rather than from its force,  and that it is
particularly suited to the cure of those  palsies  which
have been produced by  the application  of  narcotic
powers.
   1167.  Amongst the remedies of palsy,  the use of ex-
ercise  is  not to be omitted.  In a hemiplegia, bodily ex-
ercise cannot be employed; and in a more limited affec-
tion, if depending upon a compression of some part of
the  brain, it would be an ambiguous remedy: but, in
all cases where the exercises of  gestation can be em-
ployed, they are proper; as, even in cases of compres-1
sion, the stimulus of such  exercise is moderate, and
therefore safe; and, as it always determines to the sur-
face of the body,  it is a remedy in all cases of internal
congestion.
  1168.  The internal stimulants employed in palsy are
various, but chiefly the following.
  1. The volatile alkaline salts, or spirits, as they are
called, are very powerful and diffusive stimulants, ope-
rating especially on the nervous  system; and even al-
though they operate on the sanguiferous,  yet,  if given
in frequently repeated small rather than in large  doses,
their operation being transitory, is tolerably safe.
  2. The vegetables of the class named Tetradynamia,
  vol. n.                o 
 98           PRACTICE OF PHYSIC

 are many of them powerful diffusive stimulants; and at
 the same time, as quickly passing out of the body, and
 therefore a transitory operation, they are often employed
 with safety.   As they commonly prove diuretic, they
 may in this way also be of service in  some cases of se-
 rous palsy.
   3. The various aromatics, whether employed in sub-
 stance, in tincture, or in their essential oils, are often
 powerful stimulants;  but being more adhesive and in-
 flammatory than those last mentioned, they are, there-
 fore, in all ambiguous cases, less safe.
   4. Some other acrid vegetables have been employed;
 but we are not well acquainted with their peculiar vir-
 tues, or proper use.
   5. Some resinous substances, as guaiacum, and the
 terebinthinate substances, or their essential oils, have
 been, with  some probability,  employed;  but they are
 apt to become inflammatory.   Decoctions of guaiacum,
 and some other sudorifics, have been directed to excite
 sweating by the  application of  the fumes of burning
 spirit of wine in the laconicum, and  have in that way
 been found useful.
   6. Many of the fetid  antispasmodic medicines have
 been frequently  employed in palsy;  but I do not per-
 ceive in  what manner they are adapted to the cure of
 this disease, and I have not observed their good effects
 in any  case of it.
   7. Bitters and the Peruvian  bark,  have  also been
 employed,  but with  no propriety or advantage that I
 can perceive.
   1169.  With respect to the whole of these internal
stimulants, it is to be observed,  that they seldom prove
very powerful; and wherever  there is any doubt con-
cerning the nature or state of the disease,  they may
readily do harm, and are often therefore of ambiguous
use. 
                                      e
PRACTICE OF  PHYSIC.               99
                           BOOK II.

OF  ADYNAMIC ; OR DISEASES CONSISTING  IN A
  WEAKNESS OR LOSS OF MOTION IN EITHER THE
  VITAL  OR  NATURAL  FUNCTIONS.
                           CHAPTER I.*

               OF  SYNCOPE,  OR FAINTING.

 1170.  THIS is  a disease  in  which the action of the
 heart and respiration become considerably weaker than

   * The few cases of the disease, treated of in this chapter, which we have
 had an opportunity of witnessing, appeared evidently to originate in some
 gastric or uterine affection—but most  frequently in the former.  Hence the
 nausea or sickness which almost always precedes the paroxysm.
   Any exceptions to this rule that may present themselves, consist most pro-
 bably in such cases of syncope, as arise from an aneurism, polypi, ossifica-
 tions, or other organic affections of the heart and large blood-vessels.
   We have never seen an instance of the complaint which we could consi-
 der as the product of a cause seated originally in the brain.  The affection of
 the brain  we believe to be secondary.  The disease  attacks that organ, in
 common with others, in its march from the stomach throughout the system.
 The heart,  arteries, and muscles of voluntary motion, it  assails in the same
 way through the medium of sympathy.
   Our author's attempt to disclose the nature,  or as he denominates it, the
 proximate cause of this disease, is not  only unsatisfactory ; it is to us unintel-
 ligible.  Nor is it very probable that we ourselves would be more successful
 should we make an essay on the subject.   It is not our intention, therefore,
 to engage in the undertaking.  When further light shall have been thrown
 on the different kinds of impression of which the stomach is susceptible, and
 when the laws of sympathy shall have  been more completely unfolded, then
 may the nature of syncope be better understood.
  In the meantime, its  cure, as  far as we are acquainted with it, consists
 principally in  the judicious and long continued employment of tonics.
  That the stomach may be the better prepared for the action of these re-
medies, it is proper, in most cases, that they be preceded by an  emetic.
  The tonics best suited to the nature  of this disease are, hark,  bitters, cha-
lybeates combined with aromatics, elixir of vitriol,  and wine,  used in mode-
ration. 
100            PRACTICE OF PHYSIC.
 usual, or  in which for a  certain time these functions

 cease altogether.
    1171.  Physicians having observed that this affection
 occurs in  different degrees, have  endeavoured  to dis-
 tinguish these by different appellations:  but as it is not
 possible to ascertain these different degrees with any
 precision, so there can be no strict propriety in employ-
 ing those different names; and I shall here comprehend
 the whole of the affections of this kind under the title
 of Syncope.
    1172.  This disease sometimes comes on suddenly to
 a considerable degree, but sometimes  also it comes on
 gradually;  and,  in the latter case, it usually comes on
 with a sense of languor, and of anxiety about the heart,
 accompanied  at  the  same time,  or  immediately after,
 with some giddiness,  dimness of sight,  and sounding in
 the ears.   Together with these symptoms,  the pulse

  The cold bath, moderate exercise in the open air,  travelling and change
of climate are also useful. So are a sea voyage and  the constant use of the
flesh-brush.
  A generous diet is adviseable ; but it should never consist of a great va-
riety of articles.  In a particwlar manner, nothing should be eaten that is not
known to be very easily digested.  If any thing be known to be offensive to
the stomach, that ought to be studiously avoided.
  A perpetual blister on the region of the stomach has been found, if not en-
tirely to remove, at least greatly to weaken a liability to syncope.
  So has a gentle ptyalism ; and more especially, still, the use of arsenic,
until an itching and eruption have been produced on the skin.
  Faintingfits have been for a longtime suspended by an attack of podagra.
This shows the disease to be, at least in such cases, of a gouty character.
  Some females experience fainting fits only during their pregnancy; while
others, subject to them at other times, are then free from them. In such
cases, syncope is certainly connected with the uterus ; but the first link of
the chain of diseased action may be fixed in the stomach.
  If syncope make its attack at stated periods, it may, like other periodical
complaints, be prevented by the exhibition of opium or laudanum, a few
hours before the time of Us occurrence.
  For further information respecting this disease, see the writings of Vesa-
lius—Ballonius—Forestus—Schenkius—Boretus—Ramazzini—Lancisi—Se-
nac du cceur—Morgagni—De Haen, rat. med.—Hare  de Syncope—Stoll rat.
med. and Chevalier on Asphyxia Idiopathica. 
PRACTICE OF  PHYSIC.
101
and respiration become weak; and often so weak, that
the pulse is scarcely to be felt, or  the respiration  to be
perceived;  and sometimes these motions,  for a certain
time, cease  altogether.  While these symptoms take
place, the face and whole surface  of the body become
pale, and  more  or  less cold according to the degree
and duration of the paroxysm.  Very commonly at
the beginning of this,  and during its continuance, a
cold sweat appears, and perhaps continues, on the fore-
head, as well as on some other parts of the body.  Dur-
ing the  paroxysm, the  animal functions, both of  sense
and motion, are always in some degree impaired, and
very often entirely suspended.    A  paroxysm of syn-
cope is  often, after some time, spontaneously recovered
from; and this  recovery is  generally attended with a
sense of much anxiety about the heart.
   Fits of syncope are frequently attended with, or end
in, vomiting; and sometimes with convulsions, or an
epileptic fit.
   1173. These  are the phenomena  in  this disease;
and from every view of the greatest part of them, there
cannot  be a doubt that the proximate cause of this dis-
ease is a very weak or total  ceasing of the action of the
heart.   But it will be a very difficult matter to explain
in what manner the several remote  causes operate in
producing the proximate cause.  This, however, 1 shall
attempt, though  with that diffidence which becomes me
in attempting a subject that  has not  hitherto  been
treated  with much success.
   1174. The remote causes of syncope may, in  the
first place, be referred to two general heads.   The one
is, of those causes existing and acting in the brain, or
in parts of the body remote  from  the heart, but acting
upon  it by the intervention of the brain.  The  other
general  head of the remote causes of syncope,  is of 
102
PRACTICE OF PHYSIC.
 those existing in the heart itself, or in parts very imme-
 diately connected with it, and thereby acting more di-
 rectly upon it in producing this disease.
   1175. In entering upon the consideration of the first
 set of those causes (1174.)  I  must assume a proposi-
 tion which I suppose to be fully established in physiology.
 It is this: That, though the muscular fibres of the heart
 be endowed with a certain degree of inherent power,
 they are still, for such action as is necessary to the mo-
 tion of the blood, very  constantly dependent upon a
 nervous power sent into them from the brain.   At least
 this is evident, that there are certain powers acting pri-
 marily, and perhaps only in the brain, which influence
 and variously modify the action of the heart.   I  sup-
 pose therefore,  a force  very constantly during life ex-
 erted in the brain, with respect to the moving fibres of
 the heart, as well as of every part of the body; which
 force I shall call the energy of  the brain; and which I
 suppose  may be,  on different  occasions, stronger or
 weaker with respect to the heart.
   1176.  Admitting these propositions,  it will be obvi-
 ous, that if I can explain in what manner the first set
 of remote causes (1174.) diminish the  energy of the
 brain, I shall at the same time explain in what manner
 these causes occasion a syncope.
   1177. To do  this,  I  observe that  one of the most
 evident of the remote causes of syncope is a hasmorrha-
 gy, or an evacuation of the blood, whether spontaneous
 or artificial.  And as it is very manifest that the energy
 of the  brain depends upon a certain fulness and ten-
 sion of its blood-vessels, for which nature seems to have
 industriously provided by such a conformation of those
blood-vessels as  retards the motion of the blood both in
the arteries and  veins of the brain; so  we can readily
perceive that evacuations of blood, by taking off the ful- 
PRACTICE OF PHYSIC.
103
ness and tension of the blood-vessels of the brain, and
thereby diminishing its energy with respect to the heart,
may occasion  a syncope.   In many persons, a small
evacuation of  blood will have this effect; and in such
cases there is often a clear proof of the manner in which
the cause operates, from this circumstance, that the ef-
fect can be prevented by laying the body in a horizon-
tal posture; which, by favouring the afflux of the blood
by  the arteries, and retarding the return  of it  by  the
veins, preserves the necessary fulness of the vessels of
the brain.
   It is farther to  be  remarked  here, that not only an
evacuation of blood occasions syncope, but that even a
change in the distribution of the blood, whereby a larger
portion of it flows  into one part of the system of blood-
vessels,  and consequently less into others, may occa-
sion a syncope.   It is thus I  explain  the  syncope,
that readily occurs upon the evacuation of hydropic wa-
ters, which had before filled  the cavities of the abdo-
men or thorax.  It  is thus also I explain the syncope
that sometimes happens on blood-letting, but which does
not happen till the ligature which had been employed
is untied, and  admits a  larger afflux  of blood into the
blood-vessels of the arm.  Both  these cases of syncope
show, that an  evacuation of blood does not always oc-
casion  the disease by any general effect on the whole
system, but often merely by taking off the requisite ful-
ness of the blood-vessels of the brain.
   1178. The operation of some  others of the  remote
causes of syncope, may be explained on the  following
principles.   Whilst the energy of the brain is, upon dif-
ferent occasions, manifestly stronger or weaker, it seems
to  be with this condition, that a stronger exertion of it
is necessarily followed by  a weaker state of the same.
It seems to depend upon this  law in the constitution of 
104
PRACTICE OF PHYSIC.
  the nervous power,  that the ordinary contraction of a
  muscle is always alternated with a  relaxation  of the
  same; that, unless a contraction proceeds to the degree
  of spasm, the contracted state cannot be long continued:
  and it seems to depend upon the same cause that the
  voluntary motions, which always require an unusual in-
  crease of exertion, occasion fatigue, debility,  and at
  length irresistible sleep.
    From  this law, therefore,  of the nervous power, we
  may understand why a sudden and violent  exertion of
  the energy of the brain is sometimes followed by such
  a diminution of it as to occasion  a syncope; and  it is
 thus I suppose that a violent fit of joy produces syncope,
 and even death.   It is upon the same principle also, I
 suppose,  that an exquisite pain may sometimes excite
 the energy of the  brain more strongly than can be sup-
 ported, and is  therefore followed by such a  diminution
 as must occasion fainting.  But the effect of this prin-
 ciple appears  more clearly in this, that a fainting rea-
 dily happens upon the sudden remission of a considera-
 ble pain; and thus I have seen a fainting occur upon the
 reduction of a  painful dislocation.
   1179. It seems to be quite analogous when a syncope
 immediately happens  on  the finishing of any great and
 long continued effort, whether depending on  the will, or
 upon a propensity; and in this way a fainting sometimes
 happens to a woman  on  the bearing of a child.   This
 may be well illustrated by observing,  that in persons
already much weakened, even a very moderate effort
 will sometimes occasion fainting.
  1180. To explain the operation of some other causes
of syncope,  it  may be observed, that as the exertions
of the  energy of the  brain  are  especially under the
influence of the will, so it is well known  that those
modifications of the will which are named Passions and 
PRACTICE OF PHYSIC.           105
 Emotions,  have a powerful influence on the energy of
 the brain in its action upon the heart, either in increas-
 ing or diminishing the force of that energy.   Thus, an-
 ger has the former, and fear the latter effect; and thence
 it may be understood how terror often occasions a syn-
 cope  sometimes of the most violent kind,  named As-
 phyxia, and sometimes death itself.
   1181. As, from what I have just mentioned,  it ap-
 pears, that the emotions of desire increase, and those of
 aversion diminish the energy of the brain; so it may be
 understood, how a strong aversion, a horror, or the feel-
 ing which  arises upon the sight of a very disagreeable
 object, may occasion fainting.   As an example of this,
 I have known more than one instance of a person's
 fainting at the sight of a sore in another person.
   1182. To this head of horror and disgust, I refer the
 operation of those odours which in certain persons occa-
 sion syncope.   It may  be supposed, that  those odours
 are endowed with a directly sedative power, and may
 thereby occasion syncope; but they are, many of them,
 with respect to other persons, evidently of a contrary
 quality;  and it appears to me, that those odours  occa-
 sion syncope only in those persons to whom they are
 extremely disagreeable.
  1183. It is, however, very probable, that among the
 causes of syncope, there are some which, analogous to
 all those we have already mentioned, act  by a directly
 sedative power; and such may either be diffused in the
 mass of blood, and thereby communicated to the brain;
 or may be only taken into the stomach, which so rea-
 dily and frequently communicates  its affections to the
 brain.
  1184. Having now enumerated, and, as I hope, ex-
 plained the most part of the remote causes of syncope,
that either operate immediately upon the brain, or whose
  VOL. II.                p 
106           PRACTICE OF PHYSIC.
operation upon other parts of the body is communicated
to the brain, it is proper to observe,  that the most part
of these causes operate  upon certain persons more rea-
dily and  more  powerfully than  upon others; and this
circumstance,  which  may be considered as the predis-
ponent cause of syncope, deserves to be inquired into.
  It is, in the  first place, obvious, that the operation of
some of those causes depends entirely upon an idiosyn-
crasy in the persons upon whom they operate; which,
however, I cannot pretend to explain.   But in the next
place, with respect to  the  greater  part of  the  other
causes, their effects seem to depend upon a temperament
which is  in one degree or other  in common to  many
persons.  This temperament seems to consist in a great
degree of sensibility and mobility, arising from a state
of debility, sometimes depending  upon original confor-
mation,  and sometimes produced by accidental occur-
rences in  the course of life.
   1185.  The  second set of the remote causes of syn-
cope, (1174.) or those acting directly upon the heart it-
self, are certain organic affections of the heart itself, or
of the parts immediately connected with it,  particular-
ly the great vessels which pour blood into, or immedi-
ately  receive it from, the cavities of the heart.  Thus a
dilatation or aneurism of the heart, a polypus in its cavi-
ties, abscesses  or ulcerations in its substance, a close
adherence of the pericardium to the surface of the heart,
aneurisms of the great vessels near to the heart, polypus
in these, and  ossifications in these or in the valves of
the heart, are one or other of them conditions which,
upon dissection, have been discovered in those persons
who had before laboured under frequent syncope.
   1186.  It is obvious, that these  conditions are  aH of
them, either such as may,  upon occasion, disturb the
free and regular influx into,  or the free egress of the 
PRACTICE OF PHYSIC.
107
 blood from, the cavities of the heart;  or such as may
 otherwise disturb  its regular  action,  by sometimes in-
 terrupting it,  or sometimes exciting it to more violent
 and convulsive  action.   The  latter is  what is named
 the Palpitation of  the Heart,  and it commonly occurs
 in the same persons who are liable to syncope.
   1187. It is this, as I judge, that leads us to perceive
 in what manner these organic affections of the  heart
 and great vessels may occasion syncope; for it may be
 supposed, that the violent exertions made in palpitations
 may either give occasion to an alternate great relaxa-
 tion, (1178.) or to a spasmodic contraction; and  in ei-
 ther way suspend  the action of the heart, and occasion
 syncope.   It  seems to  me probable, that it is a spas-
 modic contraction of the heart that occasions the  inter-
 mission of the pulse so frequently accompanying palpi-
 tation and  syncope.
   1188. Though  it frequently happens that palpitation
 and syncope arise, as we have said,  from the organic
 affections above mentioned, it  is proper  to observe, that
 these diseases, even when in  a violent degree, do not
 always  depend  on such causes acting  directly on the
 heart, but are often dependent on some of those causes
 which we have mentioned above as acting primarily on
 the brain.
   1189. I have thus endeavoured to give the pathology
 of syncope; and of the cure I can treat very shortly.
   The  cases of syncope depending on the second set
 of causes, (1174.)  and fully recited in 1185, I suppose
 to be generally incurable; as our art, so far as I know,
 has not yet taught us to cure any one of those several
 causes of syncope  (1185.).
  The  cases of syncope depending on the first set of
causes,  (1174.) and whose operation I have endeavour-
ed to explain  in 1177. et seq.  I hold to be  generally
curable, either by avoiding the several occasional causes 
108
PRACTICE OF PHYSIC.
there pointed out, or by correcting  the predisponent
causes (1184.).   The latter, I think,  may generally be
done by correcting the  debility or mobility of the sys-
tem, by the means which I have already had occasion to
point out in another place.
                     CHAPTER II.

         OF DYSPEPSIA, OR INDIGESTION.

 1190. A WANT of appetite, a squeamishness,  some-
 times a  vomiting, sudden and  transient  distentions of
 the stomach, eructations of  various kinds, heartburns,
 pains in  the region of the stomach,  and a bound belly,
 are symptoms which frequently concur in the same per-
 sons,  and therefore may be  presumed to  depend upon
 one  and the same proximate cause.   In both views,
 therefore, they may be considered as forming one and
 the same disease, to which we have given the appella-
 tion of Dyspepsia, set at the head of this chapter.
   1191.  But as this disease is also frequently a secon-
 dary and sympathic affection, so the symptoms above-
 mentioned are often joined with  many others; and this
 has given occasion to a very confused and undetermin-
 ed description of it, under the general title of Nervous
 Diseases, or  under that  of  Chronic  Weakness.   It is
 proper, however, to distinguish them; and I apprehend
 the symptoms enumerated above are those essential to
the idiopathic affection I am now to treat of.
   1192.  It is indeed to be  particularly observed, that
these  symptoms  are  often  truly accompanied with a
certain state of  mind which may  be considered as a
part of the idiopathic affection: but I shall take no fur-
ther notice of this symptom  in the  present chapter, as 
PRACTICE OF PHYSIC.           109
 it will  be fully and more properly considered in the
 next, under the title of Hypochondriasis.
    1193. That there is  a distinct disease attended al-
 ways with the greater part of the above symptoms, is
 rendered  very probable  by this, that all these several
 symptoms may arise from one and the same cause; that
 is, from an  imbecility, loss of tone, and weaker action
 in the muscular fibres of the stomach; and  I conclude,
 therefore, that this imbecility may be considered as the
 proximate cause of the  disease I am to treat of under
 the name of Dyspepsia.*
    1194. The  imbecility of the stomach, and the con-
 sequent symptoms, (1190.) may, however, frequently
 depend  upon some organic affection of the stomach it-
 self,  as tumour, ulcer, or scirrhosity; or  upon some af-
 fection of other parts of the body communicated to the
 stomach, as in gout, amenorrhoea, and some others. In
 all these cases, however, the dyspeptic symptoms are
 to be considered as secondary or sympathic affections,
 to be cured only by curing the primary disease.  Such
 secondary and sympathic cases cannot, indeed, be treat-
 ed of here: but as I presume  that the imbecility of the
 stomach may often take  place without either any orga-
 nic affection of this part, or any more primary affection
 in any other part of the body;  so I suppose and expect
 it will appear,  from the  consideration of the remote
 causes, that the dyspepsia may be  often an idiopathic
 affection,  and  that it  is therefore properly taken  into

  * It is not from a loss of tone in the muscular fibres of the stomach, thai
the symptoms of dyspepsia arise. Healthy digestion  is not the result of
muscular action.  As far as the stomach is concerned in it, it is the result of
a kind of glandular action; or, rather, of an action sui generis,- for there is
no other organ in the system to the action of which that of the stomach
can be rightfully compared. 
i 10            PRACTICE OF PHYSIC.
 the system of methodical Nosology, and becomes the
 subject of our consideration here.*
   1195.  There can be little doubt, that in most cases,
 the weaker action of the muscular fibres of the stomach
 is the most frequent and chief cause  of the symptoms
 mentioned in  1190, but I dare not maintain  it to be
 the only cause of idiopathic dyspepsia. There is, pretty
 certainly,  a peculiar fluid in the  stomach of  animals,
 or at least a peculiar quality in the fluids, that we know
 to be there, upon  which the solution of  the  aliments
 taken into the stomach chiefly depends: and it is at the
 same time probable, that the peculiar quality of the dis-
 solving or  digesting fluids  may be variously changed,
 or that their quantity may be, upon occasion, diminish*
 ed.   It is, therefore, sufficiently probable, that a change,
 in the quality or quantity of these fluids may produce a
 considerable difference in the phenomena of digestion,
 and particularly may give occasion to many of the mor-
 bid appearances mentioned  in 1190.f
   1196. This seems to be very well founded, and points
 out another proximate cause of dyspepsia beside that
 we have already assigned; but, notwithstanding this, as
 the peculiar nature of  the digestive fluid,  the  changes
 which  it may undergo, or the causes by which it may
 be changed, are all matters so little known, that I can-
 not found any practical doctrine upon any supposition

  • In as far as dyspepsia possesses an arthritic character, it may be consi-
dered an idiopathic disease; gout itself being originally a gastric affection.
  f The peculiar fluid to which our  author alludes in this article is the
liquor gastricus. To the physiologists of the present day, the solvent powers
of this  liquor, and the general part it  performs in the process of digestion
are well understood.  There can be no doubt that in dyspepsia its qualities
are changed.  But this change  is not the sole cause of indigestion, although
it must certainly be considered as an  auxiliary cause.  The gastric liquor
being itself secreted by  the stomach,  any morbid change which it sustains
must be attributed to a previously existing diseased state of action in that
organ. 
PRACTICE  OF PHYSIC.
Ill
with respect to them; and as, at the same time, the im-
becility of the stomach, either as causing the change in
the digestive  fluid, or as being induced by that change,
seems always to be present, and to have a great share in
occasioning the symptoms of indigestion; so I shall still
consider the  imbecility of the stomach as the proximate
and almost sole cause of dyspepsia.   And I more rea-
dily admit  of this  manner of proceeding;  as, in my
opinion,  the doctrine applies very fully and clearly to
the explaining the whole  of the practice which expe-
rience has established  as  the most successful in this
disease.*   .
   1197. Considering this, then, as the proximate cause
of dyspepsia, I proceed to mention the several remote
causes of this disease; as they are such, as, on  different
occasions,  seem to produce a loss of tone in the  mus-
cular fibres  of the stomach.  They may, I think, be
considered under two  heads.  The first is,  of  those
which act  directly and  immediately upon the  stomach
itself:  the second is, of those which  act upon the whole
body, or particular parts of  it, but  in  consequence of
which the stomach is chiefly or almost only affected.
   1198. Of  the first kind are,
   1. Certain sedative or narcotic substances taken into
the stomach; such as tea, coffee, tobacco, ardent spirits,
opium, bitters, aromatics, putrids, and acescents.
   2.  The  large and frequent drinking of warm water,
or of warm watery liquids.
   3.  Frequent surfeit, or immoderate repletion of the
stomach.

  * That in dyspepsia the muscular fibres of the stomach are debilitated is
probably true—pcrliaps the same thing may be true of the whole organ.
But we repeat, that indigestion cannot be regarded as the immediate result
of this debility, in as much as digestion is not a muscular process. 
112           PRACTICE OF PHYSIC.
    4. Frequent vomiting, whether spontaneously arising,
 or excited by art.
    5. Very frequent spitting, or rejection of saliva.
    1199. Those causes which act upon the whole body,
 or upon particular parts and functions of it, are,
    1. An indolent and sedentary life.
    2. Vexation of mind, and disorderly passions of any
 kind.
    3. Intense study, or close application to business too
 long continued.
    4. Excess in venery.
    5. Frequent intoxication; which partly belongs to
 this head, partly  to the former.
    6. The being  much exposed to moist and cold air
 when  without exercise.*
    1200. Though the disease, as proceeding from the
 last set of causes, may be  considered as  a symptomatic
 affection only;  yet as the affection of the stomach is ge-
 nerally the first,  always the chief,  and  often the only
 effect  which these causes produce or discover, I think
 the affection of the stomach  may be considered as the
 disease to be attended to in practice; and the more pro-
 perly so, as in  many  cases the  general debility is only
 to be cured by  restoring the tone of the stomach, and
 by remedies first  applied to this organ.
   1201.  For the  cure of this disease, we form three se-
 veral indications;  a preservative, a palliative, and a cu-
 rative.
   The first is, to  avoid or remove the remote causes just
 now enumerated.

 * 1198—9. These two articles contain an excellent summary of the remote
causes of indigestion, which ought to be strictly attended to and carefully
remembered by all who wish to escape the disease.  Our only objection in
relation to  them, is, that there is not among them, as our author allege|ra
single sedative.  They all possess properties highly stimulating 
PRACTICE OF PHYSIC.
113
   The second is, to remove those symptoms  which es-
pecially contribute  to aggravate and  continue the dis-
ease.   And,
   The third is, to restore the tone of the stomach; that
is, to correct or remove the proximate cause of the dis-
ease.
   1202. The propriety and necessity of the first indi-
cation is sufficiently evident, as the continued applica-
tion, or frequent repetition of those causes,  must con-
tinue the disease;  may defeat the use of the remedies;
or, in spite of these,  may occasion the recurrence of
the disease.  It is commonly the neglect of this indica-
tion which renders this disease so frequently obstinate.
—How the indication is to be executed,  will be suffi-
ciently obvious from  the  consideration of the several
causes:  but it is proper for the practitioner to attend to
this, that the execution is often exceedingly difficult,
because it is not easy to engage men to break in upon
established habits,  or to renounce  the pursuit of plea-
sure; and particularly, to persuade men that these prac-
tices are truly hurtful which they have often practised
with seeming impunity.
   1203. The symptoms of this disease which especially
contribute  to aggravate and continue it, and therefore
require to be more immediately corrected or removed,
are, first, the crudities of the stomach already produc-
ed by the disease,  and discovered by a loss of appetite,
by a sense of weight and uneasiness in the stomach, and
particularly by the eructation of imperfectly digested
matters.
  Another symptom to be immediately corrected, is an
unusual quantity, or a higher degree than usual, of aci-
dity present in  the stomach, discovered by various dis-
orders in digestion, and by other effects to be mention-
ed afterwards.
  VOL. II.               Q 
114
PRACTICE OF PHYSIC.
  The  third Symptom aggravating the  disease, and
otherwise in itself urgent, is costiveness, and therefore
constantly requiring to be relieved.
  1204. The first of these symptoms is to be relieved
by exciting vomiting; and the use of this remedy, there-
fore, usually and  properly begins the cure of this dis-
ease.   The vomiting may be excited by various means,
more gentle or more violent.  The former may answer
the purpose of evacuating the contents of the stomach:
but emetics, and  vomiting, may also excite the ordinary
action of the stomach; and both, by variously agitating
the system, and particularity by determining to the sur-
face of the body,  may contribute  to remove the  causes
of the disease.  But these latter effects can only be ob-
tained by the use of emetics of the more powerful kind,
such as the antimonial emetics especially are.*
  1205. The second symptom to be palliated, is an ex-
cess of acidity,  either in quantity or quality, in the con-
tents of the stomach.   In man  there is a quantity of
acescent aliment  almost commonly taken  in,  and, as I
think, always undergoes an acetous fermentation in the
stomach; and  it  is, therefore, that, in the human sto-
mach, and in the stomachs of all animals using vegeta-
ble food, there is always found an acid present.  This
acid, however,  is  generally innocent, and occasions no
disorder, unless either the quantity of it is large, or the
acidity proceeds to  a  higher degree than  usual.  But,
in either of these cases, the acid occasions various dis-
orders,  as flatulency,  eructation, heartburn, gnawing
pains of the stomach,  irregular appetites  and cravings,
looseness, griping, emaciation, and debility.  To obviate
or remove these effects aggravating and continuing the
disease, it is not only necessary to correct the acid  pre-
  * Vomiting alone,  by exciting a new action in the stomach, contribute*,
at times, very much to the removal of dyspepsia. 
                   PRACTICE  OF PHYSIC.              \\5

  sent in the stomach; but, especially as this acid proves
  a ferment determkiiog and increasing the acescency of
  the aliments afterwards taken  in,  it is proper also, as
  soon as possible, to correct the disposition to excessive
  acidity.*
    1206. The  acidity present  in the  stomach may be
  corrected by  the  use of alkaline  salts, or absorbent
  earths; or by such substances, containing these, as  cau
  be decomposed by the acid of the stomach.   Of the al-
  kalines, the caustic is more effectual than the mild,  and


   * It is now very well known that, in healthy digestion,  the acetous fer-
 mentation never prevails.  But in indigestion, the case is otherwise.  There,
 an acid, said to be the acetous—for we have never ourselves particularly ex-
 amined it—greatly superabounds ; and requires to be neutralized by alkaline
 absorbents.
   An excellent preparation for this purpose consists of equal parts of lime
 water and sweet milk; of which a table spoonful may be taken every  hour,
 or oftener, should circumstances require it.  Lime water and mucilage of
 gum arabic, used in the same way, are also useful.  Besides neutralizing the
 superabundant acidity, these preparations furnish the stomach with alimen-
 tary matter very easy of digestion.
   When acidity and  constipation prevail at once, calcined  magnesia is the
 most suitable remedy.  It neutralizes the former, by its absorbent, and re-
 moves the latter by its purgative, qualities.
   When acidity and diarrhoea are predominant symptoms, the cretaceous
 julap, with the addition of a little laudanum, may be administered  with ad.
 vantage.  This julap may be  prepared according to the following formula.
 Take of prepared  chalk and powdered gum arabic, each half an ounce ; of
 cinnamon, or mint, and spring water, each four ounces; of laudanum,  sixty
 drops; and of loaf sugar, a sufficient quantity to render the  preparation
 agreeable.  These articles being neatly incorporated with each other, give
 of the mixture a table spoonful, according to circumstances.
  In cases of dyspepsia, accompanied with painful spasmodic affections of
 the stomach, the following remedy, although coarse and homely, has been
 found, on experience, to be highly efficacious.
  Take of hickory ashes, a quart;  of powdered soot, a table spoonful; and
 of spring water, one gallon.  Put the ingredients into an unglazed  earthen
 vessel, where they must be permitted to remain from tlirer: to five days, be-
 ing, in the mean time, repeatedly stirred and mixed together vvith a wooden
 or silver instrument; the scum rising to the surface being carefully remov-
 ed. The process  being finished, strain the liquor through coar-se filtering
paper, or allow it to settle, and administer it in  doses of from  two to four
table spoonfuls, to be repeated five or six times a day. 
116
PRACTICE OF PHYSIC.
this accounts for  the  effects of lime-water.  By em-
ploying absorbents, we avoid the excess of alkali, which
might sometimes take place.   The absorbents are dif-
ferent, as they form a neutral more or less laxative; and
hence the difference  between magnesia alba and other
absorbents.   It is  to be  observed,  that  alkalines and
absorbents may be employed to excess;  as, when em-
ployed in large quantity, they may deprive the animal
fluids of the acid necessary to their proper composition.
   1207. The disposition to acidity may be obviated
by avoiding acescent aliments, and using animal food
little capable of acescency.   This; however, cannot be
long continued  without  corrupting the state  of our
blood; and as vegetable food cannot be entirely avoided,
the excess of their acescency may in some  measure be
avoided, by choosing vegetable food the  least disposed
to a vinous fermentation,  such as leavened bread and
well fermented liquors, and, instead of fresh native acids,
employing vinegar.
   1208. The acid arising  from  acescent matters in a
sound  state of the stomach, does  not proceed to any
high degree, or is again soon involved  and made to
disappear: but this does not always happen; and a more
copious acidity, or a higher degree of it, may be pro-
duced, either from a change in the digestive fluids, be-
come less fit to moderate fermentation and to cover aci-
dity, or from their not being supplied in due quantity.
How the former may be occasioned, we do not well un-
derstand; but we  can readily perceive that the latter,
perhaps the former  also, may proceed from a weaker
action of the muscular fibres of the stomach. In certain
cases,  sedative passions, immediately after they arise,
occasion the appearance of acidity in the stomach which
did not appear before; and the use of  stimulants often
corrects or obviates an acidity that would otherwise have 
PRACTICE OF PHYSIC,            117
appeared.  From  these considerations, we conclude,
that the production and  subsistence of acidity in the
stomach, is to be especially prevented by restoring and
exciting the proper action of it,  by the several means
to be mentioned hereafter.*
   1209. But it is also to be further observed,  that
though there are certain powers in the stomach for pre-
venting a too copious acidity, or a high degree of it, they
are not, however, always  sufficient for preventing aces-
cency, or for covering the acidity produced; and  there-
fore, as long as vegetable substances remain in the sto-
mach, their acescency may go on and increase.   From
hence we perceive, that a special cause of the excess of
acidity  may be, the too long  retention of acescent mat-
ters in the stomach;  whether  this may be from these
matters being  of more difficult  solution,  or from the
weakness of the stomach more  slowly  discharging its
contents into the duodenum, or from some impediment
to the free evacuation of  the stomach by  the  pylorus.
The latter of these causes we are well acquainted with,
in the case of a scirrhous pylorus, producing common-
ly the highest degree of acidity.  In all the instances of
this scirrhosity I  have met with, I  have found it incu-
rable: but the first of these causes is to be obviated by
avoiding such aliments as are of difficult solution; and
the second is to be mended by the several  remedies for
exciting the action of the stomach, to be mentioned af-
terwards.
   1210. The third symptom commonly accompanying
dyspepsia,  which requires to be  immediately removed,
is costiveness.   There is so much connection between

  * We have already observed, and beg leave here to repeat, that no pas-
aion is or can be a sedative. Every passion is itself the result of impression,
and, at the same time, makes an impression on the individual who sustains it.
hut the term*, impression and sedative are the opposites of each other. 
118
PRACTICE  OF PHYSIC.
  the several portions of the alimentary canal with respect
  to the peristaltic motion, that, if accelerated or retarded
  in any one part, the other parts of it are commonly af-
  fected in the  same manner.  Thus,  as the brisker ac-
  tion of the stomach must accelerate the  action  of the
  intestines,  so  the  slower action of the intestines must
  in'some measure retard that of the stomach. It is there-
  fore of consequence to the proper action of the stomach,
  that the peristaltic motion of the  intestines determining
  their contents downwards, be regularly continued; and
  that all costiveness, or  interruption of that determina-
  tion, be  avoided.   This may be  done by the various
 means of exciting the action of the intestines: but it is
 to be observed here, that as very considerable evacua-
 tion  of the intestines weakens their action, and is readf
 therefore to induce costiveness  when the  evacuation is
 over: so  those purgatives which produce a large evacu-
 ation, are unfit for correcting the habit of costiveneM.
 This, therefore, should  be attempted by medicines
 which do no more than solicit the intestines to a more
 ready discharge of their present contents, without either
 hurrying their action, or increasing the excretions made
 into their cavity; either of which effects might produce
 a purging.   There are, I think, certain medicines pe-
 culiarly proper on this occasion, as they seem to stimu-
 late  especially the great guts, and to act little on the
 higher parts of the intestinal canal.*
   1211. We have  thus mentioned the several means of
 executing our second indication; and  I proceed to the
 third, which is, as we have said,  the proper curative;
 and it is to  restore the tone of the stomach, the loss of
 which we consider as the proximate  cause of the dis-

  * Anderson's  or plain rhubarb pills, are valuable laxatives in cases of dys-
pepsia.  Injections,  however, appear to be the only remedies that can act
efficiently on the great intestines, without at all disturbing the small ones. 
PRACTICE OF  PHYSIC.           ng
 ease, or at least as the chief part of it.   The means of
 satisfying this indication we refer to  two heads.  One
 is, of those means which operate directly and chiefly on
 the  stomach  itself; and the other is, of those means
 which,  operating upon the whole system, have  their
 tonic effects thereby communicated to the stomach.
   1212. The medicines which  operate directly on the
 stomach are either stimulants or tonics.
   The stimulants are saline or aromatic.
   The saline are acids or neutrals.
   Acids of all kinds seem to have the power of stimu-
 lating the stomach, and therefore often  increase appe-
 tite: but the native acids, as liable to fermentation, may
 otherwise do harm, and are therefore  of ambiguous use.
 The acids, therefore,  chiefly and successfully employed
 are the vitriolic, muriatic, and the distilled acid of vege-
 tables, as it is found in tar-water, which are all of them
 antizymics.
   The neutral salts answering this intention are especi-
 ally those which have  the muriatic acid  in their  com-
 position, though it ispresumed that neutrals of all kinds
 have more or less of the same virtue.*
   1213. The aromatics, and perhaps  some other acrids,
 certainly stimulate  the stomach,  as  they obviate the
 acescency and  flatulency of vegetable food:  but  their
 stimulus is transitory;  and  if frequently  repeated, and
 taken in large  quantities,  they may hurt the  tone of
 the stomach.
   1214. The tonics employed to strengthen the stomach

  * Of the vitriolic acid, the dose ought not to exceed ten drops, and should
be well diluted with water.  The elixir of vitriol we think a more pleasant
remedy. The tinctura martis, exhibited in doses of from ten to twenty drops.
three  times a day, is highly recommended as a tonic in indigestion.  We
ourselves have never employed it.
  As an aid to digestion, we believe that the muriate of soda  surpasses all
other saline preparations. 
120            PRACTICE OF PHYSIC.
are bitters, bitters and astringents combined, and chaly-
beates.
   Bitters are undoubtedly tonic medicines, both  with
respect to the stomach and the whole system: but their
long continued  use  has been found to destroy the tone
of the stomach and of the whole system; and, whether
this is from the  mere repetition of their tonic operation,
or from some narcotic power joined with the tonic in
them, I am uncertain.*
   1215. Bitters and astringents combined are probably
more effectual tonics than either of them taken  singly;
and we suppose such a  combination  to  take place in
the Peruvian bark; which therefore proves a powerful
tonic, both with respect to the stomach and to the whole
system.   But I have some ground to  suspect that the
long  continued use of this bark may, like bitters, de-
stroy  both the  tone of the stomach and of the whole
system.
   1216.  Chalybeates may be employed as tonics in va-
rious forms, and in considerable quantities with safety.
   They have been often employed in the form of mine-
ral waters,  and seemingly with success:  but, whether
this is owing to the chalybeate in the composition of
these waters, or to  some other circumstances attending
their use, I dare not positively determine; but the latter
opinion seems  to me the more probable.f

  • 1213—14. The caution .enjoined in these articles is highly important.
Even in the soundest stomach, an immoderate use of aromatics may induce
indigestion.  Tiie deleterious effect of a long continued course of bitters, is
also a truth too well  known to need confirmation.
  t Chalybeates may be administered under the same formula which have
been heretofore directed in relation to other diseases.
  They appear, however, to be most efficacious, when taken at watering
places, where their  operation is  aided by cheerful society, wholesome air,
moderate exercise, exemption from business, and freedom from care.
  The exercises of gestation recommended by our author, with the use of
cold air and cold water, are, if judiciously employed, important remedies in 
PRACTICE OF PHYSIC.
121
    1217. The remedies which strengthen the stomach,
 by being applied to  the whole body, are, exercise and
 the application of cold.
   As exercise strengthens the whole body, it must also
 strengthen the stomach; but it does this also in a  par-
 ticular manner, by promoting perspiration, and exciting
 the action of  the vessels  on the surface of the body,
 which have a particular consent with the muscular fibres
 of the stomach.   This particularly explains  why the
 exercises of gestation,  though not the most powerful
 in strengthening the whole system, are,  however,  very
 powerful  in  strengthening the stomach; of  which we
 have a remarkable proof in the effects of sailing.   In
 strengthening the general system, as  fatigue must be
 avoided, so bodily exercise is  of  ambiguous use;  and
 perhaps it is thereby that  riding on horseback has been
 so often found to be one of the most powerful means
 of strengthening  the stomach, and thereby  of curing
 dyspepsia.
   1218.  The other general remedy of dyspepsia is the
 application of cold; which maybe in two ways; that is,
 either by the application of cold  air, or  of cold water.
 It is probable, that,  in the atmosphere constantly sur-
 rounding our bodies, a  certain degree of cold, consi-
 derably less than the temperature of our bodies them-
 selves,  is necessary to the health of the human  body.
 Such a degree of cold seems to strengthen  the vessels
 on the surface of the body, and therefore the muscular
 fibres of  the  stomach.   But, further, it is well known,
 that if the body is in exercise sufficient to support such

the treatment of dyspepsia.  So is the keeping up the action of the skin bv
means of the flesh brush, and a covering of flannel
 A long journey and a sea voyage, have been known to cure cases of this
disease, which had withstood the use of everv other remedv.  The excite-
ment of an active military campaign has produced a similar effect.
   VOL. II.                 R 
122
PRACTICE OF PHYSIC.
a determination to the surface, as to prevent the cold
from producing an entire constriction of  the  pores, a
certain degree of cold in  the atmosphere, with such ex-
ercise, will render the perspiration more considerable.
From the sharp appetite  that in such circumstances is
commonly produced, we  can have no doubt, that by the
application of such cold, the tone of the stomach is
considerably  strengthened. Cold air, therefore, applied
with exercise, is a most powerful tonic with respect to
the stomach; and  this explains why, for that  purpose,
no exercises  within doors, or in close carriages, are so
useful as those in the open air.
   1219.  From the same  reasoning,  we  can perceive,
that the application of cold water, or cold bathing, while
it is a tonic with respect  to the system in general, and
especially as  exciting the action of the extreme vessels,
must in both  respects be  a powerful means of strength-
ening the tone of the stomach.
   1220.  These  are  the  remedies  to be  employed to-
wards  a  radical cure of idiopathic dyspepsia;  and it
might be, perhaps, expected here,  that I should treat
also of the various cases of the sympathic disease.  But
it  will be obvious that  this  cannot be properly done
without treating of all the diseases of which dyspepsia
is a symptom, which  cannot be proper in this place.  It
has been partly done already, and will be further treat-
ed of in the course of this work.  In the mean time, it
may be proper to observe, that there is not so much oc-
casion  for distinguishing between the idiopathic and
sympathic dyspepsia, as'there is in many other cases of
idiopathic and sympathic diseases. For, as the sympathic
cases of dyspepsia  are owing to a loss of tone  in  some
other part of the system, which is from thence commu-
nicated to the stomach: so the tone of the stomach re-
stored, may  be  communicated to the part primarily 
PRACTICE OF PHYSIC.            123
 affected; and therefore the remedies of the idiopathic
 may be often usefully employed, and are often  the re-
 medies chiefly employed in sympathic dyspepsia.
   1221. Another part of our business here might be to
 say,  how some other of the urgent  symptoms, besides
 those above-mentioned,  are  to be palliated.   On  this
 subject, I think it is enough to say,  that the symptoms
 chiefly requiring to be immediately  relieved, are flatu-
 lency,  heartburn, other kinds of pain in the region of
 the  stomach, and vomiting.
   The dyspeptic are ready to suppose that the whole of
 their disease consists in a flatulency.  In this it will be
 obvious that they are mistaken; but, although the fla-
 tulency is not to be entirely cured, but by mending the
 imbecility of the stomach by the means above mention-
 ed; yet the flatulent distention  of the stomach may be
 relieved by carminatives, as  they  are called, or  medi-
 cines that produce a discharge of wind from the stomach;
 such are the  various antispasmodics, of which the most
 effectual is the vitriolic aether.
   The heartburn may be relieved by absorbents, antis-
 pasmodics, or demulcents.
   The other pains of the  stomach  may  be sometimes
 relieved by carminatives, but most certainly by opiates.
   Vomiting is to be cured most effectually by opiates
 thrown by injection into the anus.*
  * Of absorbents we  have already spoken. Of the good effects of anti-
spasmodics, usually so called, in dyspepsia, we are very doubtful. As demul-
cents, mucilage of gum arabic, and new milk, are the best and most pleasant
we have ever employed.  The extract of liquorice, although much recom-
mended, we have never used—oil of anise, in doses of ten drops, and of
mint,  in three, are valuable as carminatives—laudanum, in doses of from
twenty to thirty drops, both removes acidity and relieves pain.
  In dyspepsia, late sitting is an injurious practice.  The patient should
always, therefore, retire to bed at an early hour. Let him, in a particular
manner, decline to participate in the  evening enjoyment and riot of the
table.
  An exchange of a city for a eountry, a luxurious for a frugal, and a seden 
124
PRACTICE OF PHYSIC
                           CHAPTER III.

 OF HYPOCHONDRIASIS, OR THE HYPOCHONDRIAC
   AFFECTION,  COMMONLY  CALLED  VAPORS,  OR
   LOW  SPIRITS.*

 1222.  IN certain persons there  is a  state of mind dis-
 tinguished by a concurrence of   the  following  circum-


lary for an active life, has proved oftentimes effectual in the cure of  indi-
gestion.
  A blister, kept open for a considerable time, on the epigastric region, is
a very promising remedy.
  If, as is sometimes the case, the disease be connected with chronic hepa-
titis, the use of mercury becomes indispensable.  Under this form of the
complaint, the nitric acid, given in doses of ten drops, from three to six
times a da}, and sometimes to a larger amount,  is highly recommended.
  In all chronic diseases, the dietetic part of the treatment is highly impor-
tant.  But in none other, perhaps, is it so pre-eminently so, as in dyspepsia,
  By a suitable diet alone may this complaint be removed;  without it, all
medicinal substances are administered in vain.
  Instead of attempting, by stimulating means, to raise the tone of the sto-
mach, so as to suit it to any given kind of diet, the only successful course is,
to accommodate the diet to the condition of the organ.
  A diet of milk alone, or with the addition of a little well boiled rice, or
well baked and toasted bread,  steadily persisted in,  has  produced, in this
complaint, many cures, where the cases seemed desperate.
  Both for the prevention and removal of the disease, a  thorough mastica-
tion of such solid food as may be taken is  exceedingly important—much
more so than is generally imagined.   By swallowing without chewing is it
sometimes produced.
  See on this disease—Forestus—Bonetus—Whytt—Black de humore acido
a cibis—Richter—Temple de dyspepsia—Stoll. rat. med.—Abernethy—and
Stone on diseases of the stomach.
  * Respecting the nature and character of hypochondriasis, it is not our in-
tention to enter into a detailed and protracted discussion.   We shall simpl)
state, that, from the most deliberate view we are able to take of it, we  con-
sider it as truly a gastric disease, as any one to which  our systems are liable.
We feel persuaded that the depression of spirits,  the groundless fears, the
gloom of mind, the spurious sensations, and the wild  intellectual hallucina-
tion attending it, originate in a morbid condition of the stomach. On that
organ is produced, by some cause, an irritation sui generis, which constitutes
the  actual source of the disease ; whatever else may be experienced, whe- 
PRACTICE  OF  PHYSIC.
125
 stances:  a languor, listlessness,  or  want  of resolution
 and activity  with respect to all undertakings; a disposi-

 tlier mental or corporeal, being nothing but secondary and sympathetic
 affections.
   Were we asked our reasons for considering hypochondriasis as a gastric
 affection, we might reply, that they are numerous.  I.  The causes which
 produce it are such as are known to disorder the stomach.  U. The sallow -
 ness of the complexion marks the gastric, or, as it is usually denominated,
 the bilious character of the complaint.  III. The flatulent and dyspeptic
 state of the stomach,  with the obstinate constipation of the bowels which
 accompany it, show it to be a disease of- the primae viae.  IV. Evidence to
 the same amount may be  derived from the dark and disordered appearance
 which the bile in the course of it frequently assumes.  V. We shall only add,
 that the gastric character  of the disease very strongly appears from the fact,
 that those who are subject to it, usually refer their morbid sensations to the
 abdominal region.  Men fancy themselves pregnant, sometimes of a human
 being; at other times of some inferior animal. They believe that a mechanic
 is at work in  their stomach, or that that organ is the kennel of a pack of
 hounds; that a wind-mill is in full career in their bowels, or that a flock of
 birds is there, consuming the aliment  and drinks that are swallowed. At
 other times, the same  organs are the fancied residence of snakes or lizards,
 scorpions or frog3.
   If our view of hypochondriasis be correct, the curative remedies should be
 directed to the stomach.   We, accordingly, believe that emetics, very fre-
 quently repeated, would be ultimately productive of very salutary effects.
 So, we conceive, would arsenic, carried to such an extent as to create great
 nausea, with an eruption  and troublesome itching on the  skin.
   A moderate and long continued salivation, which might revolutionize the
 stomach, would contribute, we are persuaded, to the removal of the disease.
   From the  sympathy that exists between the stomach and the skin, what-
 ever produces on the latter organ a strong  and lasting impression, is calcu-
 lated for the relief of the  hypochondriacal affection.   Hence that complaint
 has been removed by  an attack of the itch, of erysipelas, and of the nettle-
 rash.
   What would be the  effect  of severe and frequent urtication ? or of the
 long continued use  of sulphur, which  is known to act with some  force on
 the skin ?
   A real morbid affection removes such as are only, or in part,  imaginary.
 Hence, a gonorrhoea and a broken bone have dissipated entirely the illusions
 of hypochondriasis.
   What might be the effect of producing an artificial gonorrhoea, by throw-
 ing up the urethra an acrid injection ?—These things are worthy of atten-
 tion.
  For further particulars  touching this disease, consult Ballonius—Willis—-
 Fracassinus de morbo hypochondriaco—Hoffman—Baglivi—Cheyne's En-
glish malady—Turner de morbo hypochondriaco—Stoll.  rat.  med. and
Baynes de hypochondriasi. 
126           PRACTICE OF  PHYSIC.
  tion to seriousness,  sadness, and timidity;  as to all fu-
  ture events, an apprehension of the worst  or most un-
  happy state of them; and, therefore, often upon slight
  grounds, an apprehension of great evil.   Such persons
  are particularly attentive to the state of their own health,
  to even the smallest change of feeling in their bodies;
  and from any unusual  feeling, perhaps of  the slightest
  kind,  they apprehend great  danger, and even death it-
  self.  In respect to all these feelings and apprehensions,
  there is commonly  the most obstinate belief and per-
  suasion.
     1223. This state  of mind is the Hypochondriasis of
  medical writers.   See Linna3i  Genera Morborum, Gen.
  76. et Segari Systema Symptomaticum, Class XIII. Gen.
  5. The same state of mind is what has been commonly*
  called  Vapors and  Low Spirits.   Though the term
  Vapors may be founded on a false theory, and therefore
  inproper, I beg leave, for a purpose that will immedi-
  ately appear, to employ it for a little here.
     1224. Vapors, then,  or the state of mind described
  above,  is, like every other state of mind,  connected with
  a  certain state of the body, which  must  be inquired
  into in order to its being treated as a disease by  the art
  of physic.
     1225. This state  of the body,  however, is not very
  easily ascertained: for we can perceive, that on different
  occasions it is very  different; vapors being combined
  sometimes with dyspepsia, sometimes with hysteria, and
  sometimes with melancholia, which are diseases seem-
  ingly depending on  very different states of the body.
     1226.  The combination  of vapors with dyspepsia
  is very frequent, and in seemingly very different circum-
  stances.   It is, especially, these different circumstances
r that I would wish to ascertain; and I remark, that they
  are manifestly of two different kinds.  First,  as the 
PRACTICE OF PHYSIC.
127
 disease occurs in young persons of both sexes, in per-
 sons of a sanguine temperament, and of a lax and flac-
 cid habit.   Secondly, as it occurs in elderly persons
 of both sexes, of a melancholy temperament, and of a
 firm and rigid habit.
   1227. These two different cases of the combination
 of vapors and dyspepsia. I  consider as two distinct dis-
 eases,  to be  distinguished  chiefly by the temperament
 prevailing in the persons affected.
   As the dyspepsia of sanguine temperaments is often
 without vapors, and as the vapors,  when joined with
 dyspepsia in such temperaments, may be considered as,
 perhaps, always a symptom of the affection of the sto-
 mach;  so to this combination of dyspepsia and vapors
 I would still apply the  appellation of Dyspepsia,  and
 consider it as strictly the disease treated  of in the pre-
 ceding chapter.
   But the combination of dyspepsia and vapors in me-
 lancholic  temperaments, as the  vapors  or the turn of
 mind peculiar to the temperament, nearly that described
 above in 1222, are essential circumstances of the dis-
 ease; and as this turn of mind is often with few, or only
 slight symptoms  of dyspepsia; and,  even though  the
 latter be attending, as they seem to be rather the effects
 of the general temperament, than of any primary or  to-
 pical affection of the stomach; I consider this combi-
 nation as a very different disease from the former, and
 would apply to it strictly the appellation of Hypochon-
 driasis.
   1228. Having thus pointed out a distinction between
 Dyspepsia  and  Hypochondriasis,  I  shall now,  using
these terms in the strict  sense above mentioned,  make
some  observations  which  may,  I  think, illustrate  the
subject, and more clearly and fully establish the distinc-
tion proposed. 
128
PRACTICE OF PHYSIC.
   1229. The dyspepsia often appears early in life, and
 is frequently  much mended as life advances:  but the
 hypochondriasis seldom appears early in life, and more
 usually in more advanced years only; and more certainly
 still, when it has once taken place, it goes on  increas-
 ing as life advances to old age.
   This seems to be particularly well illustrated, by our
 observing the changes in  the state of the mind which
 usually take place in the course of life.   In youth, the
 mind is cheerful, active, rash, and moveable:  but, as
 life advances, the mind by degrees becomes more seri-
 ous, slow,  cautious, and steady;  till  at length, in old
 age, the gloomy, timid, distrustful, and  obstinate state
 of melancholy temperaments, is more exquisitely  formed.
 In producing these changes, it is true, that moral causes
 have a share; but it is at the same time obvious, that
 the temperament of the body determines the operation
 of these moral causes, sooner or later, and  in a  greater
 or lesser degree, to have  their effects.   The sanguine
 temperament  retains  longer  the   character  of youth,
 while the melancholic temperameut  brings on more
 early the manners of old age.
   1230. Upon the whole, it  appears, that the  state of
 the mind which attends and especially distinguishes
 hypochondriasis, is the effect of that same rigidity of the
 solids, torpor of the nervous power,  and peculiar ba-
lance between the arterial and venous  systems which
occur in advanced life, and which at all times take place
more or less in melancholic temperaments.   If, there-
fore, there be also somewhat of a  like state of mind at-
tending the dyspepsia which occurs early in life in san-
guine temperaments and lax habits, it must depend up-
on a different state of the body, and probably  upon a
weak and moveable state of the  nervous  power.
   1231.  Agreeable to all this  in  dyspepsia, there is 
PRACTICE OF PHYSIC.
129
 more of spasmodic affection, and the affection of the
 mind (1222.) is often absent, and. when present, is per-
 haps always of a slighter kind ; while in hypochondria-
 sis the affection of the mind is more constant, and the
 symptoms of dyspepsia, or the  affections of the sto-
 mach, are often absent, or, when present, are in a slighter
 degree.
   I believe the affection of the mind is commonly dif-
 ferent in the two diseases.  In dyspepsia, it is often lan-
 guor and timidity only,  easily dispelled;  while, in hy-
 pochondriasis,  it is  generally the gloomy and riveted
 apprehension of  evil.
   The two diseases are also distinguished by some other
 circumstances.    Dyspepsia, as 1 have said,  is often a
 symptomatic  affection; while hypochondriasis is, per-
 haps, always  a  primary and idiopathic disease.
   As debility may be induced by many different causes,
 dyspepsia is a frequent disease; while hypochondriasis,
 depending upon a peculiar temperament, is more rare.
   1232. Having thus endeavoured to distinguish the
 two diseases, I  suppose the peculiar nature and proxi-
 mate cause of hypochondriasis will be understood; and
 I proceed, therefore, to treat of its cure.
   So far as the affections of the body, and particularly
 of the stomach, are the same here as in the case of dys-
pepsia, the method of cure might be supposed to be also
 the same; and accordingly the practice has been carried
 on with little distinction:  but  I  am persuaded that a
 distinction is  often necessary.
   1233. There may be a foundation here for the same
 preservative indication as first laid down in the cure of
 dyspepsia; (1202.) but I cannot treat this  subject so
 clearly or so  fully as I could wish, because I have not
yet had so much  opportunity of observation as I think
necessary to  ascertain the  remote causes; and I can
  VOL. II.                 s 
130         PRACTICE OF PHYSIC.

hardly make use of the observations of others, who have
seldom or never distinguished between the two diseases.
What, indeed, has been said with respect to the remote
causes of melancholia, will often apply to the hypochon-
driasis, which  I now treat  of; but the subject of the
former has been so much involved in a doubtful theory,
that I find it difficult to select the facts that might pro-
perly  and strictly apply to the latter.  I delay this sub-
ject, therefore,  till another occasion; but in the mean-
time trust, that what I have said regarding the nature
of the disease, and some remarks I shall have occasion
to offer in considering the method of cure, may in some
measure  supply my deficiency on this subject of the re-
mote causes.
   1234.  The second indication laid down in the cure of
dyspepsia (1201.)  has properly a place here; but it is
still to be executed with some distinction.
   1235.  An anorexia, and accumulation of crudities in
the stomach, does not commonly occur in hypochondria*
sis as in  dyspepsia; and therefore vomiting  (1204.) is
not so  often necessary in the former as in the latter.
   1236.  The symptom of excess of acidity,  from  the
slow evacuation of the stomach in melancholic tempe-
raments,  often  arises to a very high degree in  the hy-
pochondriasis; and, therefore, for the same reason as in
1205, it is to be obviated and corrected with the utmost
care.   It is upon this account that the several antacids,
and the other means of obviating acidity, are to be em-
ployed in hypochondriasis, and with the same attentions
and considerations as in 1206, and following; with this
reflection, however, that the exciting the action of the
stomach  there mentioned, is to be a little differently un-
derstood, as shall be hereafter explained.
   1237.  As costiveness, and that  commonly to a con-
siderable degree, is a very constant attendant of hypo- 
PRACTICE OF PHYSIC.           131
 chondriasis, so it is equally hurtful as in dyspepsia.  It
 may be remedied by the same means  in the former as
 in the latter, and they are to be employed with the same
 restrictions as in 1210.
   1238. It is especially with respect to the third indi-
 cation laid down in the cure of dyspepsia (1201.) that
 there is a difference of practice to be observed  in the
 cure of hypochondriasis; and that often one directly op-
 posite to that in the case of dyspepsia, is to be followed.
   1239. In dyspepsia, the chief remedies are the*tonic
 medicines, which to me seem neither necessary nor safe
 in hypochondriasis;  for  in  this there is not a  loss of
 tone, but a want of activity that is to  be remedied.
   Chalybeate mineral waters have commonly been em-
 ployed in hypochondriasis, and seemingly with success.
 But this is probably to be imputed to the amusement and
 exercise usually accompanying the use of these waters,
 rather than to the tonic power of the small quantity of
 iron which they contain.   Perhaps the elementary wa-
 ter, by favouring the excretions, may have a share in
 relieving the disease.
   1240. Cold bathing is often highly useful to the dys-
 peptic, and, as a general stimulant, may sometimes seem
 useful to the hypochondriac; but it is not commonly so
 to the latter; while, on the other hand, warm bathing,
 hurtful to the dyspeptic, is often extremely useful to the
 hypochondriac.
   1241.  Another instance of a contrary practice neces-
 sary in  the two  diseases,  and illustrating their respec-
tive natures,  is,  that the drinking tea and coffee is al-
 ways  hurtful to the dyspeptic, but is commonly ex-
 tremely useful to "the hypochondriac.
   1242.  Exercise,  as  it  strengthens the system, and
therebv the stomach, and more especially, as, by increas-
ing the perspiration, it excites the action of the stomach, 
 132          PRACTICE OF  PHYSIC.

 it proves one of the most useful remedies in dyspepsia;
 and further, as, by increasing the perspiration, it excites
 the activity df the stomach, it likewise proves an useful
 remedy in the hypochondriasis.  However, in the latter
 case, as I shall explain presently,  it is still a  more use-
 ful  remedy by its operation  upon the mind than by ihat
 upon the body.
   1243. It is now proper that we proceed to consider
 the most important article  of our practice in  this dis-
 ease, and which is, to consider the treatment of the mind;
 an affection of which sometimes attends dyspepsia, but
 is always the chief circumstance in hypochondriasis.
 What I am to suggest here, will apply to both diseases;
 but  it  is the hypochondriasis that  I am to keep most
 constantly in view.
   1214. The management of the mind in hypochon-
 driacs, is often nice and difficult.  The firm persuasion
 that generally prevails in such patients, does not allow
 their feelings to be treated as imaginary,  nor their ap-
 prehension of danger to be considered as groundless,
 though  the physician  may be persuaded  that  it is the
 case in  both respects.  Such patients, therefore, are not
 to be treated either by raillery, or by reasoning.
  It  is said to be  the manner of hypochondriacs,  to
 change  often their physician; and  indeed  they often do
 it consistently; for a physician who does not  admit the
 reality of the disease, cannot be supposed to take much
 pains to cure it, or to avert the danger of which he en-
 tertains no apprehension.
  If in any case the pious fraud of a placebo be allowa-
ble,  it seems  to  be in treating hypochondriacs; who,
anxious for relief, are fond of medicines, and, though
often  disappointed,  will still taste every new drug  that
 can be proposed to them.
  1245. As it is the  nature of man to indulge every 
PRACTICE OF PHYSIC.
135
 present emotion,  so the  hypochondriac  cherishes his
 fears;  and, attentive  to cvory feeling,  finds, in trifles
 light as air. a strong confirmation of his apprehensious.
 His cure, therefore, depends especially upon the inter-
 ruption of life  alt< iition,  or upon  its being diverted to
 other objects than his own  feelings.
   1246. Whatever aversion to application of any  kind
 may appear in hypochondriacs,  there is nothing more
 pernicious to them than absolute idleness, or a vacancy
 from all earnest pursuit.   It is owing to  wealth admit-
 ting of indolence, and  leading to the  pursuit of  tran-
 sitory and unsatisfying  amusements,  or to  that of ex-
 hausting pleasures only, that the present times exhibit
 to us so many  instances of hypochondriacism.
   The occupations of business suitable to their circum-
 stances and situation in  life, if neither  attended  with
 emotion, anxiety,  nor fatigue, are always to be admitted,
 and persisted in by hypochondriacs.  But occupations
 upon which a  man's fortune depends, and which are al-
 ways, therefore, objects of anxiety to melancholic  men,
 and  more particularly where  such occupations are ex-
 posed to accidental interruptions, disappointments, and
 failures, it is from these that the hypochondriac is cer-
 tainly to be withdrawn.
   1247. *The hypochondriac who is not necessarily, by

  * From this to the end of the section, our author treats hypochondriasis
too much as if it were an imaginary rather than a real disease, a pure affec-
tion of the mind rather than of the body.
  To talk of diverting a miserable hypochondriac from an " attention to his
own feelings" is idle, unless the  cause of those  feelings be removed.  Divert
him thus for a time >ou may ; and you may. to a certain extent, do the same
to any other valetudinarian; but  his attention will return  to the source of his
suffering, as soon as the diverting impression is removed.
  To talk of a pure  mental disease,  is to speak of that which does not exist.
And if it did exist, it would be utterly beyond the influence of the healing
art. We have no medicines that can reach the mind as an immaterial and
immortal being. In the language  of the poet, to  " pluck from it a rooted 
134
PRACTICE  OF PHYSIC.
 circumstance or habits, engaged in  business, is to be
 drawn from his attention  to his own feelings by some
 amusement.
    The various kinds of sport and hunting, as pursued
 with some ardour, and attended with exercise, if not too
 violent, are amongst the most useful.
    All those amusements  which are in the  open  air,
 joined with moderate exercise, and requiring some dex-
 terity, are  generally of use.
    Within  doors,  company which  engages  attention,
 which is  willingly  yielded  to, and is at the same time of
 a cheerful  kind, will be always found of great service.
    Play, in  which some skill is required, and where the
 stake is not an object of much anxiety, if  not too long
 protracted, may often be admitted.
    In dyspeptics,  however, gaming, liable to sudden and
 considerable emotions, is dangerous;  and the long con-
 tinuance  of it,  with night  watching,  is violently debili-
 tating.   But in melancholies, who  commonly excel in
 skill, and are less susceptible of violent emotions, it ii


sorrow," and purge  it of that "foul and perilous 9tuff that preys upon the
heart," we must direct our attention and our remedies to those corporeal or-
gans on which it acts in :ill i s operations.   While they are disordered, all
mental phenomena will be wrong; reinstate them in soundness, and all will
be right.
  H\ pochondriasis is as really and radically a corporeal disease, as peripneu-
mony or hepatitis,  li depends essentially on local  irritation.  Let the seat
of irritation be carefully sought for; and, being found, let the irritation be
removed, and the mental affection will immediately disappear.
  Simply to divert the hypochondriac's attention from his uneasy feelings,
is to prescribe  for a  mere symptom—to lop off a branch while the root re-
mains untouched. It is like administering opium to allay the pain and the
cough  in pleurisy, while the cause of those affections remains in its strength.
  Whatever  course  the patient is directed to pursue, should have some
other object than mere diversion, or pastime. It should be of such a nature,
and  so  long and perseveringly continued, as deeply  to impress and even re-
volutionize the system.  Nothing short of this  can permanently relieve.
Temporary amusements may afford temporary alleviation ; but for a radical
cure, we must depend on means of a very different  character. 
PRACTICE OF PHYSIC.
135
more admissible, and is often the only amusement that
can engage them.
  Music, to a nice ear, is a hazardous amusement, as
long attention to it is very fatiguing.
  1248.  It frequently happens, that amusements  of
every kind are rejected by hypochondriacs; and in that
case, mechanical means of interrupting thought are the
remedies to be sought for.   Such  is to be found in
brisk  exercise, which requires some attention in the
conduct of it.
  Walking is seldom of this kind; though,  as gratify-
ing to the restlessness of hypochondriacs, it has some-
times been found useful.
  The required interruption of thought is best obtain-
ed by riding on horseback,  or in driving a carriage of
any kind.
  The exercise of sailing, except it be in an open boat
engaging some attention,  does  very little service.
  Exercise in an easy carriage, in the  direction of which
the traveller takes no part, unless it be upon rough roads,
or driven pretty quickly,  and with long continuance, is
of little advantage.
   1249. Whatever exercise may be  employed, it will
be  most effectual when employed  in the pursuit  of a
journey; first, because it withdraws a  person from many
objects  of  uneasiness and  care which might present
themselves at home;  secondly, as  it  engages in more
constant exercise, and in a  greater degree of it than is
commonly taken in airings  about home; and lastly, as
it is constantly  presenting new objects which call forth
a person's attention.
   1250. In our system of  Nosology, we have, next to
Hypochondriasis, placed  the Chlorosis, because I once
thought it might be considered as a genus, comprehend-
ing, besides the Chlorosis of Amenorrhoea,  some spe- 
136           PRACTICE OF PHYSIC.

cies of Cachexy: but, as  I cannot find this to be well
founded,  and cannot distinctly point out any such dis-
ease, I now omit considering Chlorosis  as a genus here;
and as a symptom of Amenorrhoea, I  have endeavour-
ed before to explain it under that title.
                     BOOK III.

 OF  SPASMODIC AFFECTIONS WITHOUT FEVER.

1251. UNDER  this title I am to comprehend all the
diseases which consist in motu abnormi;  that  is,  in a
preternatural state of the contraction and  motion of the
muscular or moving fibres in any part of the body.
  1252.  It will hence appear, why, under  this title, I
have comprehended many more diseases than Sauvages
and Sagar have comprehended under the title of Spas-
mi, or than Linnaeus has done under the title of Moto-
rii.   But I  expect it will be obvious, that  upon this oc-
casion,  it would not be proper to confine our view to
the  affections of  voluntary motion only;  and if those
Nosologists  have  introduced into the class of  Spasmi,
Palpitatio and Hysteria, it will be with  equal propriety
that Asthma, Colica, and many  other diseases, are ad-
mitted.
  1253.  It has been hitherto the method of our Noso-
logists to divide the Spasmi into the two orders of To-
nici and Clonici, Spastici, and Agitatorii: or, as many at
present use the terms, into Spasms so strictly called, and
convulsions.  I find,  however, that many, and indeed
most of the diseases to be considered under our title of
Spasmodic affections, in respect to Tonic or Clonic con-
tractions, are of a mixed kind: and, therefore, I cannot 
PRACTICE OF PHYSIC.           13)
follow the usual general division;  but have attempted
another, by arranging the several Spasmodic diseases
according  as they affect the several functions, Animal,
Vital, or Natural.
                     SECTION I.

 OF THE SPASMODIC AFFECTIONS  OF THE ANI-
                 MAL FUNCTIONS.

 1254. AGREEABLE to the language of the ancients,
 the whole of the diseases to be treated of in this section
 might be termed Spasmi; and many of the moderns con-
 tinue to apply the term in the same manner: but I think
 it  convenient to  distinguish the  terms of Spasm and
 Convulsion, by applying the former strictly to what has
 been  called the Tonic; and the latter to what has been
 called the Clonic spasm.   There  is certainly a founda-
 tion for the use of those different terms, as there is a
 remarkable difference in the state of the contraction of
 moving fibres upon different occasions.  This I have
 indeed pointed out before, in my treatise of Physiology,
 but must also  repeat it here.
   1255.  In the exercise of the several functions of the
 animal economy,  the contractions of the moving fibres
 are excited by the will, or by certain other causes spe-
 cially appointed by nature  for exciting those contrac-
tions; and these other causes I name the natural causes.
In a state of health, the moving fibres are contracted by
the power of the will and by the natural causes only.
At the same time, the  contractions produced are,  in
force  and velocity, regulated by the will, or by the cir-
cumstances of the natural causes; and the contractions,
whether produced by the one or the other, are always
  VOL. II.               T 
138           PRACTICE OF PHYSIC.
soon succeeded by a state of relaxation, and are not re-
peated but when the power of the will or of the natu-
ral causes is again applied.
   1256. Such are the  conditions of the action of the
moving fibres  in a state ©f health: but in a morbid state
the contractions of the muscles and moving fibres ordi-
narily depending upon the will are excited without the
concurrence of the will, or contrary to what the will in-
tends; and in the other functions they are excited by the
action of unusual and unnatural causes.   In both cases
the contractions produced may be in two different states.
The one is, when the contractions are to a more violent
degree than is usual in health, and are neither succeed-
ed by a spontaneous relaxation, nor even readily yield
to an extension either from  the  action of antagonist
muscles, or from other extending powers applied. This
state of contractions is what has been called a tonic
spasm, and is  what I shall name  simply and strictly a
spasm.   The other morbid state of contraction is, when
they are succeeded by a relaxation, but are immediately
again repeated without the concurrence of the will, or
of the repetition of natural causes, and are at the same
time commonly, with respect to velocity and force, more
violent than in a healthy state.  This state of morbid
contraction is what has been named a clonic spasm, and
what I shall name simply  and strictly a convulsion.
  In this section  I shall follow nearly the usual division
of the spasmodic diseases into those consisting in Spasm,
and those consisting in Convulsion; but it may not per-
haps be in my  power to follow such division exactly. 
PRACTICE OF PHYSIC.
139
                     CHAPTER I.

                  OF TETANUS.*

 1257.  BOTH Nosologists and practical writers have
 distinguished Tetanic complaints  into the several spe-
 cies of Tetanus,  Opisthotonos, and Emprosthotonos;
 and I have in my  Nosology put the Trismus, or Lock-
 ed Jaw, as a genus distinct from the Tetanus.  All this,
 however, I now judge to  be improper; and am of opi-
 nion that all the several terms mentioned denote, and are
 applicable  only to, different degrees of one and the same
 disease; the history and cure of which I  shall endea-
 vour to deliver in  this chapter.
   1258. Tetanic  complaints may, from certain causes,
 occur in every  climate that we are acquainted with; but
 they occur most frequently in the warmest climates, and
 most commonly in the warmest seasons of such climates.
 These complaints affect all ages, sexes, temperaments,
 and complexions.  The  causes from whence they com-
 monly  proceed,  are cold and moisture applied to the
 body while it is very warm, and especially the sudden
 vicissitudes of heat and cold.  Or, the disease is produc-
 ed by punctures, lacerations, or other lesions of nerves
 in any part of  the body.  There are,  probably, some
 other causes of this disease; but they are neither dis-
 tinctly known, nor well ascertained.  Though the causes
 mentioned do,  upon occasion, affect  all sorts of persons,
 they seem, however, to attack persons of middle age
 more frequently than the older or younger, the male sex

  * In the United States, especially in the middle and northern sections of
it, Tetanus rarely occurs, except as the result of a mechanical injury. Punc-
tured and lacerated wounds are its usual source. 
  140             PRACTICE  OF PHYSIC.

 more  frequently than the female,  and the robust  and
 vigorous more frequently than the weaker.*
    1259. If the disease proceed from cold, it commonly
 comes  on  in a few days after the application of such
 cold; but,  if it  arise from a puncture or other lesion of
 a nerve, the  disease does  not  commonly come on for
 many  days after  the lesion has  happened,  very often
 when there is neither pain nor uneasiness remaining in


  * Tetanus, from whatever source it may arise, whether from a punctured
 or a lacerated wound, or from vicissitudes in the sensible qualities of the at-
 mosphere, furnishes a remarkable and conclusive instance of the truth of the
 sympathetic, and the fallacy of the humoral, doctrines of pathology. Nor is
 it less satisfactory in establishing the  original  locality of general disease.
  A puncture is received in the foot, from the point of a nail free from rust,
 and every other deleterious quality.  The injury is purely mechanical.  From
 the beginning it is not painful, it seems to heal very kindly, and in a day or
 two is entirely forgotten.
  For two or three weeks, the system suffers no inconvenience.  The blood
 and all the juices are unimpaired.  No taint  adulterates them, nor are they
 marked by any morbific lentor.
  At length tetanic symptoms appear, circumscribed, indeed, at first, but
 progressing and widening,  until the whole system partakes of the disease.
 But still the blood and the juices are pure, and continue so to the termination
 of the complaint.
  The entire  pathology of this disease is connected exclusively with tbd
 solids; the complaint is local in its origin, and sympathy is the only medium
 through which it can spread.
  It is worthy of remark, that there are two kinds of injury that give rise to
 tetanus ;  a sepsative and an irritative; or one that is painful and one that is
 not.
  Tetanus from an irritative injury rarely makes its appearance in less than
 two or three weeks after the wound has been inflicted; and when thus late in
 occurring is almost always fatal.  But when the injury is sensative, as in the
 case of a  large lacerated wound, the disease is more early in its occurrence,
 and less deadly in its effects.
  Tetanus furnishes also a very memorable example of the manner in which
 diseases change their seat.  Radicated at first in the spot where the injury
is received, it becomes afterwards so  completely infixed in other parts, that
 no impression  on its original seat can have any influence in removing it.
 V> hen tetanus from an irritative injury has made its appearance, cut out the
 spot where the wound existed,  or even amputate the limb on which it was
 received, you operate in  vain.  The disease has so changed its ground, that
 it appears to have a seat in every muscle and every nerve. To cure it, you
must revolutionize the whole habit. 
PRACTICE OF PHYSIC.
141
 the wounded or hurt part, and very frequently when the
 wound has been entirely healed up.
    1260. The disease sometimes comes on suddenly to
 a violent degree, but more generally it approaches by-
 slow degrees to its violent state.  In this case it comes
 on with a sense of stiffness in the back part of the neck,
 which, gradually increasing,  renders the motion of the
 head difficult and painful.   As the rigidity of the neck
 comes on and increases, there is commonly at the same
 time a sense of uneasiness felt about the root of the
 tongue; which,  by degrees, becomes a difficulty of swal-
 lowing, and at length an entire interruption of it. While
 the rigidity of the neck goes on increasing, there arises
 a pain, often violent, at the lower end of the sternum,
 and from thence shooting into the back.  When this
 pain arises, all the muscles of the neck, and particularly
 those of the back part of it, are immediately affected
 with spasm, pulling  the head strongly backwards.  At
 the same time,, the muscles that pull  up the lower jaw,
 which upon the  first approaches of the disease were af-
 fected with some spastic rigidity, are now  generally
 affected  with more violent spasm,  and set the teeth so
 closely together  that they do not admit of the smallest
 opening.
   This is what has been named the Locked Jaw, and
 is often the principal part of the  disease.   When  the
 disease has advanced thus far, the pain at the bottom of
 the sternum returns  very frequently; and with it the
 spasms of the hind neck and lower  jaw are  renewed
 with violence and much pain. As  the disease thus pro-
 ceeds, a greater  number of muscles come to be affected
 with spasms.   After  those of the neck, those along the
whole of the spine become affected, bending the trunk
of the body strongly backwards ;  and this is what has
been named the  Opisthotonos. 
142           PRACTICE  OF PHYSIC.
   In the lower extremities, both the flexor and exten-
 sor muscles are commonly at  the same time affected,
 and keep the limbs rigidly extended.  Though the ex-
 tensors of the head  and back  are usually the  most
 strongly affected, yet the flexors, or those muscles of the
 neck that pull the head forward, and the  muscles that
 should pull  down  the lower jaw are often at the  same
 time strongly affected with spasm.  During the whole
 of the disease, the abdominal  muscles are violently af-
 fected with spasm, so that the belly is strongly retracted,
 and feels hard as a piece of  board.
  At length the flexors of the head and trunk become
 so strongly affected as to balance the extensors, and to
 keep the head and trunk straight, and rigidly extended,
 incapable of being moved in  any way ; and it is to this
 state the term of Tetanus has been strictly applied. At
 the same time, the arms, little  affected before, are now
 rigidly extended; the whole of the muscles belonging to
 them being affected with spasms, except those that move
 the fingers, which often to the last retain some mobility.
 The tongue also long retains it mobility ; but at length
 it also becomes affected with spasm, which, attacking
 certain of its muscles  only, often thrusts it violently out
 between the teeth.
  At the height of the disease, every organ of voluntary
 motion seems to be affected ; and,  amongst the  rest,
 the muscles of the face.  The forehead is drawn up
 into furrows, the eyes, sometimes distorted, are com-
 monly rigid, and immoveable in their sockets ; the nose
 is drawn up, and the cheeks are  drawn backwards to-
wards the ears, so that the whole countenance expresses
the most violent grinning.' Under  these universal spasms
 a violent convulsion commonly comes on,  and puts an
 end to life.
  1261. These spasms are every where attended with 
PRACTICE OF PHYSIC.           143
most violent pains.  The  utmost violence of spasm is,
however, not constant; but, after subsisting for a minute
or two, the  muscles admit of some remission of their
contraction, although of no such relaxation as can allow
the action of their antagonists.   This remission of con-
traction gives also some remission of pain ; but neither
is of long duration.   From  time  to time,  the violent
contractions and pains are renewed, sometimes every
ten or fifteen  minutes, and that often without any evi-
dent  exciting cause.   But such  exciting causes fre-
quently occur ;  for almost every attempt to motion, as
attempting a change of posture, endeavouring to swal-
low,  and even to speak, sometimes gives occasion to
a renewal of the spasms over the whole body.
   1262. The attacks of this disease are seldom attended
with  any fever.  When the spasms  are general and vio-
lent,  the pulse  is  contracted, hurried,  and irregular;
and  the respiration  is affected in like manner: but,
during  the remission,  both  the pulse  and respiration
usually return to their natural state.   The  heat of the
body is commonly  not increased;  frequently the face is
pale, with a cold sweat upon it; and very often the ex-
tremities are cold  with a cold sweat  over the whole
body.  When, however,  the spasms are frequent and
violent, the pulse is sometimes more full and frequent
than natural: the face is flushed, and a warm sweat is
forced out over the whole body.*
    1263. Although fever be not a constant attendant of
this disease, especially when  arising from a  lesion  of
 nerves; yet, in those cases proceeding from cold, a fe-
 ver sometimes has supervened, and is said to  have been
 attended with inflammatory symptoms.  Blood has been
  * We do not recollect ever to have seen a case of tetanus, in which the pa-
tient, was entirely exempt from febrile action.  At the commencement of
the disease, the pulse is oftentimes full and frequent, tense and strong.
Blood drawn at this time throws up a covering of coagulating lymph. 
 144          PRACTICE OF PHYSIC.

often drawn in this disease, but it never exhibits any
inflammatory  crust; and  all accounts seem to  agree,
that the blood drawn seems to be of a looser texture
than  ordinary, and that it  does  not coagulate  in the
usual manner.
   1264.  In this  disease the  head is  seldom affected
with delirium, or even confusion of thought, till the last
stage of it; when, by the repeated shocks of a violent
distemper, every function of the system is greatly dis-
ordered.
   1265. It is no less extraordinary, that, in this violent
disease, the natural functions are not either immediately
or considerably affected.   Vomitings sometimes appear
early in the disease, but commonly they are not con-
tinued; and it is usual enough for the appetite of hunger
to remain through the whole course of the disease; and
what food happens to be taken down, seems to be regu-
larly enough digested.   The excretions are sometimes
affected, but not always.  The urine is sometimes sup-
pressed,  or is voided  with  difficulty and  pain.   The
belly is costive:  but, as we  have  hardly any accounts
excepting of those case in  which opiates have been
largely employed, it is  uncertain whether the costive-
ness has been  the effect of the opiates or of the disease.
In several instances of this disease, a miliary eruption
has appeared  upon the skin; but whether this be  a
symptom of the disease, or the effect of a certain treat-
ment of it, is undetermined.   In the meanwhile, it has
not been observed to denote either safety or danger, or
to have any effect in changing the course of the  dis-
temper.
   1260. This  disease has  generally proved fatal;  and
this indeed may be justly supposed to be the conse-
quence of  its  nature; but, as we  know, that till very
lately physicians were not well acquainted with a proper 
PRACTICE OF PHYSIC.           145
 method of cure ; and that since a more proper method
 has been  known and practised, many have recovered
 from  this  disease; it may be  therefore concluded, that
 the fatal tendency of it is not so unavoidable as has been
 imagined.
   In  judging of the tendency of this disease, in particu-
 lar cases, we may remark, that, when arising from le-
 sions of the nerves, it  is  commonly more violent, and
 of more difficult cure, than when proceeding from cold;
 that the disease which comes on suddenly, and  advances
 quickly to a violent degree, is always  more dangerous
 than  that which is slower in  its progress.  Accordingly,
 the disease  often proves fatal  before  the  fourth day;
 and when a patient  has passed this  period, he may be
 supposed  to be in greater safety, and in general the dis-
 ease is the safer the longer it has continued: It is, how-
 ever,  to be particularly  observed, that,  even for many
 days after the fourth, the disease continues to be dan-
 gerous; and, even after  some considerable abatement of
 its force, it is ready  to recur  again with its former vio-
 lence and danger.  It never  admits  of any sudden, or
 what  is called critical solution;  but always recedes  by
 degrees only, and it is often very long before the whole
 of the symptoms disappear.
   1267. From  the history of the disease now described,
 it will be evident, that there is no room for distinguish-
 ing the tetanus,  opisthotonos, and trismus, or locked jaw,
 as different species of this  disease, since they  all arise
from  the  same  causes,  and are almost constantly con-
joined in  the same  person.  I have no doubt that the
emprosthotonos belongs  also to the same genus; and as
the ancients have frequently mentioned it, we can have
no doubt of its  having occurred: but, at the same time,
it is certainly in these days a rare occurrence; and, as I
have never seen it, nor find any histories in which this
   tol.  11.               u 
146
PRACTICE OF PHYSIC.
 particular state of the spasms is said to have prevailed,
 I cannot mention the other circumstances which parti-
 cularly attend it,  and may distinguish it from the other
 varieties of tetanic complaints.
   1268. This  disease has put on still a different form
 from any of those above mentioned.  The spasms have
 been sometimes confined  to one side of the body only,
 and which bend it strongly to that side.   This is what
 has been named  by Sauvages  the Tetanus Lateralis,
 and by  some  late writers the Pleurosthotonos.  This
 form of the disease has certainly appeared very seldom;
 and, in  any of the accounts given of it,  I cannot  find
 any circumstances that would lead me to  consider it as
 any other than a variety of the species already mention-
 ed, or to take further notice of it here.*
   1269. The pathology of this disease I  cannot in any
 measure attempt; as the structure of moving fibres, the
 state of them under different degrees of contraction, and
 particularly the state of the sensorium, as variously de-
 termining the motion of  the  nervous power,  are  all
 matters  very  imperfectly,  or not at all, known  to  me.
 In such  a situation, therefore, the endeavouring to give
 any rules of  practice, upon a scientific  plan, appears
 to me  vain  and  fruitless;  and  towards  directing the
 cure of  this disease, we must  be satisfied with having
 learned  something useful  from analogy,  confirmed by
 experience.
   1270. When the disease is known to arise from the
 lesion of a nerve in any part of the body,  the first, and,

  * Another variety or modification of tetanus consists in its assumption of
an intermitting character.  We once saw a case, in which the spasms ceased
to be troublesome about twelve o'clock each night, and did not return until
near twelve the next day.  The patient took, in the intervals, large quanti-
ties of bark, wine, and laudanum, and finally recovered. In this instance,
mercurial ointment was also used until a salivation was produced. In no case
of tetanus ought mercury to be omitted. 
PRACTICE OF PHYSIC.
147
as I judge, the most important step to be taken towards
the cure,  is, by every possible  means, to cut off that
part from  all communication with the sensorium, either
by cutting through the nerves in their course, or perhaps
by destroying, to a certain length, their affected part or
extremity.
   1271. When the  cure of the disease is to be attempt-
ed by medicine, experience  has taught  us that opium
has often proved an effectual remedy; but that, to ren-
der it such, it must  be given in much larger quantities
than have been  employed in any other case; and in these
larger quantities, it may, in this disease, be given more
safely than the body has been known to bear in any other
condition.   The practice has been  to give the opium
either in a solid or liquid  form,  not in  any very large
dose at once, but in moderate doses, frequently repeat-
ed, at the  interval of one, two, three, or more hours, as
the violence of  the  symptoms seem to require.   Even
when large quantities have been given in this way, it
appears that the opium does not operate here in the
same manner as in most other cases; for, though it pro-
cure some remission of the spasms and pains, it hardly
induces any sleep, or occasions that stupor, intoxication,
or delirium, which it often does in ether circumstances,
when much smaller quantities only have been given. It
is, therefore, very properly observed, that, in tetanic af-
fections, as the opium shows none of those  effects by
which it may endanger  life, there is little or no reason
for being sparing in the exhibition of  it; and  it may
be given, probably should be given, as largely and as
fast as the symptoms of the disease may seem to de-
mand.
   It is particularly to be observed, that though the first
exhibition  of the opium may have produced  some  re-
mission of the  symptoms, yet the effects of opium do 
148          PRACTICE OF PHYSIC.
 not long continue in the system; and this disease being
 for some time ready to recur, it is commonly very ne-
 cessary, by the time that the effects of the opium given
 may be supposed to be wearing off, and especially upon
 the least appearance of the return of the spasms, to re-
 peat the exhibition of  the opium in the same quantities
 as  before.  This practice is to be continued while the
 disease continues to show any disposition to return; and
 it is only after the disease has already subsisted for some
 time, and when considerable and long continued remis-
 sions have taken place, that the doses of the opium may
 be  diminished, and the intervals of exhibiting them be
 more considerable.
   1272. The administering of opium in this manner,
 has in many cases been successful; and probably would
 have been equally so in many others, if the opium had
 not been too sparingly employed, either from  the timi-
 dity of practitioners, or from its exhibition being pre-
 vented by that interruption of deglutition which so often
 attends this disease.  The latter circumstance directs,
 that the  medicine  should be immediately and largely
 employed upon the first approach of the disease, before
 the deglutition becomes difficult; or that, if this oppor-
 tunity  be lost, the  medicine in sufficient quantity, and
 with due frequency, should be thrown into the body by
 glysters; which,  however, does not seem to have been
 hitherto often practised.
  1273.  It is highly probable, that, in this disease, the
 intestines  are affected  with the spasm that prevails so
 much  in other parts of the system; and therefore that
 costiveness occurs here as a symptom of the disease.  It
 is probably also increased by the opium,  which is here
so  largely employed;  and, from  which ever  of  these
causes it arises,  it certainly must  be held to aggravate
the  disease, and that a  relaxation of the intestinal canal 
                 PRACTICE OF PHYSIC.            149

  will contribute to a relaxation of the spasms elsewhere.
  This consideration directs the  frequent exhibition of
  laxatives while the power of deglutition  remains, or
  the  frequent exhibition of glysters when it  does not;
  and the goods effects of both have been frequently ob-
  served.*
    1274.  It  has been  with some probability supposed,
  that the operation of opium in this disease, may be much
  assisted by  joining with  it  some other  of the most
  powerful antispasmodics.    The  most  promising  are
  musk and camphor; and some practitioners have been
  of opinion,  that the  former has proved very  useful in
  tetanic complaints.  But, whether it be from its not hav-
  ing been employed of  a genuine kind, or  in sufficient
  quantity, the great advantage and propriety of its use
  are not yet clearly ascertained.  It appears to me pro-
  bable, that analogous to what happens with respect to
  opium,  both musk and camphor might be employed in
 this disease,  in much larger quantities  than they com-
 monly have been in other cases.
    1275. Warm bathing has been  commonly employed
 as a remedy in  this disease,  and often with advantage;
 but,  so far as I know,  it has not alone proved a cure;
 and, in some cases,  whether  it  be from the motion of
 the body  here required, exciting the spasms, or from
 the fear of the  bath, which some persons were seized
  * Of the exhibition of purgatives in this disease, we have ourselves never
witnessed the salutary effects.  Nor, in cases where it arises from external
injuries, do we perceive the grounds on which they can be useful. We know
they are recommended  by respectable authority. Dr. Hamilton, of Edin-
burgh, represents them as entitled to our highest confidence.  But, if they
be so, it must, we think, be in cases of tetanus resulting, not from external
but internal irritation—cases where the disease originates in the alimentary
canal.  In such instances, emetics combined with purgatives might add not
a little, perhaps,  to their efficacy; for, besides giving aid in the removal of
irritation, they would contribute to the relaxation and resolution of spasm.
But, to  be useful in this disease, emetics ought to be frequently adminis-
tered. 
150           PRACTICE OF PHYSIC.
 with, I cannot determine;  but it is allowed, that the
 warm bath hath in some cases done harm, and even oc-
 casioned death.  Partial fomentations have been much
 commended, and, I believe, upon good grounds: and 1
 have no doubt but that fomentations of  the feet and
 legs, as we  now usually apply them  in fevers, might,
 without much stirring of the patient, be very assiduously
 employed with advantage*
    1276. Unctuous  applications  were very  frequently
 employed in  this disease by the ancients;  and some
 modern practitioners have considered them as very use-
 ful.  Their effects,  however, have not appeared to be
 considerable; and, as a weak auxiliary only, attended
 with some inconvenience,  they  have been very much
 neglected by the British practitioners.
    1277. Bleeding has  been  formerly employed in this
 disease; but  of late it has been found prejudicial,  ex-
 cepting in a few cases,  where, in plethoric habits, a fe-
 ver has supervened.  In general, the state of men's bo-
 dies in warm  climates is unfavourable to blood-letting:
 and, if we may form indications from the state of the
 blood drawn  out of the  veins, the state of this in tetanic
 diseases would forbid bleeding in them.f
   1278.  Blistering also  has  been formerly employed in
 this disease;  but several practitioners  assert,  that blis-
 ters are constantly hurtful,  and they are now generally
 omitted.
   1279.  These  are the practices  that  hitherto have
 been generally employed; but of late  we are informed

  * We believe the remedies recommended in this article to be wholly un-
availing.
  \ At the commencement of this disease, we have seen blood-letting prac-
tised, in plethoric subjects, with evident advantage ; and, as already men-
tioned, the blood  was sizy.  Hence, as in other complaints, regard must be
paid to the state of the system.  Besides, blood-letting is known to facilitate
the operation of other remedies. 
PRACTICE OF PHYSIC.
151
by several West India practitioners, that in  many in-
stances they have employed mercury with great ad-
vantage.   We are told,  that it must be employed early
in the disease; that it is most conveniently administered
by unction, and should be applied in that way in large
quantities, so that the body may be soon filled with it,
and a salivation raised, which is to be continued till the
symptoms  yield.  Whether  this method alone be ge-
nerally sufficient for the cure of the disease, or if it may
be assisted by the use of opium, and require this in a
certain measure to be joined with it, I have not yet cer-
tainly learned.
   1280.  I have been further informed, that the tetanus,
in all its different degrees, has been cured by giving
internally the Pissilaeum Barbadense, or, as it is vul-
garly called, the Barbadoes  Tar.   I think it proper to
take notice of this here, although I am  not exactly in-
formed what quantities of this medicine are to be given,
or in what circumstances of the  disease it is most pro-
perly to be employed.
   1281.  In the former edition of this work, among the
remedies of tetanus I did not  mention the use of cold
bathing;  because, though I heard of this, I was not in-
formed of such frequent employment of it  as might
confirm my opinion of  its general efficacy; nor was I
sufficiently informed of  the ordinary and proper admi-
nistration of it.  But now, from the information of many
judicious  practitioners who have frequently employed
it, I can say, that it is  a  remedy which in numerous
trials has been found to be of  great service in this dis-
ease; and that, while the use of the ambiguous remedy
of warm  bathing  is entirely laid  aside, the use of cold
bathing is over the whole of the West Indies commonly
employed.   The administration of it  is sometimes
by bathing the person in the sea, or more frequently by 
  152             PRACTICE  OF PHYSIC.

  throwing cold water from  a bason or bucket upon the
 patient's body, and over the whole of  it:  when this is
 done, the body is carefully  wiped dry, wrapped in blan-
 kets, and laid abed, and at  the same time a large dose
 of  an opiate  is given.   By these means a  considerable
 remission of  the symptoms is obtained;  but this remis-
 sion, at first,  does  not  commonly remain long,  but re-
 turning again in a  few hours, the repetition both of the
 bathing and  the  opiate becomes necessary.   By these
 repetitions, however, longer intervals of ease are obtain-
 ed, and at length the disease is entirely cured; and this
 even happens sometimes very quickly.   I  have only to
 add, that it does not appear to me, from any accounts I
 have yet had, that the cold bathing has been so frequent-
 ly employed,  or has been found so commonly success-
 ful  in the cases of  tetanus  in consequence of wounds,
 as in those from the application of cold.*

  • We  believe the remark of our author at the close of this article to be
 correct.  The use of the cold bath has not been found so successful in te-
 tanus from wounds, as in that arising from other causes.
  Whatever may be the case elsewhere, it is well known, that, in the United
 States, cold bathing cannot be relied on for the cure of tetanus. Although
the spasms may appear to be, for a short time, relaxed by the shock, they
 soon return with equal, if not augmented violence.
  As far as the experience of the physicians of Philadelphia enables us to
 speak, opium, wine and mercury, appear to be the only remedies on which
 any confident reliance can be placed in the treatment of tetanus.  Of these,
 the two former retard the progress of  the  disease, preventing exhaus-
 tion  and death, from the violence of the spasms, until the latter has had
 time to eradicate it entirely, by converting the tetanic into the mercurial ac-
 tion.  Opium and  wine, being, in their natures, rather palliative than cura-
 tive remedies, are insufficient of themselves, without mercury ; while, with-
 out their aid, mercury is too slow in its operation to arrest the rapid march
 of the disease. Hence, we neither know of any one case  of tetanus in this
 city being cured by the exhibition of mercury alone, nor of many, in which
 the mercurial action did not take effect.
  The usual and best preventives of  tetanus from external injuries, consist
 in the conversion of punctured into incised wounds, by means of the scalpel,
 and the  excitement of suppuration in wounds that are lacerated.  These
 things, if done immediately after the injuries have been received, and before
 the occurrence of tetanic symptoms, are of high importance; but, they are 
                    PRACTICE OF PHYSIC.               153

     1282. Before concluding this chapter, it is proper for
  me to take  some  notice of that peculiar case of the te-

 worse, perhaps, than nugatory—they are nothing, in general, but useless
 torture, if delayed until the disease shall have made its appearance.   When
 the tetanic diathesis is fairly formed,  all local applications to the injured
 part, are unavailing: even the amputation of the limb itself has been found
 insufficient to arrest the complaint.
-  Should circumstances exist to prevent the dilatation of a punctured wound,
 the application of ley,  blisters, or sinapisms to the part, is the best sub-
 stitute.  Whatever is  calculated  to  excite common  inflammation, is now
 useful.
   Fcr the production of the suppurative action, in lacerated wounds, ley,
 spirits of turpentine, or a solution of corrosive sublimate, followed by poul-
 tices frequently repeated, are the best  applications. Tincture of cantharides
 and lunar caustic, have been successfully used for the  same purpose.
   When, from a neglect of preventive  remedies, or, in spite of their use, te-
 tanus has made its appearance, a different course of practice must be com.
 menced and pursued. It is now, that, to the state of the system, a strict and
 steady attention is to be paid.
   If the patient be plethoric, and the excitement high ; or, if the latter con-
 dition exist, even without the former, blood must be drawn, and the opera-
 tion repeated, as circumstances may require.  If costiveness prevail, and any
 irritation in the bowels be suspected, purgatives are to be administered, as
 in other cases.
   But, as already stated, as soon as the  condition of the system will admit of
 them, wine, opium, and mercury, are the remedies on which we must chiefly
 rely.
   On some occasions, tetanus is reported to have been cured by wine alone.
 But such cases we have  never witnessed.   The quantity of wine used, in
 these instances, is said to have been great.
  In the treatment of this disease, opium and mercury muj'- be adminis-
 tered, not with a rigid regard to quantity, but according to their effects.
 They must be pushed until the system shall have forcibly felt their action,
 or their exhibition will be unavailing.
  Unless opium be given, until the prevailing spasms  shall have been sub-
titled by it, that the mercury may have an opportunity to act, it is given  to no
purpose ; and if the mercury be not administered in such quantities as to
salivate, the tetanic diathesis will not be removed.
  It is Dr. Physick's practice—and  we cannot cite higher authority—to ad-
minister opium in injections, in doses of from five to eight grains, repeated
at short intervals, until the spasms be overcome, and somewhat of a soporific
effect produced; applying, in the mean time, to various parts of the body,
large quantities of mercurial ointment.
  The spasms being subdued, he relaxes in the use of opium, until they
manifest a disposition to return; when he immediately recurs to the same
remedy, and in similar doses.   In the meantime, the application of the mer-
    VOL.  II.                     X 
154-            PRACTICE OF PHYSIC.
tanus, or trismus, which attacks certain infants soon af-
ter their birth, and has been properly enough named the
Trismus Nascentium.   From the subjects it affects, it
seems to be a peculiar  disease; for these are  infants
not  above  two weeks,  and  commonly  before they are
nine days old; insomuch that,  in countries where the
disease  is frequent, if children pass the period now men-
tioned, they are considered as secure against its attacks.
The symptom of it chiefly taken notice of,  is the tris-
mus, or locked jaw, which  is by the vulgar improperly
named the falling of the jaw.  But this  is  not the only
symptom, as, for the most part, it has all the same symp-
toms as the Opisthotonos and  Tetanus strictly so called,
and which occur in the other varieties of tetanic com-
plaints above described. ^ Like  the  other  varieties of
tetanus, this is most frequent  in warm climates, but it
is not, like those arising  from  the application of cold,
entirely confined to such warm climates, as instances
of it have occurred in most  of the northern countries of
Europe.   In these latter it  seems to be more frequent

curial ointment is continued, until a ptyalism be produced; when the pa-
tient  is considered, in some measure, out of danger.
  Still, however, great vigilance is necessary on the part of the practitioner,
lest, as is sometimes the case, the salivation should cease, and the disease re-
turn ; under which circumstances, the same course must be again pursued,
even, at times, with augmented vigour.
  Dr. Physick prefers giving the opium by injection, in consequence of
the difficulty of swallowing, which the patient usually experiences.  If re-
quisite, he conveys aliment into the stomach by means of a tube, which he
carefully introduces into that organ.
  The action of opium  is said to  be increased, if the exhibition of that re-
medy be alternated with that of the carbonate of potash.
  As  aids to opium, in the treatment of tetanus, musk and camphor have
been exhibited, in large doses, and, according to report, with beneficial ef-
fects.  We have ourselves made trial  of  them, but never with any decided
advantage.
  Believing all minor remedies to be useless, in our attempts to subdue this
disease, wc leave the reader to acquire a  knowledge of them from other
sources. 
PRACTICE OF PHYSIC.
155
ni eertain districts than in others; but in what manner
limited, I cannot  determine.   It seems to be more fre-
quent in Switzerland than in France.   I am informed
of its frequently occurring in the highlands of Scotland;
but I have never met with any instance  of it in the low
country.   The particular  causes  of it are  not well
known; and various conjectures have been offered; but
none of them are satisfying.  It is a disease that has
been almost constantly fatal;  and this, also, commonly
in the course of a few days.   The women are so much
persuaded of its  inevitable fatality, that they seldom or
never  call for the assistance of our art.   This has oc-
casioned our being little acquainted with the history of
the disease, or with the effects of remedies in it.  Ana-
logy, however, would lead us to employ the same reme-
dies that have proved useful in the other cases of teta-
nus; and  the few experiments that are  yet recorded;
seem to approve of such a practice.
                       CHAPTER II.


                    OF EPILEPSY.*

 1283. IN what sense I use the term Convulsion, I have
 explained above in 1256.

  * It is unfortunate for our author, that the obscurity and insufficiency of
his reasonings on the nature of diseases, are oftentimes great, in proportion
to his zeal and exertions to render them otherwise.  Nor is this more strik-
ingly the case in any instance, than in that which is, at present, immediately
before us.  To say the least, his failure to shed light on the pathology of
Epilepsy, is not surpassed by any other that occurs in the compass of his
works.
  We acknowledge our inability to supply, in a manner satisfactory to our-
selves, the professor's deficiency. With the philosophy of epilepsy, which
h-is hitherto eluded the keenest investigations, we are far from possessing a 
 156               PRACTICE OF PHYSIC.

    The convulsions  that  aifcct  the human body are iu
 several respects various;  but I am to consider here only


particular acquaintance.   Of this point, we may truly, and with propriety,
say, adhnc latet,- although it would be wrong in us to add, in a spirit of des-
pondency, semperque latebit. We shall not, however, by dwelling on the sub-
ject, add to the number of unsuccessful efforts, that have been already made
with a view to its elucidation.
  We shall simply observe, that epilepsy is one of those diseases, supposed
to be connected with lunar influence, on account of its  occurring, in many
cases, with a precise correspondence to  the position of  the moon.  Of th'19
there are recorded innumerable instances, in the writings of physicians.  It
is the result of local irritation, existing, at times, perhaps, in different  parts
of the body ; but, most frequently, we  think, in some portion of the alimen-
tary canal.   Hence, the great importance of frequent and copious purging,
in its cure; a remedy, on which some writers advise us to place our whole
reliance.
  In infants and children,  we have rarely seen a case of epilepsy, that we
could not distinctly trace to the irritation of dentition, which extends  itself
throughout the whole of the-primae vise, to improper feeding, either  as to
the quantity or quality of food, or to the action of the variolous, or some
other febrile poison, on the stomach.  In these cases, it is well known, that
the scarification of the gums, blood-letting, to guard against immediate dan-
ger, and liberal purging, constitute our most efficacious, not to say, our only
remedies.  The indiscriminate plunging  of children into warm water, under
such circumstances, is, to say the least, a  doubtful practice.
  In adults, the original irritation, although generally situated in some  part
of the alimentary canal, is referable, at times, to other parts of the body. In
the brain, however, it very rarely, if ever exists.
  An extraneous body, such as a ball or a splinter, lodged in contact with a
nerve, a tendon, a membrane, or some other highly irritable organ, is known
to have  been frequently the cause of epilepsy.  In such cases, the cure of
the disease follows the extraction of the  offending substance.
  When the epileptic diathesis occurs in infancy, it is usually removed, by
the changes that take place about the age of puberty.  Instances of this de-
scription must fall under the notice of every physician.
  We know,  in Philadelphia, a family consisting of four children, each one
of which, when young, has been subject  to epilepsy.  But in none of them
has the diathesis continued longer, than till about the fourteenth year. They
have all enjoyed, since that period, unusual  health,  and  are all possessed of
great acuteness and strength of intellect.
  Habitual  epilepsy in an adult, is among the most obstinate and unpromis-
ing of diseases.  It appears oftentimes to depend on some peculiarity of or-
ganization ; and is, hence, transmitted from parent to child ; for it may be
included in the number of hereditary complaints. We may add, that, when
inherited, the difficulty of completely eradicating it is the greater.
  In commencing the treatment of this terrible malady, the first step  is, to
evacuate thoroughly the alimentary canal.  For this purpose, active purga- 
PRACTICE  OF  PHYSIC.
15T
the chief and most frequent form in which they appear,
and  which is in the disease named Epilepsy.  This may


tives should receive a preference.  If indicated by plethora, or the state of
the pulse, venesection may also be employed.
  Then may follow,  such a course of tonics, as appears to be accommodat-
ed to the state of the system.  Bark and chalybeates, exhibited in doses ai
large as the stomach can bear,  with the occasional use of opium, and asafa>.
tida, are 6aid to have been, at times, productive of a cure.  During the coiv
tinuance of this course, the diet should be nutritive, but not heating.  Such
exercise ought also to be taken, in the open air,  as may be best calculated
to aid in giving strength to the system.  Two cloves of garlic, taken three
or four times a day, and continued for several months, are said to have proved
efficacious in the removal of epilepsy.
   Cuprum ammoniacum, flowers of zink, and nitrate of silver, are all, in their
turn, reported to have been instrumental in the eradication of this disease.
   The same thing is said of arsenic, taken in such doses as the stomach can
bear, and frequently repeated, until it shall have produced on the system its
characteristic effects.
  By certain European writers, high encomiums are bestowed on the u3e of
spirits of turpentine, in doses of from two to four drachms a day.  To be ef-
fectual, it must be continued a considerable time.
   By Dr. Chapman,  and other practitioners in this city, the same  remedy
has been repeatedly used, in the treatment of epilepsy, with very salutary
effects.
   The doses here administered, have rarely, we believe, exceeded, in quan-
tity, two drachms a day.
   In cases where epilepsy has occurred at regular periods, opium, taken-in
large  doses, a few hours before the time of the expected paroxysms, has
been efficacious; first, in the prevention of single fits, and ultimately in the
entire removal of the disease.  In these instances, the  complaint must have
been continued on the principle of habit.
   A mercurial ptyalism, continued for several weeks ;  then suffered  to de-
cline, and again renewed; until three or four courses have been undergone,
is recommended as a radical cure for epilepsy.  In some instances, we be-
lieve this practice has succeeded ; in others, we know it has failed.
   An entire change of life, from a sumptuous to an abstemious; and  from an
indolent and easy to an active and laborious one, has cured epilepsy. When
enjoying, at his ease, the luxuries and pleasures of the Roman capital, Caesar
was subject to this disease; but never experienced a fit of it, during the
toils and solicitudes of an active campaign.
   We ohce knew a case of aura epileptica to be completely cured, by the
application of a  caustic to the spot  from which the aura appeared to pro-
ceed.
  A severe attack of small-pox is said to have removed the epileptic diathe-
sis.  The same thing is reported of measles and the itch.  This shows the
powerful effect of cutaneous irritation, and, of giving to action a centrifugal
tendency, in the cure of diseases proceeding from within. 
158
PRACTICE  OF PHYSIC.
be defined, as consisting in convulsions of the greater
part of the muscles of voluntary motion, attended with
a loss of sense, and ending in a state of insensibility and

seeming sleep.
   1284.  The general form or principal circumstances
of  this disease, are much  the  same in all  the different
persons whom it affects.   It comes by fits, which often
attack  persons seemingly in perfect health; and, after
lasting for some time, pass off, and leave  the  persons
again in their  usual  state.   These  fits are sometimes
preceded  by certain symptoms, which, to persons who
have before experienced such  a fit, may give notice of
its  approach,  as we shall  hereafter explain; but even
these preludes do  not commonly occur long before the
formal attack, which in most cases comes  on suddenly
without any such warning.
   The person attacked loses  suddenly all  sense and
power  of motion; so that, if standing, he falls immedi-
ately, or, perhaps, with convulsions,  is thrown to the
ground. In that situation he is agitated with violent con-

  The cold bath, long journeys, voyages by sea, and change of country,
have given relief in epilepsy: we do not know that  they ever have cured it.
  This complaint is known to have sometimes proceeded from a suppression
of piles.  In such a case, the most promising remedy consists in the applies-
tion of leeches to the hemorrhoidal vessels.
  In the treatment of epilepsy, to preserve healthy cutaneous action, is of
great moment. Hence, the wearing of flannel, or fleecy hosiery, next to the
skin, should never be neglected.
  Epilepsy has been observed, in some instances, to give way to, or to al-
ternate with, chronic diarrhoea.
  The hint being derived from this circumstance, that disease has been suc-
cessfully  treated by purgatives,  so administered, as to keep up an artificial
diarrhoea  for months.
  During this course, the diet must be strictly regulated, and, if the habit be
sanguineous and the blood-vessels full, venesection pro re nata must be prac-
tised.
  Emetics, repeated daily, or every other day, for a great length  of time,
aided by opiates administered just before the period of  the expected pa-
roxysm, are said to have proved  successful in the removal of epilepsy. Such
a course is not without promise. 
PRACTICE OF PHYSIC.           15$
vulsions,  variously moving his limbs and the trunk of
his  body.   Commonly  the limbs on  one side  of the
body are more violently, or more considerably agitated
than those upon the other.   In all cases the muscles of
the  face and eyes are much affected, exhibiting various
and violent distortions of the  countenance.  The tongue
is often affected, and thrust out of the mouth; while the
muscles of the lower jaw are also affected;  and, shut-
ting the mouth with violence while the tongue is thrust
out between the teeth, that is often grievously wounded.
  While these convulsions continue, there is common-
ly at the same time  a frothy moisture issuing from the
mouth.   These  convulsions have  for some moments
some remissions, but are suddenly again renewed  with
great violence. „  Generally, after no long time, the con-
vulsions cease altogether; and the person for some time
remains  without motion, but in  a state of absolute in-
sensibility, and under the appearance of a  profound
sleep.  After some continuance of  this seeming sleep,
the person sometimes suddenly,  but /or the most part
by  degrees only, recovers  his  senses  and power of
motion;  but without any  memory of what had passed
from his being first seized  with the fit.  During the con-
vulsions, the pulse and respiration  are hurried  and ir-
regular;  but,  when the convulsions cease, they return
to their usual regularity and healthy state.
  This is the general form of the disease: and it varies
only in different persons,  or on  different occasions in
the same person, by the  phenomena mentioned being
more or less violent, or by their being of longer or short-
er duration.
  1285.  With respect to  the  proximate cause of this
disease, I might say, that  it  is an affection of the ener-
gy of the brain, which, ordinarily under the direction of
the will, is here, without any concurrence of it, impelled 
160
PRACTICE OF PHYSIC.
by preternatural causes.   But I could go no farther: for,
as to what  is the  mechanical condition of  the brain in ^
the ordinary exertions of  the  will,  I have no distinct
knowledge; and therefore  must be also ignorant of the
preternatural state of the same energy of the brain un-
der the irregular motions here  produced.   To form,
therefore,  the indications  of a cure from  a knowledge
of the proximate cause of this  disease, I must not at-
tempt,  but, from a  diligent attention  to  the remote
causes which  first induce and occasionally exciteHhe
disease, I think we may often obtain some  useful direc-
tions for its cure.   It shall therefore be  my business
now to point out and enumerate  these remote causes as
well as I can.
  1286. The  remote causes of epilepsy may be consi-
dered as occasional or predisponent. "There are, indeed,
certain remote causes which act independently of any
predisposition; but,  as we  cannot always distinguish
these from the others, I shall consider the whole under
the usual titles of Occasional or Predisponent.
  1287. The  occasional causes  may, I think,  be pro-
perly referred to two general heads; the first being of
those which seem to act by directly stimulating and ex-
citing the  energy  of the brain; and the second, of those
which seem to act by weakening the same.  With re-
spect to both,  for  the brevity of expressing a fact, with-
out meaning to explain the  manner in which it is brought
about, I shall use  the terms of Excitement and Collapse.
And though it be true, that with respect to some of the
causes I am to mention,  it may be  a little uncertain
whether they act  in the one way or the other, that does
not render it improper for us to  mark, with respect to
others, the mode of their operating, wherever we can
do it clearly, as the doing so may often be of use in di-
recting our practice. 
PRACTICE  OF  PHYSIC.           \Q\
   1288.  First, then, of the occasional causes acting by
 excitement: they are either such as act immediately and
 directly upon the brain itself;  or those which are first
 applied to the other parts of  the body,  and are from
 thence communicated to the  brain.
   1289.  The  causes of excitement immediately and di-
 rectly applied to  the brain, may be referred to the four
 heads of, 1. Mechanical Stimulants; 2. Chemical Sti-
 mulus;  3.  Mental  Stimulants; and, 4.  The peculiar
 Stimulus of Over Distention.
   1290.  The  mechanical stimulants may be, wounding
 instruments penetrating the cranium,  and entering the
 substance of the brain; or splinters of a fractured cra-
 nium, operating in the same manner; or  sharp-pointed
 ossifications, either  arising from the internal surface of
 the cranium, or formed in the membranes of the brain.
   1291.  The chemical stimulants (1289.) may be fluids
 from various causes lodged in certain parts of the brain,
 and become acrid by stagnation or otherwise.*
   1292.  The  mental irritations  acting by excitement,
 are, all violent emotions of the active kind, such as joy
 and anger.   The first of these is manifestly an exciting
 power, acting strongly, and immediately, on the energy
 of the brain.   The  second is manifestly,  also, a power
 acting in  the same manner.   But it must be remarked,
 that it is  not in this manner alone anger produces its
 effects: for it  acts,  also, strongly on the  sanguiferous
 system,  and may be a means of giving the stimulus of
 over distention; as,  under  a fit of anger,  the blood is

  * The error and coarseness of this doctrine are shocking—the more so, as
r»ur author professed to have rejected the humoral pathology, and to have
become the leader of the sect of modern solidists.
  To readers in the slighest degree versed in sound physiology, we need
not observe,  that no fluids ever become acrimonious, by stagnating in any
part of the brain, so as chemically to irritate that organ.  A specimen of
humoralism more gross and preposterous than this is no where to be found.
   VOL, II.                t 
162
PRACTICE OF 1PHYSIC.
impelled into the vessels of the head with violence, and
in a larger quantity.
   1293. Under the head of Mental Irritations, is to be
mentioned,  the sight of persons in a  fit of epilepsy
which has often produced  a  fit of the  like kind in the
spectator.   It may, indeed, be a question, Whether this
effect be imputable to the horror produced by a sight
of the  seemingly painful agitations of the limbs, and of
the distortions  in the  countenance of the epileptic per-
son; or if it may be ascribed to the force of imitation
merely? It is possible, that horror may sometimes pro-
duce the effect: but certainly much may be imputed to
that propensity to imitation, at all times so powerful and
prevalent in human nature:  and so  often  operating1 in
other cases  of  convulsive disorders,  which do not pre-
sent any spectacle of horror.
   1294. Under the same head of Mental Irritation, I
think proper to mention as an instance of it, the Epi-
lepsia Simulata, or the Feigned  Epilepsy, so often taken
notice  of.   Although this, at  first,  may be  entirely
feigned, I have no doubt but  that the repetition renders
it at length  real.   The  history  of Quietism and of Ex-
orcisms leads me to this opinion: and which receives a
confirmation from what we know of  the power of ima-
gination, in  renewing epileptic and hysteric fits.
   1295.  I come now  to the  fourth head of the irrita-
tations applied  immediately to the brain, and which I
apprehend'to be that of the Over Distention of the blood-
vessels in" that organ.   That  such a cause operates in
producing epilepsy, is probable  from  this, that  the dis-
sections of persons dead of epilepsy, have commonly dis-
covered the  marks of a previous congestion in the blood-
vessels of the  brain.  This perhaps  may be supposed
the effect of the  fit which proved fatal: but that the
congestion was previous thereto, is probable from the 
PRACTICE OF PHYSIC.
J6S
 epilepsy being so often joined with headach, mania,
 palsy, and apoplexy; all of them diseases depending upon
 a congestion in the vessels of the brain.   The general
 opinion receives also confirmation  from this circum-
 stance,  that, in the brain of persons dead of  epilepsy,
 there have  been often found  tumours and effusions,
 which though seemingly not sufficient to produce those
 diseases which depend on the compression of a consi-
 derable portion of the brain, may, however, have been
 sufficient to compress so many vessels as to  render the
 others,  upon any occasion of a more than  usual turges-
 cence, or impulse of the blood into the vessels of the
 brain, more liable to an over distention.
   1296. These considerations alone might afford foun-
 dation for a  probable conjecture with respect to the ef-
 fects of over distention.  But the opinion  does not rest
 upon conjecture alone.   That it is also founded in fact,
 appears from hence, that a plethoric state is  favourable
 to epilepsy;  and that every occasional turgescence, or
 unusual impulse of the blood into the vessels of the brain,
 such as a fit of anger, the heat of the sun, or  of a warm
 chamber, violent exercise, a surfeit, or a fit of intoxica-
 tion, are frequently  the  immediate exciting causes of
 epileptic fits.
   1297. I venture to remark  further, that a piece of
theory may  be admitted as a  confirmation of  this doc-
trine.   As I have formerly maintained, that a certain
 fulness  and  tension  of the  vessels of the brain is ne-
cessary  to the support of its ordinary and constant en-
ergy, in the distribution of the nervous  power;  so  it
must be sufficiently  probable, that  an  over  distention
of these blood-vessels may be a cause of violent excite-
ment.
   1298. We have now enumerated 'the several remote
or occasional causes of epilepsy, acting by excitement, 
 161          PRACTICE  >V PHYSIC.

 and acting immediately upon  the brain itself.  Of the
 causes acting by excitement, but  acting  upon other
 parts of the body, and from thence communicated to the
 brain,  they are all  of them impressions producing an
 exquisite or high degree cither of pleasure or pain.
  Impressions which produce neither the one nor the
 other, have hardly any such effects;  unless when such
 impressions are in a violent degree, and then their  ope-
 rations may be considered as a mode of pain.  It is,
 however,  to  be  remarked, that  all strong impressions
 which are sudden  and surprising, or, in other words,
 unforeseen and unexpected, have frequently the effect
 of bringing on epileptic fits.
  1299. There are certain impressions made upon dif-
 ferent parts of  the  body, which as they  often  operate
 without producing any sensation, so it is uncertain to
 what  head they belong: but  it is probable that the
 greater part of them act by excitement, and therefore
 fall to  be  mentioned here.  The  chief  instances  are,
 the teething of infants; worms; acidity or other acri-
 mony in the alimentary canal; calculi in the kidneys;
 acrid  matter in abscesses or ulcers; or  acrimony dif-
 fused in the mass of blood, as in the case of some  con-
 tagions.
  1300.  Physicians have found no difficulty in com-
 prehending how direct stimulants, of a  certain force,
 may excite the action of the brain, and occasion epi-
 lepsy:  but they have hitherto taken little notice of cer-
 tain causes which manifestly weaken the energy of the
 brain, and act. as I speak,  by collapse.  These,  how-
 ever, have the effect of exciting the action  of the brain
in such a manner as to occasion  epilepsy.   I might
 upon this  subject, speak of the vis medicatrix natures;
 and there  is a foundation for the term; but, as I do not
 admit the  Stahlian doctrine of an administering soul.  I 
PRACTICE OF PHYSIC.          165
 make use of the term only as expressing a fact, and
 would not employ it with the view of conveymg an ex-
 planation of the manner in which the powers of collapse
 mechanically produce their effects.   In the mean  time,
 however, I maintain, that there are certain powers of
 collapse  which in effect  prove stimulants, and produce
 epilepsy.
   1301.  That there are such powers,  which may be
 termed   Indirect Stimulants, I conclude  from hence,
 that several of the causes of epilepsy are such as fre-
 quently produce syncope, which we suppose always to
 depend upon causes weakening the energy of the brain,
 (1176.) It may give some difficulty to  explain why the
 same causes sometimes occasion syncope, and sometimes
 occasion  the  reaction that appears in  epilepsy; and I
 shall not attempt to explain  it:  but this, I think, does
 not prevent my supposing that the operation of  these
 causes is by collapse.  That there are such causes pro-
 ducing epilepsy, will, I think, appear very clearly from
 the particular examples of them I  am now to mention.
   1302.  The first to be  mentioned, which I suppose
 to be of  this kind, is haemorrhagy, whether spontane-
 ous or  artificial.  That  the same  haemorrhagy which
 produces syncope, often at the same time produces epi-
 lepsy, is well known; and from many experiments and
 observations it appears,  that haemorrhagies occurring
 to such a degree as to prove mortal, seldom do so with-
 out first producing epilepsy.
   1303.  Another cause acting, as I suppose, by col-
 lapse, and therefore sometimes producing syncope, and
 sometimes epilepsy, is terror; that is, the fear of  some
great evil suddenly presented.  As this produces at the
same time a sudden and considerable emotion, (1180.)
so it more frequently produces epilepsy than syncope.
   1301.  A third cause acting by collapse, and produc- 
166          PRACTICE OF  PHYSIC.
ing epilepsy, is horror;  or a strong aversion suddenly
raised by a very disagreeable sensation, and frequently
arising from a sympathy with the pain or danger of ano-
ther person.   As horror is often  a cause of syncope,
there can be no doubt  of its manner of operating in
producing epilepsy; and it may perhaps be explained
upon this general principle, That as desire excites ac-
tion and gives activity, so aversion  restrains from action,
that is, weakens the energy of the brain; and, therefore,
that the higher degrees of aversion may have the ef-
fects of producing syncope or epilepsy.
   1305. A fourth set of the causes of epilepsy, which I
suppose  also  to  act by  collapse, are certain odours,
which occasion either syncope or epilepsy;  and,  with
respect to the former, I have given my reasons (1182.)
for supposing odours in that case to act rather as disa-
greeable than as sedative.   These reasons will, I think,
also apply here; and perhaps the whole affair of odours
might be considered as  instances of the effect of  hor-
ror,  and therefore  belonging to the last head.
   1306. A fifth head of the causes producing epilepsy
by collapse, is the operation of many substances consi-
dered, and  for the  most part properly considered,  as
poisons.  Many of these,  before they prove mortal, oc-
casion epilepsy. This effect, indeed, may in some cases
be referred to the  inflammatory operation  which  they
sometimes  discover in the stomach, and other parts of
the alimentary canal; but, as the greater part of the
vegetable poisons  show chiefly a narcotic, or strongly
sedative power, it  is probably by  this power  that  they
produce epilepsy, and therefore belong to this head of
the causes acting by collapse.
   1307.  Under the head of the remote causes produc-
ing epilepsy,  we must now mention that peculiar one
whose operation is accompanied with what is called the 
PRACTICE OF PHYSIC.           1(57
Aura Epileptica. This is a sensation of something mov-
ing in some part of the limbs or trunk  of  the body,
and from thence creeping upwards to the head; and when
it arrives there, the person is immediately deprived of
sense, and falls  into an epileptic fit.  This  motion is
described by the persons feeling it sometimes as a cold
vapor, sometimes as a fluid gliding, and sometimes as
the sense of a small insect creeping along their body;
and very often they can give no distinct idea of their
sensation,  otherwise than as in general of something
moving along.   This sensation might be supposed to
arise  from some affection of the extremity or other part
of a nerve acted upon by some  irritating matter; and
that the sensation, therefore, followed the course of such
a nerve:  but I have  never found it following distinctly
the course of any nerve; and it generally seems to pass
along the teguments.  It has been*found in some in-
stances to arise from something pressing upon  or  irri-
tating a particular nerve, and that sometimes in conse-
quence of contusion or  wound: but instances of these
are more rare: and the  more common consequence of
contusions and wounds is a tetanus.   This latter effect
wounds produce, without giving any sensation of an
aura or other kind of motion proceeding from the wound-
ed part to the head: while on the other hand, the aura
producing epilepsy, often arises from a part which had
never been affected with wound or contusion, and in
which part the nature of the  irritation can seldom be
discovered.   It is natural to imagine that this aura epi-
leptica is an evidence of some irritation or direct sti-
mulus acting in the part, and from thence communicat-
ed to  the brain, and should therefore  have been men-
tioned among the causes acting by excitement; but the
remarkable difference that occurs  in seemingly  like 
168           PRACTICE OF PHYSIC.
 causes producing tetanus, gives some doubt on this sub-
 ject.
   1303. Having now enumerated the occasional causes
 of epilepsy, I proceed to consider the predisponent.  As
 so many of the above mentioned causes act upon cer-
 tain persons, and not at all upon others, there must be
 supposed in those persons a predisposition to this dis-
 ease:  but  in what this  predisposition consists, is not
 easily  to be ascertained.
   1309. As many of the occasional causes  are weak
 impressions, and  are  applied to most persons with lit-
 tle or  no effect, I  conclude, that the persons affected by
 those  causes are  more easily moved than others; and
 therefore that, in this case a certain mobility gives thG
 predisposition.  It will, perhaps, make this matter clearer,
 to show, in the first place, that there is a greater mobi-
 lity of constitution in some persons than  in others.
   1310. This  mobility  appears most clearly in the
 state of the mind.  If a person is readily elated by hope,
 and  as readily depressed by fear, and passes easily and
 quickly from the  one state to the  other; and if  he is
 easily  pleased,  and prone to gaiety,  and  as easily pro-
 voked  to anger, and rendered peevish; if liable,  from
 slight impressions, to strong emotions, but tenacious of
 none; this is the boyish temperament qui colligit ac po-
 nit iram temere, et mutater in horas; this is the varium
 et mutabile foemina;  and, both in the boy and woman,
 every  one  perceives  and  acknowledges  a mobility of
 mind.  But this is  necessarily connected with an analo-
gous state of the brain;   that is,  with a mobility in re-
spect of every  impression, and therefore liable  to a
 ready alteration of excitement and collapse, and of both
 to a  considerable degree.
   1311.  There is, therefore, in certain persons, a mo-
 bility of  constitution, generally derived from  the  state 
PRACTICE OF PHYSIC.
169
of original stamina, and more exquisite at a certain pe-
riod of life than at others; but sometimes arising from,
and particularly modified by, occurrences in the  course
of life.
  1312.  This  mobility consists in a greater  degree  of
either sensibility or irritability.   These  conditions, in-
deed, physicians consider as so necessarily connected
that the constitution, with respect to them, may be  con-
sidered as one and the same: but I am of opinion that
they are  different; and that  mobility may sometimes
depend upon an increase of the one and sometimes on
that of the other.  If an action excited,  is by  repetition
rendered more easily excited, and  more vigorously per-
formed, I consider this as an increase of irritability only.
I go  no further on this subject  here, as  it was only ne-
cessary to take notice of the case  just now mentioned,
for the purpose of explaining why epilepsy, and convul-
sions of all kinds, by being repeated, are more easily
excited, readily become habitual, and are therefore  of
more difficult cure.
   1313. However we may apply the distinction  of sen^
sibility and irritability, it appears that the mobility, which
is the predisponent cause of epilepsy, depends more par-
ticularly upon debility, or upon a plethoric state of the
body.
  1314.  What share debility, perhaps by inducing sen-
sibility, has in this matter, appears clearly from hence,
that  children, women, and other  persons  of manifest
debility, are  the  most  frequent  subjects  of this dis-
ease.
  1315. The effects of a plethoric state in disposing to
this disease appears from hence, that plethoric persons
are frequently the subjects of it: that it is commonly ex-
cited, as I have  said above, by the causes of any  unu-
sual turgescence of the blood;  and that it has been fre-
  vol. u.                z 
170
PRACTICE OF PHYSIC.
quently cured by diminishing the plethoric state of the
body.
  That a plethoric state of the body should dispose to
this disease, we may understand from several considera-
tions.   1st,  Because  a  plethoric state  implies, for the
most part, a laxity of the solids, and therefore some de-
bility in the moving fibres.  2dly, Because, in a pletho-
ric state, the tone of the moving fibres depends more
upon their tension, than upon their inherent power: and
as their tension depends upon the quantity and impetus
of the fluids in the blood-vessels, which are very change-
able, and  by many causes frequently changed, so these
frequent changes must  give a mobility to the system,
Sdly, Because a plethoric state is favourable to a con-
gestion of blood in the vessels of the brain, it must ren-
der  these more readily affected by every general tur-
gescence of the blood in the system, and therefore more
especially dis- »ose to this disease.
   1316. There  is  another circumstance of the body
disposing  to epilepsy, which I  cannot  so well account
for;  and that is the state of sleep:  but whether I can
account for it or not, it appears, in fact, that this state
gives the  disposition  I speak of: for, in many persons
liable to this disease, the fits happen only in the time of
sleep, or immediately upon the person's coming out of
it.   In a case related by De Haen,  it appeared clearly,
that the disposition to epilepsy  depended entirely upon
the state of the body  in sleep.
   1317. Having  thus considered the whole  of the re-
mote causes of epilepsy, I proceed to treat of its cure,
as 1  have said it is from the consideration of those re-
mote causes only that we can obtain any directions for
our practice in  this disease.   I begin  with  observing,
that as the disease  may be considered as sympathic  or
idiopathic, I must treat of these separately,  and judge
it proper to begin with the former. 
PRACTICE OF PHYSIC. -
171
    1318.  When this disease is truly sympathic, and de-
 pending upon a primary affection in some other part of
 the body,  such as acidity or worms in the alimentary
 canal, teething, or other similar causes, it is obvious,
 that such primary affections must be removed for the
 cure of the epilepsy; but it is not our business here to
 say how these primary diseases are to be treated.
    1319.  There is, however, a peculiar case of sympa-
 thic epilepsy;  that is, the case accompanied with the
 aura epileptka, as described in 1307, in which, though
 we can perceive by the aura epiteptica arising from  a
 particular part, that there is some affection in that part;
 yet, as in many such cases, we  cannot perceive of what
 nature the affection is, I can  only offer the following
 general directions.
    1st,  When the part can with safety be entirely de-
 stroyed, we should endeavour to do so by cutting it out,
 or  by destroying it by the application of an actual or
 potential cautery.
   2dly, When the part  cannot  be properly destroyed,
 that we should endeavour to correct the morbid affec-
 tion in  it  by blistering, or by establishing an issue upon
 the part.
   %dly, When these measures  cannot be executed, or
 do  not succeed, if the disease  seems to proceed from
 the extremity of a particular nerve which we can easily
 come at in its course, it will be proper to  cut through
 that nerve, as before proposed on the subject of tetanus.
  Uhly, When  it cannot be perceived that the aura
 arises from any precise place or point, so as to direct to
 the above mentioned operations; but, at the same time,
we  can perceive its progress along the limb; it frequent-
ly happens that the epilepsy can be prevented by a  liga-
ture applied upon the limb, above the part  from which
the aura arises; and this is always proper to be done, 
172           PRACTICE OF PHYSIC.
Doth because the preventing a fit breaks the habit of the
disease, and because the frequent compression renders
the nerves less fit to propagate the aura.
   1320.  The cure of idiopathic epilepsy, as I have said
above, is to be directed by our knowledge of the remote
causes.   There are therefore two general indications to
be formed.  The first is, to avoid the occasional causes;
and the second is, to remove or correct the predisponent.
   This method, however,  is not always purely pallia-
tive;  as in many cases the predisponent may be consi-
dered as the only proximate  cause, so our second indi-
cation may be often considered as properly  curative.
   1321.  From the enumeration given above, it will be
manifest,  that for the most part the occasional causes,
so far as they are in our power, need only to be known,
in order to be avoided; and the means of doing this
will be sufficiently obvious.   I shall here, therefore, of-
fer only a few remarks.
   1322.  One of the  most frequent of the occasional
causes is that  of over distention,  (1314) which, so far
as it depends  upon a  plethoric  state of the system,  I
shall say hereafter how it is to be avoided.   But as, not
only in the plethoric, but in  every moveable constitution,
occasional turgescence is a frequent means  of exciting
epilepsy, the avoiding  therefore of such  turgescence is
what ought to be most constantly  the object of attention
to persons liable to epilepsy.
   1323. Another  of the most frequent exciting causes
of this disease are, all strong  impressions suddenly made
upon the senses; for as such impressions, in moveable
constitutions,  break in upon  the usual force, velocity,
and order of the motions of the  nervous system,  they
thereby  readily produce epilepsy.  Such impressions
therefore, and especially those which are suited to ex- 
.   PRACTICE OF PHYSIC.
173
cite any emotion or passion of the mind, are to be most
carefully guarded against by persons liable to epilepsy'
   1324.  In many cases of epilepsy, where the predis-
ponent cause cannot be corrected or removed, the re-
currence of the disease can only be prevented by  the
strictest attention to avoid the occasional; and as  the
disease  is often confirmed by repetition  and habit, so
the avoiding the frequent recurrence of it is of the ut-
most importance towards its cure.
   These are the few remarks I  have to offer with re-
spect to the occasional causes; and must  now observe,
that, for the most part,  the complete, or, as it is called,
the radical cure,  is only  to  be  obtained  by removing
or correcting the predisponent cause.
   1325.  I have said above,  that the predisponent  cause
of epilepsy is a certain mobility of  the sensorium; and
that this depends upon a plethoric  state of the system.
or upon a certain state of the debility in it.
   1326.  How the plethoric state of the system is to be
corrected,  I have treated  of fully above in 781. et seq.
and I need not  repeat it here.  It will be enough to say,
that it is chiefly to be done by a  proper management of
exercise and diet;  and,  with respect to the latter, it is
particularly to  be  observed  here, that an abstemious
course has been frequently  found to  be the most cer-
tain means of curing epilepsy.
   1327.  Considering the  nature of the matter poured
out by issues,  these may be supposed to be a constant
means of obviating the plethoric state of the  system;
and it is, perhaps, therefore, that they have been  so of-
ten found useful in epilepsy.   Possibly, also, as an open
issue  may  be a means of determining occasional tur-
gescences  to such places, and  therefore of diverting
them  in some measure from their action upon the brain;
so also, in this manner, issues may be useful in epilepsy. 
174
PRACTICE OF PHYSIC.  ,
    1328.  It might be supposed that blood-letting would
 be the most effectual means of correcting the plethoric
 state of the system; and such it certainly proves when
 the plethoric state has become considerable, and imme-
 diately threatens morbid effects.   It is, therefore, in such
 circumstances,  proper and necessary:  but as we have
 said above, that blood-letting is not  the proper  means
 of obviating a recurrence of the plethoric state, and, on
 the contrary, is often the means  of favouring it; so it is
 not a remedy  advisable in every circumstance of epi-
 lepsy.  There is, however, a case of epilepsy in which
 there is a periodical or occasional recurrence of the ful-
 ness and turgescence of the sanguiferous system,  giv-
 ing occasion to a recurrence of  the  disease.   In such
 cases, when the means of preventing plethora have been
 neglected, or may have  proved  ineffectual, it is abso-
 lutely necessary for the practitioner to watch the returns
 of these turgescences, and  to obviate their effects by
 the only certain means of doing it, that is,  by a large
 blood-letting.
   1369. The second cause of mobility which we have
 assigned, is a state of debility.  If this  is owing, as it
 frequently is, to original conformation, it is perhaps not
 possible to cure it; but when it has been brought on in
 the course of  life,  it  possibly  may admit of  being
 mended; and, in either case, much may be done to ob-
 viate and prevent its effects.
   1330. The means of correcting debility, so far as it
can be  done, are, the person's being  much in cool air;
 the frequent use of cold bathing; the use  of cold exer-
 cise, adapted to  the strength and  habits of the person;
 and, perhaps,  the use of astringent  and tonic medi-
 cines.
   These remedies are suited to strengthen the inherent
 power of the solids or moving fibres: but as the strength 
PRACTICE OF PHYSIC.
175
of these depends also upon their tension, so when de-
bility has proceeded from inanition,  the strength may
be restored, by restoring the fulness and tension of the
vessels by a nourishing diet; and we have had instances
of the propriety and success of such a practice.
  1331. The means of obviating the effects of debility,
and of the mobility depending upon it, are the use of
tonic and antispasmodic remedies.
  The tonics are, fear, or some  degree of terror; as-
tringents;  certain  vegetable and metallic  tonics; and
cold-bathing.
   1332. That fear, or some degree  of terror, may be
of use in  preventing epilepsy, we have a  remarkable
proof in Boerhaave's cure of  the epilepsy,  which hap-
pened  in the Orphan-house at Haerlem.  See  Kauu
Boerhaave's treatise, entitled Impetum Faciens, § 406.
And we have met with several other instances of the
same.
  As the operation of horror is in many respects analo-
gous to that  of terror, several seemingly superstitious
remedies have been employed  for the cure of epilepsy;
and if they have ever been  successful, I think it must
be imputed to the horror they had inspired.
   1333. Of the astringent medicines used for  the cure
of epilepsy the most celebrated is the viscus quercinus,
which, when given in large  quantities,  may possibly be
useful; but I believe it was more especially so in ancient
times,  when  it was an object of superstition.   In the
few instances in  which I have seen  it employed it did
not prove of any  effect.
   1334. Among the vegetable tonics, the bitters are to
be reckoned; and  it  is by  this quality  that I  suppose
the orange-tree leaves to have been useful: but they
are not always so.
   1335. The vegetable  tonic, which from its use in 
176
PRACTICE OF PHYSIC.
 analogous cases is the most promising, is the Peruvian
 bark; this, upon occasion, has been useful, but has also
 often failed.   It is especially adapted to those epilep-
 sies which  recur  at certain periods, and which are at
 the same time without the recurrence of any plethoric
 state or turgescence of the blood; and in such periodical
 cases, if the bark is employed some time before the ex-
 pected recurrence, it may be useful; but it must be given
 in large quantity, and as  near to  the time  of the ex-
 pected return as possible.
   1336. The metallic tonics seem to be more power-
 ful than the vegetable, and a great  variety of the former
 have been employed.
   Even arsenic has been employed in the cure of epi-
 lepsy; and its use in intermittent fevers gives an analogy
 in its favour.
   Preparations of tin have been formerly recommended
 in the cure of epilepsy, and in the cure of the analo-
 gous disease of hysteria;  and several considerations
 render the virtues of tin, with respect to these diseases,
 probable: but I have had  no experience of its use in
 such cases.
   A much safer metallic tonic is to be found in the pre-
 parations of iron; and we have seen some  of them em-
 ployed in  the cure of epilepsy, but have  never found
 them to be effectual.   This, however, I think, may be
 imputed to  their not having been  always  employed in
 the circumstances of the disease, and in the quantities
of the medicine, that were proper and necessary.
   1337. Of the metallic tonics, the most celebrated and
 the most frequently employed is copper, under various
 preparation.  What preparation of it may be the  most
 effectual, I dare not determine; but of late the cuprum
 ammoniacum has been frequently found successful.
   1338. Lately the flowers of zinc have been recom- 
PRACTICE OF PHYSIC.           177
mended by a great authority as useful in all convulsive
disorders; but in cases of epilepsy, I have not hitherto
found that medicine useful.
   1339. There have been of late some instances of the
cure of epilepsy by the accidental use of mercury; and
if the late accounts of the  cure  of tetanus by this re-
medy are confirmed, it will allow us to  think that the
same may be adapted also to the cure of certain cases
of epilepsy.
   1340. With respect to the employment of any of the
above mentioned  tonics in  this disease, it must be ob-
served, that in all cases where the disease depends upon
a constant or occasional plethoric  state of the system,
these remedies are likely to be ineffectual; and if suffi-
cient evacuations  are not made at the same time, these
medicines are likely to be very hurtful.
   1341. The other set of  medicines which we have
mentioned  as suited to  obviate the effects  of the  too
great mobility of the system, are  the medicines named
antispasmodics.   Of these  there is a long  list in  the
writers  on the Materia Medica, and  by these  au-
thors recommended for the cure of epilepsy.   The
greater part, however, of those taken from  the vegeta-
ble kingdom,  are manifestly  inert and insignificant.
Even the root of the wild valerian hardly supports its
credit.
   1342. Certain substances  taken from the animal king-
dom seem to be much more powerful: and of these the
chief, and seemingly the mosf powerful, is musk; which,
employed in its genuine state, and in due quantity, has
often been an effectual remedy.
   It is probable also, that the oleum animate, as it has
been named, when in its purest state, and exhibited at
a proper time, may be an effectual remedy.
   1343.  In many diseases,  the most powerful antispas-
  vol. ii.               a  a 
178           PRACTICE OF PHYSIC.

modic is certainly opium; but  the  propriety of its use
in epilepsy has been disputed among physicians. When
the disease depends  upon  a plethoric state in which
bleeding may be necessary,  the employment of opium
is likely to be very hurtful:  but, when there is no  ple-
thoric or inflammatory state present, and the disease
seems to depend upon irritation or upon increased irri-
tability, opium is likely to prove the most certain remedy.
Whatever effects in this  and other  convulsive disorders
have been attributed to the hyoscyamus, must probably
be attributed to its possessing a narcotic power similar
to that of opium.
   1344. With respect to the use of antispasmodics, it
is to be observed, that they  are always most useful,  and
perhaps only useful,  when  employed at a time when
epileptic fits are frequently recurring, or near to the
times of the accession of fits which recur after consider-
able intervals.
   1345. On the subject of  the cure of epilepsy, I have
only to add, that as the disease in many cases  is conti-
nued by the power of habit only, and  that in all cases
habit lias a great share in increasing mobility, and there-
fore in continuing this disease; so the breaking in upon
such habit, and changing the whole habits of the  sys-
tem, is likely to be a powerful remedy in epilepsy.  Ac-
cordingly, a considerable change of climate, diet,  and
other circumstances in the manner of life,  has  often
proved a cure of this disease.
   1346.  After treating of  epilepsy, I might here treat
 of particular convulsions, which  are to be distinguished
 from epilepsy by their being more partial:  that is, affect-
 ing certain parts of  the body only, and by their not be-
 ing attended with a loss of  sense,  nor ending in  such
 a comatose state as epilepsy always does.
   1347. Of such convulsive  affections many different 
PRACTICE OF PHYSIC.
179
instances have been observed and recorded by physi-
cians.   But many of these have been manifestly sym-
pathic affections, to be cured  only by curing the pri-
mary disease upon  which they depend, and therefore
not to be treated of here: or, though they are such as
cannot be referred  to another disease, as many of them
however have not any specific character with which they
occur  in different persons, I must therefore leave them
to be treated upon  the  general  principles I have laid
down with respect  to epilepsy, or  shall lay down with
respect to the following convulsive disorder;' which, as
having very constantly in  different persons  a peculiar
character,  I  think  necessary to  treat of more particu-
larly.
                     CHAPTER III.

    OF THE  CHOREA,  OR DANCE  OF ST. VITUS.

 1348. THIS disease  affects  both  sexes, and almost
 only young persons. It generally happens from the age
 of ten to that of fourteen years.  It comes on always
 before the age of puberty, and  rarely continues beyond
 that period.*
   1349. It is chiefly  marked by convulsive  motions,
 somewhat varied in different persons, but nearly of one
 kind in all; affecting the leg and arm on the same side,
 and generally on one side only.
   1350. These convulsive motions  commonly first af-
 fect the leg and foot.   Though the limb be at rest, the

 * Wo have known persons advanced in years to  be severely afflicted with
St. Vitus's dance. 
180           PRACTICE OF PHYSIC.
foot is often agitated by convulsive motions, turning it
alternately outwards and inwards. When walking is at-
tempted, the affected leg is  seldom lifted as  usual in
walking, but is dragged  along as if the whole limb were
paralytic: and, when it is attempted to be lifted, this
motion is unsteadily performed, the limb becoming agi-
tated by irregular convulsive  motions.
   1351. The arm of the same side is generally affected
at the same time; and, even when no voluntary motion
is attempted, the arm is frequently agitated with various
convulsive motions. But especially when  voluntary mo-
tions are attempted, these are not properly executed,
but are  variously hurried  or  interrupted by convulsive
motions in a direction contrary to that intended.  The
most  common  instance of this is in  the person's at-
tempting to carry a cup of liquor to his mouth, when it is
only after repeated  efforts, interrupted by frequent con-
vulsive retractions and deviations, that the cup can be
carried  to the month.
   1352. It appears to me, that the will often  yields to
these convulsive motions,  as to a propensity, and there-
by they are often increased, while the person affected
seems to be pleased with  increasing the  surprise and
amusement which  his  motions  occasion in  the by-
standers.
   1353. In this disease the mind is often affected with
some degree of fatuity; and often shows the  same va-
ried, desultory, and causeless emotions which occur in
hysteria.
   1354. These are the  most  common circumstances of
this disease; but at  times,  and in different persons, it is
varied by some difference in the convulsive  motions,
particularly by these affecting the head and trunk of the
body.  As in this disease there seem to be propensities
to motion, so various fits of leaping and running occur 
PRACTICE  OF PHYSIC.
181
 in the persons affected;  and  there have been instances
 of  this disease, consisting of such convulsive  motions,
 appearing as an epidemic in a certain corner of the coun-
 try. In such instances, persons of different ages are af-
 fected, and may seem to make an exception to the gene-
 ral  rule  above laid down;  but still the persons  are,  for
 the most part, the young of both  sexes, and of the more
 manifestly moveable constitutions.
    1355.  The method of curing this  disease has been
 variously proposed.   Dr.  Sydenham  proposed to cure
 it by alternate bleeding and purging.  In some plethoric
 habits I have found some  bleeding useful; but in many
 cases I have found repeated  evacuations, especially by
 bleeding, very hurtful.
   In many cases, I have found the disease, in spite of
 remedies of all kinds, continue for many months; but I
 have also found it often readily yield to tonic remedies,
 such as the  Peruvian bark, and chalybeates.
   The late  Dr. De Haen found several persons labour-
 ing under this disease cured by the application of elec-
 tricity.*

  * In the treatment of this disease, we have had but little experience, hav-
 ing never attended more than three or four cases of it.  Blood-letting has,
 at times, been practised in it with advantage.  As far as we are informed on
 the subject, very salutary effects have resulted in it from  active and copious
 purging, succeeded by tonic and antispasmodic remedies. One of the most
 promising tonics, in this disease, consists in a saturated solution of the sul-
 phate of  copper in water.  The dose of this is from six to ten drops, to be
 repeated three or four times a day. The shower bath and country air ought
 not to be neglected.
  In some instances, the disease appears to proceed from the irritation of
 teething; in others, from that of worms in the alimentary canal.  In the for-
 mer case, scarification of the gums;  in the latter, drastic purgatives, consti-
tute the most efficacious remedy.
  Believing the complaint to be seated in the stomach, some physicians pro-
mise themselves great advantage from the use of emetics, frequently repeat-
ed, alternating with tonics.
  As  antispasmodics, and to allay irritation in this disease, opium, musk, and
castor, camphor, asafcetida and cicuta, have most reputation. 
182            PRACTICE OF PHYSIC.
                         SECTION II-

OF THE  SPASMODIC  AFFECTIONS OF  THE VITAL
                       FUNCTIONS.


                        CHAPTER IV.

      OF  THE  PALPITATION OF THE HEART.*


1356.  THE motion thus named is a  contraction  or
systole of the heart, that is performed with more rapi-
dity, and generally also with more force than usual, and
wheu at the same time the heart strikes with more than
usual violence  against the inside of the ribs,  producing
often a considerable sound.
   1357.  This  motion, or palpitation, is occasioned  by
a great variety of causes, which have been recited with
great pains by  Mr. Senac and others; whom,  however,
I cannot follow in all the particulars  with  sufficient dis-
cernment, and  therefore shall here only attempt to refer

  When not forbiddan by the presence of inflammation, the tonics commonly
administered in other diseases, of great irritability, are useful in this.
  When the irregular motions  are confined principally to the lower extre-
mities, tight bandaging  of them with flannel rollers is said to have proved
serviceable.  We apprehend, however, that this remedy is, at best, but a
palliative ; unless, indeed, it may possibly act as a counter-irritation to that
which originally produces the disease.
  Beneficial effects are said to have been derived, in this disease, from  blis-
ters and caustics applied to the back of the neck and along the spine.  Pro-
vided the irritation and discharge be continued for a considerable time, we
think these remedies sufficiently promising to justify a trial of them.   But
the complaint being chronic, no application can suddenly relieve it.
  This disease is often removed by the changes that occur in the system1
about the period of  puberty.
  • Palpitation of the heart is oftentimes an urthritic affection, and, as such,
has its origin in the stomach.  Its treatment,  when thus produced, will be
readily understood, from what has been said on the subject of atonic gout.
An emetic has sometimes completely removed it. 
              PRACTICE OF PHYSIC.           J 83

all the several cases of this disease to a few  general
heads.
  1358.  The first is of those arising from the application
of the usual stimulus to the heart's contraction; that is,
the  influx of the venous blood into its cavities, being
made with more velocity, and, therefore,  in the same
time, in greater quantity than usual.   It seems  to be in
this manner that violent exercise occasions palpitation.
  1359. A second head of the cases of palpitation, is of
those arising from any resistance given to the free and
entire evacuation of the ventricles of the heart.   Thus
a ligature made  upon the aorta occasions palpitations of
the most violent kind.   Similar resistances, either in the
aorta or pulmonary artery, may  be readily imagined;
and such have been often found in the dead bodies of
persons who, during life, had been much affected with
palpitations.
  To this head  are to be referred all those cases of pal-
pitation arising from causes producing an accumulation
of blood in the great vessels near to the heart.
  1360. A third head of the cases of palpitation, is of
those arising from a more violent and rapid influx of the
nervous power into the muscular fibres of the heart.  It
is in this manner that  I suppose  various causes acting
in the  brain, and  particularly certain  emotions of  the
mind occasion palpitation.
  1361. A fourth head of the cases of  palpitation, is
of those arising from causes producing a weakness in
the action of the heart, by diminishing the energy of the
brain with respect to it.   That such causes operate in
producing palpitation, I presume from  hence, that all
the several causes mentioned above (1177. et. seq.) as
in this manner producing syncope, do  often  produce
palpitation.  It is on this ground that these two diseases
are affections  frequently occurring in the same person, 
184           PRACTICE OF PHYSIC.
 as the same causes may occasion the one or the other,
 according to the force of the cause and mobility of the
 person acted upon.   It seems to be a law of the human
 economy,  that a  degree of  debility  occurring in any
 function, often produces a more vigorous exertion of the
 same, or at least an effort towards it, and that commonly
 in a convulsive manner.
   I apprehend it  to be the convulsive action, frequent-
 ly ending  in some degree  of a spasm, that gives occa-
 sion to the intermittent pulse so frequently accompany-
 ing palpitation.
   1362. A fifth head of the cases of palpitation may
 perhaps be of those arising  from a peculiar irritability
 or mobility of the heart.  This, indeed,  may be con-
 sidered as a predisponent cause only, giving occasion to
 the action of the greater part of the causes recited above.
 But it  is proper to  observe, that this predisposition is
 often the chief part of the remote cause; insomuch that
 many of the causes producing  palpitation  would not
 have this effect  but  in  persons peculiarly predisposed.
 This head, therefore, of the cases of palpitation, often
 requires to be distinguished from all the rest.
   1363. After  thus  marking the several  cases and
 causes of palpitation, I think  it necessary, with a view to
 the cure of this disease, to  observe,  that the several
 causes of it may be again reduced to two heads.   The
 first is,  of those consisting in, or depending  upon, cer-
 tain organic affections of the  heart itself, or of the great
 vessels immediately connected with it.  The second is,
 of those consisting in,  or depending upon,  certain  af-
 fections subsisting and acting in other parts of the body,
 and acting either by the force of the cause, or in conse-
 quence  of the mobility of the heart.
  1364. With respect to the  cases depending upon the
first set of causes,  I  must repeat  here what I said  with 
PRACTICE OF PHYSIC.
185
respect to the like cases of syncope that I do not know
any means of curing  them.  They, indeed, admit  of
some palliation, first,  by avoiding every circumstance
that may hurry the circulation of the blood; and, second-
ly, by every means of avoiding a plethoric state of the
system, or any occasional turgescence of the blood.  In
many of these cases, blood-letting may give a tempora-
ry relief: but in so far as debility and mobility are con-
cerned, in such cases this remedy is likely to do harm.
   1365. With respect to the cases depending upon the
other set of causes, they may be various, and require
very different measures; but I  can here say in  general,
that these cases may be considered as of two kinds; one
depending upon primary affections in other parts of the
body,  and acting by the force of the particular causes;
and  another depending  upon a state of mobility in the
heart  itself.  In the first of these, it is  obvious, that
the cure of  palpitation  must be obtained by curing the
primary affection; which is not  to be treated of here.
In the second, the cure must be obtained, partly  by
diligently avoiding the occasional causes,  partly and
chiefly by correcting the mobility of the system, and of
the heart in particular; for doing which we have treat-
ed of the proper means elsewhere.
                     chapter v.

   OF DYSPNCEA, OR DIFFICULT  BREATHING.*

 1366. THE  exercise of respiration, and  the organs
of it, have so  constant and considerable  a  connection

 * The various affections enumerated in this chapter, being nothing but
symptoms o( more general diseases, do not require a distinct consideration.
   VOL. II.               Bb 
186           PRACTICE OF PHYSIC.
with almost the whole of the other functions and party
of the human body, that upon almost every occasion
of disease,  respiration must be affected.  Accordingly,
some difficulty and disorder in this function, are in fact
symptoms very generally accompanying disease.
   1337. Upon this account,  the  symptom of  difficult
breathing deserves a chief place and an ample considera-
tion in the  general system of Pathology; but what share
of consideration it ought to have in a treatise of Prac-
tice, I find it difficult to determine.
   1368. On this  subject, it is, in the  first place, neces-
sary to distinguish between the  symptomatic and idio-
pathic affections; that is, between those difficulties of
breathing which are symptoms only of a more general
affection, or of a disease subsisting primarily  in other
parts than  the organs of respiration,  and that difficulty
of breathing which depends upon a primary affection of
the lungs themselves.   The  various  cases of  sympto-
matic dyspnoea I have taken pains to enumerate in my
Methodical Nosology, and it will  be  obvious they are
such  as cannot be taken notice of here.
   1369. In my Nosology  I  have also taken pains to
point out and enumerate the proper, or at least the great-
er part of the proper, idiopathic cases of the dyspnoea:
but from that enumeration it will, I think,  readily ap-
pear, that few, and indeed hardly any, of  these cases,
will admit  or require much of our notice in this place.
   1370. The Dyspnoea Sicca, species 2d} the Dyspnoea
Aerea, sp.  3d, the Dyspnoea Terrea, sp. 4>th, and Dysp-
noea Thoracica, sp. 1th, are some of them with difficulty
known, and are all of them  diseases which in my opinion
do not admit of cure.  All, therefore, that can be' said
concerning them here is, that they may admit  of some

They can be cured only by the cure  of the complaints of which they form a
part. 
              PRACTICE  OF PHYSIC.           187

palliation; and this, I think, is to be obtained chiefly by
avoiding a plethoric  state of the  lungs, and every cir-
cumstance that may hurry respiration.
   1371. Of the Dyspnoea Extrinseca, sp. 8th, I can
say no more, but that these external causes marked in
the Nosology, and perhaps some others that might have
like effects, are to be carefully avoided; or, when they
have been applied, and  their effects have  taken place,
the disease is to  be palliated by the means mentioned in
the last paragraph.
   1372. The other species, though enumerated as idio-
pathic,  can hardly be  considered as  such, or  as re-
quiring to be treated of here.
   The Dyspnoea Catarrhalis, sp. 1st, may be considered
as a species  of  catarrh, and is  pretty certainly to be
cured by the same remedies as that species of catarrh
which depends rather upon the increased afflux of mu-
cus to the bronchia?, than upon any inflammatory state
in them.
   The Dyspnoea Aquosa, sp. 5th, is certainly to be con-
sidered as a species of dropsy, and is to be  treated by
the same remedies as the other species of that disease.
   The Dyspnoea Pinguedinosa, sp. 6th, is in like man-
ner to be considered as a symptom or local effect of the
Polysarcia, and is only to  be cured by correcting the
general fault of the system.
   1373. From this view of those idiopathic  cases of
dyspnoea,  which are  perhaps all  I could  properly ar-
range under this title, it will  readily appear that there
is little room for  treating of them here; but there is still
one case of difficult breathing, which  has been properly
distinguished from every other under the title of Asthma;
and as it deserves our particular attention, I shall here
separately consider it. 
188
PRACTICE  OF PHYSIC.
                            CHAPTER VI.


                         OF ASTHMA.*


 1374. THE  term of  asthma  has  been commonly ap-
 plied by the vulgar, and  even by many  writers on the

  * To our author's description of asthma, as exhibited in this chapter, no-
thing, perhaps, can be added, that would, in any measure, improve it. In
relation to the treatment of it, we shall briefly offer the following remarks,
  The practice in  this disease is naturally divided into that which is requi-
site  during the existence of a paroxysm; and that which is suitable during
the interval.
  Asthmatic paroxysms are frequently induced by improprieties in the quan-
tity or quality of food, and probably also of drink.
  In such a case, the first indication is, a thorough evacuation of the alimen-
tary canal. If nothing exist to forbid an emetic, its exhibition may be highly
useful.  Even a repetition of it may perhaps be advisable. Purgatives will,
at all events, be safe and proper.
  If the habit of the patient be full, and the febrile symptoms considerable,
blood-letting is necessary, to relieve congestion in the lungs, and prevent
effusion, the rupture of blood-vessels, or other effects which might thence
ensue.  This operation must be repeated, or not, according to circumstances.
  Should blood-letting be inadmissible, or fail to give relief, the application
of cups to the breast, or along the spine, and of  blisters also, in case the fe-
brile symptoms have sufficiently subsided, may prove beneficial.
  It is now that the various expectorants are  recommended.  Of these,
tartarized antimony, or ipecacuanha,  in nauseating doses, gum ammoniac,
powdered squills, combined with nitre, a combination of camphor and myrrh,
and the radix Senekae, in powder or decoction, are  in high repute.   So, of
late, is the digitalis purpurea, exhibited in powder, or the saturated tincture.
By certain British writers, this  last mentioned remedy is  greatly preferred
to either of the others.  It is reported to be productive of the happiest ef-
fects, in regulating the pulse, and facilitating expectoration; at the same
time that it diminishes the matter expectorated, in quantity, by weakening
the force of the determination to the lungs.   We have never used it in this
disease ;  and are, therefore, unable to speak of it from experience.
  To promote expectoration and remove spasm,  the smoking of the leaves
and root of the datura stramonium, is strongly recommended.  We believe
that this remedy has proved, in many cases, exceedingly useful.  In one case
reported to us, it was followed by violent pains in the groins; which, how-
ever, soon disappeared. 
PRACTICE  OF  PHYSIC.
189
Practice of Physic, to every case of difficult breathing,
that is, to  every species of Dyspnoea.   The Methodical

  A  well known remedy is the use of Mudge's inhaler, or the inhalation of
the steams of warm water, from any other apparatus.   Breathing over the
fumes of turpentine, thrown on burning coals, is also recommended.  From
neither of these processes, however, have we observed much benefit to be,
at any time, derived.  Yet others have spoken of them in the highest terms.
  The same remedies that have been recommended as expectorants, may
be made to act the part of sudorifics. In this latter intention, if properly re-
gulated, they  may be rendered highly useful.
  Of antispasmodics  in this  disease, opiates  hold the foremost rank.  If
united to ether, their efficacy is thought to  be materially increased.  In
cases where an acid prevails  in the stomach, a combination  of  opium and
prepared chalk, is a remedy of high reputed efficacy.   We have never our-
selves been witness to its effects.
  In the resolution of spasm, ether alone may be administered with advan-
tage. So may  asafoetida, musk,  and castor;  especially if given in large
doses.   Although a coarse and homely remedy, the juice of garlic is by no
means inefficient.   A table-spoonful of it may be given at a dose, in mixture
with an equal quantity of water.
  What would be the influence of arsenic, in shortening the continuance of
a paroxysm of asthma ?—Mercury  has been tried with but little effect.
  As a remedy in this disease, the breathing of factitious airs has been tried.
But report, on the subject, differs with regard to the effects of the different
kinds.  Some practitioners speak favourably of oxygenous gas, while others
give a preference to an atmosphere containing a superabundance of azote
or hydrogen.  We are inclined to believe, that, in this complaint, no perma-
nent advantage has ever been derived from the use of  either.  Wholesome
atmospheric air is the best medium for the respiratory process.
  As remedies in the interval, for the prevention of asthmatic paroxysms,
tonics are alone, or chiefly, in vogue.
  Nor are we sensible of any of them being specifically applicable to this
complaint.
  Bark and bitters, chalybeates and zink, cuprum vitriolatum and the nitrate
of silver, may be exhibited as the  practitioner may deem expedient.
  Issues, setons, and  perpetual blisters, are remedies which we think de-
serving of a trial.
  The flesh-brush should be used, flannel or fleecy hoisery worn next to the
skin, and exercise taken freely in  the open air. If the patient be able to bear
it, riding on horseback is the mode of exercise that ought to be preferred.
  As a tonic in this disease,  the cold bath has,  by some, been strongly re-
commended.  It ought not, however, to be used without great caution.   If
it be followed by a pleasant glow on the surface of the body, accompanied
with sprightliness, and an increase of vigour, it is admissible, and may be use-
ful.  But, if succeeded by a sensation of chilliness, dulness, or lassitude, let
it be immediately abandoned.
  An abstract choice  of a place of residence for asthmatic patients appears

                                                           / 
t90             PRACTICE  OF  PHYSIC.
nomologists, also, have distinguished Asthma from Dysp-
noea chiefly, and almost solely, by the former being the
same affection with the latter, but in  a higher degree.
Neither  of these  applications of the  term seems  to
have been  correct  or proper.   I am of opinion,  that
the  term  asthma  may be most  properly  applied,  and
should be confined,  to  a case  of  difficult  breathing
that  has  peculiar  symptoms,   and  depends  upon  a
peculiar  proximate  cause,  which   I hope  to  assign
with sufficient certainty.   It is this disease I  am  now
to  treat of, and  it is  nearly  what  practical  writers
have generally distinguished from the other cases of dif-
ficult breathing, by the title of Spasmodic  Asthma, or
of Asthma convulsivum; although, by not distinguishing
it with sufficient  accuracy  from the  other  cases of
Dyspnoea, they have introduced  a great deal of confu-
sion  into  their treatises on this subject.
   1375. The  disease I am to treat of, or the Asthma to
be  strictly so  called,  is often a hereditary disease.   It
seldom appears very early in  life,  and hardly till the time
of  puberty, or after it.   It affects both sexes, but most

to be impracticable.  Some are most comfortable and healthy in the city,
others in the country; some in an elevated and dry, and others in a low and
humid situation.  In this respect, therefore, let each individual choose  for
himself, provided his means be such as to entitle him to a choice.
  Asthmatic patients should use a diet nutritious and easily digested; and
be exceedingly temperate in the use of wine and other fermented liquors.
  For the entire removal of this complaint, where it is practicable to remove
it, the chief reliance must be placed on diet  and regimen.
  Let the patient pursue such a course, and this  must vary according to the
different  circumstances of different cases—as may be best calculated to re-
volutionize the general habit, and strengthen the system, and, in the present
state of science, the healing art can, perhaps, effect nothing farther.
  Instances have occurred where, in consequence of a reverse of fortune,
men who had previously led an easy and indolent life, have been cured of
asthma by being compelled to labour.  In these cases an adoption of sim-
pler fare  co-operated, no doubt, with laborious exercise, in the removal of
the disease.  In a complaint so essentially connected with the condition of
the stomach, the diet should be skilfully and  perseveringly regulated. 
PRACTICE OF  PHYSIC.           191
frequently the male.  I  have not observed it to  be
more frequent in one kind of temperament than in ano-
ther; and it does not seem to  depend upon any general
temperament of the whole body, but upon a particular
constitution  of the lungs alone.   It frequently attacks
persons of a full habit; but it hardly ever continues to
be repeated for some length of  time without occasion-
ing an emaciation of the  whole  body.
   1376. The attacks of this disease are generally in the
night-time, or towards the approach of night; but there
are also some instances of their coming on in the course
of the day.   At whatever time they come on, it is for
the most part suddenly, with  a sense of tightness and
stricture across the breast, and a sense of straitness in
the lungs impeding inspiration. The person thus attack-
ed, if in a horizontal  situation is immediately obliged to
get into somewhat of an erect posture, and requires a
free and cool air.  The difficulty of breathing goes on
for some time increasing; and both inspiration and  ex-
piration are  performed  slowly, and  with  a wheezing
noise.   In violent fits, speaking is difficult and uneasy.
There is often some  propensity  to coughing, but it can
hardly be  executed.
   1377.  These  symptoms often  continue for  many
hours together, and  particularly from midnight  till  the
morning is far advanced.  Then commonly a remission
takes place by degrees; the breathing becomes less la-
borious and  more full, so that the person can speak and
cough with more ease; and, if the cough brings up some
mucus, the remissions become  immediately more con-
siderable,  and the person falls into a much wished for
sleep.
   1378. During these fits the pulse often continues in
its natural state;  but  in some persons the fits are attend-
ed with a frequency  of pulse, and with some heat and 
192
PRACTICE OF PHYSIC.
 thirst, as marks of some degree of fever.   If urine be
 voided at the beginning of a fit, it is commonly in con-
 siderable quantity, and with little  colour or odour; but,
 after the fit is over, the urine voided is in the ordinary
 quantity, of a high colour, and sometimes deposits a sedi-
 ment.  In some persons, during the fit, the face is a lit-
 tle flushed  and turgid; but more  commonly it is some-
 what pale and shrunk.
   1379. After  some sleep in the  morning,  the patient,
 for the rest of the day, continues to have more free and
 easy breathing, but it is seldom entirely such. He still
 feels  some tightness  across his breast, cannot breathe
 easily in a horizontal posture, and can hardly bear any
 motion of his body, without having his breathing render-
 ed more difficult  and uneasy.   In the afternoon he has
 an unusual flatulency of his  stomach, and an unusual
 drowsiness; and, very frequently,  these symptoms pre-
 cede the first attacks of the disease.  But, whether these
 symptoms appear or not, the difficulty of breathing re-
 turns towards the evening; and then sometimes gradu-
 ally increases, till it becomes as violent as in the night
before: or if, during the day, the difficulty of breathing
has been moderate, and the person got some sleep in
 the first part of the night, he is, however, waked about
midnight,  or at some time between  midnight and two
o'clock  in  the morning; and is  then suddenly seized
with a fit of difficult  breathing, which runs the  same
course as the night before.
   1380. In this manner fits return for several  nights
successively: but generally, after some nights passed
in this way, the fits suffer more considerable remissions.
This especially  happens when the  remissions are attend-
ed with a more copious expectoration in the mornings,
and that this continues from  time to time throughout
the day.  In these circumstances, asthmatics, for a long 
PRACTICE OF PHYSIC.           193
 time after, have not only more easy days, but enjoy also
 nights of entire sleep, without the recurrence of the dis-
 ease.
   1381. When this disease, however, has once taken
 place in the manner above described, it is  ready to re-
 turn at times for the whole of life after.  These returns,
 however,  happen with different circumstances in differ-
 ent persons.
   1382. In some persons the  fits are readily excited by
 external heat,  whether of the weather or  of a warm
 chamber, and  particularly by  warm bathing.  In  such
 persons fits are more frequent in summer,  and particu-
 larly during the dog-days, than at other colder seasons.
 The same persons are also readily affected by changes of
 the weather; especially by sudden changes  made from a
 colder to a warmer, or what is commonly the same thing,
 from a heavier to a lighter atmosphere.  The same per-
 sons are also affected by every circumstance straitening
 the capacity of the thorax, as  by any ligature made, or
 even by a plaster laid upon it;  and a like effect happens
 from any  increased bulk of the stomach, either by a full
 meal, or by air  collected in it.  They are likewise much
 affected by exercise, or whatever  else can hurry the
 circulation of the blood.
   1383. As asthmatic fits seem thus  to depend upon
 some fulness of the vessels of  the lungs, it is probable
 that an  obstruction of perspiration, and the blood being
 less determined to the surface'of the body, may favour an
 accumulation in the lungs, and thereby be a means of ex-
 citing asthma. This seems to be the case of those asth-
 matics who have fits most frequently in the winter sea-
 son, and who have commonly more of a catarrhal affec-
 tion accompanying the  asthma; which  therefore occurs
 more  frequently in winter, and more manifestly from
the application  of cold.
   vol.  11.              c c 
194
PRACTICE OF PHYSIC.
   1384  Beside these cases of asthma excited by heat
or cold, there are others, in which the fits are especially
excited by powers applied to the nervous system; as by
passions of the  mind; by particular odours, and by irri-
tation of smoke and dust.   That this disease is an affec-
tion of the nervous system, and depending upon a mo-
bility of the moving fibres of the lungs, appears pretty
clearly from  its being frequently  attended  with  other
spasmodic affections depending upon mobility; such as
hysteria, hypochondriasis, dyspepsia, and atonic gout.
   1385.  From the whole of the history of asthma now
delivered, I  think it will readily appear, that the proxi-
mate cause of this disease is a preternatural, and in some
measure a spasmodic constriction of the muscular fibres
of the bronchiae; which not only prevents the dilatation
of the bronchia? necessary to a  free and full inspiration,
but gives also a rigidity which  prevents a full and free
expiration.   This preternatural constriction, like many
other convulsive and spasmodic affections, is readily ex-
cited by a turgescence of the blood, or other cause of
any unusual  fulness and distention of the vessels of the
lungs.
   1386.  This disease, as coming by fits, may be gene-
rally distinguished from most other species of dyspnoea,
whose  causes being more  constantly applied, produce
therefore a more constant difficulty of breathing. There
may, however,  be some fallacy in  this matter, as some
of these causes may be liable to have abatements and
intensities, whereby the dyspnoea produced by them
may seem to come  by fits; but I  believe it is seldom
that such fits put on the appearance of the genuine
asthmatic fits described above. Perhaps, however, there
is still another case that may give  more difficulty; and
that is when several of the causes, which we have as-
signed  as causes of several of the species  of difficult 
PRACTICE OF  PHYSIC.           19j
breathing referred to the genus of Dyspnoea, may have
the effect of exciting a genuine asthmatic fit.  Whether
this can happen to any but the peculiarly predisposed to
asthma, I am  uncertain; and, therefore,  whether in any
such cases, the asthma may be considered as symptoma-
tic; or if, in all such cases, the asthma may not still be
considered  and treated  as an idiopathic  disease.
   1387. The asthma, though often threatening imme-
diate death, seldom occasions it, and many persons have
lived long under this disease.  In many  cases, however,
it does prove  fatal; sometimes very quickly, and perhaps
always at length.  In some young persons  it has ended
soon,  by occasioning a phthisis pulmonalis.  After a
long continuance, it often ends in a hydrothorax; and
commonly, by occasioning some aneurism of the heart
or great vessels,  it thereby proves fatal.
   1388. As it is seldom that an asthma has been entire-
ly cured; I therefore cannot propose any method of cure
which experience has approved as generally successful.
But the disease admits of alleviation in several respects
from the use of remedies; and  my business now shall
be chiefly to  offer some remarks upon  the choice and
use of the remedies which have been commonly employ-
ed in cases of asthma.
   1389. As the  danger of an asthmatic  fit arises chiefly
from the difficult transmission of the blood through the
vessels of the  lungs, threatening suffocation; so the most
probable means of obviating this seems to be blood-let-
ting: and, therefore, in all violent fits, practitioners have
had recourse  to  this  remedy.  In first attacks, and es-
pecially in  young and  plethoric persons,  blood-letting
may be very  necessary, and is commonly allowable.
   But it is also evident, that, under the frequent recur-
rence of fits,  blood-letting cannot be frequently repeated
without exhausting and weakening the patient too much. 
W3           PRACTICE OF  PHYSIC.
It is further to be observed that blood-letting is not so
necessary as might be imagined, as the passage of the
blood through the lungs is not so much interrupted as
has been commonly supposed. This I particularly con-
clude from hence, that,  instead of the suffusion of face,
which is the usual effect of such interruption, the face,
in asthmatic fits, is often shrunk and pale.   I conclude
the same also from this, that, in asthmatic fits, blood-
letting does not commonly give so much relief as, upon
the contrary supposition, might be expected.
   V390. As I have alleged  above, that a turgescence
of the blood  is frequently the exciting cause of asth-
matic fits, so it might be supposed, that a plethoric state
of the system might have a great share in producing a
turgescence of the blood in the lungs;  and especially,
therefore, that blood-letting might be a  proper remedy
in asthma.   I allow it to be so in the first attacks of the
disease:  but as the disease,  by continuing, generally
takes off the plethoric state of the system; so, after tire
disease has continued for some time, I allege that blood-
letting becomes less and less necessary.
   1391.  Upon the supposition of asthmatics being in a
plethoric state, purging might be supposed to prove a
remedy in this disease:  but, both because the supposi-
tion is not commonly well founded,  and because purg-
ing is seldom found to relieve  the vessels of the thorax,
this remedy has not appeared to be well suited to asth-
matics; and large purging has always been found to do
much harm.  But as asthmatics are always hurt by the
stagnation and accumulation  of matters in the alimen-
tary canal, so costiveness must be avoided, and an open
belly proves useful. In the time of fits, the employment
of emollient and moderately relaxative glysters has been
found to give considerable relief.
   1392.  As a flatulency of the stomach, and other symp- 
PRACTICE OF PHYSIC.
197
 toms of indigestion, are frequent attendants of asthma,
 and very troublesome to asthmatics; so, both for remov-
 ing these symptoms, and for taking off all determination
 to the lungs, the frequent use of gentle  vomits is pro-
 per in this disease.  In certain cases, where a fit was
 expected to come  on in the course  of the  night,  a vo-
 mit given in the evening has frequently seemed to pre-
 vent it.
   1393. Blistering between the shoulders, or upon the
 breast, has been frequently employed to relieve asthma-
 tics; but in the pure spasmodic asthma we treat of here,
 I have rarely found blisters useful, either in preventing
 or relieving fits.
   1394. Issues are certainly useful in  obviating ple-
 thora; but as such indications seldom arise in cases of
 asthma, so issues have been seldom found useful in this
 disease.
   1395. As asthmatic fits  are so frequently excited by
 a turgescence of the blood, so the obviating and allaying
 of this by acids and neutral salts, seems to have been at
 all times the object of practitioners.  See Floyer on the
 asthma.
   1396. Although a plethoric state  of the system may
 seem to dispose to asthma, and  the occasional turges-
 cence of the blood  may seem  to be frequently the  excit-
 ing cause of the fits; yet it is evident, that the disease
 must have arisen chiefly from a peculiar  constitution in
 the moving fibres of the bronchia?, disposing them upon
 various occasions  to fall into a spasmodic constriction;
and  therefore,  that  the entire cure  of the disease can
 only be expected from the correcting of that predispo-
sition, or from  correcting the preternatural mobility or
irritability of the lungs in that respect.
  1397. In cases  wherein this predisposition depends
upon original conformation, the Gure must be difficult. 
198           PRACTICE OF PHYSIC.
and perhaps impossible; but it may perhaps be moderat-
ed by the use of antispasmodics. Upon this footing, va-
rious remedies of that kind have  been commonly em-
ployed, and particularly the fetid gums; but we have not
found them of any considerable efficacy,  and have ob-
served them to be  sometimes hurtful  by their heating
too much.  Some other antispasmodics which might be
supposed powerful, such as musk, have been properly
tried. The vitriolic ether has been found to give relief.
but its effects  are not lasting.
  1398.  As in other spasmodic affections, so in this,
the most certain and powerful antispasmodic is opium.
I have often found it effectual,  and generally safe; and
if there have arisen doubts with respect to its safety, I
believe they have arisen from not distinguishing between
certain plethoric and inflammatory cases of dyspnoea im-
properly  named asthma,  and the genuine spasmodic
asthma we treat of here.
  1399.  As in many cases this  disease depends upon a
predisposition  which cannot be  corrected by our art, so
in such cases the patient can only escape the disease by
avoiding the occasional or exciting causes, which I have
endeavoured  to  point out above.   It is, however, diffi-
cult to give any general rules here, as different asthma-
tics have their different idiosyncrasies with respect to
externals.  Thus, one asthmatic finds himself easiest
living in  the midst of a great city, while another cannot
breathe but in the free air of the country.  In the latter
case, however, most  asthmatics bear  the air of a low
ground, if tolerable free and dry, better than that of the
mountains.
  1400.  In diet,  also, there is  some  difference to be
made with respect to different asthmatics.  None of
them bear a large or full meal, or any food that is of slow
and difficult solution in the stomach; but many of them 
               PRACTICE OF PHYblC.           199

bear animal food of the lighter kinds, and in moderate
quantity.   The use of vegetables which readily prove
flatulent, are always very hurtful. In recent asthma, and
especially in the young and plethoric, a spare, light, and
cool diet is proper, and commonly necessary; but after
the disease has continued for  years, asthmatics com-
monly bear,  and  even require, a tolerable full diet,
though in all cases a very full diet is very hurtful.
   1401.  In drinking, water, or cool watery liquors, are
the only safe and fit drinks for  asthmatics; and all liquors
ready  to ferment,  and become flatulent, are hurtful to
them.   Few asthmatics  can  bear any kind of strong
drink; and any excess  in such is always  very hurt-
ful to them. As asthmatics are commonly hurt by tak-
ing warm or tepid  drink; so, both upon that account
and upon account of the  liquors weakening the  nerves
of the stomach, neither tea nor coffee is proper in this
disease.
   1402.  Asthmatics commonly  bear no bodily motion
easily but that  of the most gentle kind.  Riding, how-
ever,  on horseback, or going in a carriage, and espe-
cially sailing, are very often useful to asthmatics.
                     chapter vir.

    OF  THE CHINCOUGH, OR HOOPINGCOUGH.*

 1403.  T HIS disease is commonly epidemic, and ma-
 nifestly contagious.  It seems to  proceed from a con-

  * In relation to the contagion of hoopingcough, we have already made a
frank expression of our doubts.  We would not be understood as positively
denying to it that property; but we are at a loss for facts to prove its posses-
sion of it.  The mere occurrence of the disease, in a number of individuals be- 
  200              PRACTICE  OF  PHYSIC.

  tagion of  a specific nature,  and  of a  singular quality.
  It does not, like  most other contagions, necessarily pro-


 longing to the same family or neighbourhood, at once,  or in succession, is
 by no means sufficient  for the purpose. It is well known that this may take
 place, and still the complaint be nothing but an epidemic.
   That hoopingcough does exist and spread,  independently of contagion, ia
 a position which we cannot for a moment hesitate to believe.   It often ap
 pears suddenly, in the country, without any obvious cause,  and prevails
 throughout neighbourhoods  of considerable  extent, where  the inhabitant!
 are thinly scattered,  and the children have no communication with each
 other.  In these instances, it frequently attacks, at the same time, families
 remotely situated, between which no kind of intercourse exists.  With fici.-.
 of this description, no one can long reside in the country, and not be fami-
 liar.  The disease must,  therefore,  originate in a common source; and that
 source must necessarily be the atmosphere,  Besides, in passing through a
 neighbourhood, hooping-cough never observes that regular march, which
 would justify a belief that it is communicated only from the sick to the well.
 It docs not, for example,  commence in the north,  and travel to the south;
 in the east, and travel to  the west;  nor are  its  movements the reverse of
 these. It attacks scatteringly and promiscuously, as if it proceeded from a
 common  source ; and were governed, in its march, by the different suscepti-
 bilities of those who become subject to it; or, by the variety in their expo-
 sure to exciting causes.
   To our author's mode of treatment, which is highly judicious, we have
 but little to subjoin.  The complaint being slight,  is, comparatively speak-
 ing, but rarely the subject of medical advice.
  In such cases, however, as it may have obstinately resisted other means,
 the following remedies are worthy of a trial.
  A preparation  composed  of opium,  ipecacuanha, and the carbonate oT
 soda.   The proportions of this mixture recommended for a child of two
 years old, are  one drop of laudanum, five drops of ipecacuanha wine, and
 two grains of the carbonate of soda, exhibited, in a pleasant vehicle, every
 fourth hour, for several days, obviating costiveness by calomel or rhubarb.
 To children older or younger, the remedy must be  apportioned according
 to their ages.
  The acetate  of lead,  in doses of from the fourth to the eighth of a grain,
 exhibited, in some agreeable menstruum, every fourth or fifth hour, is recom-
 mended as a safe and useful remedy.
  The production of a slight strangury, by means of the tincture of cantha-
 rides, and the compound tincture of camphor combined, has acquired some
 leputation, as  a measure  calculated to moderate the cough and shorten it*
 continuance.
  Artificial musk,  dissolved  in rectified spirits of wine, and exhibited in
small but repeated doses, is also spoken  of as highly efficacious.  Of this
remedy we have no knowledge.
  Hemlock, tincture of digitalis, hyosycamus, and arsenic, have all been pro-
posed as remedies in hoopingcough.  None of these have we ourselves ex- 
                 PRACTICE OF PHYSIC.             201

 duce a fever;  nor  does  it, like most  others, occasion
 any  eruption, or produce otherwise any evident change
 in the state of the  human fluids.   It  has,  in common
 with the catarrhal contagion, and  with that of the mea-
 sles, a peculiar  determination  to  the  lungs; but with
 particular effects there, very different from those of the
 other two; as will appear from the history of the disease
 now to be  delivered.
    1404.  This  contagion, like  several  others, affects
 persons but once in the course of their lives;  and there-
 fore, necessarily, children  are most commonly the sub-
 jects of this disease: but there  are many instances of it
 occurring  in  persons  considerably advanced in life;
 though it  is probable, that the further that persons are
 advanced  in life, they  are the less liable to be affected
 with this contagion.
    1405. The disease commonly comes  on with the ordi-


 hibited, except the latter, which, given in the dose of the twelfth or six-
 teenth of a grain, and repeated  every three or  four hours, we have found to
 be advantageous.  To moderate the cough, paregoric elixir is highly useful.
  Convalescence, in hoopingcough, is best promoted by pure air, exercise in
the country, the use of the flesh-brush, or the wearing of flannel next to the
skin, and a mild and plain,  hut nourishing diet.   As a tonic in this complaint,
after the removal of inflammatory symptoms, tincture of bark, chalybeates,
and infusion of Colombo, in doses suited to the age and strength of the pa-
tient, are recommended-
  We concur with our author, in a particular manner, in the salutary effects
of emetics in this disease.  They  should be repeated daily, or even twice
or three times a day, if requisite.  Added to their evacuating effect, they,
by their specific impression on the stomach, act favourably on the lungs and
the whole system, through the medium of sympathy. They diminish febrile
action, and weaken the muscular spasm which proves so troublesome.
  They are indicated chiefly in those cases where respiration is oppressed,
and the patients do not puke during the paroxysms of coughing.  Where
each paroxysm terminates, as it usually does,  by a spontaneous evacuation
of the stomach, emetics are not called for.
  Let those who wish to  be further informed on the subject of hooping-
cough, consult Willis—Sydenham—Morton de tussi convulsiva—Hoffman,
Suppl. ii—Huxham—Fothergill—Stoll  rat. med.—Butler on the kinck-
cough, and on hemlock—Kirkland de pertussi—and R. Pearson
   VOL. II                  J) d 
202          PRACTICE OF  PHYSIC.
  nary symptoms of a catarrh arising from cold; and often,
  for many days, keeps entirely to that appearance; and I
  have had instances of a disease which, though evidently
  arising from the chincough contagion, never put on any
  other form than that of a common catarrh.  This, how-
  ever, seldom happens; for, generally in the second, and
  at farthest in the third week after the attack, the disease
  puts on its peculiar and characteristic symptom, a con-
  vulsive cough.  This is a cough in which the expiratory
  motions peculiar to coughing are made  with more fre-
  quency, rapidity and violence, than usual.   As these
  circumstances, however, in different instances of cough-
<  ing, are in very different degrees; so no exact limits can
  be put to determine when the cough can be strictly said
  to be convulsive; and it is therefore especially by ano-
  ther circumstance that the chincough is distinguished
  from every other form of cough.  This circumstance is,
   when many expiratory motions have been convulsively
  made, and thereby  the air is in great quantity thrown
  out from the lungs, a full  inspiration is necessarily and
  suddenly  made; which, by the air  rushing in through
  the glottis  with unusual velocity, gives a peculiar sound.
  This sound is somewhat different in different cases, but
  is in general called a Hoop; and from it the whole of
  the disease is  called the Hooping Cough.   When this
  sonorous inspiration has happened, the convulsive cough-
  ing is again renewed, and continues in  the same  man-
  ner as before, till a quantity of mucus is thrown up from
  the lungs, or  the contents of  the stomach are thrown
  up by vomiting.   Either of these evacuations commonly
  puts an end to the coughing,  and the patient remains
  free from it for some time after.  Sometimes it is only
  after several alternate fits of coughing and hooping that
  expectoration or vomiting takes  place;  but it is com- 
PRACTICE OF PHYSIC.
203
 inonly after the second coughing that these happen, and
 put an end to the fit.
   1406. When the disease, in  this manner, has taken
 its  proper form,  it generally continues for a long time
 after, and generally from one month to three; but some-
 times much longer, and that with very various circum-
 stances.
   1407. The fits of coughing return at various inter-
 vals, rarely observing any exact period.   They happen
 frequently in the  course of the day, and more frequently
 still in the course of the night.   The patient has com-
 monly some warning of their coming on; and, to avoid
 that violent and painful concussion which the  coughing <
 gives to  the whole body, he clings fast to any thing  that
 is near to him, or demands to be held fast by any per-
 son that he can come at.
   When the fit is over, the patient sometimes breathes
 fast, and seems fatigued for a little after: but in many
 this appears very little; and children are commonly so
 entirely relieved,  that  they immediately return to their
 play, or  what else they were occupied in before.
   1408. If it happens that the fit of coughing ends in
 vomiting up the contents of the stomach, the patient is
 commonly immediately after seized with a strong crav-
 ing and demand for food, and takes it in  very greedily.
   1409.  At the first coming on of  this disease, the ex-
 pectoration is'sometimes none at all, or of a  thin mu-
 cus only; and while this continues to be the case,  the
 fits of coughing are more violent, and continue longer;
but commonly the expectoration soon  becomes con-
 siderable, and a very thick mucus, often in great quan-
 tity, is thrown up; and as this is more readily brought
 up, the fits of coughing are of shorter duration.
   1410. The violent fits of coughing frequently inter-
 rupt the  free transmission of  the  blood  through  the 
204           PRACTICE OF PHYSIC.
lungs, and thereby the  free return of blood from the
vessels of the head.   This occasions that turgescence
and suffusion of face which commonly attends the fits of
coughing, and seems to occasion  also those eruptions
of blood  from the nose, and even from the eyes and
ears, which sometimes happen in this disease.
   1411.  This disease often takes place in the manner
we have  now  described, without any pyrexia attending
it; but, though Sydenham had  seldom observed  it, we
have found the disease very frequently accompanied with
pyrexia, sometimes from the very beginning, but more
frequently only after the disease had continued for some
time.   When it  does accompany  the disease, we have
not found it appearing  under any  regular intermittent
form.  It is  constantly  in some  degree present; but
with evident exacerbations towards evening,  continuing
till next morning.
   1412.  Another symptom very frequently attending
the chincough, is a difficulty of breathing; and that not
only immediately before and after fits  of  coughing, but
as constantly present, though in different degrees in dif-
ferent persons.  I have  hardly ever seen an  instance of
a fatal chincough, in which a considerable degree of py-
rexia and dyspnoea had not been  for some  time  con-
stantly present.
   1413.  When by the power of the contagion this dis-
ease has  once taken  place, the  fits of coughing are of-
ten repeated, without any evident exciting  cause: but
in many  cases, the contagion may be considered as giv-
ing a predisposition only; and the  frequency of fits de-
pends in  some measure upon  various exciting causes;
such as, violent exercise; a full  meal;  the having taken
in food of difficult solution; irritation of the lungs by
dust, smoke or disagreeable odours of a strong kind:
and especially any considerable emotion of the mind. 
PRACTICE OF PHYSIC.           205
   1414. Such are the chief circumstances of this dis-
ease, and it is of various event;  which, however, may
be commonly foreseen  by attending  to the  following
considerations.
  The younger that children are, they  are in the greater
danger from  this  disease; and  of those  to  whom  it
proves fatal, there are many more  under two years old
than above it.
  The older that children are, they are the more secure
against an unhappy event; and this I  hold to  be a very
general rule, though I own there are  many exceptions
to it.
  Children  born  of phthisical and asthmatic parents
are in the greatest danger from this disease.
  When the  disease, beginning in the form of a catarrh,
is attended with fever and difficult breathing, and with
little expectoration, it often proves fatal, without taking
on the form of the hoopingcough;  but, in most of such
cases, the coming on of the convulsive cough and hoop-
ing, bringing on at the same time a more free expecto-
ration, generally removes the danger.
   When the disease, is fully formed, if the fits are nei-
ther frequent  nor violent, with moderate expectora-
tion,  and the patient,  during  the intervals of the fits,
is easy, keeps his appetite, gets sleep, and  is without
fever or difficult breathing, the disease is attended with
no  danger;   and  these  circumstances becoming  daily
more favourable, the  disease very soon spontaneously
terminates.
  An expectoration, either very scanty or very copious,
is attended with danger; especially if  the latter circum-
stance is attended with  great difficulty of breathing.
  Those cases in which the fits terminate by a vomit-
ing, and are immediately followed by  a craving of food,
are generally without danger. 
206
PRACTICE OF PHYSIC.
   A moderate haemorrhagy from the nose often proves
 salutary; but very large haemorrhagies are generally very
 hurtful.
   This disease coming upon  persons under a state of
 much debility, has very generally an unhappy event.
   The danger of this disease sometimes arises from the
 violence of the fits of coughing, occasioning apoplexy,
 epilepsy, or immediate suffocation: but these accidents
 are very rare; and the danger of the disease seems ge-
 nerally to  be in proportion to the fever and dyspnoea
 attending it.
   1415. The cure of this disease has been always con-
 sidered as difficult,  whether the purpose be to obviate
 its fatal tendency when it is violent, or merely to short-
 en the course of it when it is mild.   When the conta-
 gion is recent, and continues to act, we neither know
 how to correct, nor  how to expel it;  and therefore the
 disease  necessarily continues  for  some  time: but it is
 probable, that the contagion in this, as in other instances,
 ceases at length to act; and that then the disease con-
 tinues, as in other convulsive affections,  by the power
 of habit alone.
   1416.  From this view of the matter I maintain, that
 the practice must be different, and adapted to two differ-
 ent indications,  according to the period of the disease.
 At the beginning of the disease, and for some time after,
 the remedies to be employed must be such  as may ob-
 viate the violent effects of the disease, and the fatal ten-
 dency of it; but, after the disease has continued for some
time, and  is without any violent symptoms, the  only
remedies which can be required are those  which may
interrupt its course,  and put an entire stop to it sooner
than it would have spontaneously ceased.
   1417.  For answering the first indication.  In pletho-
ric subjects, or in others, when from  the circumstances 
PRACTICE OF PHYSIC.
207
of the cough and fits it appears that the  blood is diffi-
cultly transmitted through the lungs, blood-letting is a
necessary remedy; and it may be even  necessary to re-
peat it, especially in the beginning of the disease; but,
as spasmodic affections do notcommonly admit of much
bleeding, so it is seldom proper in the chincough to re-
peat this remedy often.
   1418.  As costiveness frequently attends this disease,
so it is necessary to obviate or remove it by laxatives
employed; and keeping an open belly is generally use-
ful:  but  large evacuations in this way are  commonly
hurtful.
   1419.  To obviate or remove the inflammatory deter-
mination to the lungs that sometimes occur in this dis-
ease, blistering is often useful, and  even repeated blis-
tering has been of service; but issues have not so much
effect, and should by no means supersede the repeated
blistering that may be indicated.   When blisters are
proper, they are more effectual when applied to the tho-
rax,  than when applied to any distant parts.
   1420.  Of ?\\  other  remedies,  emetics are the most
useful in  this disease; both in general by interrupting the
return of spasmodic affections, and in particular by de-
termining very powerfully to the surface of the  body,
and thereby taking off determinations to the lungs.  For
these purposes, I  think, full vomiting is frequently to
be employed;, and, in the intervals necessary to be left
between the times of full vomiting, nauseating doses of
the  antimonial emetics may be  useful.   I have never
found the sulphur auratum, so much praised by  Clos-
sius, to  be a convenient medicine, on account of the
uncertainty of its dose; and the tartar emetic employed
in the manner directed by the late Dr. Fothergill, has
appeared to be more useful.
   1421.  These are the remedies to be employed  in the 
208
PRACTICE OF PHYSIC.
first stage of the disease for obviating its fatal tendency,
and putting it into a safe train. But in the second stage,
when I suppose the contagion has ceased to act, and that
the disease continues merely by the power of habit, a
different indication arises, and different remedies are to
be employed.
   1422. This disease, which often continues for a long
time, does not, in my opinion, continue during the whole
of that  time in consequence of the contagion's remain-
ing in the body and continuing to act in it.   That the
disease does often continue long after the contagion has
ceased to  act, and that too by the power of habit alone,
appears to me probable from hence, that terror has fre-
quently cured the disease; that any considerable change
in the state of the system, such as the coming on of the
small-pox, has also cured it; and lastly, that it has been
cured by antispasmodic and tonic medicines; whilst none
of all these means of cure can  be supposed either to
correct or to expel a  morbific matter,  though they are
evidently suited to  change the state and habits of the
nervous system.
   1423. From this view we are  directed to the indi-
cation that may be formed, and in a great  measure to
the remedies which may be employed  in what we sup-
pose to  be the second stage of the disease.  It may per-
haps be alleged, that  this indication of shortening the
course of the disease is not very important  or neces-
sary, as it supposes that the danger or  violence is over,
and in consequence, that  the disease will soon sponta-
neously cease.
   The last supposition, however, is  not well founded;
as the disease, like many other convulsive and spasmo-
dic affections, may continue for a long time by the  power
of habit alone, and by the repetition of paroxysms, may
have hurtful effects; more especially as the violence of 
              PRACTICE OF PHYSIC.          £09

 paroxysms,  and therefore their hurtful effects, may be
 much aggravated by various  external causes that may
 be accidentally applied.   Our indication, therefore, is
 proper; and we proceed to consider the several reme-
 dies which may be employed  to answer it.
   1424. Terror may possibly be a powerful remedy,
 but it is difficult to measure the degree of it that shall
 be produced; and, as a slight  degree of it may be inef-
 fectual, and a high degree of it dangerous, I cannot pro-
 pose to employ it.
   1425. The other remedies which we suppose suited
 to our second indication, and which indeed have been
 frequently employed in this disease, are antispasmodic
 or tonics.
  Of the antispasmodics,  castor has been particularly
 recommended by Dr. Morris;  but in  many trials we
 have not found it effectual.
  With more probability musk has been employed:
 but whether it be from our not having it of a genuine
 kind, or not employing it in  sufficiently large doses, I
 cannot  determine; but we have not found it commonly
 successful.  Of antispasmodics, the most certainly pow-
 erful is opium: and when there is no considerable fe-
 ver or difficulty of breathing  present, opium has often
 proved useful in moderating the violence of the chin-
 cough; but I have not known  it employed so as entirely
 to cure the disease.
  If hemlock has proved a remedy in this disease, as
 we  must believe from Dr. Butter's  accounts, I agree
 with that author, that it is to be considered as an anti-
 spasmodic.  Upon this supposition, it is a probable re-
 medy; and from the accounts of Dr. Butter and some
 others, it seems to have been  often useful: but, in our
 trials, it has often  disappointed us, perhaps  from the
preparation  of it not having been always proper.
  vol.  n.               e e 
210
PRACTICE  OF  PHYSIC.
   1426. Of the tonics, I consider the cupmoss* for-
merly celebrated, as of this kind; as also the bark of the
mistletoe; but I have  had no experience of either, as I
have always trusted to the Peruvian bark.   I consider
the use of this medicine as the most certain means of
curing the disease in  its second stage;  and when there
has been little fever present, and a sufficient quantity of
the bark  has been given, it has seldom failed of soon
putting an end to the disease.
   1427. When convulsive  disorders may be supposed
to continue by the force of habit alone, it has been found
that a considerable change in the whole of the circum-
stances and manner of life has proved a cure of such
diseases; and analogy has supplied this in the case of
the chincough so far,  that a change of air has been em-
ployed,  and supposed to be useful. In several instances
I have observed it to  be so; but I have never found the
effects of it durable,  or sufficient to put an entire stop
to the disease.
                      section ui.

 OF THE SPASMODIC AFFECTIONS  IN THE NATU-
                  RAL FUNCTIONS.



                     CHAPTER VIII.

 OF THE PYROSIS, OR WHAT  IS  NAMED  IN SCOT-
            LAND, THE WATER-BRASH.*

 1428. THE painful sensations referred to the stomach,
 and which are probably occasioned by real affections of

  • We have known a few cases of pyrosis  to be successfully treated by a
mixture of equal quantities of lime-water and new milk, in the dose of a te> 
PRACTICE OF PHYSIC.           211
 this organ, are of different kinds.   Probably they pro-
 ceed from affections of different natures, and should
 therefore be distinguished by different appellations; but
 I must own that the utmost precision in this matter will
 be difficult.   In  my essay towards a methodical noso-
 logy, I have, however, attempted it.   For  those pains
 that are either acute and pungent, or accompanied with
 a sense of distention, or  with a sense of constriction,
 if they are at the same  time,  not attended with any
 sense of acrimony or heat, I employ the appellation of
 gastrodynia.   To express those painful  or uneasy sen-
 sations which seem to arise from  a sense of acrimony
 irritating the part, or from such a sense of heat as the
 application of acrids, whether  externally or internally
 applied, often  gives, I  employ the term of cardialgia;
 and by this I particularly mean to  denote those feelings
 which are expressed by the term heartburn in the Eng-
 lish language.  I  think the term soda  has been com-
 monly employed by practical writers to express an affec-
 tion attended  with feelings of  the latter kind.
   1429.  Beside the pains denoted by the terms gastro-
 dynia, periadynia, cardialgia, and soda, there is, I think,
 another painful  sensation different from all of these,
 which is named by Mr. Sauvages, pyrosis suecica; and
 his account of it is taken  from Linnaeus, who names it
 cardialgia sputatoria.   Under the title of pyrosis, Mr.

ble-spoonful five or six times a day; with the occasional use of opiates, and
of blisters to the epigastric region.
 For the cure of this disease, the oxyd of bismuth is highly recommended.
Five grains  of that medicine, with a scruple of gum tragacanth, may be
taken, by an adult, three or four times a day.
 The nux vomica, recommended by Linnaeus, may  be exhibited in ten
grain doses, to be repeated twice or three times a day.
 A good rule for persons subject to this disease is, never to  allow their
stomachs to become entirely empty, but to eat, occasionally, even on awak-
ing at night, if the disease attack them in the morning, a cracker or a bit <>i
crust of brfatL 
 212          PRACTICE OF PHYSIC.

 Sauvages has formed a genus, of which the whole of the
 species,  except  the  eighth, which  he  gives under the
 title of Pyrosis suecica, are all of them species of the
 gastrodynia or of the cardialgia;  and if there is a ge-
 nus to be formed under the title of pyrosis, it  can  in
 my opinion comprehend only the species I have men-
 tioned. In this case, indeed, I own  that the term is not
 very proper; but my aversion to introduce new names
 has made me  continue to employ the term of Mr. Sau-
 vages.
   1430.  The Gastrodynia  and Cardialgia I judge to be
 for the most part symptomatic affections; and therefore
 have given them no place in this work: but the Pyrosis,
 as an idiopathic disease, and never before treated of in
 any system, I  propose to treat of here.
   1431.  It is  a disease frequent among people in lower
 life; but occurs  also, though more rarely, in people of
 better condition.   Though  frequent in Scotland, it is
 by  no means so frequent as Linnaeus reports it to be
 in Lapland.   It appears most commonly in persons un-
 der middle age,  but  seldom in any  persons before the
 age of puberty.   When it  has once taken place,  it is
 ready to  recur occasionally for a long time after; but it
 seldom appears in persons considerably advanced in life.
 It affects both  sexes, but more frequently the female.  It
 sometimes attacks pregnant  women, and some women
 only when they are in that condition. Of other women,
 it more frequently affects  the unmarried; and  of the
 married,  most  frequently the barren. I have had many
 instances of its occurring in women labouring under a
 fluor albus.
  1432.  The  fits of this  disease usually come on in
 the morning and forenoon, when the stomach is empty.
The first symptom of it is a pain at the pit of the sto-
mach, with a sense of constriction,  as if the stomach 
PRACTICE OF PHYSIC.
213
 was drawn towards the back; the pain is increased by
 raising the body into an erect posture, and therefore the
 body is bended forward.  This pain is often very severe;
 and after  continuing for sc,me time,  it brings on an
 eructation of a thin watery fluid in considerable quan-
 tity.   This fluid has sometimes an acrid taste, but is
 very often absolutely insipid.   The eructation is for
 some time frequently repeated; and does not immedi-
 ately give relief to the pain which preceded it, but does
 so  at length, and puts an end to the fit.
    1433. The fits of this  disease commonly come on
 without any evident exciting cause: and I have not found
 it steadily connected with any particular diet. It attacks
 persons using animal food, but I think more frequently
 those living on milk and farinacea. It seems  often to be
 excited by cold applied  to the  lower extremities; and
 is readily excited by any considerable emotion of mind.
 It is often without any symptoms of dyspepsia.
   1434. The nature of this affection is not very obvious;
 but I  think  it may be  explained in  this manner:  It
 seems to begin by a spasm of the muscular fibres of the
 stomach; which is afterwards, in a certain manner, com-
 municated to  the blood-vessels  and exhalants, so as  to
 increase the impetus of fluids in these  vessels, while a
 constriction takes place on  their extremities.   While
 therefore the  increased  impetus determines a greater
 quantity than  usual of fluids into these vessels, the con-
 striction  upon their extremities allows only the pure
 watery parts to be poured out,  analogous, as I judge, in
 every  respect to what happens in the diabetes hys-
 tericus.
  1435. The  practice in this disease  is as difficult  as
the  theory.   The paroxysm  is only to be certainly re-
lieved  by  opium.  Other  antispasmodics,  as  vitriolic
ether and volatile alkali, are sometimes of service, but 
214
PRACTICE  OF PHYSIC.
not constantly so.   Although opium and other antispas-
modics relieve the fits, they have no effect in preventing
their recurrence.   For this purpose, the whole of the
remedies of dyspepsia have been employed without suc-
cess.   Of the use of the nux vomica, mentioned as a
remedy by Linnaeus, I have had no experience.
                     CHAPTER IX.

                  OF THE COLIC*

 14S6. THE  principal symptom  of this  disease, is a
pain felt in the lower belly. It is seldom fixed and pun-
gent in  one  part,  but is a painful distention in some
measure spreading over the whole of the belly; and par-
ticularly with a sense of twisting or wringing round the
navel.  At the same time, with this pain, the navel and
teguments of the belly are frequently drawn inwards,
and often the muscles of the belly are  spasmodically
contracted, and this in separate portions, giving the ap-
pearance of a bag full of round balls.
   1437. Such pains in a certain degree, sometimes oc-
cur in cases of diarrhoea and  cholera; but these are less
violent and more transitory,  and are named Gripings.
It  is only when more violent and  permanent, and
attended  with costiveness, that they constitute  colic.
This is also attended with vomiting, which  in  many
cases is frequently repeated, especially when any thing
is taken down into the stomach; and in such vomitings,

  * Bilious colic is always a febrile'disease, and, like other forms of pyrexia,
is ushered in by a  chill.  It may be regarded as a bilious fever thrown on
the bowels.  The chill, by which it is introduced, distinguishes it from othef
kinds of colic. 
PRACTICE OF PHYSIC.
215
not only the contents of the  stomach are thrown  up,
but also the contents of the duodenum,  and therefore
frequently a quantity of bile.
   1438. In sgme cases of colic,  the peristaltic motion
is inverted through the whole length of the alimentary
canal, in such a manner that the contents of the great
guts, and therefore, stercoraceous matter, is thrown up
by vomiting; and the same inversion appears still more
clearly from this, that what is thrown  into the rectum
by glyster is again thrown out by the mouth.   In these
circumstances of inversion the disease  has been named
Ileus, or the Iliac Passion; and this has been supposed
to be a peculiar disease distinct from  colic; but to  me
it appears that the two diseases are owing to the same
proximate cause, and have the same symptoms, only in
a different degree.
   1439. The colic is often without any pyrexia attend-
ing it.  Sometimes, however, an inflammation  comes
upon the part of the intestine especially affected;  and
this inflammation aggravates  all the symptoms  of the
disease, being probably what  brings on the most con-
siderable inversion of the peristaltic motion; and, as the
stercoraceous  vomiting is what especially distinguishes
the ileus, this has been considered as always depending
on an inflammation of the intestines.  However, I  can
affirm, that as there are inflammations  of  the intestines
without stercoraceous vomiting, so I have seen instances
of stercoraceous  vomiting without inflammation;  and
there is therefore no ground for distinguishing ileus from
colic, but as a higher degree  of the same affection.
   1440. The symptoms of the colic, and the dissections
of bodies dead of this disease, show very  clearly that it
depends upon  a spasmodic constriction of a part of the
intestines, and that  this therefore is to  be  considered
as the proximate cause of the disease.   In some of the 
216
PRACTICE OF PHYSIC.
 dissections of persons dead of this disease, an intus-sus-
 ception has been remarked to have happened; but whe-
 ther this be constantly the case in all the appearances
 of ileus, is not certainly determined.
   1441. The colic has commonly been considered as
 being of different species, but I cannot follow the writers
 on this subject in the distinctions they have established.
 So far, however, as a difference  of  the remote  cause
 constitutes a  difference of species, a distinction may
 perhaps be  admitted; and accordingly in my Nosology
 I  have marked  seven different  species: but  I am well
 persuaded, that  in all these different species the proxi-
 mate cause is the same, that is, a spasmodic constric-
 tion of a part of the intestines: and consequently, that
 in all these cases the indication of cure is the same, that
 is, to remove the constriction mentioned.   Even in  the
 several species named Slercorea,Callosa,and Calculosa,
 in which the disease depends upon an  obstruction of the
 intestine,  I  am  persuaded that these obstructions  do
 not produce the symptoms of colic, excepting in so far
 as they produce spasmodic constrictions of the  intes-
 tines; and therefore, that the means of cure in these
 cases, so far as they admit of  cure,  must be obtained
 by the means  which the general indication above men-
 tioned suggests.
   1442. The cure,  then,  of the colic universally, is to
 be obtained by  removing the spasmodic  constrictions
 of the intestines; and the  remedies suited to this pur-
pose may be referred to three general heads.
   1. The taking off the spasm by various antispasmodic
 powers.
  2. The exciting the action  of the intestines by pur
gatives. 
PRACTICE OF PHYSIC.
21?
    3. The employing mechanical dilatation.*
    1443.  Before entering upon a  particular account of
 these remedies, it will be proper to observe,  that in all
 cases of violent colic,  it is advisable to practice  blood-
 letting; both as it may be useful in obviating the inflam-
 mation  which  is  commonly  to  be  apprehended, and
 even  as it may be  a means of relaxing the spasm of the
 intestine.   This remedy may perhaps be improper in
 persons of  a weak and lax habit, but in all persons of
 tolerable vigour it  will be a safe remedy; and in all cases
 where  there  is the  least suspicion  of an inflammation
 actually coming on, it will be absolutely necessary. Nay,
 it will be even proper to repeat it perhaps several times,
 if, with a full and  hard pulse,  the appearance of  blood
 drawn,  and  the relief  obtained  by the  first  bleeding,
 shall  authorise such repetition.
    1444.  The  antispasmodic  powers  that may be em-
 ployed, are, the application of heat  in a dry or humid


  * The leading indication of cure, in the treatment of colic, is, to evacuate
 thoroughly the alimentary canal.  Opiates, and other remedies, employed
 previously to this process, are useful only, or principally,  as far as they fa-
 cilitate the retention of purgatives on the stomach and in their operation.
 The complete evacuation of the alimentary canal, with blood-letting, and
 blisters to the abdomen,  to  prevent intestinal inflammation, and the judi-
 cious employment of opiates, seldom fail to effect a cure.
  Opiates should seldom  be administered previously to purgatives, unless
 with a view to suppress vomiting, or relieve pain,  which cannot be tolerated.
 In cases, however, that have not been preceded  by costiveness, or which
 have been brought on by  passions or affections of the mind, or by the imme-
 diate action of cold, opiates may be safely and usefully administered, even
 before the exhibition of purgatives.
  In cases where opiates are forbidden, the pain  of colic may  be  relieved
 by warm fomentations to  the abdomen, or by the use of the warm bath.  Of
 these two remedies the latter is preferable, when no circumstances exist to
render it improper.  By acting favourably on the skin, and subduing a kind
 of spasm which there exists, it tends, not a little, to remove by sympathy
the spasm and painful excitement of the intestines.
  A similar effect may, to a considerable extent, be produced, by passing
 equally and with as much tightness as can be borne without inconvenience
 a flannel roller around the body from the pubes to the scrobiculus cordis:
 vol.  n-                  rf 
218
PRACTICE OF PHYSIC.
 form, the application of blisters, the use of opium, and
 the use of mild oils.
   The application of heat in a dry form, has been em-
 ployed by applying  to the belly of the patient a living
 animal, or bladders filled  with warm water, or bags of
 substances which  long retain their heat; and all these
 have sometimes been applied with success; but none of
 them seem to me so powerful as the application of heat
 in a humid form.
   This may  be employed either by the immersion of a
 great part of the body in warm water, or by fomenting
 the belly with cloths wrung out of hot water.  The im--
 mersion has  advantages from the application  of it to a
 greater part  of the body,  and particularly to the lower
 extremities:  but immersion cannot always be conveni-
 ently  practised,  and fomentation may have the advan-
 tage of being longer continued; and it may have nearly
 all the benefit of immersion, if it be at the same time
 applied both  to the belly and to the lower extremities.
   1445-  From considering that  the teguments of the
 lower belly have such a connection with the intestines,
 as at the same time to be  affected with spasmodic con-
 traction,  we  perceive  that blisters applied to the belly ,
 may have the effect of taking off  the spasms both from
 the muscles of the belly and from the  intestines; and
 accordingly,  blistering has often been employed in the
 colic with advantage.  Analogous to this, rubefacients
 applied to the belly have been frequently found useful. |
   1446. The use of opium in the colic may seem to be
 an ambiguous remedy.   Very certainly it may for some
time relieve the pain, which is often so violent and ur-
gent that it is difficult to abstain from the use of such a
remedy.   At the same time, the use of opium  retards
or suspends the peristaltic motion so much, as to allow
 the intestines to fall into constrictions; and may there- 
PRACTICE OF PHYSIC.           219
fore, while it relieves the pain, render the cause of the
disease more obstinate. On this account, and further as
opium prevents the operation of purgatives so often ne-
cessary in this disease, many practitioners are averse to
the use of it, and some entirely reject the use of it as
hurtful.   There are, however, others who think they
can employ opium in this disease with much advantage.
  In all  cases where  the colic comes on without  any
previous costiveness, and arises from cold, from passions
of the  mind, or other  causes which operate especially
on the nervous system, opium proves a safe and certain
remedy; but in cases which have been preceded by cos-
tiveness, has however continued for some days without
a stool, so that a stagnation of faeces in the colon is to
be suspected, the use of opium is of doubtful effect.  In
such cases,  unless  a stool has been  first  procured by
medicine,  opium cannot be employed but with some
hazard of aggravating the disease.  However, even in
those circumstances of costiveness, when, without in-
flammation,  the violence  of the spasm is to be suspect-
ed, when vomiting prevents the exhibition of purgatives,
and when  with all this the pain  is extremely urgent,
opium is  to be employed, not  only as an anodyne,  but
also as an antispasmodic, necessary to favour  the opera-
tion of purgatives; and may be so employed, when, either
at the same time with the opiate, or not long after it, a
purgative can be exhibited.
  Is the hyoscyamus,  as often showing, along with its
narcotic, a purgative quality, better suited to this disease
than opium?
   1447.  It is seemingly on  good  grounds that several
practitioners have recommended the large use of mild
oils in this disease, both as antispasmodics and as laxa-
tives; and, where  the  palate and stomach could admit
them, I have found them very useful.  But as there are 
 220           PRACTICE OF PHYSIC.

 few Scottish stomachs that can admit a large use of oils,
 I have had  few opportunities of employing them.
   1448. The  second  set of remedies  adapted to the
 cure of colic, are purgatives; which, by exciting the ac-
 tion of the  intestines, either above  or below the ob-
 structed place, may remove the constriction; and there-
 fore these purgatives may be given either by the mouth,
 or thrpwn by glysters into the anus.  As the disease is
 often seated in the great guts; as glysters, by having a
 more sudden operation,  may give more immediate re-
 lief; and as purgatives given by the mouth  are ready to
 be rejected by vomiting; so it  is common, and indeed
 proper, to attempt curing the colic  in the first place by
 glysters.  These may at first be of the mildest kind,
 consisting of a large bulk of water, with some quantity
 of mild oil;  and such are sometimes sufficiently effica-
 cious: however, they are not always so; and it is com-
 monly necessary to render  them more  powerfully sti-
 mulant by the addition of neutral salts, of which the
 most powerful is the common or marine salt.   If these
 saline  glysters,  as  sometimes  happens, are rendered
 again too quickly,  and on  this  or otherwise are found
 ineffectual,  it may be proper instead of these salts, to
 add to the glysters  an infusion  of  senna,  or of some
 other purgative that can be extracted by water. The an-
 timonial wine  may be sometimes employed in glysters
 with advantage.  Hardly any glysters are more effec-
 tual than those made  of  turpentine properly prepared, j
 When all other injections are found ineffectual, recourse
 is to be  had to  the injection of tobacco smoke; and, <
 when even  this fails, recourse  is to be had to the me-
 chanical dilatation to be mentioned hereafter.*

 * We repeat,  that our author is mistaken, in representing purgatives as
the " second set of remedies" in the treatment of the colic. When the sto-
mach  can retain them, and no peculiarities exist to prevent their use, they 
PRACTICE OF PHYSIC.
22\
   1449. As glysters often fail altogether in relieving this
disease, aud as even  when they give  some relief they
are often imperfect in producing a cempletecure; so it
is  generally proper,  and often  necessary, to attempt a
more entire and certain cure by  purgatives given  by
the mouth.  The  more powerful of these, or, as they
are 'called, the drastic  purgatives, may  be sometimes
necessary; but their use is to be avoided, both because
they  are apt to be rejected by  vomiting, and because
when they do  not succeed in removing the obstruction
fhey  are  ready to  induce an  inflammation.   Upon this
account it is usual,  and indeed  proper, at least  in the
first place, to  employ the milder and less inflammatory
purgatives.  None have succeeded with me better than
the chrystals of tartar, because this  medicine may be
given in small  but repeated doses to a considerable quan-
tity;  and under this management it is the purgative least
ready to be rejected by vomiting, and much less so than
the other neutral salts.  If a stronger purgative  be re-
quired, jalap properly prepared, is less  offensive to the
palate, and sits better upon the stomach, than most other
powerful  purgatives.  On many occasions of colic, no-
thing is more  effectually purgative than a large dose of
calomel.   Some practitioners have attempted to remove
the obstruction of the intestines by antimonial emetics

are unquestionably the first.  If the stomach be altogether unretentive, in-
jections constitute  the best substitute for the use of purgatives.  The anti-
monial injection, consisting of from fifteen to twenty grains, of tartarized an-
timony, dissolved in a suitable quantity of water, and carefully administered,
is an important remedy. So is the turpentine injection, composed of from
half an ounce, to six drachms, of Venice turpentine, mixed in a pint of tepid
water, by means of the yolks of two or three eggs.
  An injection more powerful, perhaps, than either, may be prepared, by
boiling half a drachm of tobacco, in a quart of water, until it be reduced to
a pint. This may be used at once, or twice, as circumstances may require.
  An excellent common injection, consists of a solution of Glauber's salts, in
water or chamomile tea, or of balsam capivi, mixed in water, by means of the
yolk of an egg. 
 222           PRACTICE OF  PHYSIC.

 exhibited in small doses, repeated at proper intervals;
 and when these doses are not entirely rejected by  vo-
 miting, they often prove  effectual purgatives.
   When every purgative has failed, the action of the
 intestines has been effectually excited by throwing cold
 water on the lower extremities.*
   1450.  The third means of overcoming the spasm of
 the  intestines in this disease, is by employing a mechani-
 cal  dilatation;  and it has been frequently supposed that
 quicksilver, given in large  quantity, might operate in
 this manner.  I have not, however, found it successful;
 and the theory of it is with me  very doubtful.   Some
 authors have mentioned the use of gold and silver pills,
 or, balls, swallowed down; but  I have no experience of
 such practices, and I cannot suppose them a  probable
 means  of relief.
   1451. Another means  of mechanical dilatation and a
 more probable measure, is by injecting a large quantity
 of warm  water by a  proper syringe,  which may throw
 it with some force, and in a continued stream, into the
 rectum.  Both from  the  experiments reported  by  the
 late Mr.  De Haen, and from those I  myself have had
 occasion to make, I judge this remedy to be one of the
 most powerful  and effectual.!
   1452.  I have now  mentioned all the several means
 that may be employed for the cure of the  colic, consi-

  • A purgative, which  we have found to answer exceedingly well, and of
which the stomach  is usually retentive, consists of Glauber's, Itochelle, or
Epsom salts, dissolved in Seltzer water, and taken in moderate doses, re-
peated every hour, until it shall have operated.
  When the stomach can retain it, castor  oil is a very valuable purgative.
So is calomel, followed, in an hour or two, by jalap and cream of tartar.
  Injections of  cold water have succeeded in moving the bowels, in colic,
when other remedies have failed.
  ■j- Two gallons of tepid water are said to have been thrown into the intes-
tines of some patients, with the happiest effects.  Of this mode of practice
we have had no experience. 
PRACTICE OF PHYSIC.
2S8
dered as a genus; but before I quit this subject, it may
be expected that I should take notice of some of the
species  which may seem  to  require  a particular con-
sideration.  In this view it may be expected that I should
especially take  notice of that species named the colic of
Poitou,  and particularly known in England by the name
of the Devonshire colic*
   1453. This species of the disease is certainly a pecu-
liar one, both in respect of its cause and its effects; but,
as to the first, it has been lately so much the subject of
investigation, and is so well ascertained by  the learned
physicians Sir George Baker and Dr. Hardy, that it is
unnecessary for me to say any thing of it here.
  With respect to the cure of it, so far as it appears in
the form of a colic, my want of experience concerning it
does not allow me to speak with any confidence on the
subject; but, so far as I can learn from others, it ap-
pears to me, that it  is to be treated by all the several
means that I have proposed above for the cure of colic
in general.
   How far the peculiar effects of this  disease are to be
certainly  foreseen  and obviated,  I have not properly
learned; and I  must leave the matter to be  determined
by those who have had sufficient experience in it.
                     chapter x.

                OF THE  CHOLERA

 1454. IN this disease, a vomiting and purging concur-
ring  together,  or frequently alternating with one ano-

  * The most prompt and certain remedy, we have ever seen employedf.
in the treatment of colica pictonum, is a mercurial ptysalism. When adopted
■?arly in the disease, it seldom fails to effect a cure. 
224,           PRACTICE OF PHYSIC.
  ther,  are the  chief symptoms.   The  matter  rejected
  both  upwards and  downwards appears  manifestly to
  consist chiefly of bile.
    1455.  From this last  circumstance  I conclude, that
  the disease depends upon an increased secretion of bile,
  and its copious effusion into the alimentary canal: and,
  as in this it irritates and excites the motions above men-
  tioned, I infer, that the bile thus effused in larger quan-
  tity is at the same time  also  of a more acrid quality.
  This appears likewise from the violent  and very painful
  gripings that attend the disease, and which we can im-
  pute  only to  the violent spasmodic  contractions of the
  intestines that take place here.   These  spasms are com-
  monly  communicated  to the abdominal muscles, and
  very frequently to those of the extremities.*
    1456.  In the manner now described, the disease fre-
 quently proceeds with great violence, till the strength of
 the patient is greatly, and often suddenly, weakened;
 while  a coldness of the extremities, cold  sweats, and
 faintings, coming on, an end is put  to the patient's life,
 sometimes in the course of one day. In other cases the
 disease is less violent, continues for a day or two, and
 then ceases by degrees; though such recoveries seldom
 happen without the use of remedies.

  * Cholera morbus  is as completely a gastric affection, as any one in the
 whole catalogue of diseases. Gastritis itself is not more so.  The original
 irritation is in the stomach ; and the augmented secretion of bile follows as
 a consequence.  Our author, therefore, has evidently mistaken the effect
 for the cause—a mere symptom, for the original disease.
  In evidence of the truth of what we have said, we would observe, that the
 first discharges, in this disease, are not bilious; but  consist merely of the
 contents of the stomach and bowels.  No bile is evacuated, until it has been
first secreted, as an effect of the disease—at least, it is not evacuated in large
 quantities until thus produced.  Nor does that fluid appear to be cha-
racterized by any  unusual acrimony in cholera.  It is  probably more bland
than even in health j  being discharged, as soon as secreted; and having,
therefore, no time  to acquire acrid qualities, by the absorption of its aque-
ous portion. 
PRACTICE OF PHYSIC.
225
   1457. The attacks of this disease are seldom accom-
panied with any symptoms of pyrexia; and though, dur-
ing the course of it, both the pulse and respiration are
hurried and irregular, yet these symptoms are generally
so entirely removed by the remedies that quiet the spas-
modic affection peculiar to the disease,  as  to leave no
ground for supposing that it had been accompanied by
any proper pyrexia.
   1458.  This is a disease attending a very warm state
of the  air; and, in  very warm climates, it may perhaps
appear at any time of the year: but even in such cli-
mates it is most frequent during their warmest seasons;
and in temperate climates, it appears only in the warm
seasons.  Dr. Sydenham considered the appearances of
this disease in England to be confined to the month of
August; but he himself observed it to appear sometimes
towards the  end  of summer, when the season was unu-
sually warm; and that, in proportion  to the heat, the
violence  of the disease was greater.   Others have ob-
served that it appeared more  early in summer, and al-
ways sooner or later, according as the great heats sooner
or later set in.
   1459.  From all these circumstances, it is, I think,
very evident, that this disease is the effect of a warm at-
mosphere, producing some change  in the state of the
bile in the human body:  and  the change may consist,
either in  the  matter  of the bile being  rendered  more
acrid, and thereby fitted to excite a more copious secre-
tion ; or,  in the same matter, its being prepared to pass
off in larger quantity than usual.
   1460.  It has been remarked, that in warm climates
and seasons, after extremely hot and dry weather, a fall
of rain cooling the atmosphere seems especially to bring
on this disease; and it is very probable that  an obstruct-
ed perspiration may have also a share in this, though it
   vol. u.               a g 
 226            PRACTICE OF PHYSIC.

 is also certain that the disease does appear  when uu
 change in the temperature of the air,  nor any applica-
 tion of cold has been observed.
   1461. It is possible, that, in some cases, the heat of
 the season may  give only a predisposition, and that the
 disease  may be excited  by certain ingesta  or other
 causes; but it  is equally certain, that the disease has
 occurred without any previous change or  error, either
 in  diet, or in the manner  of life,  that could be ob-
 served.*
   1462. The Nosologists  have  constituted  a  genus
 under the title of Cholera, and under this have arranged
 as a species every affection  in which a  vomiting and
 purging of any kind happened to concur.   In many of
 these  species, however, the matter evacuated is not bili-
 ous; nor does the evacuation  proceed from any cause
 in the state of  the  atmosphere.  Further, in many of
 these  species also, the vomiting which occurs is not an
 essential,  but merely  an  accidental  symptom  from the
 particular violence of  the disease.    The appellation of
 Cholera, therefore, should, in my opinion, be confined
 to the disease I  have described above; which by its pe-
 culiar cause, and perhaps also by its symptoms, is very
 different from all the other species  that have been  as-
 sociated with it.  I  believe  that  all the  other species
 arranged under  the title  of Cholera by Sauvages or
 Sagar, may be properly enough referred  to the  genus
 of Diarrhoea; which  we are  to treat of  in  the next
 chapter.
 f The distinction I have  endeavoured to establish be-

  * The appearance of cholera, independently of improper exposure, or
some impropriety in diet or drink, is a rare occurrence. In an adult, we have
never witnessed an event of this kind ;  it being always practicable to derive
the disease from some exciting cause.  In relation to children, we are per-
suaded the fact would  be found equally true, were we able to obtain the ne-
cessary information. 
                 PRACTICE OF  PHYSIC.            221

 iween the proper Cholera, and the other diseases that
 have sometimes  got the same  appellation,  will,  as I
 judge,  supersede the question, Whether  the Cholera,
 in temperate climates, happens at any other season than
 that above assigned?
    1463.  In  the case of a genuine cholera,  the cure of
 it has been long  established by experience.
    In the beginning of the disease, the evacuation of the
 redundant bile is to be  favoured by the plentiful exhi-
 bition of mild diluents, both given by the mouth, and
 injected by the anus; and  all evacuant medicines, em-
 ployed  in either way, are not only superfluous, but com-
 monly hurtful.*
    1464.  When the redundant bile appears to be suffi-
 ciently  washed out, and even before that, if the spas-
 modic affections  of the alimentary canal become  very
 violent, and are communicated in a considerable degree
 to other parts of the body, or when a dangerous debility
 seems to  be induced, the irritation is  to be immediately
 obviated  by opiates in  sufficiently large doses,  but in
 small bulk, and given either by the mouth,  or by glys-
 ter.f
  * In the United States, it is rarely, we think, necessary to give any thing
for the purpose of "favouring the evacuation ;" the emotions excited by the
complaint itself, being amply sufficient for that purpose.  The exhibition of
a little tepid water, to facilitate  the operation  of vomiting, and thus,  the
more speedily and completely to evacuate the contents of  the alimentary
canal, is, perhaps, occasionally useful. But, as soon as the irritating ingesta
are discharged, the indication is, to allay the commotion, and thus prevent
any further evacuation.
  f Opium, in substance, is preferable to any liquid preparation of it. We
have found a pill, consisting of half a grain, exhibited every half hour, to be
productive of very salutary effects.  Should this practice fail to check the
disease, in three or four hours, let from two to three drachms of laudanum,
mixed in a little flaxseed tea or bailey water, be given by injection, and re-
peated as circumstances may require.
  In the mean time, external applications are not without their use.
  Let flannel, wet in some spirits or brandy, be placed on the abdomen, and 
22S
PRACTICE  OF PHYhlC
    1465. Though the patient be in this manner relieved,
it frequently happens,  that  when the operation of  the

wrapt round the extremities.   The efficacy of this remedy appears to be
increased, by mixing with the liquor used, some oil or essence of mint.
  Blisters and sinapisms may be advantageously applied to the  same parts
So may pulverized pepper, ginger, or other spices, formed into a plaster, by
means of soap, and moistened with spirits.
  A patient in cholera, should never swallow more of any liquid than a
mouthful or two at  a time. Nor ought even that to be frequently repeated.
The mere mechanical distention of the stomach will produce vomiting.
  We have known much relief to be derived, in this disease, from swallow-
ing, every half hour, or oftener, half a wine-glassful of soda or seltzer wa-
ter.
  An infusion of dried mint is also a very pleasant and useful beverage.
  After the stomach and bowels have been thoroughly evacuated of their irri-
tating contents,  a flannel roller, passed, with some degree of tightness,
round the abdomen, is found to be a useful remedy.
                      CHOLERA INFANTUM.

  One of the most troublesome diseases, with which the physicians of the
United States are called to contend, is the Cholera Infantum.
  This is a disease of the summer season, and  is productive of great mor-
tality.  It occurs principally in large cities; and is most troublesome to chil-
dren, from about the fifth or sixth month, until the close of the second yea?
of their age.  It ^attacks them, occasionally,  at a later period; but not with
such violence, nor in so dangerous a form.
  The predisposing cause of Cholera Infantum,  is the warmth and impurity
of the air of a large city, during the summer  months; the chief exciting
causes, improprieties in articles of clothing and food.  Sudden changes in
the atmosphere, from heat to  cold, and from dryness  to humidity, are also
calculated to bring it into action.
  The fruits of the season are a most prolific source  of this disease.   Chil-
dren, under their third year, should never be suffered to touch them.
  It is a popular belief, that ripe fruits are innocent: some think salutary.
This is an error fraught with mischief.  Whether ripe or green—although
most so in the  latter state—they are certainly productive of the  complaint
we are considering.
  Cholera Infantum is most obstinate and fatal during dentition :  by  which
it, therefore, appears to be aggravated.
  In a large city, the most efficacious mode  of  treating this disease, is to
send the subjects of it to reside in the pure air of the country, where they
speedily recover.  If this measure be  adopted early in the complaint, the
cure is certain: and it often  succeeds,  even when appearances are almost
hopeless. 
PRACTICE  OF PHYSIC.
229
 opium is over,  the disease shows a tendency to return;
 and,  for  at  least some days  after  the  first  attack,  the

  In cases where a removal to the  country, if not impracticable, is highly
inconvenient, the following course of practice may be advantageously pur-
sued.
  Evacuate completely the  alimentary canal, of all  its offensive  and irri-
tating contents.  This may be best effected by ipecacuanha, as an emetic,
and calomel or castor oil as a purgative.  If the pulse be active and strong,
as is sometimes the  case, a few ounces of blood may be  drawn  with ad-
vantage.
  These things being done, let irritation be calmed  by means of opiates;
and, if no febrile symptoms forbid, tone restored to the stomach and bowels,
by a decoction of Colombo, quassia, or centaury.  The first  of  these reme-
dies we think entitled to a preference.
  The most suitable articles of diet are, liquid farinaceous preparations ;
such as rice or barley water, gruel, made of oat-meal parched, panado, pre-
pared from  well-baked biscuit, arrow-root or tapioca.  These  preparations
should be sweetened with loaf sugar ;  and, provided no febrile symptoms
exist,  a small  quantity of some grateful aromatic may be advantageously
added to them.
  In case  the puking continue obstinate, external applications  become  in-
dispensable.
  Green peppermint, stewed in brandy, applied to the wrists and stomach,
and frequently renewed, is highly useful.  So are plasters of Venice treacle,
or of soap and  powdered cloves, applied to the same parts.
  If these remedies fail to check the vomiting, recourse must be had to blis-
ters ;  which are also to be applied to the stomach and wrists.
  A pleasant and useful drink, under these circumstances, is, an infusion of
the dried  leaves of peppermint, or weak brandy and water,  sweetened with
loaf sugar. Care should, however, be taken, that too much drink be not
swallowed at a time ; otherwise  the  stimulus of distention will prove in-
jurious.
  Anodyne injections, judiciously administered, are serviceable.
  When the stomach  becomes retentive, and nothing but  a troublesome
diarrhoea remains, astringent preparations  may  be  tried with advantage.
Of these, a decoction of cinnamon, of logwood, of the root of the dew-berry
briar, and  of pomegranate peel, are among the most useful.
  Saccharum Saturni, combined with opium, may be also  advantageously
employed
  In the treatment of children, it is highly important, to render medicines,
as far as practicable, agreeable to the palate.  When, in the disease we are
considering, sweetening is used, for this purpose, it should be of the bes"
refined loaf sugar.
  To  relieve  griping, and determine to the skin, the warm  bath may, at
times,  be usefully employed. This is more especially the case, when the
complaint  immediately succeeds the disappearance of a cutaneous eruption. 
230
PRACTICE OF  PHYSIC.
 irritability of the intestines, and  their disposition to fall
 into painful spasmodic  contractions,  seem to continue.
 In this  situation, the repetition of  the opiates, for per-
 haps several days, may  come to be necessary; and as the
 debility commonly induced by the  disease  favours the
 disposition to spasmodic affections,  it is often useful and
 necessary, together with the opiates, to employ the tonic
 powers of the Peruvian bark.

The efficacy of the warm bath is increased, by impregnating the water with
muriate of soda.
  If there be a coldness and torpor of the skin, warm spirituous fomentations
to the abdomen prove somewhat advantageous.  The patient should, in the
mean time, be clothed in flannel.
  If, notwithstanding the treatment here directed, the disease continue,
with frequent bilious evacuations, a hot skin and an excess of arterial ac-
tion, there is reason to suspect hepatic derangement.
  In  that case the indication is, an alterative course  of mercury,  connected
with blistering on the region of the liver.  The blue pill constitutes the pre-
paration most suitable to the infantile constitution.
  The amount of this article administered must vary according to circum-
stances, of which  the practitioner must be himself the judge.
  The best substitute in large, cities for the  pure  air of  the country, is the
air of the  upper stories of their buildings. We are persuaded that the dele-
terious matter which contaminates the atmosphere,  does not rise to a great
elevation—it does not, perhaps, ascend above the second story of a common
city dwelling.
  The health of children, then, may be, in no inconsiderable degree, se-
cured, by using as a nursery, during the summer season, a large well venti-
lated third-story room.  We have had the experiment tried with very flat.
tering success.
  For the same  reason, during an epidemic prevalence of yellow fever,
adults may, to a considerable extent, preserve their health, by sleeping, and
indeed living in their third stories.
  This fact is well known, and the practice is followed, in oriental countries,
where the true plague prevails.
  In marshy countries,  sleeping on the  ground floor, contributes not a lit-
tle to the propagation of bilious fever.  We are persuaded that to sleep on
upper stories would be much more salutary 
PRACTICE OF PHYSIC.
231
                     CHAPTER XL

         OF DIARRHCEA, OR LOOSENESS.*

  1466.  THIS  disease consists in evacuation by stool,
  more frequent and  of more liquid matter  than usual.
  This leading and  characteristic symptom is so diversi-
  fied in its degree,  in its  causes, and  in  the  variety of
  matter  evacuated, that  it is  almost impossible to  give
  any general history of the disease.
    1467. It is to be distinguished from dysentery, by
  not being contagious; by being generally without fever;
  and by being with the evacuation of the  natural excre-
  ments, which are, at least,  for some time, retained in
  dysentery.   The two diseases have been  commonly dis-
  tinguished by the gripings being more violent in the
  dysentery; and they  are commonly less violent and less
  frequent in diarrhoea: but as  they frequently do occur
  in this also, and sometimes to a considerable degree, so
  they do not afford any proper distinction.
    1468. A diarrhoea is to be distinguished from cholera
  chiefly by  the difference of their causes;  which, in
  cholera,  is of one peculiar kind; but in diarrhoea is
  prodigiously  diversified, as we shall see presently.  It
  has been common to distinguish cholera  by the evacua-
  tion downwards being of bilious matter, and by this be-
  ing always accompanied with a  vomiting of the same
  kind; but it does not universally apply, as  a diarrhoea
  is sometimes attended with vomiting, and even of  bi-
  lious matter.

   • Both diarrhoea and cholera ought to stand under the order Profluvia, in-
stead of that of Spasmi. 
232
PRACTICE OF PHYSIC.
   1469. The disease of diarrhoea,  thus distinguished,
is very greatly diversified; but in all cases, the frequency
of stools is to be imputed to a preternatural increase of
the peristaltic motion in the whole, or at least in a con-
siderable portion, of the intestinal canal.  This increas-
ed  action is in different degrees,  is often  convulsive
and spasmodic, and at any rate is a motus abnormis: for
which reason,  in the Methodical Nosology, I have re-
ferred it to  the order of Spasmi, and accordingly treat
of it in  this place.
   1470. Upon the same ground, as I consider  the dis-
ease named Lientery to be an  increased peristaltic mo-
tion over  the whole of the intestinal canal, arising from
a  peculiar irritability, I  have considered it as merely a
species  of diarrhoea.  The idea of a laxity of the intes-
tinal canal being the cause either of lientery, or other
species  of diarrhoea, appears to me to be without foun-
dation,  except in the single case of frequent liquid stools
from  a  palsy of the sphincter ani.
   1471. The increased action of the peristaltic motion,
I consider as always the chief part of the  proximate
cause of diarrhoea: but the disease is  further,  and in-
deed chiefly, diversified by the different causes of this
increased action; which  we are now to inquire  into.
   1472. The several causes of the  increased action of
the intestines  may  be  referred,  I  think,  in  the  first
place, to two general heads.
   Hhe first is, of the diseases of certain parts of the body
which, either from a consent of the intestines with these
parts, or from the relation which the intestines  have to
the whole system,  occasion an increased action in  the
intestines,  without  the transference of any  stimulant
matter from the primary J ceased part to them.
   The second head of the causes of the increased action 
PRACTICE OF PHYSIC.
233
 of the intestines is the stimuli of various  kinds, which
 are applied directly to the intestines themselves.*
   1473.  These affections of other parts of the system
 may affect the intestines without transference or appli-
 cation of any of the  stimulant matter; we learn from
 hence that the passions of the mind do in some  persons
 excite diarrhoea.
   1474.  That diseases in other parts may in like man-
 ner affect the intestines, appears from  the dentition of
 infants  frequently exciting  diarrhoea.   I believe that
 the gout often affords another instance of the same kind;
 and probably there are others also, though not  well as-
 certained.                                          J
   1475.  The  stimuli (1472.)  which may be  applied
 to the intestines are of very various  kinds; and  are
 either,
   1. Matters introduced by the mouth.
   2. Matters poured into the intestines by the several
 excretories opening into them.
   3. Matters poured from certain  preternatural open-
 ings made into  them in certain diseases.
   1476. Of those (1475, 1.) introduced by the mouth,
 the first to be  mentioned are  the aliments commonly
 taken in.  Too great a quantity of these taken in, often
 prevents their due digestion in the stomach;  and  by

  * Our author makes, in this section, one of the clearest recognitions of the
doctrine of sympathy, that is any where to be found in his writings.
  Of the two kinds of diarrhoea, of which he here speaks, one is the result
of proximate irritation of the bowels themselves, and the other of irritation
or a deleterious impression on a distant part. But, in the latter case, diarrhoea
can be excited only by sympathy.
  This is not a mere abstract or theoretical division of the disease ; it is, in
a practical point of view, peculiarly important.  According as the complaint
arises from  proximate or remote irritation, must the treatment for the re-
moval of it be different.  In one case you must operate more on the intes-
tines themselves; in the other, on remote but sympathizing organs.
   VOL. II.                H h 
234
PRACTICE OF PHYSIC.
being thus sent in their crude, and probably acrid, state
to the intestines, they frequently excite diarrhoea.
   The same aliments, though  in proper quantity, yet
having too great a proportion, as frequently happens, of
saline or saccharine  matter along with them, prove sti-
mulant to the intestines,  and excite diarrhoea.
   But our aliments prove especially the causes of diar-
rhoea, according as they,  from their own nature, or from
the weakness of the stomach, are disposed to undergo
an undue degree of fermentation there, and thereby be-
come stimulant to the  intestines.   Thus acescent ali-
ments are ready to produce diarrhoea; but whether from
their having any directly purgative quality,  or only as
mixed in an over proportion with the bile, is not well
determined.
   1477. Not only the acescent, but also the putrescent
disposition of the aliments, seems to occasion a  diar-
rhoea; and  it appears that even the effluvia of putrid
bodies taken  in  any way  in large  quantity, have the
same effect.
   Are oils or fats, taken in as part of our aliments, ever
the cause of diarrhoea?  and if so, in what manner do
they operate?*
   1478. The other matters introduced by the mouth,
which may be causes of diarrhoea,  are those thrown in
either as medicines, or poisons that have the faculty of
stimulating the alimentary canal.   Thus,  in the list of
the Materia Medica. we  have a long catalogue of those
named purgatives; and in  the list of poisons, we have
many possessed of the same quality. The former, given
in a certain quantity, occasion a temporary diarrhoea;
and given in very large doses, may occasion it in excess,
and continue it longer than usual, producing that species
of diarrhoea named a Hypercatharsis.
* If oil or fats prove indigestible, they may certainly produce diarrhoea. 
PRACTICE OF PHYSIC.
235
   1479.  The matters (1475, 2.) poured into the cavity
of the intestines from the excretories opening into them,
and which may occasion diarrhoea, are either those from
the pancreatic or biliary duct, or those from the excre-
tories in  the coats of the intestines themselves.
   1480.  What changes may happen in the pancreatic
juice I do not exactly know; but I suppose that an acrid
fluid may issue from the pancreas, even while still entire
in its structure; but more especially when it is in a sup-
purated,  scirrhous, or cancerous state, that  a very acrid
matter may be poured out by the pancreatic duct, and
occasion diarrhoea.
   1481.  We know well,-that from  the biliary duct the
bile may be poured out in greater quantity than usual:
and there is little doubt of its being also sometimes pour-
ed out of a more  than ordinary acrid quality.  It is very
probable, that in both ways the bile is frequently a cause
of diarrhoea.
   Though I have said above that diarrhoea may  be com-
monly distinguished from cholera,  I must  admit here,
that  as the causes producing that state of the bile which
occasions cholera, may occur in all the different  possible
degrees of force, so as, on one occasion, to  produce the
most violent and  distinctly marked  cholera; but, upon
another,  to produce only the gentlest diarrhoea: which,
however, will be  the same disease,  only  varying in de-
gree: so I think it probable, that in  warm climates, and
in warm seasons, a diarrhoea biliosa of this kind may fre-
quently occur, not to be always certainly distinguished
from cholera.
  However this may be, it is sufficiently probable, that,
in some cases, the bile, without having been acted up-
on by the heat of the climate or season, may be redun-
dant  and  acrid, and prove therefore a particular cause of
diarrhoea. 
230
PRACTICE OF PHYSIC.
   1482. Beside bile from the several causes and in the
conditions  mentioned, the  biliary duct  may pour out
pus, or other matter from abscesses  in the liver, which
may be the cause of diarrhoea.
   Practical writers take notice of a diarrhoea wherein
a thin and bloody liquid is discharged; which they sup-
pose to have  proceeded from the liver, and have there-
fore given  the  disease the  name of Hepatirrhoea: but
we have not met  with any instance of this kind; and
therefore cannot properly say any thing concerning it.
   1483.  A second set of excretories, from which mat-
ter is poured into the cavity of the intestines, are those
from the coats of the intestines  themselves;  and are
either the exhalants proceeding directly from the extre-
mities of arteries, or  the excretories from  the mucous
follicles:  and both these sources  occur  in  prodigious
number over the internal surface of the whole intestinal
canal.  It is probable  that it is chiefly the effusion  from
these sources which,  in most instances, gives the  mat-
ter of the liquid stools occurring  in  diarrhoea.*
   1484.  The matter  from both sources may be poured
out in larger quantity  than usual, merely by the increas-
ed action of  the intestines,  whether that be excited by
the passions of  the mind (1473.),  by diseases  in other
parts of the system (1472, 1.), or by the various stimu-
lants mentioned  1476, and following; or the quantity of

  * When the cutaneous perspiration is suppressed by cold, the secretory
action of the vessels of the intestines is increased by sympathy, not by a me-
chanical determination of a greater quantity of fluids to the part.
  We do not believe,  that either urine or pus is ever taken up into the
blood-vessels, and thrown off by the intestines, in the form of a diarrhoea.  It
is certain that they may both  be absorbed; but not in their formal character.
They undergo a digestion or change, in consequence of the action of the ab-
sorbents, and, being thus received into the blood-vessels, pass off again,  in
the common mass oi excreted fluids—partly by the  intestines, partly by
the skin, and in part, perhaps, !.y Uic kidneys themselves. Even when the
water of dropsies passes off by the intestines, it must be through the regu
lar medium of absorption and secretion 
PRACTICE OF  PHYSIC.
237
 matter poured out may be increased,  not so much  by
 the increased action of the intestines, as by an increased
 afflux of fluids from other parts of the system.
   Thus, cold applied to the surface of the body, and
 suppressing perspiration, may determine a greater quan-
 tity of fluids to the intestines.
   Thus, in the ischmia renalis, the urine taken into the
 blood-vessels is sometimes determined to pass off again
 by the intestines.
   In like manner, pus or serum may be absorbed from
 the cavities in which they have been stagnant, and  be
 again poured out into the intestines, as frequently hap-
 pens,  in particular with respect  to  the water of drop-
 sies.
   1485. It is to be observed here, that a diarrhoea may
 be excited  not only by a copious afflux  of fluids from
 other parts of the system,  but likewise by the mere de-
 termination of various acrid matters  from  the  mass of
 blood into the cavity  of the intestines.  Thus it is sup-
 posed that  the morbific matter of fevers is sometimes
 thrown out into  the cavity of the intestines, and gives a
 critical diarrhoea: and whether I do or do not admit the
 doctrine of critical evacuations, I think it is probable
 that the morbific matter of the exanthemata is frequently
 thrown upon the intestines, and occasions diarrhoea.
   1486.  It is to me further probable, that the putres-
 cent  matter diffused  over the mass of blood in putrid
 diseases, is frequently poured out by the exhalants into
 the intestines, and proves  there the cause, at  least  in
 part,  of the diarrhoea so commonly attending these dis-
 eases*

  * 1485-6. The intelligent reader will at once perceive,  that the doctrine,
contained in these two articles, participates too much, of the humoral pa-
thology, to be correct. Nor are we inclined to think much more favourably
of the pathological sentiments, expressed in the four succeeding article?,
They are mostly antiquated, obsolete, and erroneous. 
238           PRACTICE OF PHYSIC.
   1487. Upon this subject of the matters poured into
the cavity of the intestines, I  have  chiefly considered
them  as poured out in unusual quantity, but it is pro-
bable that, for the most part,  they are also changed in
their quality, and  become of a more acrid and stimulant
nature; upon which account especially it is that they ex-
cite, or at least increase a diarrhoea.
   1488.  How far, and in what manner, the exhalant
fluid may be changed in its nature and quality, we do
not certainly know; but with respect to the fluid from
the mucous excretories, we know,  that when poured
out in unusual quantity, it is  commonly, at the  same
time,  in a more liquid and acrid form;  and may prove,
therefore, considerably irritating.
   1489.  Though the copious effusion of a more liquid
and acrid matter from  the mucous excretories,  be pro-
bably owing to the matter being poured out immedi-
ately as it is secreted  from the blood into the mucous
follicles, without being  allowed to stagnate in the latter,
so as to acquire that  milder quality and thicker con-
sistence we commonly  find in the mucus in its  natural
state; and although we might suppose the excretions of
a thin and acrid fluid should always be the effect of
every determination  to the mucous  follicles,  and of
every stimulant applied to  them; yet it  is certain,  that
the reverse is sometimes the case;  and  that  from the
mucous follicles, there is frequently an increased excre-
tion of a mucus, which appears in its proper form of a
mild, viscid, and thickish matter.  This commonly oc-
curs in the case of dysentery; and it has been observed
to give a species of diarrhoea, which has been properly
named the Diarrhoea Mucosa.
   1490.  A third source of matter poured into the ca-
vity of the intestines,, and occasioning diarrhoea (1475,
3.) is from those preternatural  openings produced  by 
PRACTICE  OF PHYSIC.
239
  diseases in the intestines or neighbouring parts.   Thus
  the blood-vessels on the  internal surface of the  intes-
  tines may be opened by erosion, rupture, or anastomo-
  sis, and pour into the cavity their blood, which, either
  by its quantity, or  by its acrimony, whether inherent,
  or acquired by stagnation, may sometimes give a diar-
  rhoea evacuating bloody matter.  This is what 1  think
  happens in that disease which has been called the Me-
  lama, or Morbus Niger.
     1491. Another preternatural source of matter poured
  into the cavity of the intestines, is the rupture of ab
  scesses seated either in the coats of the intestines them-
  selves, or in any of the contiguous  viscera, which, dur-
  ing an inflamed  state, haa formed an adhesion with
  some part of the  intestines.  The  matter thus poured
  into their cavity may be various, purulent, or sanious,
  or both together,  mixed at the same time with more or
  less of blood; and in  each of these states  may  be  a
  cause  of diarrhoea.
    1492. Amongst the stimuli that may be directly ap-
 plied  to the  intestines, and which, by increasing their
 peristaltic  motion, may occasion  diarrhoea, I must not
 omit to mention  worms as  having frequently that ef-
 fect*
   1493.  I must also mention here a state of the intes-
 tines, wherein their peristaltic motion is preternaturally
 increased, and a diarrhnea produced; and that is, when
 they are affected  with an erythematic  inflammation.
 With respect  to the existence of such a state, and its
 occasioning diarrhcea, see what is said above in 398, and
 following.   Whether it is to be considered as a particu-

  * When, by cold, or any other cause, the irritability of the intestines is in-
creased, the presence of worms, by augmenting irritation, may produce a
diarrhaa.  But we are certain that the disease can be thus produced, with-
<mt such an increase of the irritability. 
240         PRACTICE OF  PHYSIC.
lar and distinct case of diarrhoea, or is always the same
with  some of those produced by  one or other of the
causes above mentioned, 1 have not been able to deter-
mine.
   1494. Lastly,  by an accumulation of alimentary or
of other matter poured into the cavity of the intestines
from  several of the sources above mentioned, a diar-
rhoea may be especially occasioned when the absorptioa
of  the lacteals,  or of other absorbents, is prevented,
either by an obstruction of their orifices,  or by an  ob-
struction of the mesenteric glands  through which alone
the absorbed fluids can be transmitted.
   In  one instance of this kind,  when the chyle prepared
in the stomach mid duodenum is  not absorbed in  the
course of the inu-atines,  but passes off in considerable
quantity by the anus, the disease has been named Mor-
bus Cceliacus, or simply and  more properly Cwliaca;
which accordingly I have considered  as  a species of
diarrhoea.*
   1495. I have thus endeavoured to point out the va-
rious species of disease that may come under the gene-
ral appellation of diarrhoea; and from that enumeration
it will appear, that many, and indeed the greater part of
the cases of diarrhoea, are to  be considered as sympa-
thetic affections,  and to be cured only by curing  the
primary disease  upon  which  they depend; of which,
however, I cannot properly treat here.   From our enu-
meration it  will also appear,  that  many of the  cases of
diarrhoea which may be considered as  idiopathic, will
not require my saying much of them  here.   In many
instances, the disease is ascertained, and also the cause

  * Chyle, strictly so called, is not, we think, prepared either in the stomach
or duodenum.  These organs contain the materials, of which chyle is to be
formed ; but not the chyle itself. That fluid receives the finishing touch of
its elaboration from the lacteals. 
PRACTICE OF PHYSIC.
241
assigned, by the condition of the matter evacuated; so
that what  is necessary  to  correct or remove  it will be
sufficiently obvious to  practitioners of any knowledge.
In  short, I do not find that I can offer any general plan
for the cure of diarrhoea; and all that I  can pretend to
do  on this subject,  is to give some general remarks on
the practice  that has been  commonly followed in  the
cure of this disease.
    1496. The practice in this disease has chiefly pro-
ceeded upon the supposition of an acrimony in the fluids,
or  of a laxity in the simple and moving fibres of the in-
testines; and the remedies employed have accordingly
been, correctors of particular acrimony,  general demul-
cents,  evacuants  by  vomiting or purging,  astringents,
or  opiates.  Upon  each  of  these kinds of remedies  I
shall now  offer  some remarks.*


  *  In point of correctness and verity, the doctrines of " acrimony in the
fluids," and "laxity in the simple and moving fibres," stand precisely on the
same footing.   They  are both erroneous.  Of the doctrine of acrimony, we
have already spoken, and shall not,  therefore, dwell on  it at present.
  The idea of laxity, as here used, is mechanical, and applicable only to dead
matter.  Of living matter, particularly of the state or structure of secretory
vessels, it is not predicable. The term irritability, would be much more suita-
ble in this place ; and would convey an idea nearer to the truth than that of
laxity.
  The treatment of diarrhoea must correspond to the  nature and causes of
the disease : and, these being various, it is obvious that the treatment must
be various also.  Even a brief view of the mode of treating every form and
description  of diarrhoea, would occupy, perhaps, an entire volume.  Nor is
this  necessary, inasmuch as most varieties of the complaint,  being nothing
but  symptoms of other diseases, are included, of course, in the accounts of
these diseases.
  In the treatment of this complaint, whatever may be its cause or charac-
ter,  an attention to diet is of the utmost moment.  Nothing,  as an article of
food, is admissible, unless it be light, bland in its qualities, free from aces-
cency, and easily digested. Rice, sago, tapioca, gum arabic, powdered arrow-
root, and well-baked bread and crackers, made into panado, may be used
without injury. They may also be  rendered savoury, by the addition of
some agreeable aromatic.  If animal food be used, salted meat is better than
fresh. Fruit  is inadmissible.  Milk, if boiled, may be taken with safety, and
sometimes with advantage. As a general rule, in diarrhoea, tea is preferable
    VOL. II.                 I i 
2-13
PRACTICE  OF  PHYSIC.
     1497.  An  acid  acrimony is,  upon several occasions,
  the cause of  diarrhoea, particularly  in children; and in

 to coffee, and black tea preferable to green.  In  some cases, well prepared
 chocolate is preferable to either.   In diarrhoea, it is important that every ar-
 ticle of diet be thoroughly cocked.
   As drinks, malt liquors and cider are improper.  So, in general, are wines;
 because, although not really acid,  they are somewhat acescent.  Well pre-
 pared spirits or  brandy,  mixed with water,  form a beverage which is less
 exceptionable.
   If the diarrhoea proceed from a suppression of perspiration, the indication
 of cure is  obvious.  Let the cutaneous action be restored, and the  disease
 will be at an end.
   This indication may be answered by an emetic, followed by sudorifics, of
 which opium shall constitute a part.  In the  treatment of this form of the
 disease, it is necessary that flannel be worn next the skin.  A flannel roller,
 passed several times round  the abdomen, so as to  make a gentle and uniform
 pressure, is highly useful.   If requisite, let the  warm bath be resorted to,
 with the application of blisters, to the abdomen and extremities.   This prac-
 tice, with the proper use of opiates, will seldom fail to  effect a cure.
   If acidity prevail in  the stomach, let absorbents be used.  In this case,
 lime-water, either alone,  or mixed with new milk, is an efficacious remedy.
 So is the common cretaceous julap, combined with laudanum. This mixture
 is known to consist of prepared chalk,  mucilage  of gum arabic, cinnamon,
 mint or lavender water, common water, laudanum and loaf sugar.  As much
 of this preparation, as  may contain  from five to ten drops  of laudanum, may
 be administered three or  four times a day, or oftener, if necessary.
  If diarrhoea be produced, by the  sudden disappearance of some cutaneous
 eruption, as of prickly heat, in hot weather, let means be adopted for its im-
 mediate restoration.   The remedies, here, will be nearly the same, as under
 suppressed perspiration.  In such a case, we have  seen a little spiced brandy
 productive of an excellent effect.   If any fever, however, be present,  this
 article is inadmissible.
  Does  the disease proceed  from  bad water, or unwholesome  food ?  Let
 these articles be abandoned or corrected.   The mode of correction will de-
 pend on the nature of the qualities to be removed.
  If diarrhoea arise from repelled gout; let that complaint be recalled to the
 extremities, by such remedies, as are calculated  for the purpose; most of
which we have mentioned on a former occasion.
  If the disease prove obstinate, let  astringents be  tried, in  combination with
opiates. The  astringents,  most in vogue, are, alum, catechu, galls, logwood,
 gum kino, and saccharum saturni.  This latter article, given to the amount
of from two to three grains, combined with half a grain of opium, and repeat-
ed, if requisite, every two or three  hours, is highly efficacious.
  We have exhibited,  with much advantage, in this disease, as well as in the
latter stages of dysentery, a strong decoction of  the peel of the pomegra-
nate, and also of the rotit  of the blackberry, or, as it is usually termed, the
dewberry, of our own country. 
PRACTICE OF PHYSIC.           243
  such cases the absorbent earths have been very properly
%.memployed.   The common,  however, and  promiscuous
  use of these  hath been very injudicious; and where
  there  is any putrescency, they must be hurtful.
     1498. The cases in which there is a putrid or putres-
  cent acrimony  prevailing, have been, I think,  too sel-
  dom taken notice of; and, therefore, the use of acids too,
  seldom  admitted.   The acrimony  to  be suspected in
  bilious cases, is probably of the putrescent kind.
     1499. The general correctors of acrimony  are the
  mild  diluents and demulcents.  The former  have not
  been  so much employed  in diarrhoea as they ought;
  for, joined  with demulcents,  they very much increase
  the  effects of the latter: and  although  the demulcents,
  both mucilaginous  and  oily,  may  by  themselves be
  useful, yet, without the assistance of diluents they can
  hardly be introduced in such  quantity as to answer the
  purpose.
     1500. As  indigestion  and  crudities  present  in the
  stomach are so often  the cause  of diarrhoea,  vomiting
  must, therefore, be frequently very useful in this dis-
  ease.
     In  like  manner, when  the disease  proceeds,  as it
  often does, from obstructed perspiration, and mcreased
    These articles may be rendered, we think, more efficacious, by the addi-
  tion of a small'quantity of some pleasant aromatic.
    As an astringent, they are particularly useful, in the diarrhoeas of children.
    If the stomach fail to retain opiates, let them be given by injection.
    If the disease be in children,  and dentition the cause, the scarification of
  the gums, to remove irritation, will be useful.  If it proceed from worms,
  give the wormseed oil, and purge copiously, with calomel and rhubarb.
    As a tonic, to strengthen the bowels,  after diarrhoea has disappeared, Co-
  lombo root, quassia, bark, or chalybeates, may be used.  The mode of pre-
  paring and exhibiting these remedies, is known to every one.
    In this complaint, aromatics, combined with opium and astringents, make
  an important remedy.
    Should other remedies fail, a journey on horseback, a sea voyage, or a
  change of climate, may be tried.  Ipecacuanha, in small, but repeated doses,
  to promote perspiration, is highly useful. 
244          PRACTICE OF PHYSIC.

afflux of fluids to the intestines, vomiting is perhaps the
most effectual means of  restoring the determination of.
the fluids to the surface  oi' the body.
   It is  possible also, that vomiting may give some in-
version of the peristaltic motion,  which U determined
too much  downwards in  diarrhoea; so that upon  the
whole  it is a remedy which may be very generally use-
ful in this^disease.
   1501. Purging has been supposed to be  more uni-
versally necessary, and has  been more generally prac-
tised.   This, however, in my opinion, proceeds upon
very mistaken notions with respect to the disease; and
such a practice seems to me for the most part superflu-
ous, and in many cases very hurtful.  It goes upon the
supposition of an acrimony present  in  the  intestines,
that ought to be carried out by purging: but, if that acri-
mony has  either been   introduced by  the mouth, or
brought into the intestines from other parts of the body,
purging can neither be  a means of correcting nor of
exhausting it; and must rather  have the  effect of in-
creasing its afflux, and of aggravating its effects.   From
whatever source the acrimony which can excite a diar-
rhoea proceeds, it may be supposed sufficient to evacu-
ate itseu,' so far as  that can be done by purging; and
as in cholera, so in the same kind of diarrhoea, it will
be  more proper  to  assist the  evacuation by diluents
and demulcents, than to  increase the irritation by pur-
gatives.
   1502. If, then, the use of purgatives in diarrhoea may
be  considered,  even when  an acrimony is present, as
superfluous, there are many other cases in which it may
be extremely hurtful.  If the irritability of  the  intes-
tines shall, from affections in other parts of the system.
or other causes, have been already very much increased,
purgatives  must necessarily aggravate the disease.  In 
              PRACTICE OF PHYSIC.            245

the case of lientery, nobody thinks of giving a purga*
tive; and  in  many  cases of  diarrhoea approaching to
that, they must be  equally improper.  I  have already
observed,  that when diarrhoea proceeds from  an afflux
of fluids to the intestines, whether in too great quantity,
or of an acrid quality,  purgatives may be  hurtful;  and,
whoever, therefore,  considers the numerous and various
sources from which acrid matter may be poured into
the cavity of the  intestines, will readily perceive,  that
in many cases of diarrhoea, purgatives may be extremely
pernicious.
   There is one case in particular to be taken notice of.
When, from a general  and  acrid dissolution of the
blood, the serous  fluids run off too copiously in the ca-
vity of the intestines;  and excite that diarrhoea  which
attends the advanced state of hectic fever, and is  pro-
perly called a Colliquative Diarrhoea, I have, in such
cases, often seen  purgatives given with the most bane-
ful effects.
   There is still another case of diarrhoea in which pur-
gatives are pernicious; and that is, when the disease de-
pends, as we have  alleged  it sometimes may, upon an
erythematic inflammation of the intestines.
   I need hardly add, that if there be a case of diarrhoea
depending upon a laxity of the solids, purgatives cannot
there be of any service, and may do much harm. Upon
the whole, it will, I think, appear, that the use of pur-
gatives in diarrhoea is  very much limited; and that the
promiscuous use  of them, which has been  so  common,
is injudicious,  and often  pernicious.  I believe  the
practice has  been chiefly owing to the use of purgatives
in dysenteric cases, in  which they are truly useful; be-
cause,  contrary to the  case of diarrhoea, there is in dy-
sentery a  considerable  constriction of the  intestines.
   1503. Another set of remedies employed in diarrhoea 
 246           PRACTICE OF PHYSIC.

 are astringents.  There has been some hesitation about
 the employment of these in recent cases, upon the sup-
 position that  they might  occasion the retention of an
 acrid matter that should be thrown out.  I cannot, how-
 ever, well understand or assign the cases in which such
 caution  is necessary, and I  think that the power of
 astringents is  seldom so great  as to render their use very
 dangerous.
   The only difficulty which has occured to me, with
 respect to their use,  has  been to judge of  the circum-
 stances to which they are especially adapted.  It appears
 to  me to be only in those where the  irritability of the
 intestines depends upon a loss of tone; and this, I think,
 may occur from  the debility  of  the  whole  system, or
 from  causes acting on the  intestines alone.   All violent
 or long continued spasmodic and convulsive affections
 of the intestinal canal necessarily induce a debility there;
 and such causes often take place, from violent irritation,
 in colic, dysentery, cholera, and diarrhoea.
   1504. The  last of the remedies of diarrhoea that re-
 main  to be mentioned are opiates.  The same objec-
 tions  have been made to the use  of  these, in recent
 cases of diarrhoea, as to that of astringents;  but on no
 good  grounds: for the effect of opiates, as astringent, is
 never very permanent; and an evacuation  depending
 upon  irritation, though it may be for some time suspend-
 ed by opiates,  yet always returns very soon.   It is only
by taking off  irritability that opiates are useful in  diar-
 rhoea; and, therefore, when the  disease depends upon
 an increase of irritability alone, or when, though pro-
 ceeding  from  irritation,  that  irritation is corrected or
exhausted, opiates  are the most useful and certain re-
medy. And  though opiates are not suited to  correct or
remove  an irritation  applied, they are often of great be-
nefit  in  suspending  the effects of that irritation when- 
                  PRACTICE OF PHYSIC.              241

ever these are violent: and, upon the whole,  it will ap-
pear, that  opiate^  may be  very frequently,  and with
great propriety, employed in the cure of diarrhoea.
                          CHAPTER XII.


                    OF  THE  DIABETES.*

 1505.  THIS disease  consists in the voiding of an un-
 usually large quantity of urine.

  * It is much to be regretted, that, in diabetes, neither the pathology, nor
the practice, is settled, as yet, on satisfactory principles.
  While some consider the disease, as arising out of a morbid and imperfect
state of action of the stomach, and the several assimilating  organs, others
regard it, as consisting in an inflammatory affection of the kidneys.   Out of
these two different opinions, different modes of practice must necessarily
arise.
  Our own experience in this complaint being exceedingly limited—for, for-
tunately, its occurrence, in  the United States, is not very frequent—we can
do nothing better, at present, than become the organ for communicating to
our readers, a brief statement of the practice of others.
  For the cure of diabetes, which he appears to have studied with much at-
tention, Dr. Rollo prescribes, " a diet, consisting wholly of animal food, ab-
staining rigidly from every  kind of vegetable matter, from which sugar may
be produced: he likewise enjoins the hepatized ammonia, to be taken daily,
in doses of three or four drops, to  be taken three or four times a day, and
gradually increased, until a  giddiness be produced; exercise to be avoided;
antimonial wine, with opium, to be taken, at night; an ulceration, about the
size of half a crown, to be formed, opposite to each kidney; and the bowels
to be kept open, by aloes and soap."
  " A case of diabetes mellitus, is recorded, in the thirteenth volume of the
Medical Journal, by Mr. Earnest, surgeon to the Sheffield general infirmary,
which was successfully treated, by  putting the patient on a diet, consisting,
principally, of animal food, with a generous allowance of porter; giving, at
the same time, the  nitric  acid, in the proportion of from two to  three
drachms, of the acid, to two pounds of water, with about an ounce of sugar,
daily."
  " We are informed, by Dr. Ferriar,  that he has cured three confirmed
cases of this disease, by a combination of cinchona, uva ursi, and opium, taken
three times a day, in the proportion of a scruple, of each of the former, to
half a grain of the latter, and, that, from the great success he had met with, 
248
PRACTICE  OF  PHYSIC.
    As hardly any secretion can be increased without an
 increased  action of the vessels concerned in it, and as


 from  this medicine, he found it unnecessary to try Dr. Rollo's plan.  The
 doses were taken, with lime-water, which was also directed, for the patient'i
 common drink."
  By those, who, from the vascular appearance, and enlarged size, which the
 kidneys present, on dissection, consider diabetes, as consisting in an inflam-
 matory affection of those organs, a different mode of treatment is, of course,
 adopted.
  It appears that, by those physicians, " several cases, of this disease, were
 successfully treated, by an antiphlogistic regimen, and very copious deple-
 tion, by venesection, employed, under the most unpromising  circumstances,
 such as a low, feeble pulse, loss of strength and spirits, and cold and (Edema-
 tous extremities.  These cases seem to support the opinion, that  an inflam-
 matory action does  really take place, in the kidneys of those, labouring un.
 der this disease.
  In one of the cases recorded, it  appears that venesection was repeated,
 until one hundred and eighty ounces of blood had  been taken away; and
 that the result was,  a perfect restoration of health.
  " A very visible change was observed, in the appearance of the blood, dur-
 ing the process:  at first, it was black, and had only a very small proportion of
 crassamentum ; but, as more and more of it was taken away, it gradually ac-
 quired the appearance, which it exhibits in persons,  who labour under in
 flammatory fever. The same practice was followed, with the same result, in
 all the other cases :  the condition of the blood was changed, and the health
 was restored, as in the instance recited; and it is to the bleeding, alone,that
 any essential benefit is attributed."
  It has been proposed to  treat  diabetes, by purging and puking, alone, giv-
 ing' a cathartic and an emetic, alternately,  until the disease be removed, or,
 it be clearly ascertained, that the remedies are insufficient.  Of the efficacy
 of this practice,  we are unable to speak, and propose it, therefore, only for
 consideration. We  think it likely to be improved by an occasional interpo-
 sition of tonics
  For  further information,  on  this  disease,  see  Bartholin—Sydenham—
 Ruysch—Fothergill—Meyers de Diabete—Rollo on Diabetes—Watt on Bia-
 betes—Latham on Diabetes, and Girdlestone  on Diabetes.
  Although six years have  elapsed since the preceding note was written, we
 have not, in principle or substance, any thing material  to add to it.
  In the  main, the doctrine of the phlogistic nature of diabetes appears to
 prevail—such a doctrine, at least, as leads, in part, to an antiphlogistic plan
 of treatment.  But it is only in part: for, while the lancet is used with consi-
derable freedom, an  animal diet is strictly enjoined.
  Of the compatibility of these two measures, so opposite in their nature,
 and of the propriety of uniting them in the same  scheme of practice, no-
 thing short of experience  could have  convinced us   To that experience,
 however, we are compelled to do homage, and, on its altar, to sacrifice theory
 to fact. 
                PRACTICE OF PHYSIC.           249

  some instances of this disease are attended with affec-
  tions manifestly spasmodic. I  have had no doubt of ar-
  ranging the diabetes under the order of spasmi
    1506.  The disease  is  always  accompan;ot; with  a
  great degree of thirst, and therefore with  .he takmg in
  of a great quantity of drink. This in some measure ac-
  counts  for the very extraordinary quantities of  urine
  voided: but still, independent  of this, a peculiar disease
  certainly takes place; as the quantity of  urine voided
  does almost always exceed the whole of the  liquids,
  and  sometimes the whole  both of solids and liquids
  taken in.
    1507. The urine voided in this disease is always very
  clear, and at first sight appears entirely without any co-
  lour; but viewed in a certain light, it generally appears
  to be slightly tinged with a yellowish green, and m this
  respect has  been very  properly compared  to a solution
  of honey  in a large  proportion of water.
    Examined by the taste, it is very generally found to
  be more or less sweet;  and many experiments that have
  now been made in different instances of the disease show
 clearly that such urine contains, in considerable quan-
 tity,  a saccharine matter which appears to be very ex-
 actly of the nature of common sugar.
    1508.  Doctor Willis seems  to me to have been the
 first  who took notice of the sweetness  of the urine in
 diabetes,  and almost every  physician of England  has
 since taken notice of the same. It is to be doubted, in-
 deed, if there is any case of idiopathic diabetes, in which

  In the treatment of diabetes,  particular attention should be paid to the
condition of the bowels, and, by suitable clothing, and the use of the flesh-
brush, especially on the lumbar region, the healthy action of the skin ought
to be vigilantly preserved.
  What would be the effect of rubbing on the lumbar region a paste made
of tartar emetic, flour, and water, which is known to produce on the skin a
specific and obstinate pustular inflammation ?
  VOT* tl.                 Kk 
250           PRACTICE OF PHYSIC.

tbe urinejs of a different kind.  Though neither the
ancients, nor, in the other countries of Europe, the mo-
dems, till the latter were directed to it by the  English
have taken notice of the sweetness of the urine, it does
not persuade me,  that either in ancient or in modern
times the urine in  diabetes was of another kind.  I my-
self,  indeed, think  J have met with one instance of dia-
betes in which  the urine was perfectly insipid; and it
would seem that a like observation had occurred to Dr.
Martin Lister.   I  am  persuaded,  however, that  such
instances are very  rare; and that the other is by much
the more common, and perhaps the almost universal oc-
currence. I judge, therefore, that the presence of such
a saccharine matter may be  considered as the principal
circumstance in idiopathic diabetes; and it gives at least
the only  case of that disease that  I  can properly  treat
of here,  for 1 am  only certain  that what I am further
to mention relates  to such a case.
   1509.  The antecedents of this  disease, and conse-
quently the remote causes of it, have not been well as-
certained.   It may be true that it frequently happens to
men  who, for a long time before, had been intemperate
in drinking; that it happens  to persons of a broken con-
stitution,  or who, as we often express it,  are  in  a ca-
chectic state; that it sometimes follows intermittent fe-
vers; and  that it  has often occurred from excess in
drinking  of mineral \vaters.#   But none of these causes
apply very generally to the cases that occur: such cases
are not always, nor even frequently, followed by a dia-
betes; and there are many instances  of diabetes, which
could not be referred  to any of them.  In most of the
cases of this disease which J  have met with, I could not
refer it to any  particular cause.
   1510.  This disease commonly comes on slowly, and
almost imperceptibly, without any previous disorder. It 
PRACTICE OF PHYSIC.
25\
 often arises to a considerable degree, and subsists long
 without being accompanied with evident disorder in any
 particular part of the system.   The great thirst which
 always, and the voracious appetite which frequently oc-
 cur in it, are often  the. only remarkable symptoms. Un-
 der the continuance of the disease, the body is often
 greatly emaciated;  and a great weakness also prevails.
 The pulse is commonly frequent; and an obscure fever
 is for the most part present.  When the disease proves
 fatal, it generally ends with a  fever, in many circum-
 stances,  particularly those of emaciation  and debility,
 resembling a hectic.
   1511. The proximate cause of this disease is not cer-
 tainly or clearly known.  It seems to have been some-
 times conuected with  calculous affections of  the kid-
 neys; and it is possible, that an irritation applied there
 may increase the secretion of  urine.  It perhaps often
 does so; but how it should produce the singular change
 that takes place in  the state of the urine, is not to be
 easily explained.   It certainly often  happens,  that cal-
 culous matters are  long present in  the urinary passages,
 without having any such effect as  that of producing
diabetes in any shape.
   Some have supposed that the disease occurs from a
relaxed state of the secretory  vessels of the  kidneys;
 and indeed the dissections of persons who had died of
this  disease have shown  the kidneys in a very flaccid
state.  This, however, is probably to be considered as
rather the effect than the cause of the disease.
   That no topical  affection of the kidneys has a  share
in producing this disease,  and that a  fault in  the assimi-
lation of the fluids  is  rather to be blamed,  I conclude
from hence, that even the sohd food taken in, increases
the quantity of the  urine voided, at the same time with
 an increase of the saccharine matter above mentioned. 
252           PRACTICE OF PHYSIC.
   1512.  The diabetes has been supposed to  be owing
to a certain state of the bile: and it is true, that this dis-
ease has sometimes occurred to persons who were at the
same time affected  with diseases of the liver: but this
occurrence does not often take  place; and the diabetes
frequently occurs separately from  any affection of the
liver.  In twenty instances of  diabetes  which  I have
seen, there was not  in  any one of  them any evident
affection of the liver.
   The explanation  that has been offered of the nature
and operation of the bile, in  producing diabetes, is very
lrypothetical,  and no wise satisfying.
   1513. As I have already said, I think it probable, that
in most  cases the  proximate cause  of  this disease is
some fault in the assimilatory powers, or in those em-
ployed in converting alimentary matters  into the proper
animal fluids.   This I formerly hinted to Dr. Dobson,
and it has been prosecuted and published by him; but
I must own that it is  a theory embarrassed with some
difficulties which I cannot at present very well remove.
   1514.  The proximate  cause  of diabetes being so lit-
tle known or  ascertained, I cannot propose any rational
method of cure in the disease.  From the testimony of
several authors, I believe that the disease has been cured:
but I believe  also, that this has seldom happened; and
when the disease has  been cured, I doubt much if it
was  effected  by the several remedies to which these
cures have been ascribed.   In  all the instances of this
disease which I myself have seen, and in several others
of which I  have been  informed, no cure of it has ever
been made in Scotland, though many instances of it have
occurred, and in most of them the remedies recommend-
ed by authors have been diligently employed.   I can-
not, therefore, with any advantage, enter into a detail
of these remedies; and as the disease, together  with its 
PRACTICE OF PHYSIC.          25$
several circumstances, when they shall hereafter occur,
is likely to become the subject of diligent investigation,
I avoid going farther at present,  and judge it prudent
to suspend  my opinion till I shall  have more  observa-
tions and experiments upon which I can form it more
clearly.
                    CHAPTER XIII.

9F THE HYSTERIA, OR THE HYSTERIC DISEASE.

1515.  THE many and various symptoms which have
been supposed to belong to a disease under this appel-
lation,  render it extremely difficult to  give a  general
character or definition of it.   It is, however, proper in
all cases to attempt some general idea; and, therefore, by
taking the most common form, and that concurrence of
symptoms by  which it  is principally distinguished,  I
have formed a character in my system of methodical
nosology, and shall  here endeavour to illustrate it by
giving  a more full history of the phenomena.
   1516.  The  disease attacks  in  paroxysms  or fits.
These commonly begin by some pain and fulness felt in
the left side  of the  belly.  From this a ball seems to
move with a grumbling noise into the other parts of the
belly; and, making as it were various convulsions there,
seems  to move into the  stomach; and more distinctly
still rises up to the top of the gullet, where it  remains
for some time, and by its pressure upon the larynx gives
a sense of suffocation.  By the time that the disease has
proceeded thus far,  the patient is affected with  a stupor
and insensibility, while  at the  same time the  body is
agitated with  various convulsions.  The trunk of  the
body is wreathed to  and fro, and the limbs are variously 
254           PRACTICE OF PHYSIC.
agitated; commonly the convulsive motion of one ami
and hand, is that of beating with the closed fist upon the
breast very violently and  repeatedly.  This state con-
tinues for  some time, and has during that time some
remissions and renewals of the convulsive motions; but
they at length cease, leaving the patient in a stupid and
seemingly sleeping state.   More or less suddenly, and
frequently with repeated sighing and sobbing, together
with a murmuring noise in the belly, the patient returns
to the exercise of sense and motion, but generally with-
out any recollection  of the several circumstances that
had taken  place during the fit.*
   1517. This  is the form of what is called ah hysteric
paroxysm, and is the most common form; but its pa-
roxysms are considerably varied in different persons,
and  even in the  same person at different times.  It
differs, by  having  more or fewer of  the circumstances
above mentioned; by these circumstances being more
or less violent; and by the different duration of  the
whole fit.
   Before the fit there is sometimes a sudden and  un-
usually large flow of limpid urine.   At the coming on
of the fit,  the  stomach is sometimes affected with vo-
miting, the lungs with considerable difficulty of breath-
ing,  and the heart with palpitations.  During the fit, the
whole of the belly, and particularly the navel, is drawn
strongly inwards; the sphincter ani is sometimes so firm-
ly constricted as not to admit a small glyster-pipe,  and
there is at the same time an entire suppression of urine.
Such fits are,  from  time  to time,  ready to recur;  and
during the intervals, the  patients are liable to involun-
tary motions, to fits of laughing and crying,  with sudden
transition from the one to the  other; while sometimes
" The ball, spoken of in this article, is called the globus hystericus. 
              PRACTICE OF PHYSIC.          255

false imaginations, and some degree of delirium, also
occur.
   1518. These affections have been supposed peculiar
to the female sex; and indeed they most commonly ap-
pear in females: but they  sometimes, though  rarely,
attack also the male sex; never, however, that I have
observed, in the same exquisite degree.
   In the female sex, the disease occurs especially from
the age of puberty to that of thirty-five years; and though
it does sometimes, yet it very seldom appears before the
former or after the latter of these periods.
   At all ages, the time at which it most readily occurs
is that of the menstrual period.
   The disease more especially affects the females of the
most exquisitely sanguine and plethoric habits, and fre-
quently affects those of the most robust and masculine
constitutions.
   It affects the barren more than the breeding women,
and therefore frequently young widows.
   It occurs especially in those females  who are liable
to the  Nymphomania;  and the Nosologists have  pro-
perly enough marked one of the varieties of this disease
by the  title of Hysteria Libidinosa.
   In the persons liable to the fits of this disease,  it is
readily excited  by the  passions of the  mind, and by
every considerable emotion, especially those brought on
by surprise.
   The persons liable to this disease acquire often such
a degree of sensibility,  as  to  be strongly affected by
every impression that comes upon them by surprise.
   1519. In this history, there appears to be .a concur-
rence of symptoms  and circumstances properly mark-
ing a very particular disease, which I think may be dis-
tinguished from all others. It  seems to me to have beeu
improperly considered  by physicians as the same  with 
256           PRACTICE OF PHYSIC.
 some other  diseases, and particularly with hypochon-
 driasis.  The two diseases may have some symptoms in
 common, but for the  most part are considerably differ-
 ent.
   Spasmodic affections occur in both diseases: but nei-
 ther  so frequently, nor to so great  a degree, in hypo-
 chondriasis as in hysteria.
   Persons liable to  hysteria are sometimes affected at
 the same time with dyspepsia.   They  are often,  how-
 ever, entirely free from it; but I believe this never hap-
 pens to persons  affected with hypochondriasis.
   These different circumstances mark some difference
 in the two diseases;  but they are still  more certainly
 distinguished by the  temperament they attack, and by
 the time of life at which they appear to be most exqui-
 sitely formed.
   It  has been generally supposed, that  the two diseases
 differ only in respect of their  appearing in different
 sexes.   But  this is not well  founded:  for although the
 hysteria appears most commonly in  females, the  male
 sex is not absolutely free from  it, as  I have  observed
 above; and although the hypochondriasis  may be  most
 frequent in men,  the instances  of it in the female sex
 are very common.*

  * Hysteria attacks, most frequently,  the sanguine  and plethoric; hypo-
chondriasis, the melancholic.
  Hypochondriasis seldom appears early, nor hysteria late in life.  Hypo-
chondriasis becomes aggravated, hysteria relieved,  by an advancement in
years.
  Hysteria, although so called, from its being supposed to have its seat in
the uterus, is, notwithstanding, much of a gastric disease. It, for the most
part, originates in the alimentary canal, and always  affects that  part,  in a
very prominent degree.  Hence the great flatulency of the stomach and
bowels, with which it is, usually, accompanied.
  An incontestible proof, that it is not,  necessarily, a uterine disease, is, that
men are subject to it as well as women.  In the male sex, however, it is nei-
ther so frequent, nor so strongly marked.
  The  treatment of this complaint must vary,  according to the object. th« 
PRACTICE OF PHYSIC.              251
    1520. From all these considerations, it must, I think,
 appear,  that  the  hysteria  may be very  well,  and pro-
 perly, distinguished from hypochondriasis.
    Further,  it seems to me to have been with great im-
 propriety, that almost every degree of the irregular mo-


practitioner has in view—to resolve a paroxysm, or to prevent its recur-
rence.
  To answer the former indication, blood-letting is, usually, necessary; es-
pecially if the subject be young and plethoric.  In constitutions of greater
delicacy, that remedy is less requisite.  In every case, however, it is safe,
and, in most, useful.
  The patient is,  sometimes, roused from the paroxysm by the application
of powerful odours to the nostrils ;  as  those of musk, asafoetida, camphor,
ether,  or volatile salts.   The dashing of cold water on the extremities, is,
occasionally, productive of a similar effect.
  If the bowels be constipated, a laxative injection,  with  the addition of
asafoetida, castor, or  musk, may be usefully administered.   In case of the
insensibility proving obstinate, let blisters, or sinapisms, be applied to the
 ancles  or wrists.
  As soon as the patient is able to swallow, let tincture of asafoetida, or cas-
tor, ether, or the volatile spirits of ammonia, be freely administered.  In cases
 of unusual violence, opium  or laudanum may be advantageously given, in
 large doses.  In hysteric affections, this latter remedy is justly regarded, as
 the most powerful of antispasmodics.
  For the prevention of the paroxysms of hysteria, the indication is, to com-
 municate tone to the stomach, and bowels, and, through the medium of these
 organs, to the system at large.  This object is to be attained  by nearly the
 same measures and means, that have been already prescribed, for the cure
 of dyspepsia—bark, chalybeates, and bitters ; wholesome air, moderate, but
 continued exercise, freedom from care, and cheerful society.
  Hysteric patients will derive benefit from rising early,  keeping the mind
 agreeably occupied, riding on  horseback, frequenting water-places, the
 practice of cold bathing, and the  use of a plain, but nutritive diet.   Let this
 diet consist of articles free from acescency.
  The preservation of a regular habit of body, is an object of great import-
 ance, in the treatment of hysteria; and, if the disease arise from the obstruc
 tion of the catamenia, that secretion ought to be promptly restored.
  In common with other diseases of the  class Neuroses, hysteria has been
 successfully treated by active and copious purging.  Under this operation,
 has been removed, at times, a vast amount of fseces, which appeared to have
 been the exciting cause of the disease.
  The purgatives which appear to have  answered best  are of the drastic
 kind, as calomel combined with jalap, or  with scammony or gamboge.
  To attacks of hysteria excited by passions or emotions of the mind, this
 purgative plan  of treatment would seem less applicable.
    VOL.  II.                   L 1 
258
PRACTICE OF PHYSIC.
tions of the nervous system has been referred to the one
or other of these two diseases.  Both are marked by a
peculiarity of temperament, as well as by certain symp-
toms commonly accompanying that; but some of these,
and many others usually marked  by the name of ner-
vous symptoms may, from various causes, arise in tem-
peraments different from that which is peculiar to either
hysteria or hypochondriasis, and without being joined
with the peculiar symptoms of either the one  or the
other disease: so that the appellations of Hysteric and
Hypochondriac  are very inaccurately applied to them.
Under what view these symptoms  are otherwise to be
considered, I am not  ready to determine; but must re-
mark, that the appellation of Nervous  Diseases is too
vague and undefined to be  of any  useful application.
   1521.  Having ihus endeavoured to distinguish hys-
teria from every other disease, I  shall now attempt its
peculiar  pathology.   With  respect to this,  I think it
will, in the first place, be obvious, that its paroxysms
begin by a convulsive and spasmodic affection of the
alimentary canal, which is afterwards communicated to
the brain,  and to a great part  of the nervous system.
Although the disease appears to begin in the alimentary
canal, yet the connection which the paroxysms so often
have with the menstrual flux, and with the diseases that
depend on the state of the genitals, shows, that the phy-
sicians have at all  times judged rightly in considering
this disease as an affection of the uterus and other parts
of the genital system.
   1522.  With regard to this, however, I can go no far-
ther.  In  what manner the  uterus, and in particular the
ovaria, are affected in this disease; how the affection of
these is communicated,  with particular circumstances,
to the alimentary  canal; or how the affection of this,
rising upwards, affects the brain, so as to occasion the 
PRACTICE OF PHYSIC.          259
particular convulsions  which occur in  this disease, I
cannot pretend to explain.
  But although I cannot trace  this disease to its first
causes, or explain the whole of the phenomena, I hope,
that with respect to the general nature of the disease, I
may form general conclusions, which may serve to direct
our conduct in the cure of it.
  1523.  Thus, from a consideration of the  predispo-
nent and occasional causes,  it will, I think, appear, that
the chief part of the proximate  cause  is a mobility of
the system,  depending  generally  upon its  plethoric
state.
  1524. Whether this  disease ever arises from  a mo-
bility of the system, independent of any plethoric state
of it, I cannot positively determine; but in many cases
that have  subsisted  for some time, it is evident  that a
sensibility, and consequently a mobility, are acquired,
which often appear when neither a general plethora can
be supposed to subsist, nor  an occasional turgescence
to have happened.  However, as we have shown above,
that a distention of the vessels of the brain seems to  oc-
casion epilepsy, and that a turgescence  of the blood in
the vessels of the lungs  seems to  produce asthma; so
analogy leads me to suppose, that a turgescence of blood
in the uterus, or in other parts of the  genital system,
may occasion the  spasmodic  and  convulsive motions
which appear in hysteria.  It will at the same time  be
evident, that this affection of the genitals  must especi-
ally occur in plethoric  habits; and every circumstance
mentioned in the history of the disease serves to confirm
this opinion with respect to  its  proximate cause.
  1525. From this view of the subject, the analogy of
hysteria  and epilepsy  will  readily appear;  and why,
therefore, I am to say that the  indications of cure  are
the same  in both. 
260             PRACTICC OF PHYSIC.
   As the indications, so the several means of of answer-
ing them are so much  the same in  both  diseases, that
the same observations and directions, with regard to the
choice and  employment  of these remedies,  that have
been delivered above on the subject of epilepsy, will ap-
ply, pretty exactly  to hysteria; and therefore need not to
be repeated here.
                        CHAPTER xiv.


    OF CANINE MADNESS  AND  HYDROPHOBIA.*


 1526. THIS  disease has been  so  exactly  and  fully
 described in books  that are in every body's hands, that

  * This disease is, properly enough, denominated  canine madness:  for, al-
though man, and various animals, are liable to suffer from it, the dog alone,
appears to be capable of communicating it.
  It is true, that we both hear and read, of the complaint  being produced,
by the bite and scratch of the cat: but, we know of no well authenticated in-
stance, where this event has occurred.  We doubt whether any such instance
exist.  Nor is it true, that any one of the human race, has, ever yet, communi-
cated it to another. The poisonous saliva of the dog, appears to be necessary
for the communication of the disease. If a disease somewhat similar to canine
madness, has ever resulted injuries, effected by the  teeth orxlaws of the cat,
it appears to have been, on the principle of a punctured ov lacerated wound-
such a wound, as proves, on other occasions, productive of tetanus.
  The length of time, at which ca,nine madness appears, after the reception
of the injury producing it, varies, in dogs, and other domestic animals, from
six or seven days, to  as many weeks:  in man, it is, usually, from twenty to
forty days.  Instances are, however, on record, wherein several years  are
said to have elapsed, between the injury, and the occurrence of the disease.
In these cases, we feel persuaded, that an error exists ; and that the disease
must have been imputed, to too distant a cause.  Some more recent,  but
unobserved, source of irritation, must have been its real origin.
  " Madness in the dog is, usually,  preceded by a dull, heavy look, hanging
of the  ears and tail,  stupor, surliness, and snapping at by-standers; soon
after which, his breathing becomes quick and laborious, his tongue hangs
out of his mouth and changes to a leaden colour; he discharges a frothy sa-
liva, refuses all food and drink, runs about, bites at  every thing that comes 
                  PRACTICE OF PHYSIC.               261

 it is on no account necessary for me to give any history
 of it here; and  with respect   to the pathology  of  it, I

near him, and, at last,  becomes quite furious. This is the last stage, in which
he seldom lives above thirty hours.  The nearer to this state, the more
dangerous is the bite, and the more direful its effects."
  In man the symptoms, usually attendant on the bite of a mad dog, are as
follows:
  " The part bitten  begins, after some time, to be painful; then come on
wandering pains,  with  an uneasiness and heaviness, disturbed sleep,  and
frightful dreams, accompanied with great restlessness, sudden startings and
spasms, sighing, anxiety, and a love of solitude. These symyptoms, continuing
to increase, daily, the cicatrix of the wound becomes hard and elevated ; a
peculiar tingling sensation is felt, in the part, and pains begin to shoot, from
the place which was  wounded, all along, up to the throat, with a straitness,
and sensation of choking, and a horror and dread, at the sight of water, and
other liquids, together with tremors and loss of appetite.  The patient is,
however, capable of swallowing any solid substance, with tolerable ease;
but, the moment that a fluid is brought in contact with his lips, it causes him
to start back, with dread and horror, although he labours, perhaps, under
 distressing thirst."
  Real hydrophobia  appears to be peculiar to the  human race; for rabid
animals do not manifest any dread of water.
  On the nature of canine madness, dissections have,  hitherto, thrown no de-
finitive light; appearances being widely different, in different cases.
  All agree, that the  only certain mode of prevention,  is the excision of the
part, as speedily as possible, after the reception of the injury.  Where this
cannot be effected, let the wound be  thoroughly washed, with soap  and
water, have a blister,  or a caustic applied to it, and be kept open, and a free
mercurial ptyalism be produced.  As a preventive,  this latter remedy has
strong recommendations.
  In relation  to the treatment of the disease, after it has actually made its
appearance, we regret that much less unanimity prevails.
  As physicians differ  much, in  their views,  respecting its nature ; some
considering it'of a nervous and spasmodic, others of a vascular and inflamma-
tory character ; a corresponding difference must necessarily, mark their me-
thods of cure.
  For  the  removal of this disease, some practitioners  place their reliance,
almost exclusively, on a mercurial ptyalism, and cite many instances of the
success of that remedy.
  Others depend  on  very copious blood-letting, as the most effectual means
for the cure of hydrophobia.  Instances are recorded, wherein from one to
three hundred ounces of blood, have been drawn, in a very short time, with
perfect success.
  Another class of physicians speak, in high commendation, of the  effects
of opium,  administered  in  large, and  repeated doses.   With this  arti-
cle, musk, castor, asafoetida. and other powerful antispasmodics,  are di-
rected to be combined.  If, in any way, opium can prove  really useful, in 
262
PRACTICE  OF PHYSIC.
 find that  I can say nothing satisfying to myself,  or that
 I  can expect to  prove so to others.    I find also, with
 respect to the cure of this disease,  that there is  no sub-
 ject in which the  fallacy of  experience  appears  more
 strongly than in this.   From  the  most  ancient to the
 present times, many  remedies  for preventing and cur-
 ing this disease have been recommended under the sanc-
 tion of pretended experience, and have perhaps also kept
 their credit  for some  time:  but  succeeding  times have
 generally, upon  the  same  ground of  experience,  de-
 stroyed that credit entirely: and most of  the  remedies

 this disease, it is by being exhibited, in such quantities, as to be productive
 of its own specific effects : to throw the system into somewhat of a soporose
 state, by subduing the powerful irritation it experiences;  and to keep it thus
 until the action of the morbific cause be extinguished.
  Arsenic is another remedy,  which is said to have been efficacious, in the
 treatment of hydrophobia.  This article, when given in sufficient quantities,
 possesses great power,  to overcome existing action, in the system,  and to
 introduce  its own.  Its operation, moreover, may be rendered very rapid.
 In relation, therefore, to the treatment of hydrophobia, we regard it as a
 medicine, of considerable promise.
  Various other remedies have been proposed, for the cure of this disease;
 but not, we believe, on a very solid foundation.  Among these may be men-
 tioned, the cuprum ammoniacum, tincture of cantharides, in quantities, suffi-
cient to produce strangury,  the hot and cold bath, either separately, or al-
 ternated with each other, and the  general and frequent inunction of the
 body, with sweet oil.   Having never witnessed the effects of these means,
 we are not prepared to say, what confidence they deserve.   Although pow-
 erful, in themselves, we doubt their sufficiency, to arrest the course  of the
 disease in question?
  Since the publication of the first edition of this work, we have had cause
 to be more thoroughly convinced than before, that hydrophobia may and
 does result from the bite of animals not in a rabid condition.
  That dogs not rabid have, by their bite, produced this complaint, we now
 know  from observation.  That cats', merely irritated and impassioned, may
 have done the same thing, we are prepared to believe.  But, that the latter
 animal ever does, by the  bite of a mad dog, become truly rabid, so as to se-
 crete a contagious saliva capable of communicating real canine madness, we
 do not believe.  At least we know  of no facts confirmatory of such a doc-
 trine.
  As far as we have been able  to  inform ourselves on the subject, canine
 madness, in the true signification of the terms, attaches exclusively to ani-
 mals of the dog  kind,  including the domestic  dog, the  wolf, the fox, the
 iack-!l, and perhaps the hyena. 
PRACTICE OF PHYSIC.
263
 formerly employed are now fallen into absolute neglect.
 In the present age, some new remedies have been pro-
 posed, and have experience alleged  to vouch for their
 efficacy: but many doubts  still remain  with respect to
 this: and though I cannot determine in this matter from
 my own experience, I think it incumbent on me to give
 the best judgment I can form with respect to the choice
 of the remedies at present recommended.
   1527. I am, in the first place, firmly persuaded, that
 the most certain means  of preventing the consequences
 of the bite, is to cut out, or otherwise destroy, the part
 in which the bite has been made.   In this  every body
 agrees; but with this difference, that some are of opi-
 nion that it can only be effectual when it is done very
 soon after the wound has been made, and they therefore
 neglect it when this opportunity is missed. There have
 been, however,  no  experiments  made proper to deter-
 mine  this matter: and there  are many  considerations
 which lead me to think, that the poison is not immedi-
 ately communicated to the system; and, therefore, that
 this measure of destroying the part may be practised
 with advantage, even many days after the bite has been
 given.
  1528.  Whilst the state of our  experience, with  re-
 spect to several remedies now in use, is uncertain, I can-
 not venture to assert that any of  these is  absolutely in-
 effectual; but I can give it as my opinion, that the effi-
 cacy of mercury, given very largely, and persisted in for
 a long time, both as a means of preventing the  disease,
 and of curing it when it has actually come on, is better
supported by experience than  that of any other remedy
now proposed or commonly employed. 
26-1
PRACTICE OF PHYSIC.
                            BOOK  IV.

 OF VESANIJE,  OR, OF THE DISORDERS OF THE IN-
                TELLECTUAL  FUNCTIONS.



                            CHAPTER I.

                OF VESANLE IN GENERAL.*


 1529.  THE  Nosologists,  Sauvages and  Sagar, in a   ,
 class of diseases under the title of VesanijE, have com-

  * Although, by no means, satisfied with what Dr. Cullen has left us, on
the subject; yet, neither on the theory, nor treatment, of madness, do we
feel ourselves prepared to go into detail.
  As  far as a corporeal affection is concerned, the disease has, oftentimes,   I
its seat in the prima; vis—as often, perhaps, as in the brain itself.  Hence,   1
in its treatment, the efficacy of emetics, nauseating medicines, and drastic   I
purgatives.  But, that it does, also, originate in the brain, is a position, too   1
strongly fortified, to admit of a doubt.
  In the present state of medical science,  madness,  when hereditary, may
be deemed incurable.  The  only means, on which, in this case, reliance
can be placed, are those of prevention.  These consist, of course, in a strict
avoidance of exciting causes.   In general,  let the descendants deviate, as
much as practicable, from the course of life, which their predecessors have
pursued; and, in this way, endeavour to change their constitutions.
  Did the  ancestors live luxuriously ?—let the descendants live abstemi-
ously : did 'the former lead a sedentary ?—let the latter lead an active, or,
even a laborious life : were those devoted to intense thinking ?—let these
inflexibly avoid the habit:  was the father given to late hours, and inclined
to morning indulgence, on his pillow ?—let the  son  go to bed early, and
never fail to rise  with the dawn.
  Madness, being, in every case, a disease of great obstinacy, requires, for
its cure—where a cure can be  effected—a determined treatment, with me-
dicines of a powerful and revolutionary character.
  Bleeding, cupping, and leeching; vomiting, and severe purging; perpe-
tual blisters, setons, or caustics ; the hot and cold bath, alone, or, in alterna-
tion with each other; opium and camphor, mercury, saccharum saturni, and
arsenic, digitalis and tobacco, in extract or decoction.  Such are the princi-
pal remedies, by which; under a skilful and vigorous administration, insanity
has been cured.                                           • •
  If remedies be  applied to the mind, they, too, must be of a revolutionizing
character: they must beguile the lunatic of himself, and sever his predomi- 
                   PRACTICE  OF  PHYSIC.              265

 prehended  the two orders,  of Hallucinatwnes, or False
 Perceptions, and  of Morositates,  or Erroneous Appe-


 lant train of thought: such are, some pleasing, but constant occupation, or
 hard labour; the excitement of strong feeling, a sea-voyage, or a long jour-
 ney:  or, they must be such, as harmonize with his course of thought,  and
 appear to him,  calculated to remove evils or maladies, under which he  fan-
 cies himself to  be labouring.  In confirmation of the propriety of this latter
 mode of treatment, the following case is recorded, in the writings of^a Ger-
 man author.
   " A madman, who, believing that he wore a pair of large  bull's horns,
 would, sometimes, menace, with his head, those who approached him,  was
 assured, that, on a certain day, these excrescences should be amputated. In
 the mean time, having, on the preceding night,  been thrown into a very
 profound sleep, by a large dose of opium, a pair of horns were fixed on his
 head, and dexterously removed, in the morning, by the surgeon.  The effect
 was, an immediate  exemption from the strange hallucination, under which
 he laboured."
   For further, and very extensive information, on the  subject of madness, see
 Rush—Crichton—Crowther—Pinel—Withering—Arnold---Haslam—Mor-
 gagni—Willis—Battie—and a number of other practical writers.
   If the  expression,  " as far as a corporeal affection is concerned," used in
 the commencement of the second paragraph  of this note, can be so con-
 strued as to imply a doubt whether we consider madness  as a disease exclu-
 sively corporeal, it is proper and requisite that this doubt be removed.
   Unequivocally, then,  we  know of none but corporeal affections.   In  the
 existence of a disease of the mind, correctly speaking, it is impossible for us
 to believe.  If  the immaterial part of man may sickek, it may also die.  A be-
 lief in a disease of the mind, then, implies a doubt, at least, of its immorta-
 lity, if not an actual disbelief of it.
   Compounded as we are of soul and body, all manifestations of mind, whe-
 ther sane or insane, are made, in  our present  condition, through the me-
 dium of matter.
   That we see,  hear, taste, smell, feel, and move, through the instrumenta-
 lity of material organs, every physiologist is compelled to acknowledge.  Nor
 is  it less certain, that we.think in the same way.
   The brain is as essentially the organ of thought, as the eye is of vision,
 or the ear of hearing. As perfect vision, therefore, depends on a sound
 eye, and the reverse, and perfect  motion on muscles free from disease, so
 does sound thought depend entirely on a healthy brain.
   The physician who believes in the  existence of a  disease purely mental,
 is  neither a physiologist  nor a metaphysician.  Nor,  if he practise  Ins pro-
 fession according to his belief, will he ever prove successful in his treatment
 of any of the forms of madness.
  Voluntary motion is as much a mental  operation as memory, imagination,
 or simple volition;  yet is it  evidently performed by material organs ; and
that physician would  be  justly held in ridicule and contempt, who, to  re-
medy the immobility of a limb produced by inflammatory rheumatism, would
    VOL.  II.                    m m 
 2()6             PRACTICE  OF PIIVSIC.

tites and  Passions;  and, in like manner, Linnaeus in his
class of Mentales,  corresponding  to the Vesaniae of
 Sauvages, has  comprehended the two orders of  Imagi-
narii and Pathetici, nearly the  same with the Halluci-
nations  and Morositates of that author.   This, how-
ever, from  several considerations, appears to  me im-
proper; and I have  therefore formed  a class  of Vesaniaj
nearly the same with the Paranoiae  of Vogel,  exclud-
ing from it the Hallucinationes and Morositates, which
I have referred to  the Morbi Locales.   Mr. Vogel has
 done the like,  in separating from the Paranoiae the false
perceptions  and  erroneous  appetites; and  has  thrown

prescribe for an affection of the mind, instead of a  disease of the muscles
and membranes.
  Indeed to talk of prescribing for a disease of the mind is folly.  As well
may we profess to perform a surgical operation on the mind.  That immate-
rial  essence is as unimpressible by our calomel and our jalap, as it is untan-
gible by our trocar or our amputation-knife.  It will admit the application
of the tourniquet and the ligature, as readily as it will feel the influence of
tartar emetic.
  In all mental diseases, it is matter that is deranged, not mind—the organ
acted on, not the being that acts.
  In attempts to illustrate this subject, the brain may be made to represent
u musical instrument of many strings, and the mind the performer that eli-
cits music.
  If the instrument be deranged, the skill of the musician is unavailing. No
harmony is awakened by his touch. Discord is the only reward of his efforts.
  In a case like this, what would be thought of the artist, who,  when em-
ployed to remedy the evil, instead of repairing the instrument,  would un-
dertake to rectify some imaginary defect in the  musician's power of per-
forming !
  Equally irrational and  unavailing is the conduct of that physipian, who,
when called to a case of insanity, affects to prescribe for the immortal part.
  Diseases of the mind, then, which are in reality nothing  but affections of
the brain, original or sympathetic, must be treated like diseases of other or-
gans,  by depletion or repletion, abstraction or stimulation, according as the
existing action is excessive or defective.
  Whatever may be its fate as to minor details,  we feel  persuaded, that,
much and ignorantly ridiculed as it has been, the  system of Phrenology, by
Gall and Spurzheim, is calculated to shed more light on diseases of the mind,
than any other discovery or improvement of modern times.
  For much interesting matter on this subject, we refer the reader  to " Spurz-
heim on Insanity." 
PRACTICE OF PHYSIC.
267
these into another class, to which he has given the title
of Hyperaestheses.
   1530.  It is indeed true, that certain hallucinationes
and morositates are frequently combined with what I
propose to consider as strictly a vesania or an erroneous
judgment; and sometimes the hallucinationes seem to
lay the foundation of, and to form almost entirely, the
vesania.  But as most part of the hallucinationes  enu-
merated by the nosologists are affections purely topical,
and  induce no other  error of judgment  beside  that
which relates to the single object of the sense or parti-
cular organ affected; so these are certainly to be sepa-
rated from the diseases which consist in a more gene-
ral affection of the judgment.  Even when the halluci-
nationes constantly accompany or seem to induce the ve-
sania, yet being such as arise from internal causes, and
may  be presumed to  arise from the  same cause as the
more general affection of the judgment, they are there-
fore  to be considered as symptoms of this only.
   In like manner I judge with respect to  the morosi-
tates, or erroneous  passions, that accompany vesania;
which, as consequences of a false judgment, must  be
considered as arising  from the same causes, and as
symptoms only, of the more general affection.
   There is, indeed, one case of a morositas which seems
to induce a vesania,  or more general affection  of the
judgment; and this may lead us to consider the vesania,
in this case, as a symptom of an erroneous appetite, but
will  not afford any good reason for comprehending the
morositates in general under the vesaniae, considered as
primary diseases.
   The limitation, therefore, of the class of vesaniae to
the lesions of our judging faculty, seems from every con-
sideration to be proper.
   The particular diseases to be comprehended under 
268
PRACTICE OF  PHYSIC.
this class, may be distinguished according as they affect
persons in the time of waking or sleeping. Those which
affect men awake, may again be considered as they con-
sist in an erroneous judgment, to which I shall give the
appellation of Delirium; or as they consist in a weak-
ness or  imperfection of judgment,  which I shall name
Fatuity.  I begin with the consideration of delirium.
   1531. As  men differ greatly in the soundness and
force of their judgment, so it may be proper here to
ascertain more precisely what error or imperfection of
our judging faculty is to be considered as morbid, and
to admit of the appellations of delirium and fatuity. In
doing this, I shall  first consider the morbid errors of
judgment under  the  general appellation  of delirium,
which has  been  commonly employed to denote every
mode of such error.
   1532. As our judgment -is chiefly exercised in dis-
cerning and judging of the several relations of things, I
apprehend that delirium may be defined to be—in a per-
son awake, a false or mistaken judgment of those rela-
tions of things, which, as  occurring most frequently in
life, are those about which the generality of men form
the same judgment; and particularly when the judgment
is very different from what the person himself had be-
fore usually formed.
   1533. With this mistaken judgment of relations there
is frequently joined some  false  perception of external
objects,  without any evident fault in the organs of sense,
and which seems therefore to depend upon an internal
cause; that is, upon the imagination arising from a con-
dition in the brain presenting objects which  are  not ac-
tually present. Such false  perceptions must necessarily
occasion a delirium, or an erroneous judgment, which
is to be  considered as the disease.
  1534.  Another circumstance, commonly attending 
PRACTICE OF PHYSIC.          269
delirium, is a very unusual association  of ideas.  As,
with respect to most of the affairs of common life, the
ideas laid up in the memory are,  in  most men, asso-
ciated in the same manner; so a very unusual associa-
tion, in any  individual, must prevent his forming the or-
dinary judgment of those relations which are the most
common foundation of association in the memory: and
therefore this  unusual  and commonly hurried associa-
tion of ideas,  usually is, and may be considered as, a
part of delirium.  In particular it may be considered
as a certain mark of a general morbid affection  of the
intellectual  organs, it being an interruption or perver-
sion of the ordinary operations of memory,  the com-
mon and necessary foundation of the exercise of judg-
ment.
   1535. A  third circumstance attending delirium, is an
emotion or  passion, sometimes of the angry, sometimes
of the timid kind; and from whatever cause in the per-
ception  or  judgment, it  is  not proportioned to such
cause, either  in the manner formerly customary to the
person himself, or in the manner usual with the gene-
rality of other men.
   1536. Delirium, then, may be more shortly defined—
in a person awake, a false judgment arising  from per-
ceptions of imagination, or from false recollection, and
commonly  producing disproportionate emotions.
   Such delirium is of two kinds; as it is combined with
pyrexia and comatose  affections; or, as  it  is entirely
without any such combination. It is the latter case that
we name Insanity; and it is this kind of delirium only
that I am to treat of here.
   1537. Insanity may perhaps be properly considered
as a genus  comprehending  many different species, each
of which may deserve our attention; but before proceed-
ing to the consideration of particular species, I think it 
270
PRACTICE OF PHYSIC.
proper to attempt an investigation of the cause of insa-
nity in general.
  In  doing this, I shall take it for granted, as demon-
strated elsewhere, that although this disease seems to be
chiefly, and sometimes solely, an affection  of the mind;
yet the connection between the mind and body in this
case is such, that these affections of the mind must be
considered as depending upon a certain state of our cor-
poreal part. See Halleri Prim. Lin. Physiolog. § 570.
See Boerhaavii Inst. Med.  § 581. 696.
  1539.  Admitting this proposition, I must in the next
place assume another, which I likewise suppose to be
demonstrated elsewhere.  This is, that the part of our
body more immediately  connected with the  mind,  and
therefore more especially concerned in every affection
of the intellectual  functions, is  the common origin of  A
the nerves; which I shall, in what follows, speak of un-  ;
der the appellation of the brain.
  1540.  Here, however, in assuming this last proposi-
tion, a very great difficulty immediately presents itself.
Although we cannot doubt that the operations of our
intellect  always depend upon  certain  motions taking  J
place in  the brain, (see Gaub. Peth. Med. § 523;) yet
these motions have never been the objects of our senses,
nor have we been able to perceive that any particular
part of the brain has more concern in the operations
of our intellect than any other.   Neither have we at-
tained any knowledge of what share the several parts
of the brain have in that operation; and  therefore, in
this situation of our science, it must be a very difficult
matter to discover  those states of  the brain that may
give occasion  to the various state  of  our intellectual
functions.
   1541.  It may be observed, that the different state of
the motion of  the blood in the vessels of the brain has 
PRACTICE OF PHYSIC.
271
some share in affecting the operations of the intellect:
and physicians, in seeking for the causes of the different
states of  our intellectual functions, have hardly looked
further than into the state of the motion of the blood,
or into the condition of the blood itself: but it is evident
that the operations of the intellectual functions ordina-
rily go on, and are  often  considerably varied, without
our being able to perceive any difference either in the
motions or in the conditions of the blood.
   1542.  Upon the other hand, it is very probable that
the state  of the intellectual functions depends chiefly
upon the state and condition of what is termed the ner-
vous power, or, as we suppose, of a subtile very movea-
ble fluid, included or inherent, in a  manner  we do not
clearly understand, in  every part of  the medullary sub-
stance of the brain  and nerves, and which in  a living
and healthy man is capable of being moved from every
one part to every other of the nervous system.
   1543. With respect to  this power, we  have pretty
clear proof that it frequently has a motion from the sen-
tient extremities of  the nerves towards the brain, and
thereby produces sensation; and we have the same proof,
that in consequence of volition the  nervous power has
a motion from the  brain into the muscles  or organs of
motion.   Accordingly, as sensation excites our intellec-
tual operations, and volition is the effect of  these, and
as the connection between sensation and volition is al-
ways by the intervention of the brain and of intellectual
operations; so we can hardly doubt,  that these latter
depend upon certain motions, and the various modifica-
tion of these motions, in the brain.
   1544.  To ascertain the different states of these mo-
tions may be very difficult; and physicians  have com-
monly considered it to be so very mysterious, that they
have generally  despaired of attaining any knowledge 
272           PRACTICE OF PHYSIC.
with regard to it: but 1 consider such absolute despair,
and the negligence it inspires, to be always vey blame-
able; and I shall now venture to go some length in the
inquiry, hoping that some steps made with  tolerable
firmness may enable us to go still further.
   1545. To  this purpose, I think it  evident,  that the
nervous power, in the  whole  as  well as in the several
parts of the nervous system, and particularly in the brain,
is, at different times in different degrees of mobility and
force.   To  these different states, I beg leave to apply
the terms of Excitement and  Collapse.   To that state
in which the mobility  and force are  sufficient for the
exercise of the functions,  or when these states are any
way preternaturally increased, I give the name of Ex-
citement;  and to that  state in which  the mobility and
force are not sufficient for the ordinary exercise of the
functions, or when they  are  diminished from the state
in which  they had been  before, I give the name of
Collapse.   I  beg, however, it may be observed, that by
these  terms I mean to express matters of fact only;
and without  intending, by these terms, to explain the
circumstance  or condition, mechanical or  physical, of
the nervous power or fluid in these different states.
   1546.  That these different  states of excitement and
collapse take  place on different occasions, must, I think,
be manifest from numberless  phenomena of the animal
economy: but it is especially to our present purpose to
observe, that the different states of excitement and col-
lapse, are in no instance more remarkable, than in the
different states of waking and sleeping.   In the latter,
when quite complete, the motion  and mobility of the
nervous power, with respect to the whole of what are
called  the animal functions,  entirely cease,  or, as I
express it, are in a state of collapse;  and are very dif-
ferent from the state of waking, which in healthy  per- 
              PRACTICE OF PHYSIC.           273
           »
sons I would call a state of general and  entire excite-
ment.
   1547. This  difference in the states of the nervous
jtower in sleeping and waking being admitted, I must
in the next place observe, that when these states  are
changed from the one into the other, as commonly hap-
pens every day, the change is hardly ever made instan-
taneously, but almost always by degrees, and in some
length of time only; and this may be observed with re-
spect to both sense and motion.   Thus when a per-
son  is falling asleep, the  sensibility is gradually dimi-
nished: so that, although some degree of sleep has come
on, slight impressions will  excite  sensation, and  bring
back excitement; which  the same, or even stronger im-
pressions will be insufficient to produce when the state
of sleep has continued longer, and is, as we may say,
more  complete.  In like manner, the power of volun-
tary motion is gradually diminished.  In  some mem-
bers it fails sooner than in others; and it is sometime
before it becomes general and considerable over  the
whole.
  The same gradual progress may  be remarked in a
person's coming out of sleep: the ears in this case  are
often awake before the eyes are opened or see clearly,
and the senses are often  awake before the power of vo-
luntary motion is recovered; and it is curious to observe,
that in some cases,  sensation may be  excited without
producing the ordinary association of ideas. See Mem.
de Berlin, 1752.
  1548. From all this, I think it  will clearly appear,
that not only the different states of excitement and col-
lapse can take place in different degrees, but that they
can take place in different parts of the brain, or at least,
with respect to the different functions, in different de-
grees.
  vol. n.               N n 
274
PRACTICE OF PHYSIC.
   As I presume that almost every person has perceived
 the  gradual approach of sleeping  and waking, I like-
 wise suppose every person has observed, that, in such
 intermediate state of unequal excitement, there almost
 always occurs more or  less of delirium, or dreaming,
 if any body chooses to call  it so.  There are in this
 state false perceptions,  false associations,  false judg-
 ments, and  disproportionate emotions;  in short, all the
 circumstances by which I have above defined delirium.
   This clearly shows that delirium may  depend, and I
 shall hereafter endeavour to  prove that it  commonly
 does depend upon some inequality in  the  excitement
 of the brain; and that both these assertions are founded
 on this, that in order to the proper exercise  of our in-
 tellectual functions, the excitement must be complete,
 and  equal in every part  of  the brain.   For though we
 cannot say that the vestiges of ideas are laid up in dif-
 ferent parts of the brain, or that they are in some mea-
 sure diffused over the whole, it will follow upon either
 supposition, that as our  reasoning  and our  intellectual
 operations always require the orderly and exact recol-
 lection or memory of associated ideas; so, if any part
 of the brain is not excited, or not excitable,  that re-
 collection cannot  properly  take place, while at the
 same time other parts of the brain, more excited and
 excitable, may give false perceptions, associations, and
judgments.
  1549.  It will serve to illustaate this, that the  collapse
 in sleep  is more or less  complete;  or that the sleep, as
we  commonly  speak, is  more or less  profound; and
therefore, that in many cases, though sleep takes place
to a considerable  degree, yet certain  impressions do
still take effect, and excite motions, or, if you will, sen-
sations in the brain;  but which  sensations,  upon  ac-
count of a collapsed state of so great a part of the brain, 
PRACTICE OF PHYSIC.
275
 are generally of the delirious kind, or dreams, consist-
 ing of false preceptions, associations, and judgments,
 that would have been corrected if the brain had been
 entirely excited.
   Every one, I believe, has observed, that the most im-
 perfect sleeps, are those chiefly attended with dream-
 ing; that  dreams, therefore, most  commonly occur to-
 wards morning, when the complete state of sleep is
 passing away; and further, that dreams are  most com-
 monly excited by strong and uneasy impressions made
 upon the body.
   I apprehend it may also be an illustration of the same
 thing, that, even in waking hours,  we have an instance
 of an unequal state of excitement  in the brain produc-
 ing delirium.  Such, I think, occurs in the case of fever.
 In this it  is manifest, that the energy of the brain, or
 its excitement, is considerably diminished with respect
 to the animal functions: and it is accordingly upon this
 ground that I  have explained above, in 45, the delirium
 which so  commonly  attends fever.   To  what I have
 there said I shall here only add, that i1> may serve to
 confirm my doctrine,  that the delirium in fever  comes
 on at a certain period of the disease only, and that we
 can commonly discern its approach by a more  than usual
 degree of it appearing in the time  of the patient's fall-
 ing into or coming out of sleep.  It appears, therefore,
 that delirium, when it first comes on in fever, depends
 upon an inequality of excitement;'and it can hardly be
 doubted,  that  the delirium  which  comes  at length to
prevail in the entirely weakened state of fevers, depends
upon the same cause prevailing in  a more  considerable
degree.
   1550. From what has been now delivered, I hope it
will be sufficiently evident, that delirium may be, and 
216^          PRACTICE OF PHYSIC.

frequently is,  occasioned by an inequality in  the ex-
citement of the brain.
   How the different portions of the brain may  at the
same time be  excited or collapsed in different degrees,
or how the energy of the brain may be in different de-
grees of force, with respect to the several animal, vital,
and natural functions, I cannot pretend to explain; but
it is sufficiently evident in fact, that  the  brain may be
at  one and the same time in different conditions with
respect to these functions.  Thus in inflammatory dis-
eases, when by a stimulus applied to the brain the force
of the vital functions is preternaturally increased, that
of the  animal is either little  changed, or considerably
diminished.   On the contrary, in many cases of mania.
the force of the animal functions depending always on
the brain,  is prodigiously increased, while the state of
the vital function in the heart, is very little or not at all
changed.   I must, therefore, say again, that how diffi-
cult soever it  may be to explain the mechanical or phy-
sical condition of the brain in such cases, the facts are
sufficient to show that  there  is such an inequality as
may disturb our intellectual operations.
   1551. I have thus endeavoured to explain the general
cause of Delirium; which is of two kinds, according as
it is with,  or  without, pyrexia.   Of the first I take no
further notice  here, having explained it as well as I
could above in 45.
   I proceed now to consider that delirium which pro-
perly belongs  to the class of Vesaniae, and which  I shall
treat of under the general title of Insanity.
   1552. In entering upon this  subject, it immediately
occurs, that in many instances of insanity, we find, upon
dissection after death, that peculiar circumstances had
taken place in  the general condition  of the brain.   In
many cases, it has been found of a drier, harder, and 
PRACTICE OF PHYSIC.          277
firmer consistence, than what it is usually of in persons
who had not been affected with that disease.  In other
cases, it has been found in a more humid, soft, and flaccid
state; and  in  the observations of the late Mr. Meckel,
it has been found considerably changed in its density
or specific gravity.   Whether these different states have
been observed to be uniformly the same over the whole
of the brain, I cannot certainly learn; and I suspect the
dissectors  have not always accurately inquired into this
circumstance: but  in several instances, it appears that
these states had been different in different parts of the
brain; and instances  of this inequality will afford a con-
firmation of our general doctrine.
  The accurate Morgagni has  observed, that in mani-
acal persons the medullary portion of the brain is usu-
ally dry, hard, and firm: and this he had so frequently
observed, that he was disposed to consider it as generally
the  case.  But in most of the particular  instances which
he has given, it appears, that, for the most part, while
the cerebrum was  of an unusually hard  and  firm con-
sistence, the cerebellum was  of its usual softness, and
and in many  of the cases it was unusually soft and flac-
cid.   In some other cases,  Morgagni observes, that
while a part of the cerebrum was harder and firmer than
ordinary, other parts of it were preternaturally soft.
  1553. These observations tend to confirm our gene-
ral  doctrine: and there are  others which I think will
apply to the same purpose.
  Upon the dissection of the bodies of persons who had
laboured under insanity, various organic affections have
been  discovered in particular parts of the brain; and it
is sufficiently probable,  that such  organic  affections
might have produced a different degree of excitement
in the free and affected parts, and must have interrupted
in some measure the free communication between the 
278
PRACTICE OF PHYSIC.
several parts of the brain, and in either way have occa-
sioned insanity.
   There have  occurred so many instances of this kind,
that I believe physicians are generally disposed to sus-
pect organic lesions of the brain to exist in almost every
case of insanity.
   1554. This,  however, is probably a mistake: for we
know that  there have been many instances of insanity,
from which the persons have entirely recovered; and it
is difficult  to suppose that  any organic lesions of the
brain had  in such case taken place.  Such  transitory
cases, indeed, render it probable, that a state of excite-
ment, changeable by various causes, had been the cause
of such instances of insanity.
   1555. It is indeed further asserted, that in many in-
stances of insane  persons,  their brain had  been ex-
amined after death, without showing that any organic
lesions had before subsisted in the brain, or finding that
any morbid state of the brain then appeared.  This, no
doubt, may serve to show, that organic lesions had not
been the cause of the disease; but it does not assure us
that no morbid change had taken place in  the brain:
for it is probable, that the dissectors were not always
aware of its  being the  general condition of  hardness
and density,  as different in different parts of the brain,
that was to be attended to, in order to discover the cause
of the preceding disease; and therefore many of them
had not with this view examined the state of the brain,
as Morgagni seems carefully to have done.
   1556.  Having  thus endeavoured  to investigate the
cause of insanity in general, it were to be wished that
I could apply the doctrine to the distinguishing the se-
veral species of it, according as they depend upon the
different state and circumstances of the brain, and there-
by to the establishing of a scientific and accurately adapt- 
PRACTICE OF PHYSIC.          219
ed method of cure.   These purposes, however, appear
to me to be extremely difficult to be attained; and I can-
not hope to execute them here. All I can do is to make
some attempts, and offer some reflections, which further
observation, and greater sagacity, may hereafter render
more useful.
   1557. The ingenious Dr. Arnold has been  com-
mendably employed  in distinguishing the different spe-
cies of insanity as they appear with  respect to the mind;
and his labours may hereafter prove useful, when we
shall come  to know something more of the  different
states of the brain corresponding to these different states
of the  mind; but at present I can make little applica-
tion of his  numerous distinctions.   It appears  to me
that he  has chiefly pointed out and enumerated distinc-
tions, that are merely varieties, which can lead to little
or no variety of practice: and I  am especially led to
form the latter conclusion, because these varieties appear
to me to be often combined  together, and to  be often
changed into one another, in the same person;  in whom
we must therefore suppose a general cause of the disease,
which, so far as it can be known, must establish the pa-
thology, and especially direct the practice.
   1558. In my limited views of the different  states of
insanity, I must go on to consider them under the two
heads of Mania and Melancholia: and though I am  sen-
sible that these two genera do not comprehend the whole
of the  species of insanity, I am not clear in assigning
the other species which may not be comprehended  un-
der those titles.  I shall however,  endeavour, on  pro-
per occasions as I go along,  to point them out as  well
as I can. 
280           PRACTICE OF PHYSIC.
                    CHAPTER II.

            OF MANIA, OR MADNESS.

1559. THE circumstances which I have mentioned
above in 1536,  as constituting delirium in general, do
more especially belong to that kind of it which I shall
treat of here under the title of mania.
  There is sometimes a false perception or imagination
of things present that are not; but this is not a constant,
nor even a frequent, attendant of the disease.  The false
judgment, is of relations long before laid up in the me-
mory.  It very often turns upon one single subject; but
more commonly the mind  rambles from dne subject to
another with an equally false judgment concerning the
most part of them; and  as at the same time there is
commonly a false association, this increases the confu-
sion of ideas, and therefore the false judgments.  What
for the most part more especially distinguishes the dis-
ease is a hurry of mind,  in  pursuing any thing  like a
train of thought,  and  in  running from one  train  of
thought to another.  Maniacal  persons  are in general
very irascible;  but what  more particularly  produces
their angry emotions, is, that their false judgments lead
to some action  which is always pushed with impetuo-
sity and violence; when this is interrupted or restrain-
ed, they break  out into violent anger and furious vio-
lence against every person near them, and upon every
thing that stands  in the way of  their impetuous will.
The false judgment often turns  upon a mistaken opi-
nion of some injury supposed to have  been formerly re-
ceived,  or now supposed to be intended: and it is re-
markable that  such an opinion is often with respect to 
PRACTICE OF PHYSIC.           281
their former dearest friends and relations; and therefore
their resentment and  anger are particularly directed to-
wards these. And although this should not be the case,
they commonly soon lose that respect and regard which
they formerly had for their friends and relations.  With
all these circumstances, it will be readily perceived, that
the disease must be attended very constantly with that
incoherent and absurd speech we call raving.  Further,
with the circumstances mentioned,  there  is commonly
joined an unusual force in  all the voluntary motions;
and an insensibility or resistance of the force of all im-
pressions, and  particularly a resistance of the powers
of sleep, of cold, and even of hunger; though  indeed in
many instances a voracious appetite takes place.
   1560. It appears to me that the whole of these cir-
cumstances and symptoms point out a considerable and
unusual excess in the excitement of the brain, especia-
ally with respect to the animal functions; and it appears
at the same time to be manifestly in some measure une-
qual, as it very often takes place with respect to these
functions alone, while at the same time the vital and na-
tural are commonly very little changed from their ordi-
nary healthy state.
   1561. How this excess of excitement is produced, it
maybe difficult to explain. In the various instances of
what Sauvages has named the Mania Metastatica, and
in all the  instances I have mentioned  in  my  Nosology
under the title of the Mania Corporea, it may be sup-
posed that a morbid organic  affection is produced in
some part of the brain:  and how that may produce an
increased or unequal excitement in certain parts of it,
I have endeavoured to explain  above  in  1553.   But I
must at the same time acknowledge, that  such remote
causes of mania have very rarely occurred;  and that
   VOL. n.               o o 
282
PRACTICE OF PHYSIC.
 therefore some  other  causes  of the  disease must be
 sought for.
   The  effects of violent emotions or passions of the
 mind have  more  frequently occurred as  the  remote
 causes  of mania; and it is sufficiently probable,  that
 such violent emotions, as they do often immediately pro-
 duce a temporary increase of excitement, so they may,
 upon some occasions of their permanent inherence or
 frequent repetition,  produce a more considerable  and
 more permanent excitement, that is, a mania.
   With respect  to those  causes of  mania which arise
 in consequence  of a melancholia which had previously
 long subsisted; whether  we consider  that melancholia
 as a partial insanity, or as a long persisting attachment
 to one train of thinking, it will be readily perceived, that
 in either case, such an increase of excitement may take
 place in so considerable a degree, and in so large a por-
 tion of the brain, as may  give occasion to complete ma-
 nia.
   1562. These  considerations with regard to the  re-
 mote causes appear to me to confirm sufficiently  our
 general doctrine of increased and unequal excitement in
 the mania which I have  described  above:  but  I must
 own that I  have not exhausted the subject, and that
 there are cases of mania of which I cannot assign  the
 remote causes:  but although I cannot in  all cases  ex-
 plain in what manner the mania is produced, I presume,
 from the  explanation  given, and especially from  the
 symptoms enumerated above, to conclude, that the  dis-
 ease described above depends upon an increased excite-
 ment of the brain; an opinion in which I am the more
confirmed, as I think it will point out the proper method
of cure.   At least I  think it will most clearly explain
the operation of those remedies which, so far as I  can
learn from nay own experience and that of others, have 
PRACTICE OF PHYSIC.
283
proved the most successful in this disease; and, to illus-
trate this, I now enter upon the consideration of these
remedies, and to make some remarks upon the proper
manner of employing them.
   1563. Restraining the anger and violence of madmen
is always necessary for preventing  their hurting them-
selves or others: but this restraint is also to be consi-
dered as a  remedy.  Angry passions are always ren-
dered more violent by the indulgence of the  impetuous
motions they produce; and even in madmen the feeling
of restraint will sometimes prevent the efforts which their
passion would otherwise occasion. Restraint, therefore,
is useful,  and ought to be complete; but it should  be
executed in the easiest manner possible for the patient,
and the strait waistcoat  answers every purpose better
than any other that has yet  been thought of.  The
restraining madmen by the force of other men, as occa-
sioning  a constant struggle  and violent agitatiou, is
often hurtful.  Although, on many occasions, it may not
be safe to allow maniacs to be upon their legs or  to walk
about,  it is never desirable to confine them to a hori-
zontal situation; and whenever it can be admitted, they
should be more or less in an erect  posture.   Although
there may be no symptoms of any preternatural  fulness
or increased impetus of blood in the vessels of the brain,
a horizontal posture always  increases the fulness and
tension  of these vessels,  and  may thereby increase the
excitement of the brain.
  1564. The restraint mentioned requires confinement
within doors, and it should be in a place which presents
as few objects of sight and hearing as possible, and par
ticularly, it should be removed from the objects that the
patient was formerly acquainted with,  as these would
more readily call up ideas and their various associations.
It is for this reason that the confinement of madmen 
 2bl          PRACTICE OF PHYSIC.

 should hardly ever be  in  their usual habitation; or if
 they are, that their apartment should be stripped of all
 its former furniture.   It is also for the most part pro-
 per, that maniacs should be without the company of any
 of their former acquaintance; the appearance of whom
 commonly excites emotions  that  increase the disease.
 Strangers may at first be offensive; but in a little time
 they come to be objects  either of indifference or of fear,
 and they should not be frequently changed.
   1565. Fear being  a  passion that diminishes  excite-
 ment, may therefore  be  opposed to the excess of it; and
 particularly to the angry  and irascible  excitement  of
 maniacs.  These being more susceptible of fear than
 might be suspected, it appears to me to have been com-
 monly useful.  In most  cases it has appeared to be ne-
 cessary to employ a very constant impression of fear;
 and therefore to inspire them with the awe and dread  of
 some particular persons, especially of those  who are  to
 be constantly near them.  This awe and dread is, there-
 fore, by one means or other, to be acquired; in the first
 place,  by their being the  authors of all the restraints
 that may be occasionally proper; but sometimes it may
 be necessary to acquire it even by stripes and  blows.
 The former, although having the appearance of more
 severity, are much safer than strokes or blows about the
 head.   Neither of them, however, should be employed
 further than seems very necessary, and should be trusted
 only to those whose discretion can  be  depended upon.
 There is one case  in  which they are superfluous;  that
 is, when the  maniacal rage is either not susceptible  of
 fear, or incapable of remembering the objects of it; for
in such instances, stripes and blows would  be wanton
barbarity.  In many cases of a moderate disease, it  is
of advantage that the persons who are the  authors of
restraint and punishment, should  be upon other occa- 
PRACTICE OF PHYSIC.
285
 sions thebestowers of every indulgence and gratification
 that is admissible; never, however, neglecting to employ
 their awe when their indulgence shall have led to any
 abuse.
   1566. Although in mania, no particular irritation nor
 fulness of the system  seem to be present, it  is plain,
 that the avoiding all irritation and means of fulness is
 proper; and, therefore,  that a diet neither stimulating
 nor nourishing  is commonly to  be employed.  As it
 may even be useful to diminish  the fulness of the sys-
 tem,  so both a  low and a spare diet is likely in  most
 cases to be  of service.
   1567. Upon the same principle, although no unusual
 fulness of the body be present, it may be of advantage
 to diminish  even its ordinary fulness by different evacu-
 ations.
   Blood-letting, in particular, might be supposed useful;
 and in all recent cases of mania it has been commonly
 practised, and  I think with advantage; but  when the
 disease has subsisted for some time,  I have seldom found
 blood-letting of  service.   In those instances in which
 there is any frequency or fulness of pulse, or any marks
 of an increased impetus of the blood in the  vessels of
 the head, blood-letting is a proper and even a necessary
 remedy.   Some practitioners, in such cases, have  pre-
 ferred a particular manner of blood-letting, recommend-
 ing arteriotomy, scarifying the hind-head,  or  opening
 the jugular vein; and where any fulness or inflammatory
 disposition in the vessels of the brain is to be suspected,
 the opening of the vessels  nearest to them is likely to
be of the greatest service.  The opening, however, of
either the temporal artery or the jugular vein in mania-
cal persons  is very often inconvenient; and it may gene-
rally be sufficient to open a  vein in the  arm, while the
body is kept in soinewhat of an erect posture, and such 
286
PRACTICE OF PHYSIC.
 a quantity of blood drawn as  nearly brings on a dehV
 quium animi, which is always a pretty certain mark of
 some diminution of the fulness and tension of the ves-
 sels of the brain.
   1568. For the same purpose of taking off the fulness
 and tension  of these vessels of the brain, purging may
 be  employed; and I can in  no other  view understand
 the celebrated use of hellebore among the ancients.  I
 cannot, however,  suppose any specific power in helle-
 bore; and can by  no means find that, at least the black
 hellebore, is so efficacious with us as  it is said to have
 been  at Anticyra.  As costiveness, however, is  com-
 monly a very constant and hurtful attendant of mania,
 purgatives come to be sometimes very necessary; and
 I have known some benefit obtained from the frequent
 use of pretty drastic purgatives.   In  this,  however, I
 have been frequently disappointed; and I  have  found
 more  advantage from the  frequent use of  cooling pur-
 gatives,  particularly the soluble tartar, than from more
 drastic medicines.
  1569. Vomiting has  also been frequently employed
 in mania; and by determining powerfully to the surface
 of the body, it may possibly diminish the fulness and
 tension of the vessels, and thereby the excitement of the
brain; but I  have  never carried the use of this remedy
so far as might enable me to judge properly of its effects.
 Whether it may do harm by impelling the blood too for-
 cibly into the vessels of the brain, or whether by its
 general  agitation of the whole  system it may remove
 that inequality of  excitement which prevails  in mania,
I have not had experience enough to determine.
  1570.  Frequent shaving of the  head has  been  found
 of service in mania, and by promoting perspiration it
probably takes off from the excitement of  the internal
parts.  Tnis, however, it is likely, may be more efiV* 
PRACTICE OF  PHYSIC.           gQ7
 ttially done by blistering, which more certainly takes
 off the excitement of subjacent parts.   In recent cases
 it has been found useful by inducing sleep;  and when
 it has that effect,  the repetition of it may be proper: but
 in maniacal cases that have lasted for some time,  blis-
 tering has not appeared to me to be of any service; and
 in such cases also I have not found perpetual blisters,
 or any other form of issue,  prove useful.
   1571. As heat is the principal means of first exciting
 the nervous system, and establishing the nervous power
 and vital principle in animals; so,  in cases of preterna-
 tural excitement, the application of cold might be sup-
 posed a proper remedy: but there are many instances
 of maniacs who have been exposed for a great length
 of time to a considerable degree of cold without having
 their symptoms anywise relieved.   This may render in
 general the application of cold a doubtful remedy; but
 it is at the same time certain, that  maniacs have often
 been relieved, and sometimes entirely  cured, by the use
 Of cold bathing, especially when administered in a cer-
 tain manner.  This seems  to consist, in throwing the
 madman in the cold water by surprise; by detaining
 him in it for some length of time; and pouring water
 frequently upon the head, while the whole of the body
 except the head  is  immersed in the  water; and  thus
 managing the whole process, so as that, with the assist-
 ance of some fear a refrigerant effect may be produced.
 This, I can affirm, has been often useful; and that the
 external application of cold may be of service, we know
further from the benefit which has been received in some
maniacal cases from the application of ice and snow to
the naked head, and from the application of the noted
clay cap.
  Warm bathing also has been recommended by some
practical writers;  and in some rigid melancholic habits 
9Q8          PRACTICE  OF PHYSIC.

it may possibly be useful, or as employed in the man-
ner prescribed by some, of immersing the lower parts
of the body in warm water, while cold water is poured
upon the head and upper parts.   Of this  practice, how-
ever, I have had  no  experience, and in the  common
manner of employing warm bathing I have found it ra-
ther hurtful to maniacs.
   1572. According to my supposition that the disease
depends upon an increased excitement of the brain,
especially with respect to the animal  functions, opium,
so commonly powerful in inducing sleep,  or a consider-
able collapse as to these functions,  should be a power-
ful remedy of mania.  That it  has truly  proved such. I
believe  from  the testimony of Bernard tluet,  whose
practice is narrated  at the end of  Wepferi  Historia
Apoplecticorum.  I leave  to my readers to study this
in the work I have referred to, where every part of the
practice is fully,  and it appears to me, very judiciously
delivered.   I  have never indeed carried the trial so far
as seems to be requisite to an  entire cure:  but I have
frequently employed in some maniacal cases large doses
of opium; and when they had the effect of  inducing
sleep, it was  manifestly with advantage.  At the same
time, in some cases,  from  doubts, whether the disease
might not depend upon some organic  lesions of the
brain,  when  the opium would be  superfluous; and  in
other cases, from doubts,  whether  there might not be
some  inflammatory affection joined  with  the  mania,
when the opium  would be  hurtful, I have never pushed
this remedy to the extent  that might be necessary  to
make an entire cure.
   1573. Camphor has been recommended as a remedy
of mania, and there are instances alleged of its having
performed an entire cure.   As it appears from the ex-
periments of  Beccaria that this substance is possessed 
PRACTICE OF PHYSIC.           289
 of a sedative  and narcotic virtue, these cures  are  not
 altogether improbable: but in several trials, and even in
 large doses,  I have found no benefit from it;  and ex-
 cepting those in the Philosophical Transactions, No.
 400, I have hardly met  with any other testimonies in
 its favour.
   1574.  I have been informed that some maniacs have
 been cured by being compelled  to constant  and even
 hard labour, and as a forced attention to the conduct of
 any bodily exercise is a very certain means of diverting
 the mind from pursuing any train of thought, it is highly-
 probable that such exercise may be useful in many cases
 of mania.
   I must conclude this subject with observing that even
 in several cases of complete mania, I have known a cure
 take place in the course of a journey carried on for some
 length of time.
   1575. These are the remedies which have been chiefly
 employed in the mania that  has been above described,
 and I believe  they  have been employed promiscuously
 without supposing that the mania was to be distinguish-
 ed into different species.   Indeed I am not ready to say
 how far it is  to be so distinguished, but I shall  offer
 one observation which may  possibly merit attention.
  It appears to me that there are two different cases of
 mania that are especially different according to the ori-
 ginal temperament of the persons whom  the  disease
 affects.   It perhaps occurs most frequently in persons
 of a melancholic or atrabilarian  temperament; but it
 certainly does also often occur in  persons of that  very
opposite temperament which physicians have named the
sanguine.  According as the disease happens to occur
in persons of the  one or other of these temperaments,
I apprehend it may be considered as of  a different na-
ture; and I believe, that accurate observation, employed
  VOL. II.               p p 
290           PRACTICE OF PHYSIC.
upon a sufficient number of cases, would discern some
pretty constant difference, either of the symptoms, or at
least of the state of the symptoms, in the two cases.  I
imagine that false imaginations, particular aversions and
resentments, are more fixed and steady in  the  melan-
cholic than in the sanguine: and that somewhat  inflam-
matory is more commonly joined  with mania in the
sanguine than in the melancholic.   If such difference,
however, does truly take place, it will be obvious, that
it may be proper to make  some difference  also in the
practice.  I am of opinion, that in the mania of san-
guine persons,  blood-letting  and other  antiphlogistic
measures are more proper, and have been more useful,
than in the melancholic.  I  likewise apprehend that
cold bathing is  more useful in the sanguine  than in the
melancholic:-but have  not had  experience enough to
ascertain these  points with  sufficient confidence.
  I have only to add to this other observation, that ma-
niacs of  the sanguine temperament recover more fre-
quently and more entirely than those  of the melancholic.
                    CHAPTER III.

OF MELANCHOLY, AND OTHER FORMS OF INSA-
                       NITY.

1576.  MELANCHOLY has been commonly consi-
dered as partial insanity; and as such it is defined in
my Nosology; but I now entertain doubts if this be alto-
gether proper.  By a partial insanity,  I understand  a
false and mistaken judgment upon one particular sub-
ject, and what relates to it; whilst, on every other sub-
ject, the person affected judges as the generality of other
men do,   Such cases have  certainly occurred; but,  I 
PRACTICE OF PHYSIC.
291
believe, few in which the partial insanity is strictly limit-
ed.   In many cases of general  insanity,  there  is one
subject of anger or fear, upon which the false judgment
more  particularly turns, or which is at least more fre-
quently than any other the prevailing object of delirium:
and though,  from the inconsistency which this princi-
pal  object of delirium must  produce,  there is there-
fore also  a great deal of insanity with regard to most
other objects; yet this last is in  very different degrees,
both in different persons, and in the same person at dif-
ferent times.  Thus, persons considered as generally in-
sane, will, however, at times, and in some  cases, pretty
constantly judge  properly enough of present circum-
stances and incidental occurrences; though, when Jhese
objects engaging attention are not presented, the ope-
rations of imagination may readily bring  back a gene-
ral confusion, or recall the particular object of the deli-
rium.  From these considerations, I am inclined to con-
clude, that the limits between general and partial insa-
nity cannot always  be  so  exactly assigned, as to deter-
mine when  the partial affection  is to be considered as
giving a peculiar species of disease, different from  a
more general insanity.
  1577. When insanity, neither strictly partial nor en-
tirely nor constantly general, occurs in persons of a san-
guine temperament, and is attended with  agreeable ra-
ther than with angry or gloomy  emotions, I think such
a disease must be considered as different from the ma-
nia described above; and also, though partial, must be
held  as  different from the proper  melancholia to  be
mentioned hereafter.
  1578. Such a disease, as different from those de-
scribed (1555.) requires, in my  opinion, a different ad-
ministration of remedies; and it will be proper for me
to take particular notice of this  here. 
292           PRACTICE OF PHYSIC.^

   Although it may be necessary to restrain such insane
persons as we have mentioned (1577.) from pursuing
the objects of their false imagination or judgment, it
will hardly be requisite to employ the same force of re-
straint that is necessary in the impetuous and angry ma-
nia. It will be generally sufficient to acquire some awe
over them, that may be employed, and sometimes even
be necessary, to check the  rambling of  their imagina-
tion, and incoherency of judgment.
   1579. The restraint just now mentioned as neces-
sary will generally require  the patient's being confined
to one place, for the sake of excluding the objects, and
more  particularly the  persons, that might excite ideas
connected with the chief objects of their delirium.  At
the same time, however, if it can be perceived there
are objects or persons that can call off their attention
from  the pursuit of their own disordered  imagination,
and fix it a little upon some others,  these  last may be
frequently presented  to them: and for  this reason, a
journey, both  by its having  the effect of interrupting all
train of thought, and by presenting objects engaging at-
tention, may often be useful.   In such cases also, when
the insanity,  though  more especially fixed upon one
mistaken subject, is not confined to this alone, but is
further apt to ramble over other subjects with incohe-
rent ideas, I apprehend the confining or forcing  such
persons to some constant uniform labour, may prove an
useful remedy.
   1580. When  such cases as in 1577, occur in san-
guine temperaments, and may therefore approach more
nearly to Phrenitic Delirium; so, in proportion as the
symptoms of this tendency are more evident and consi-
derable, blood-letting  and purging will be the more pro-
per, and necessary.
   1581. To this species of insanity, when occurring in 
PRACTICE OF PHYSIC.
293
 sanguine temperaments, whether it be more or less par-
 tial, I apprehend that cold bathing is particularly adapt-
 ed ; while in the partial insanity of melancholic persons,
 as I shall show hereafter, it is hardly admissible.
   1582. Having thus treated of a species of insanity,
 different, in my apprehension, from both the Mania and
 Melancholia, I proceed to consider  what seems  more
 properly to belong to this last.
   1583. The  disease,  which I name Melancholia, is
 very  often a partial insanity only.  But as in many in-
 stances, though the false imagination  or judgment seems
 to be with respect to one subject only; yet it seldom
 happens that this does not produce much inconsistency
 in the other intellectual operations:  and as, between a
 very general and a very partial insanity, there are all the
 possible intermediate degrees: so  it  will  be often diffi-
 cult, or perhaps improper, to distinguish melancholia
 by the character of Partial Insanity alone. If I mistake
 not,  it must be distinguished by its occurring in persons
 of a melancholic temperament, and by its being always
 attended  with some seemingly groundless,  but very
 anxious fear.
   1584. To explain the cause of this, I must observe,
 that persons of a melancholic temperament are for the
 most  part of a serious, thoughtful disposition, and dis-
 posed to fear and caution, rather than to  hope and te-
 merity.   Persons of this  cast are less moveable than
 others by any impressions: and are therefore capable of
 a closer or more continued attention  to one particular
 object, or train of thinking. They are even ready to be
 engaged in  a  constant application to one subject; and
 are remarkably tenacious of whatever emotions they
happen  to be affected with.
   1585. These circumstances of the melancholic cha-
racter, seem clearly to show, that persons strongly af- 
294           PRACTICE OF  PHYSIC.
fected with it may be readily  seized with  an anxious
fear; and that this, when much indulged, as is natural
to such persons, may easily grow into a partial insanity.
   1586. Fear and dejection of mind, or a timid and de-
sponding  disposition, may  arise  in certain states,  or
upon certain occasions of mere debility: and it is upon
this footing, that I suppose it sometimes to  attend dys-
pepsia.   But in these cases, I believe  the  despondent
disposition hardly ever arises to a considerable degree,
or proves so obstinately fixed as when it occurs in per-
sons of a melancholic temperament.  In these last, al-
though  the fear proceeds from the same dyspeptic feel-
ings as in the other case, yet it will be obvious, that the
emotion may arise to a more considerable degree; that
it  may  be more anxious, more fixed, and more atten-
tive; and therefore may exhibit all the various circum-
stances, which I have mentioned in  1222, to take place
in the disease named hypochondriasis.
   1587. In considering this subject formerly in distin-
guishing dyspepsia from hypochondriasis, although the
symptoms  affecting the body  be  very  much  the same
in both, and even those  affecting  the mind be some-
what similar, I  found no difficulty in distinguishing the
latter disease, merely from it occurring in persons of a
melancholic temperament.  But I must now  acknow-
ledge, that I am at a loss to  determine how in  all cases
hypochondriasis and melancholia  may be distinguished
from one another, whilst the same temperament is com-
mon to  both.
   1588. I apprehend,  however, that  the distinction
may be generally ascertained in the following manner.
   The hypochondriasis I  would consider as  being  al-
ways attended  with dyspeptic symptoms: and though
there may be, at the same time, an anxious melancholic
fear arising from the feeling of these  symptoms; yet 
             PRACTICE OF PHYSIC.          295

while this fear is only a mistaken judgment with respect
to the state of the person's own health, and to the dan-
ger to be from tnence apprehended,  I would still con-
sider the disease as a hypochondriasis, and as distinct
from the proper melancholia.   But when an anxious
fear and despondency arises from a mistaken judgment
with respect to other circumstances than those of health,
and  more  especially when the person is  at the same
time without any  dyspeptic symptoms,  every  one  will
readily allow this to be a disease widely different from
both dyspepsia and hypochondriasis; and it is, what I
would strictly name melancholia.
   1589. In this there seems little difficulty; but as an
exquisitely melancholic temperament may induce a tor-
por and slowness in the action of the stomach, so it gene-
rally produces  some  dyspeptic symptoms: and from
thence  there may be some difficulty in distinguishing
such a case from hypochondriasis.   But I would main-
tain, however, that when the characters of the  tempera-
ment are strongly  marked; and more particularly when
the false  imagination turns  upon other subjects than
that of health, or when, though relative to the person's
own body, it is of a groundless and absurd kind; then,
notwithstanding the appearance of  some  dyspeptic
symptoms, the case is still to be considered as  that of
a melancholia, rather than a hypochondriasis.
   1590. The disease of melancholia, therefore, mani-
festly depends upon the general temperament of the
body; and although,  in many persons, this  tempera-
ment is not attended with any morbid affection either of
mind or body; yet when it becomes exquisitely formed,
and is in a high degree,  it may become a disease affect-
ing both,'and particularly the mind.   It will therefore
be proper to consider in what this melancholic tempera-
ment especially consists; and  to this  purpose,  it  may 
296          PRACTICE OF PHYSIC.

be observed, that in it there is a degree of torpor in the
motion of the nervous power, both with respect to sen-
sation and volition; that there is a general rigidity of the
simple solids; and that the balance of the sanguiferous
system, is  upon the  side of the  veins.   But all these
circumstances are the directly opposite of those of the
sanguine temperament; and must therefore also  pro-
duce an opposite state of the mind.
   1591. It is this state of the mind, and the state of the
brain corresponding to  it, that is the chief object of our
present consideration.  But what  that state of the brain
is, will be  supposed to  be difficult to explain;  and it
may perhaps seem rash in me to attempt it.
   I  will, however, venture to  say, that  it is probable
the melancholic temperament of mind depends upon a
drier and firmer texture in the medullary substance of
the brain; and that this perhaps proceeds from a certain
want of fluid in that substance, which appears from its
being of a lesser specific gravity than  usual.   That this
state of the  brain in melancholia  does actually exist, I
conclude, first, from  the general  rigidity of  the whole
habit; and,  secondly,  from dissections, showing such a
state of the  brain to have taken place in mania, which
is often no  other than a higher degree of melancholia.
It does not appear to me anywise difficult to suppose,
that the same state of the brain may in a moderate de-
gree give melancholia; and in a higher, that mania which
melancholia so  often  passes  into;  especially  if I shall
be allowed further to suppose, that either a greater de-
gree of firmness in the substance of the brain may  ren-
der it susceptible of a higher degree of excitement, or
that  one portion of the brain  may be liable to acquire a
greater firmness than  others,  and consequently give oc-
casion to that inequality of excitement upon which ma-
nia so much depends. 
PRACTICE OF PHYSIC.
297
   1592. I have  thus  endeavoured to deliver what ap-
pears to  me most probable with respect  to the proxi-
mate  cause of melancholia; and although  the matter
should in some respects remain doubtful, I am well per-
suaded that these observations may be often employed
to direct our practice in this disease, as I shall now  en-
deavour to show.
   1593. In most of the  instances of  melancholia,  the
mind is to be managed very much in  the same  manner
as I have advised above with regard to hypochondriasis;
but as in the  case of proper melancholia,  there is com-
monly a false imagination or judgment appearing as a
partial insanity,  it  may  be further necessary in such
cases to employ some artifices for correcting such imagi-
nation or judgment.
   1594. The  various remedies for relieving the  dyspep-
tic symptoms  which always attend hypochondriasis, will
seldom be either requisite or proper in melancholia.
  There is only  one of the dyspeptic symptoms, which,
though there should  be no  other, is very constantly
present in melancholia, and that is costiveness.  This
it is always proper and even necessary to  remove; and
I believe it is upon this account that  the use of purga-
tives has been found  so often  useful in  melancholia.
Whether there be any purgatives peculiarly proper in
this case, I dare  not positively determine; but with re-
spect  to the choice of purgatives in melancholia, I am
of the same opinion that I delivered above on this same
subject with respect to mania.
   1595.  With respect to other  remedies, I judge that
blood-letting will more seldom be proper  in melancho-
lia than  in mania;  but how far  it may be in any case
proper, must  be determined by the same considerations
as in the case of mania.
   1596.  The cold bathing that  I judged to  be  so very
  vol. n.              o. q 
298           PRACTICE OF PHYSIC.
 useful in several cases of insanity, is, I believe, in me-
 lancholia, hardly ever fit to be admitted; at least while
 this is purely a partial affection, and without any marks
 of violent excitement.   On the contrary, upon account
 of the general rigidity prevailing in melancholia, it is
 probable that warm bathing may be often useful.
   1597. With respect to opiates which I have supposed
 might often be useful in cases of mania, I  believe they
 can seldom be properly employed  in the partial  insani-
 ties of the  melancholic, except in certain  instances of
 violent excitement, when the melancholia approaches
 nearly to the state of mania.
   1598. In such cases of melancholia approaching to a
 state of mania, a low diet  may sometimes be necessary;
 but  as  the employing  a low diet almost unavoidably
 leads to the use of vegetable food,  and as this in every
 torpid state of the stomach is ready to produce some dys-
 peptic symptoms, such vegetable food ought, in moderate
 cases of melancholia, to be used with some  caution.
  Though exercise, as a  tonic power,  is not proper
 either in hypochondriasis or melancholia; yet, with  re-
spect to its effects upon the mind,  it may be extremely
 useful in both, and in melancholia  is to be employed in
 the same manner that I have advised above in the case
 of hypochondriasis.
  1599. Having now delivered my doctrine with  re-
 spect to the forms of insanity, I should in the next place
 proceed to consider the other genera of Amentia and
 Oneirodynia, which  in  the Nosology I have arranged
 under the order of Vesanias; but as I cannot preten^ to
throw much light upon these subjects, and as they are
seldom the objects of practice,  I think it allowable  for
me  to pass  them over at present; and the particular cir-
cumstances of this work in some measure require that
I should do so. 
PRACTICE OF PHYSIC.
209
                    PART III.

                 OF CACHEXIES.

1600. UNDER this title I propose to establish a class
of diseases,  which consist  in a  depraved state of  the
whole, or of a considerable part, of the habit of  the
body, without any primary pyrexia or neurosis  com-
bined with that state.
   1601.  The term  Cachexy has been  employed by
Linnaeus and Vogel, as it had been formerly by other
authors,  for the name of a particular disease; but the
disease to which  these authors have affixed it, comes
more properly under another appellation; and the term
of Cachexy  is  more properly employed  by Sauvages
and Sagar for the name of a class.  In this I have  fol-
lowed the last mentioned nosologists,  though I find it
difficult to give such a character of the class as will
clearly apply to all the species I have comprehended
under it.  This difficulty would  be still greater,  if, in
the class I have established under the title  of Cachexies,
I were to comprehend all the diseases that those other
nosologists have done;  but I am willing to be thought
deficient rather than very incorrect.  Those difficulties,
however, which still remain in methodical nosology,
must not affect  us much in  a treatise of practice.    If I
can here properly distinguish and describe the several
species that  truly and most commonly exist,  I shall be
the less concerned about the accuracy of my general
classification; though at the same time this, I think, is
always to be attempted; and I shall pursue it as well as
I can.                     • 
300          PRACTICE OF PHYSIC.
                     BOOK I.
                OF  EMACIATIONS.

1602. EMACIATION, or a considerable diminution
of the bulk or plumpness of the whole body, is for the
most part only a symptom of disease, and very seldom
to be considered as a primary and idiopathic affection.
Upon this account, according to my general plan, such
a symptom  might perhaps have been  omitted  in the
Methodical Nosology: but both the uncertainty of con-
cluding it to be always symptomatic, and the consistency
of system,  made  me introduce  into the Nosology, as
others had  done, an order under the title of Marcores;
and this  renders it requisite now to take some notice of
such diseases.
  1603.  Upon this occasion,  therefore, I hope it may
be useful to investigate the several causes of emaciation
in all the different cases of disease in which it appears.
And this I  attempt, as the surest means of determining
how far it is a primary or a symptomatic affection only;
and even in the latter view, the investigation  may be
attended  with some advantage.
  1604.  The causes of  emaciation may, I apprehend,
be referred  to two general heads; that is, either to a
general deficiency of fluid in the vessels of the body, or
to the particular deficiency of the oil  in the  cellular
texture of it.  These causes  are frequently combined
together; but it will be proper, in the first place, to con-
sider them  separately.
  1605.  As a great part of the body of animals is made
up of vessels filled  with fluids, the bulk of the whole
must depend very much on  the size of  these vessels,
and the quantity of  fluids present in them: and it will 
PRACTICE OF PHYSIC.
301
therefore  be sufficiently obvious,  that a deficiency of
the fluids  in these vessels must, according to its degree,
occasion a proportionate diminution of the  bulk of the
whole  body.   This,  however,  will appear still  more
clearly,  from considering that in the living and sound
body the vessels every where seem to be preternaturally
distended by the quantity of fluids present in them; but
being at the same time  elastic,  and constantly endea-
vouring to contract themselves, they must, on the with-
drawing of the distending force,  or,  in other words,
upon  a diminution of the quantity of  fluids, be in pro-
portion contracted and diminished in their size.   And
it may  be further observed,  that as  each  part of the
vascular system communicates with every other part of
it; so every degree of diminution of the quantity of fluid,
in any one part,  must in proportion diminish  the bulk
of the vascular system, and consequently of the whole
body.*
   1606.  The diminution  and  deficiency of the fluids

  * There may, however, and often does, occur, a partial, without a general,
diminution of the bulk of the body.  This  is manifested, in the shrivelling
of a palsied limb, and other accidents, which frequently present themselves.
  Throughout the greater portion of this book, the reasoning of our author
is visionary and erroneous, in a very eminent degree.
  As far as we now recollect, emaciation may, in every case, where it occurs,
be correctly  attributed to one of four causes; a deficiency in  the quantity
of aliment used; a deficiency of -wholesome  and nutritious matter, in the ali-
ment ; a debility, defect, or disorder, in the organs of assimilation and nu-
trition ; or, a morbid increase, in the action, of the organs of absorption.
  Oil cannot, we believe, be absorbed, in its formal stale—we mean,  as oil.
Previously to absorption, it  must undergo an essential change, suiting it to
the appetency, or habit of selection, of the  vessel, which absorbs.
  It is not, therefore, as the professor alleges, taken up, either to lubricate,
and prepare  for action, the moving fibres of the body; nor yet to envelop,
and render harmless, any acrimony, in the blood, or other fluids, of the
body.
  Such coarse, mechanical views, in physiology and pathology, are unworthy
of refutation.  From this, to the close of the work, therefore,  we shall no-
sice them no further. 
302
PRACTICE OF PHYSIC.
may be occasioned  by different causes: such as, first,
by a due quantity of aliments not being taken in; or by
the aliment taken in not being of a sufficiently nutri-
tious quality. Of the want of a due quantity of aliment
not being taken into' the body, there is an instance in
the atrophia lactantium Sauvagesii, species 3. and many
other examples have occurred of emaciation from want
of food, occasioned by poverty,  and other accidental
causes.
  With respect to  the quality of food, I apprehend it
arises from the want of  nutritious matter in the food
employed, that persons living entirely on vegetables are
seldom of a plump and succulent habit.
  1607. A second cause of the deficiency of fluids may
be,  the aliments  taken in  not being conveyed to the
blood-vessels.  This may occur from a person's being
affected with a frequent vomiting; which, rejecting the
food soon after it had been taken in, must prevent the
necessary supply of fluids to the blood-vessels. Another
cause, frequently interrupting the conveyance of the
alimentary matter into the blood-vessels, is an obstruc-
tion of the conglobate or lymphatic glands of the me-
sentery, through which the chyle must necessarily pass
to the thoracic duct.  Many  instances of emaciation,
seemingly depending  upon this cause, have been ob-
served by physicians, in persons of all ages, but especi-
ally in the young.   It has also been remarked, that such
cases have most frequently occurred in scrophulous per-
sons, in whom the mesenteric  glands are commonly af-
fected with tumour  or obstruction, and in whom, gene-
rally at the  same time,  scrophula appears externally.
Hence the Tabes scrophulosa Synop.  Nosolog. vol. ii.
p. 266.  And under these  I have put as synonimes Tabes
glandularis, sp. 10.  Tabes mesenterica, sp. 9.  Scrophu-
la mesenterica, sp. 4.  Atrophia infantilis, sp. 13. Atro- 
PRACTICE OF PHYSIC.
303
 phia rachitica, sp. 8.  Tabes rachialgica, sp. 16. At the
 same time, I have frequently found the case occurring
 in persons who did not show any external appearance
 of scrophula, but in whom the mesenteric obstruction
 was afterwards discovered by dissection.  Such also I
 suppose to have been the case in the disease frequently
 mentioned by authors under the title of the Atrophia in-
fantum.  This has received its name from the time of life
 at which it generally appears; but I have met with in-
 stances of it at fourteen years of age ascertained by dis-
 section.   In several such cases which I have seen, the
 patients were without  any scrophulous appearances at
 the time, or at any period of their lives before.
   In the case of phthisical persons, I shall hereafter
 mention another cause of their emaciation; but it is pro-
 bable  that an  obstruction of the  mesenteric  glands,
 Which so frequently happens  in such persons,  concurs
 very powerfully in producing the  emaciaton that takes
 place.
  Although a scrophulous taint  may be the most fre-
 quent cause of mesenteric obstructions, it is sufficiently
 probable that other kinds of acrimony may produce the
 same, and the emaciation that follows.
  It may perhaps be supposed, that the interruption of
 the chyle's passing into the blood-vessels may be some-
 times owing to a fault of the absorbents on the internal
surface of the intestines.  This, however,  cannot be
readily ascertained; but the interruption of the chyle's
passing into  the blood-vessels may certainly be owin«-
to a rupture of the thoracic duct; which, when it does
not prove soon fatal, by occasioning a hydrothorax must
in a short time produce a general emaciation.
  1608. A third cause of the deficiency of the  fluids
may be a fault in  the organs of digestion,  as not  duly
converting  the  aliment into a chyle fit to form  in  the 
  304          PRACTICE OF PHYSIC.

  blood-vessels a proper nutritious matter.  It is not, how-
  ever, easy to ascertain the cases  of emaciation which
„ are to be attributed to this cause; but I apprehend that .
  the emaciation which attends long subsisting cases  of
  dyspepsia,  or of hypochondriasis,  is  to  be explained
  chiefly in  this way.  It is  this which I have placed  in
  the Nosology under the title of the Atrophia debilium;
  and of which the Atrophia Nervosa,  Sauv. sp. 1.  is a
  proper instance, and therefore put there as a synonime.
  But  the other titles of Atrophia Lateralis, Sauv. sp. 15.
  and Atrophia  senilis, Sauv. sp. 11. are not so properly
  put there, as they must be explained in a different man-
  ner.
    1609. A fourth cause of a deficiency of the fluids in
  the body,  may be excessive evacuations  made  from  it
  by different outlets; and Sauvages has  properly enume-
  rated the following species, which  we have put as sy-
  nonimes under the title of Atrophia  inantforum'; ras,
  Tabes nutricum, sp. 4; Atrophia nutricum, sp. 5; Atro-
 phia a leucorrhoea, sp. 4; Atrophia ab alvifluxu, sp. 6; i
  Atrophia a ptyalismo, sp. 7; and lastly,  the Tabes a  san-
  guifluxu;  which,  it is  to  be  observed, may arise not
  only from spontaneous hasmorrhagies  or accidental
  wounds, but also from blood-letting in too large a quan-
  tity,  and too frequently repeated.
   Upon this subject it seems proper to observe, that a
  meagre habit  of  body frequently depends upon a full
  perspiration being constantly kept  up, though, at the
  same time, a large quantity of nutritious aliment is re-
  gularly taken in.
    1610. Besides  this deficiency of fluids from  evacua-
 tions by which they are carried entirely out of the body,
  there may be a deficiency of fluid and emaciation  in a
  considerable part of the body, by the fluids being drawn
  into  one part  or collected  into one cavity; and,of  this * 
PRACTICE OF PHYSIC.           305
 we have  an instance  in the  Tabes a hydrope, Sauv.
 sp. 5.
   1611. In the Methodical Nosology, among the other
 synonimes of the Atrophia inanitorum 1 have set down
 the Tabes dorsalis; but whether properly or not, I at
 present very much doubt. In the evacuation considered
 as  the cause of this tabes, as the quantity  evacuated
 is never so great as to account for a general deficiency
 of fluids in the body, we must seek for another expla-
 nation of  it.  And whether the effects of the evacuation
 may be accounted  for, either from  the  quality of the
 fluid evacuated, or from the singularly enervating plea-
 sure attending the evacuation, or from the evacuation's
 taking off the tension of parts, the tension of which has
 a singular power jn supporting the tension and vigour
 of the whole body, I cannot positively determine; but I
 apprehend that upon one or other of these suppositions
 the emaciation  attending the tabes dorsalis must be ac-
 counted for: and therefore, that it is to be considered as
 an instance of the Atrophia debilium, rather than of the
 Atrophia inanitorum.
   1612. A fifth cause of a deficiency of fluids, and of
 emaciations in the whole or in a particular part of the
 body, may be the concretion of the small vessels, either
 not admitting of fluids, or of the same proportion  as
 before; and this seems to me to be the case in the Atro-
phia senilis,  Sauv.  sp. 2.   Or it may be a palsy of the
 larger trunks of the arteries rendering them unfit to pro-
 pel the blood into the  smaller vessels; as is  frequently
 the case of  paralytic limbs, in which  the  arteries are
 affected as well  as the muscles.   The Atrophia lateralis,
 Sauv. sp.  15, seems to be of this nature.
   1613. A second general head  of the causes of ema-
 ciation I have mentioned in 1603, to be a deficiency of
 oil.  The extent  and quantity of the cellular texture
  VOL. II.               r r 
 306           PRACTICE OF PHYSIC.

 in every part of the body, and therefore how consider*
 ble a part it  makes in the bulk of the whole, is now well
 known.  But this substance, in different circumstances, ,
 is more or less filled with an oily matter; and therefore
 the bulk of it, and in a great measure that of the whole
 body, must be greater or less, according as this substance
 is more or less filled in that manner.   The deficiency
 of fluids, for a reason  to be immediately explained, is
 generally accompanied with a deficiency of oil: but phy-
 sicians have commonly attended  more to the  latter
 cause of  emaciation than to the other, that being usu-
 ally the most evident; and I shall now endeavour to as-
 sign the several causes of the deficiency of oil, as it oc-
 curs upon different occasions.
   1614. The business of secretion  in the human body
 is in general little understood, and in no instance less so
 than  in that of the secretion of oil from blood whi$h
 does not appear previously  to have contained it.  It is
 possible, therefore, that our theory of the deficiency of
 oil may be in several respects imperfect;  but there are
 certain facts that may, in the mean time, apply to the
 present purpose.
   1615.  First, it is probable, that a deficiency of oil may
 be owing to a state of the  blood in  animal bodies less
 fitted to afford a  secretion of oil, and consequently to
 supply the waste of it that is constantly  made.   This
 state of the blood must especially depend upon the. state
 of the aliments  taken in,  as containing less of oil or
 oily matter.   From many observations made, both with
 respect to the human body and to that of other animals,
 it appears pretty clearly, that the aliments taken in by
 men and domestic animals, according as they contain
 more of oil, are in general  more nutritious, and  in par-
 ticular are better fitted to fill the cellular texture of their
bodies with oil. t  I might illustrate this, by a minute and 
PRACTICE OF PHYSIC.           307
particular consideration of the difference of alimentary
matters employed; but it will be enough to give two in-
stances.  The one is, that the herbaceous part of vege-
tables does not fatten animals, so much as the seeds of
vegetables,which manifestly contain, in any given weight,
a greater proportion of oil:  and a  second instance is,
that in general vegetable aliments do not fatten men so
much as animal food, which generally contains a larger
portion of oil.
  It will be obvious that, upon the same principles, a
want of food, or a less nutritious food,  may not only
occasion a general deficiency of fluids (1605.) but must
also afford less oil, to be poured into the  cellular tex-
ture.   In such cases,  therefore, the  emaciation pro-
duced is to be attributed to both these general causes.
  1616. A second case of the deficiency of oil may be
explained in this manner. It is pretty manifest, that the
oil of the blood is secreted and deposited in the cellular
texture in greater or lesser  quantity, according as the
circulation of the  blood is faster or slower; and there-
fore that exercise, which hastens the circulation of the
blood, is a frequent cause of emaciation. Exercise pro-
duces this  effect in two ways.   1st. By increasing the
perspiration, and thereby carrying off a greater  quan-
tity of the nutritious matter, it leaves less of it to be de-
posited in the cellular texture;  thereby not  only pre-
venting an accumulation of fluids,  but, as I have said
above, causing a  general deficiency .of  these, which
must also cause a deficiency of oil  in the  cellular tex-
ture.   2dly, It is well known, that the oil deposited in
the cellular texture is,  upon many occasions,  and for
various purposes of the economy, again absorbed, and
mixed or  diffused  in the mass of blood, to be from
thence perhaps carried entirely out of the body by the
several excretions.   Now, among other purposes of the 
308
PRACTICE OF PHYSIC.
 accumulation and reabsorption of oil, this seems to be
 one, that the oil is requisite to the proper action of the
 moving fibres in every part of the body;  and therefore
 that nature has provided for an absorption of oil to be
 made, according as the action of the moving fibres may
 demand  it.   It will thus be obvious, that the exercise of
 the  muscular and  moving fibres every where, must oc-
 casion an absorption of oil; and consequently that such
 exercise  not only prevents  the secretion  of oil, as has
 been already said, but may also  cause a  deficiency of
 it, by occasioning an absorption of what  had been de-
 posited;  and in this  way perhaps especially, does it pro-
 duce emaciation.
   1617. A  third case of the deficiency of oil may occur
 from the  following cause.  It is probable, that one pur-
 pose of the accumulation of oil in the cellular  texture
 of animals is, that it may, upon occasion, be again ab-
 sorbed from thence, and carried into the mass of blood,
 for the purpose of enveloping and correcting any unu-
 sual acrimony arising and existing in  the state of the
 fluids.  Thus, in most instances in which we can discenr
 an acrid  state of the  fluids, as in scurvy, cancer, syphilis,'
 poisons, and several other diseases, we find at the same
 time a deficiency of oil  and an emaciation take place;
 which, in my apprehension, must be attributed  to  the
 absorption of oil, which the presence of acrimony in
 the body excites.
  It is not unlikely that certain poisons introduced into
 the  body, may subsist there;  and, giving occasion to
 an absorption of oil,  may lay a foundation for the Tabes
 a veneno, Sauv. sp. 17.
  1618.  A  fourth cause of emaciation, and  which I
would  attribute to a sudden and considerable absorp-
tion  of oil from the cellular texture,  is that of fever,
which so generally produces emaciation. This may per- 
PRACTICE OF PHYSIC.
309
 haps be in part attributed to the increased perspiration,
 and therefore to the general deficiency of fluids that
 maybe supposed to take place: but whatever share that
 may have in producing the effect,  we can, from  the
 evident shrinking and  diminution  of the  cellular sub-
 stance, wherever it falls under our observation, certainly
 conclude, that there has been a very considerable  ab-
 sorption of the oil which had been before deposited in
 that substance.  This explanation is rendered the more
 probable from this, that I suppose the absorption men-
 tioned is necessarily made  for the purpose of envelop-
 ing or correcting an  acrimony, which manifestly does
 in many,  and may be suspected to arise in all cases of
 fever.  The most remarkable instance of emaciation oc-
 curring in fevers,  is that which appears in the case of
 hectic fevers.  Here the emaciation may be attributed to
 the profuse sweatings that commonly attend  the dis-
 ease; but there is much reason to believe, that an acri-
 mony also is present in the blood; which, even in the
 beginning of the disease, prevents the secretion and  ac-
 cumulation of oil;  and in  the more advanced states of
 it, must  occasion a more considerable  absorption  of
 it; which, from the shrinking of the cellular substance,
 seems  to go farther than in almost any other instance.
  Upon the subject  of emaciations from  a deficiency
 of fluids,  it may be observed, that every increased eva-
 cuation excites  an absorption  from  other parts, and
 particularly from the cellular texture; and it is therefore
 probable,  that a deficiency of fluids, from increased eva-
 cuations, produces an emaciation, not only by the waste
of the fluids in the vascular system, but also by occasion-
ing a considerable absorption from the cellular texture.
  1619. I have thus endeavoured to explain the several
cases and  causes of emaciation; but I could not prose-
cute the consideration  of these here  in the order they 
310           PRACTICE OF PHYSIC.
are set down in the Methodical Nosology. In that work
I was engaged chiefly in arranging the Species of Sau-
vages:  but it is my opinion now, that the arrangement
there given is erroneous, in both  combining and sepa-
rating species improperly: and it seems to me more pro-
per here to take notice of diseases, and put them toge-
ther, according  to the  affinity of their  nature, rather
than by that of their external appearances.  I doubt, if
even the  distinction of the Tabes  and Atrophia, at-
tempted in the Nosology, will properly apply; as I think
there are certain diseases  of the  same nature,  which
sometimes appear with, and sometimes without fever.
   1620.  After having  considered the various cases of
emaciations, I should perhaps treat of their cure: but it
will  readily appear, that the greater part of the cases
above mentioned are  purely symptomatic, and  conse-
quently that the cure of them  must be that of the pri-
mary diseases upon which they depend. Of those cases
that  can any wise be considered  as  idiopathic,  it will
appear that they are to  be cured  entirely by removing
the remote causes; the means of accomplishing  which
must be sufficiently obvious.
                     BOOK II.

 OF 1NTUMESENTLE, OR GENERAL SWELLINGS.

1621. THE swellings to be treated  of in  this place,
are those which extend over the whole or a great part
of the body;  or such at least,  as, though of small ex-
tent, are however of the  same nature with those that
are more generally extended.
  The swellings comprehended under this artificial or-
der, arc hardly  to be  distinguished ftom one another. 
PRACTICE OF PHYSIC.           3\\
otherwise than by the matter they contain or consist of.
And in this view  I have divided the order into four sec-
tions, as the swelling happens  to contain,  1st,  Oil;
2d, Air;  3d, A watery fluid; or, 4th, As the  increased
bulk depends upon the enlargement of the whole sub-
stance of certain parts, and particularly of one or more
of the abdominal viscera.
                      CHAPTER I.

             OF ADIPOSE SWELLINGS.

 1622. THE only disease to be mentioned in this chap-
 ter, I have, with other nosologists, named Polysarcia;
 and in English it may  be named Corpulency,  or, more
 strictly, Obesity; as it  is placed here upon the common
 supposition of its depending chiefly upon the increase
 of oil in the cellular texture of the body.  This corpu-
 lency, or obesity, is in  very different degrees in different
 persons, and is often considerable without being consi-
 dered as a disease.   There is, however, a  certain de-
 gree of it, which will  be generally allowed to be a dis-
 ease; as, for example,  when it  renders persons,  from a
 difficult respiration, uneasy in themselves, and, from the
 inability of exercise, unfit for discharging the duties of
 life to others:  and for that reason I have given  such a
 disease a place here.   Many physicians have consider-
 ed it as an object of practice,  and as giving, even in a
very high degree, a disposition  to many diseases. lam
of opinion that it should be an  object of practice more
frequently than it has been, and therefore that it merits
our consideration here.
  1623. It may perhaps be  alleged, that I have not 
312           PRACTICE OF PHYSIC.
 been sufficiently correct,  in putting the disease of cor-
 pulency as an intumescentia pinguedinosa, and there-
 fore implying its being an increase of the bulk  of the
 body from an accumulation of oil in the cellular texture
 only. I am aware of this objection: and as 1 have already
 said, that emaciation (1604.) depends either  upon a
 general  deficiency of fluids  in  the  vascular system, or
 upon a  deficiency of oil  in  the cellular  texture; so I
 should perhaps have observed farther,  that  the corpu-
 lency, or general fulness of the  body, may  depend
 upon the fulness of the vascular system as well as upon
 that of the cellular texture.   This is true; and for the
 same reasons I ought, perhaps,  after Linnaeus and Sa-
 gar, to have set down plethora  as a particular disease,
 and as an instance  of morbid intumescence.  I have,
 however, avoided  this, as  Sauvages and  Vogel have
 done; because I apprehended that plethora is to be con-
 sidered as a state of temperament only, which may in-
 deed dispose to disease; but not as a disease in itself,
 unless, in the language of the Stahlians, it be  a plethora
 commota,  when  it  produces a disease  accompanied
 with particular  symptoms, which  give  occasion to its
 being distinguished by a different appellation.  Further,
 it appears to me,  that the symptoms which  Linnaeus,
 and more particularly those which Sagar employs in the
 character of plethora, never do occur but  when the in-
 tumescentia pinguedinosa has a  great share in produc-
 ing them.  It is,  however, very necessary to observe
 here, that plethora and obesity are generally  combined
 together; and that in some cases of corpulency it may
 be difficult to determine which of the causes has the
 greatest  share in  producing it.  It is indeed very pos-
sible that a plethora may occur  without great obesity;
but I apprehend that obesity never happens to a consi-
derable degree without producing apld/wra ad spatiuni 
PRACTICE  OF  PHYSIC.            313
in a great part of the system of the aorta, and therefore
a plethora ad molem in the lungs, and in the vessels of
the brain.*
   1624. In  attempting  the cure of  polysarcia,  I am
of opinion that the conjunction of plethora and obesity,
in the manner just now mentioned, should be constantly
attended to; and when the morbid effects of  the ple-
thoric habit are threatened, either in the head or lungs,
that blood-letting is  to be practised: but  at the  same
time it is to be observed, that persons of much obesity
do not bear blood-letting well; and when  the  circum-
stances I have mentioned do not immediately require it,
the  practice upon account of obesity alone is hardly
ever to be employed.  The same remark is to be  made
with respect to any other evacuations that  may be pro-
posed for the cure of corpulency: for without the  other
means  I am to mention,  they can  give but a very im-
perfect relief;  and, in so far as they  can either empty
or weaken  the system,  they  may favour the return of
plethora, and the increase of obesity.
   1625. Polysarcia, or corpulency, whether it depend
upon plethora or obesity, whenever it  either can be con-
sidered as a disease or threatens to induce one, is to be
cured, or the effects of it are to be obviated, by diet and
exercise.   The diet must be  sparing; or  rather,  what,
is more admissible, it must be such as affords little nu-
tritious matter.   It must therefore be chiefly, or almost
only, of vegetable matter, and at the  very utmost of milk.
Such a diet should be employed, and generally ought
to precede exercise; for obesity does not easily  admit of

  * It is very well known, that fat persons have much less hlood, than those
who ate lean.  A butcher will tell you, that, from the vessels of a fat ox, lie
e«n draw, comparatively, but little blood.
  Although it is true, therefore, that great obesity does augment the plethora
*d spatium, it diminishes the plethora ad molem.
   VOL. II.                S S 
314           PRACTICE OF PHYSIC.

bodily exercise; which is, however, the only mode that
can be very effectual.  Such, indeed, in many cases,
may seem difficult to  be admitted; but I am of opinion,
that  even the most corpulent may be brought to bear it,
by at first attempting  it very moderately, and increasing
it by degrees very slowly, but at the same time persist-
ing in such attempts  with great constancy*
   1626. As these, though the only effectual measures,
are often difficult  to be admitted or carried into execu-
tion,  some other means have been thought of and em-
ployed for  reducing  corpulency.  These, if 1 mistake
not,  have all been certain methods of inducing a saline
state in the mass of blood, for such I suppose to be the
effects of vinegar and  of soap, which have been proposed.
The latter, I believe, hardly passes into the blood ves-
sels,  without being resolved and formed into a neutral
salt; with the acid which  it meets with in the stomach.
How well acrid and saline substances are fitted to dimi-
nish obesity, may  appear from what has been said above
in 1616. What effects vinegar, soap, or other substances
employed,  have had in reducing corpulency, there have
not proper opportunities of observing  occurred to me:
but I am well persuaded,  that the  inducing a saline and
acrid state of the  blood, may have worse consequences
than the corpulency  it was intended  to correct; and
that no person should hazard these, while he may have
recourse to the more safe and certain means of absti-
nence and exercise.
  * In addition to the use of a spare diet, and constant exercise, persons, hv
dined to obesity, should take but little sleep.  Those who sleep only fro»
five to six hours—a space sufficient to satisfy the demands of nature—»i*
rarely grow fat. 
PRACTICE OF PHYSIC.
315
                     CHAPTER II.

           OF FLATULENT SWELLINGS.

 1627. THE cellular texture of the human body very
 readily admits of air, and allows the same to pass from
 any one to every other part of it.  Hence Emphysemata
 have often appeared from air collected in the cellular
 texture under the  skin, and in several other  parts of
 the body.  The flatulent swellings under the skin, have
 indeed most commonly  appeared in consequence of air
 immediately introduced from without:  but in some in-
 stances of flatulent swellings, especially those of the
 internal  parts not communicating with the alimentary
 canal, such an  introduction cannot  be perceived or
 supposed; and,  therefore, in  these cases, some other
 cause of  the production and collection of air must be
 looked for, though it is often not to be clearly ascer-
 tained.
   In every solid as well as every fluid substance which
 makes a part of the human body, there is a considera-
 ble quantity of air in a fixed state, which may be again
 restored to its elastic  state, and  separated  from those
 substances, by the power of heat, putrefaction, and per-
 haps other causes: but  which of these may have pro-
 duced the several  instances of pneumatosis and flatu-
 lent  swellings, that have  been recorded by authors, I
 cannot pretend to  ascertain.   Indeed  upon account of
these difficulties, I cannot proceed with any clearness
on the general subject of pneumatosis; and, therefore,
with regard to flatulent swellings, I find it  necessary to
routine myself to the consideration of those of  the ab- 
316            PRACTICE OF  PHYSIC.

dominal region alone; which I  shall now treat of under
the general name of Tympanites.*
   1628. The tympanites is a swelling of the abdomen:
in which the teguments appear to be much stretched by
some distending power within, and equally stretched in
every  posture  of the  body.   The  swelling does  not
readily yield to any  pressure; and in  so far as  it  does,
very quickly recovers its former state upon the pressure
being  removed.   Being struck,  it gives a sound like a
drum, or other stretched animal membranes.  No fluc-
tuation within  is to  be perceived; and the  whole feels
less weighty than might be expected from its bulk. The
uneasiness of  the distention is  commonly relieved  by
the discharge of air from  the alimentary canal,  either
upwards or downwards.
   1629. These are  the characters by  which the tym-
panites may be distinguished from the ascites or phys-
conia, and  many experiments show,  that  the  tympa-


  * There can be doubt, that gaseoijs substances appear, occasionally, as the
result of disordered secretory action.  The cases of pneumatosis, here men-
tioned, may, therefore, arise from a morbid condition of the vessels that
secrete the fat, or of those that supply the cellular membrane with the fine
halitus, which softens and lubricates it.
  In tympanites intestinulis, moreover, we have no doubt, that instead of being
evolved from fermenting food, the air, which so greatly distends the alimen-
tary canal, is generated, by the secretory vessels of that tube, in place of
the fluid, intended for the lubrication of its internal surface. Hence the dry-
ness of the fecal discharges, in that disease
  In relation to the treatment, we have nothing to subjoin, to what our au-
thor, himself, has left us, on that subject.  We believe  the disease to con-
sist in a debilitated state of the  alimc ntary canal, and that tonics afford the
most promising remedies. But what tonics are entitled to a preference, our
experience does not enable us to determine
  In addition to internal medicines, we think that blisters, applied to the
abdominal region, promise to be useful.
  Mercury, given as an alterative, especially  in the form of the blue pill,
and continued for a considerable time, is said to havt been found efficacious
in the treatment of tympanites.  As in all other chronic affections, the heal
>hy action of the skin must here be preserved as far as possible, by suitabl*
slothing, and the use of the flesh-brush, 
PRACTICE OF PHYSIC,
317
nites always depend upon a preternatural  collection of
air. somewher? within the teguments  of the abdomen:
but the seat of the air is in different cases somewhat dif-
ferent; and this produces the different species of the
disease.
  One species is, when the air collected is  entirely con-
fined  within  the cavity  of the alimentary canal,  and   «
chiefly in that of the intestines. This species, therefore,
is named the Tympanites inteslinalis, Sauv. sp. 1. It is,
of all others, the most common; and to it especially be-
long the characters given above,
  A  second  species is,  when the air collected is not
entirely confined to the cavity of the  intestines,  but is
also present between their coats; and such is that which
is named by Sauvages Tympanites entcrophysodes, Sauv.
sp.  3.  This  has certainly been a rare occurrence; and
has probably  occurred only in consequence of the tym-
panites intestinalis, by the air escaping from the cavity
of the intestines into the interstices of the coats.   It is,
however, possible that an erosion of the internal coat of
the intestines may give occasion to the air, so constantly
present in  their cavity, to escape into the interstices of
their coats, though in the whole of their cavity there has
been  no previous accumulation.
  A third species is, when the air is collected in the sac
of the peritonaeum, or what is commonly called the ca-
vity of the  abdomen, that is, the space between the pe-
ritonasum and viscera; and then the disease is named
Tympanites abdominalis, Sauv. sp. 2.  The existence
of such a tympanites, without any tympanites intesti-
nalis, has been disputed;  and it certainly has been a rare
occurrence: but from several dissections, it is unques-
tionable  that such a disease has sometimes truly oc-
curred.
   \ fourth species of tympanites is,  when the tympa- 
 318           PRACTICE OF PHYSIC.

 nites intestinalis and ahdominalis are joined together, or
 take place at the same time.   With respect to this, it
 is  probable that the tympanites intestinalis is the pri-
 mary disease; and the  other only a consequence of the
 air escaping,  by an  erosion or rupture of the coats  of
 the intestines, from  the cavity of these into that of the
 abdomen   It is indeed possible that in consequence of
 erosion or rupture, the air which is so constantly pre-
 sent in the intestinal canal, may escape from thence in
 such  quantity, into the cavity 6f the  abdomen,  as to
 give a tympanites abdominalis whilst there was no pre*
 vious considerable accumulation  of air in the intestinal
 cavity  itself;  but I have not facts to ascertain this mat-
 ter properly.
   A fifth species has also been enumerated. It is when
 a  tympanites abdominalis happens to be joined with
 the hydrops ascites; and  such a disease  therefore is
 natned by Sauvages  Tympanites asciticus, Sauv. sp. 4.
 In  most cases of tympanites,  indeed, some quantity of
 serum  has, upon dissection, been found in the sac of
 the peritonaeum; but that is not enough to constitute
 the species now mentioned; and when  the collection of
 serum  is more considerable,  it  is commonly  where,
 both from the causes  which  have preceded, and like-
 wise from the symptoms which attend,  the ascites may
 be  considered  as the  primary disease;  and  therefore
 that this combination does not exhibit a proper species
 of the tympanites.
   1630.  As  this last is not a proper  species, and as
some of the others are not only extremely rare, but
even when occurring,  are neither  primary, nor to be
easily distinguished, nor, as considered in themselves,
admitting of any cure,  I shall  here take no further no-
tice of them; confining myself, in what follows, to the 
PRACTICE OF PHYSIC.
319
consideration of the most frequent case, and almost the
only object of practice, the  Tympanites intestinalis.
  1631.  With respect to this, I cannot perceive that
it arises in any peculiar temperament, or depends upon
any predisposition,  which  can  be discerned.   It oc-
curs in either sex, at every age, and frequently in young
persons.
  1632. Various remote causes of it have been assigned:
but many of these have  not commonly the effect of pro-
ducing this  disease; and although some of them have
been truly antecedents of it, I can in  few instances dis-
cover the manner in whichi they produce  the disease,
and therefore caunot certainly ascertain them to  have
been causes of it.
   1633  The  phenomena of this disease in its several
stages are the following:
  The tumour of the belly sometimes grows very quickly
to a considerable degree, and seldom in the slow man-
ner the ascites commonly  comes on    In  some cases,
however, the tympanites  comes on  gradually, and is
introduced by an unusual flatulency of the stomach and
intestines, with frequent borborygmy, and uncommonly
frequent  expulsion  of air  upwards and  downwards.
This state  is  also frequently attended with colic pains,
especially felt about the navel, and upon the sides  to-
wards the back,  but generally as the disease advances,
these pains become less considerable.  As the disease
advances, there is a pretty  constant desire to discharge
air, but it is accomplished with difficulty; and when
obtained, although it give some relief from the sense of
distention, this relief is commonly transient and of short
duration.  While the disease is coming on, some ine-
quality of tumour and tension may be perceived in dif-
ferent parts  of  the belly; but the distention soon  be-
comes equal over the whole, and exhibits the phenomena 
320
PRACTICE OF PHYSIC.
mentioned in the  character.  Upon  the first  coming
on  of the disease,  as well  as  during its progress, the
belly is  bound, and the faeces discharged are commonly
hard and dry.  The urine, at  the beginning, is usually
very little changed in quantity or quality from its natu-
ral state: but as the  disease continues, it is commonly
changed in both respects;  and at  length sometimes  a
strangury,  and  even an ischuria,  comes  on.  The
disease  has seldom advanced far, before the appetite is
much impaired, and  digestion ill  performed: and the
whole  body,  except  the belly,  becomes considerably
emaciated.  Together with these  symptoms, a thirst
and uneasy sense of heat at length come on,  and a con-
siderable frequency of pulse occurs,  which  continues
throughout the  course  of  the disease.   When the tu-
mour of the  belly arises to a considerable  bulk, the
breathing becomes very  difficult,  with a frequent dry
comji.   With all  these symptoms  the strength of the
paiient  declines: and the  febrile  symptoms daily in-
creasing; death at  length ensues,  sometimes probably
in consequence of a gangrene coming upon  the intes-
tines.
  1634. The tympanites is commonly of some dura-
tion, and to be reckoned a  chronic disease.   It is very
seldom  quickly fatal,  except where such an affection
suddenly arises in  fevers.   To this  Sauvages has pro-
perly given  a different  appellation, that  of  Meteoris-
rnus; and  I  judge it may always  be considered as a
symptomatic  affection, entirely distinct from the tympa-
nites we are now considering.
  1635. The tympanites is generally a fatal disease,
seldom admitting of  cure:  but what may be attempted
in this way, I shall try to point out, after I shall have
endeavoured  to  explain  the proximate  cause, v\hi«h 
PRACTICE OF PHYSIC.           321
 alone can lay the foundation of what may be rationally
 attempted towards its cure.
   1636. To ascertain the proximate cause of tympa-
 nites, is somewhat difficult.   It has been supposed, in
 many cases, to be merely an uncommon quantity of air
 present in the alimentary canal, owing to the extrication
 and detachment of a greater quantity of air than usual
 from the alimentary matters taken in.   Our vegetable
 aliments, I believe, always undergo some degree offer-
 mentation ; and in consequence,  a quantity of air is ex-
 tricated and  detached from  them in the stomach and
 intestines: but it appears,  that the mixture of the animal
 fluids which our aliments meet  with in the alimentary
 canal, prevents the same quantity of air from being de-
 tached  from them that would have been in their fer-
 mentation without such mixture; and it is probable that
 the same mixture contributes also to  the reabsorption
 of the air that had been  before in some measure de-
 tached.  The extrication, therefore, of an unusual quan-
 tity of air from the aliments, may, in certain circum-
 stances, be such, perhaps, as to  produce a tympanites:
 so that this disease may depend  upon a fault of the di-
 gestive fluids, whereby they are unfit to prevent the too
 copious extrication of air, and  unfit also to occasion
 that reabsorption of air which in sound persons com-
 monly happens.  An unusual  quantity of air in the ali-
 mentary canal, whether owing to the nature of the ali-
 ments taken in, or to the fault of the digestive fluid,
 does certainly sometimes take place; and may possibly
 have, and in some measure certainly has, a share in
 producing certain flatulent disorders of the alimentary
canal;  but  cannot be supposed to produce the tympa-
nites, which  often occurs when  no previous disorder
had  appeared in the system.   Even in those cases of
tympanites which are attended at their beginning with
  VOL. II.              t t 
322           PRACTICE OF  PHYSIC.

flatulent disorders in the whole of the alimentary canal,
as we know that a firm tone of the intestines both mo-
derates the extrication of air, and contributes to its re-   I
absorption  or ready expulsion, so the flatulent symp-
toms which happen to appear at the coming  on of a
tympanites, are, in my opinion, to be referred to a loss
of tone in the muscular fibres of the  intestines, rather
than to any fault in the digestive fluids.
   1637.  These, and other considerations, lead me to
conclude, that the  chief part of the proximate cause of
tympanites, is  a loss of tone  in the muscular fibres of
the intestines.  But further, as air of any kind accumu-
lated in the cavity of the intestines should, even by its
own elasticity, find its  way either upwards or down-
wards, and should also, by the assistance of inspiration,
be entirely thrown  out  of the body;  so, when neither
the reabsorption nor the  expulsion takes place,  and the
air is accumulated  so as to produce tympanites, it is pro-
bable that the passage of the air along the course of the  ?
intestines is in some places of these interrupted.  This ,;'
interruption,  however, can hardly be supposed to pro-
ceed from  any other cause than spasmodic constrictions
in certain parts of the canal; and I conclude, therefore,
that such constrictions concur as part in the proximate
cause  of tympanites.—Whether these spasmodic con-
strictions are to be attributed to the remote cause of
the disease, or may be considered as the consequence
of some degree of atony first arising, I cannot with cer-
tainty, and do not  find it necessary to determine.
   1638. Having  thus endeavoured  to  ascertain  the
proximate  cause of tympanites, I proceed to treat of its  £
cure; which  indeed has seldom  succeeded, and almost
never but  in a recent disease.  I must, however, en-
deavour  to say what may be reasonably attempted; what 
PRACTICE OF PHYSIC.
323
has commonly been attempted; and what attempts have
sometimes succeeded in the cure of this disease.
   1639.  It must be a first indication to evacuate the
air accumulated in the intestines:  and for this purpose
it is necessary that those constrictions, which had espe-
cially occasioned its accumulation, and continue to in-
terrupt its passage  along the course of the intestines,
should be removed.  As these, however, can hardly be
removed but  by exciting  the peristaltic motion in the
adjoining portions  of  the  intestines, purgatives  have
been  commonly employed; but it is at the same time
agreed,  that the more gentle laxatives only  ought to be
employed, as the more drastic, in the overstretched and
tense state of  the intestines, are in danger  of  bringing
on inflammation.
   It is for this reason, also, that glysters have been fre-
quently  employed; and they are the more necessary, as
the faeces collected  are generally found to be in a hard
and dry state.   Not only upon account of^-this state of
the faeces, but, farther, when glysters produce a con-
siderable evacuation of air, and  thife show that they
have some effect in relaxing the  spasnfe of the intes-
tines, they ought to be repeated very frequently.
   1640. In order to take off the constrictions of the in-
testines,  and  with  some view  also to the  carminative
effects of the  medicines,  various antispasmodics  have
been  proposed,  and commonly employed; but  their
effects are seldom considerable, and it is  alleged that
their heating and inflammatory powers have sometimes
been hurtful.  It is, however, always proper to join some
of the milder  kinds with both the purgatives and glys-
ters that are employed; and it has been very properly
advised  to give always the chief of antispasmodics, that
is, an  opiate, after  the  operation  of purgatives  is
finished. 
324           PRACTICE OF PHYSIC
    1641.  In consideration of the  overstretched,,tense,
 and dry state of the intestines,  and especially of the
 spasmodic constrictions that prevail, fomentations and
 warm bathing have been proposed as a remedy; and are
 said to have been employed with advantage:  but  it has
 been remarked that very warm baths have not been
 found so useful as tepid,baths long continued.'
    1642. Upon the supposition that this disease depends
 especially upon an atony of the alimentary canal, tonic
 remedies seem to be properly indicated.  Accordingly
 chalybeates,  and various  bitters, have been employed;
 and if any tonic, the Peruvian bark might probably be
 useful.
    1643. But as no tonic remedy is more powerful than
 cold applied to the surface of the body, and cold drink
 thrown into the stomach;  so  such a remedy has been
 thought  of in this disease.  Cold drink has been con-
 stantly prescribed, and cold bathing has been employed
 with advantage; and there have been several instances
 of the disease being suddenly and entirely cured by the
 repeated application of snow to the lower belly.
    1644. It is hardly necessary to remark, that  in the
 diet of tympanitic persons, all  sorts of food ready to
 become  flatulent in the stomach are to be avoided; and
 it is probable, that the fossil acids and neutral salts, as
 antizymics, may be useful.
    1645. In obstinate and desperate cases of tympanites,
 the operation of the paracentesis has been  proposed: but
 it is a very doubtful  remedy,  and  there  is  hardly any
 testimony of its having been practised with success.  It  t
 must be obvious, that this  operation is a remedy  suited
 especially, and almost only, to the tympanites abdomi-
* nalis; the existence of which, separately from the intes-
 tinalis, is very doubtful, at least not easily ascertained.
 Even if its existence could be ascertained, yet it  is not 
             PRACTICE OF PHYSIC.           325

very likely to be cured by this remedy; and how far
the operation might be safe in the tympanites intesti-
nalis, is not yet determined by any proper experience.
                       chapter m.

        OF WATERY SWELLINGS,  OR DROPSIES.

j"  1646.  A PRETERNATURAL collection of serous
   or watery fluids, is often formed in different parts of the
   human body; and although the disease thence arising
   be distinguished according to  the different parts which
   it occupies, yet the  whole of such collections come
   under the general appellation of Dropsies.  At the same
   time, although the particular  instances of such collec-
   tion  are to be distinguished from each other according
   to the parts they occupy, as well  as  by other circum-
   stances attending them; yet all of them seem to depend
   upon some general causes, very much in common to
   the whole.  Before proceeding, therefore,  to  consider
   the several species,  it may be proper to endeavour to
   assign the general causes of dropsy.
      1647. In persons of health, a  serous or watery fluid
   seems to be constantly poured out, or exhaled in vapour,"
   into every cavity and interstice of the human body capa-
   ble of receiving it; and the same fluid, without remain-
   ing lon<$ or being accumulated in  these spaces,  seems
   constantly to be soon again absorbed from thence  by
   vessels adapted  to the purpose.  From this view of the
   animal economy, it will be obvious, that if the quantity
   poured out into any space, happens to be greater than
   the absorbents can at the same time take up, an unusual
   accumulation of serous fluid will be made in such parts;
    i th, j.;h  the quantity poured out be  not more than 
326           PRACTICE OF PHYSIC.
 usual, yet if the absorption be anywise interrupted or
 diminished, from this cause also an unusual collection
 of fluids may be occasioned.
■*■  Thus,  in general, dropsy may be imputed to an in-
 creased effusion, or  to a diminished absorption; and I
 therefore proceed to inquire into the several causes of
 these.
   1648.  An increased effusion may happen, either from
 a  preternatural increase of the ordinary exhalation, or
 from the rupture of vessels carrying, or of sacs con-
 taining, serous or watery fluids.
   1649.  The ordinary exhalation  may be increased by
 various causes, and particularly by  an interruption given
 to the free return of the venous blood from the extreme
 vessels of the body to the right ventricle of the heart.
 This interruption seems to operate by resisting the free
 passage of the blood from the arteries into the veins,
 thereby increasing the force of the arterial fluids in the
 exhalants, and consequently the quantity of fluid which
 they pour out.
   1650.  The  interruption of the  free return of the
 venous blood from  the extreme vessels, may be owing to
 certain circumstances affecting the course of the venous
 blood; very frequently, to certain conditions in the right
 ventricle  of the heart itself, preventing it from receiv-
 ing the usual  quantity of blood from the vena cava; or
 to obstructions in  the vessels' of the lungs  preventing
 the entire evacuation of the right ventricle, and thereby
 hindering its receiving the usual quantity of blood from
 the cava.  Thus, a polypus in the  right ventricle of the
 heart, and the ossification of its valves,  as  well as all
 considerable and permanent obstructions of the lungs3
 have been found to be causes of dropsy.
   1651.  It may serve as an illustration of the operation
 of these general  causes,  to remark, that the return of 
PRACTICE OF PHYSIC-.
327
 the venous blood is in some measure resisted when the
 posture of the body is such as gives  occasion  to the
 gravity of the  blood  to oppose the motion of it in the
 veins, which takes effect when the force of the circula-
 tion is weak; and from whence it is that an upright pos-
 ture of the body produces or increases serous swellings
 in the lower extremities.
    1652.  Not only those causes interrupting the motion
 of the venous blood more generally, but, farther, the in-
 terruption of it in particular  veins,  may likewise have
 the effect of increasing exhalation, and producing drop-
 sy.  The most remarkable instance  of this is, when
 considerable obstructions of the liver prevent the blood
 from flowing freely into it from the vena portarum and
 its numerous branches; and  hence these obstructions
 are a frequent cause of dropsy.
    1653.  Scirrhosities of the  spleen and other viscera,
 as well as the scirrhosity  of the  liver, have  been con-
 sidered as causes of dropsy; but the manner in which
 they can produce the disease, I do not perceive, except
 it may be where they happen to be near some conside-
 rable vein, by the compression of which they may occa-
 sion  some  degree  of ascites; or, by  compressing the
 vena  cava,  may produce  an anasarca of  the lower ex-
 tremities.  It  is indeed true, that scirrhosities of the
 spleen and other viscera, have been  frequently disco-
 vered in  the bodies of hydropic persons: but I believe
 that  they have been  seldom  found unless when scir-
 rhosities  of the liver were also present;  and I am in-
 clined to think, that  the former have been the effects of
" the latter, rather than the cause of the dropsy;  or that,
 if scirrhosities of the other  viscera have appeared in
 hydropic bodies when that of the liver was not present,
 they must have been the effects of some of those causes
 of dropsy to be hereafter mentioned; and consequently 
328          PRACTICE OF PHYSIC.

to be the accidental attendants, rather than the causes,
of such dropsies.
   1654. Even in smaller portions of the venous system,  i
the interruption of the motion of the blood in particu-
lar veins has had  the same effect.  Thus a polypus
formed in the cavity of a vein, or tumours formed in its
coats, preventing the free passage of the blood through
it, have had the effect of producing dropsy in parts to-
wards the extremity of such veins.
   1655. But the cause most frequently interrupting the
motion of the blood through the veins  is, the compres-
sion of tumours existing near to them; such as aneu-
risms in the arteries, abscesses, and scirrhous  or steato-
matous tumours in the adjoining parts.
   To this head may be referred the compression of the
descending cava by the bulk of the uterus in pregnant
women, and the compression of the same by the bulk
of  water  in  the ascites; both of which compressions
frequently produce serous swellings in the lower extre- y
mities.
   1656. It may be supposed, that a general preterna- .
tural plethora of the venous system may have the effect
of  increasing exhalation; and that this plethora may 1
happen from the suppression of fluxes, or  evacuations  |
of  blood, which had for some time taken place in the
body, such as the menstrual and haemorrhoidal fluxes.
A dropsy, however, from such a cause, has been at least
a rare occurrence; and when it seems to have happen-
ed, I should suppose it owing to the same causes as the
suppression itself, rather than to the plethora  produced  J
by it.           ,                                  *
   1657. One of the  most  frequent causes of an in-
creased exhalation, I apprehend to be the laxity of the
exhalant vessels.   That such a cause may operate, ap-
pears probable from this, that paralytic limbs, in  which 
PRACTICE OF PHYSIC.
329
such a laxity is to be suspected^ are frequently affected
with serous, or as they are called, oedematous swellings.
  But a much more remarkable and frequent example
of its operation occurs in the case of a general debility
of the system, which is so often attended with dropsy.
That a general debility does induce dropsy, appears suf-
ficiently from  its being so commonly the consequence
of powerfully debilitating causes: such as fevers, either
of the continued or intermittent kind, which have last-
ed  long; long continued and somewhat excessive eva-
cuations of any kinds;  and in short, almost all diseases
that have been of  long continuance,  and have  at the
same time  induced the other symptoms of a general de-
bility.
''- Among  other causes  inducing a general debility of
the system, and thereby dropsy, there is one to be men-
tioned as frequently occurring, and that is, intemperance
in the use of intoxicating liquors; from whence it is that
drunkards of  all kinds,  and especially dram-drinkers,
are so affected with this disease.
   1658. That  a general debility may produce a laxity
of  the exhalants, will  be readily  allowed: and  that
by  this especially it occasions dropsy,  I judge from
thence, that while most of the  causes already mention-
ed are suited to produce dropsies of particular parts only,
the state of 'general debility gives  rise to an increased
exhalation into  every cavity and interstice of the body,
and therefore brings on  a general disease.  Thus, we
have seen  effusions of a serous fluid made, at the same
time,  into the cavity of the cranium, into that of the
thorax and the  abdomen, and likewise into the cellular
texture almost over the whole of the body.  In  such
cases, the operation of a general cause discovered itself,
by these several dropsies increasing in one part as they
 diminish one another, and this alternately in the different
  vol. h.                 uu 
330
PRACTICE OF PHYSIC.
 parts.  This combination, therefore, of the different
 species of dropsy, or rather, as it may be termed,  this
 universal dropsy,  must. I think, be referred to a gene-
 ral cause; and in  most instances,  hardly any other can
 be thought of, but a general laxity of the exhalants.  It
 is  this,  therefore, that  I  call the hydropic diathesis;
 which  frequently operates by itself; and frequently in
 some measure, concurring with other causes, is especi-
 ally that which gives them their full effect.
   This state of the system, in its first appearance, seems
•to be what has been considered as a particular disease
 under the name of  Cachexy; but in every instance of
 it that has  occurred to me, I have always  considered,
 and have always found it, to be the beginning of gene-
 ral dropsy.
   1659.  The several  causes  of dropsy  already  men-
 tioned may produce  the disease, although there be no
 preternatural abundance of serous or watery fluid  in the
 blood-vessels; but  it  is now to be remarked, that a pre-
 ternatural abundance of that kind  may often give occa-
 sion to the  disease, and  more especially  when such
 abundance concurs with the causes above enumerated.
   One cause of such preternatural abundance may be
 an unusual quantity of water takt n into the body  Thus,
 an unusual  quantity  of water taken in by drinking, has
 sometimes occasioned a dropsy.   Large quantities  of
water, it is true, are  upon many occasions taken in; and
being :is  readily thrown out again by stool, urine,  or
perspiration, have  not produced any disease.  But it is
also certain,  that, upon some occasions,  an unusual
quantity of watery liquors  taken  in has run off by  the
several internal exhalants, and produced a dropsy.  Thii
seems to have happened either from the excretories not
being fitted to throw  out the fluid so fast as it had been
taken in, or from the  excretories having been obstructed 
                PRACTICE OF  PHYSIC.          331

by accidentally concurring causes.   Accordingly it is
said, that the  sudden taking in of a large quantity of
very cold water, has produced dropsy,  probably from
the cold producing a constriction of the excretories.
  The proportion of watery fluid in the blood  may be
increased, not only by the taking in a large quantity of
water by drinking, as now mentioned, but it is possible
that it may be increased also by water taken in from the
atmosphere by the skin in an absorbing or imbibing
state.  It is well known that the skin may be, at least
occasionally, in such a state; and it is probable, that in
many cases of beginniug  dropsy, when the circulation
of the blood on the surface of the body is very languid,
that the skin may be changed from  a perspiring to an
imbibing state; and thus,  at least, the  disease  may be
very much increased.
   1660. A second  cause of a preternatural abundance
of watery fluids in  the blood-vessels, may be, an inter-
ruption of the ordinary  watery excretions; and accord-
ingly it is alleged, that  persons much exposed to a cold
and moist air  are liable to dropsy.  It  is also said, that
an interruption, or considerable  diminution, of the  uri-
nary secretion, has  produced the disease; and it is cer-
tain, that in the case of  an ischuria renalis, the serosity
retained in  the blood-vessels has been  poured out into
some internal  cavities, and has occasioned dropsy.
   1661. A third cause of an over proportion of serous
fluid in the blood ready to run off by the exhalants, has
been very  large evacuations of blood,  either spontane-
ous or artificial.   These evacuations,  by abstracting a
large proportion of red globules and gluten, which are
the principal means of retaining serum in the red ves-
sels, allow  the serum to run off more readily by the ex-
halants:  and  hence dropsies have been frequently the
consequence of such evacuations. 
332
PRACTICE OF PHYSIC
    It is possible also, that large and long continued is-
 sues, by abstracting a large proportion of gluten, may
 have the same effect.
    An over proportion of the serous parts of the  blood,
 may not only be owing to the spoliation just now men-
 tioned, but may, I  apprehend, be likewise owing to a
 fault in the  digesting and assimilating powers in  the
 stomach and other organs; whereby  they do not pre-
 pare and convert the aliments taken in, in such a man- J
 ner as to produce from them the due proportion of red
 globules and gluten; but, still continuing to  supply the
 watery parts, occasion these to be in an over proportion,
 and consequently ready to run off in too large quantity
 by the exhalants.   It is in this manner that we explain,
 the dropsy, so often attending chlorosis:  which appears
 always at first by a pale colour of the whole body, show-
 ing a  manifest  deficiency of red blood;  which in that
 disease can only be attributed to an imperfect digestion
 and assimilation.
   Whether a like imperfection  takes place in what ha*
 been called a Cachexy, I  dare not determine.  This dis-
 ease indeed has  been commonly  and very evidently*  „
 owing to the general causes of debility above mentioned:
 and it being probable that the general debility may af-
 fect the organs of digestion and  assimilation; so the im-
 perfect state of these functions, occasioning a deficiency
 of red globules  and gluten, may often  concur with the
 laxity of the exhalants in producing dropsy.
   1662. These are the several causes  of increased ex-
 halation, which I have mentioned as the chief cause of
 the effusion producing dropsy; but I have likewise ob-
served in  1648, that with the same effect, an  effusion
may also be made by  the rupture  of  vessels carrying u
watery fluids.
  In this way, a  rupture of the thoracic duct, has given 
PRACTICE OF PHYSIC.          333
occasion to an effusion of chyle and lymph into the ca-
vity of the thorax; and a rupture of the lacteals has oc-
casioned a like effusion into the cavity of the abdomen;
and in either case a dropsy has been produced.
  It is sufficiently probable, that a rupture of lympha-
tics,  in consequence of strains, or the violent compres-
sion  of neighbouring  muscles, has occasioned an effu-
sion; which, being diffused in  the cellular texture, has
produced dropsy.
  It belongs  to  this  head  of causes, to remark, that
there are many instances of a rupture or erosion of the
kidneys, ureters, and bladder  of urine; whereby the
urine has been poured into the cavity of the  abdomen,
and produced an ascites.
  1663.  Upon this subject, of the  rupture  of vessels
carrying, or of vesicles containing, watery fluids, I must
observe, that the dissection of dead bodies has often
shown vesicles formed upon the surface of many of the
internal parts; and it  has been supposed, that the rup-
ture of such vesicles, commonly named Hydatides, to-
gether with their continuing to pour out a watery fluid,
has been frequently the cause of dropsy.   I cannot deny
the possibility of such a cause, but suspect the matter
must be explained in  a different manner.
  There have been frequently found, in almost every
different part of  animal bodies, collections of spherical
vesicles, containing a  watery fluid; and  in many cases
of supposed dropsy, particularly in those called the pre-
ternatural encysted dropsies, the swelling has been en-
tirely owing to a collection of such hydatides.  Many
conjectures  have been  formed with  regard to  the
nature and  production of these  vesicles:  but the matter
at last seems to be ascertained.  It seems to be certain,
that each of these vesicles has within it, or annexed to
it, a Hving animal of the worm kind: which seems to have 
334
PRACTICE OF PHYSIC.
the power of forming a vesicle for the purpose of its
own economy, and of filling it with a watery fluid drawn
from the neighbouring parts: and this animal has there-
fore been properly named by  late  naturalists the Tcenia
hydatigena.   The origin and economy  of this animal,
or an account of the  several  parts  of  the human body ,
which it occupies, I cannot prosecute further here; but
it was proper lor me in delivering the causes of dropsy,
to say thus much of hydatides: and  I  must conclude*
with observing, I am  well persuaded, that most of the
instances of preternatural encysted dropsies which have
appeared in many different parts of th  human body,
have been truly collections of such hydatides; but how
the swellings occasioned  by  these are to  be  distin-
guished from other species of dropsy, or how they are
to be treated  in practice, I cannot at present determine.
  1664. After having mentioned these; I return to con-
sider the other general cause of dropsy,  which I have
said in 1647  may be, an interruption or diminution of
the absorption  that should take up the exhaled fluids
from the several cavities and interstices of the body; the
causes of which  interruption, however, are not easily •
ascertained.
  1665. It seems probable, that absorption may be di-
minished, and even cease altogether, from a loss of tone i
in the absorbent extremities of the lymphatics.   I can-
not indeed doubt that a certain degree of tone or active
power is necessary in these absorbent extremities; and
it appears probable, that the same general debility which
produces that laxity of the exhalaut vessels, wherein I
have supposed the hydropic diathesis to consist, will at
the same time occasion a loss of tone in the absorbents;
and therefore that a laxity of the exhalents \\ ill generally
be accompanied with  a loss of tone in the absorbents;
and that this  will  have  a  share in the prpduction of 
              PRACTICE OF PHYSIC.           335

dropsy.   Indeed it is probable that the diminution of
absorption has a considerable share in the matter; as
dropsies are often cured  by medicines which seem to
operate by exciting the action of the absorbents.
   Ki66. It  has been  supposed, that the absorption  per-
formed by the extremities of lymphatics may be inter-
rupted by an obstruction  of these vessels, or at least of
the conglobate glands through which these vessels pass.
This, however, is very  doubtful.  As the lymphatics
have branches frequently communicating with one  ano-
ther, it is not probable that the obstruction of any  one,
or even  several of these, can have any considerable ef-
fect in interrupting the absorption of  their extremities.
  And for the same  reason  it is as  little probable  that
the obstruction of conglobate glands can have such an
effect: at least it is only an obstruction of the glands of
the mesentery, through which so considerable a portion
of the lymph passes,  that can possiblv have the effect of
interrupting absorption.   But even  this we should not
readily suppose, there being reason to believe that these
glands,  even in a considerably tumefied state, are not
entirely  obstructed:  and accordingly I have known se-
veral instances of the most part of the mesenteric glands
being considerably tumefied, without either interrupt-
ing the transmission  of fluids to  the  blood-vessels, or
•ccasioning any dropsy.
  An hydropic swelling,  indeed,  seems  often to affect
the arm from a tumour of  the  axillary  gland:  but  it
seems to me doubtful, whether the tumour of the  arm
may not be owing to some compression  of the axillary
vein rather than to an obstruction of the lymphatics.
  1667. A particular interruption of absorption may be
supposed to take place in the brain.   As no lymphatic
vessels have yet very certainly been discovered in  that
•rgan, it may be thought that  the absorption, which  cer- 
330           PRACTICE OF PHYSIC.

tainly takes plaqe there, is performed by the extremities
of veins, or by vessels that carry the fluid directly into
the veins;  so that any impediment  to  the free motion
of the blood in the veins of the brain, may interrupt the
absorption there, and occasion that  accumulation of se-
rous fluid which so frequently occurs from a congestion
of blood in these veins.  But I give all this as a matter
of conjecture only.
   1668. Having thus explained  the general causes of
dropsy, I should proceed, in the next place, to mention
the several parts of the body in which serous collections
take place, and so to mark the different species of drop-
sy: but I do not think it necessary for me to enter into
any minute detail upon  this  subject.  In many cases,
these collections  are  not to  be ascertained by any ex-
ternal symptoms, and therefore cannot be the objects of
practice; and many of them, though in some  measure
discernible, do not seem to be curable by our art.  I
the more especially avoid mentioning very particularly
the several species, because that has already been suffi-
ciently  done by Dr.  D.  Monro,  and other  writers in
every body's hands.   I must confine myself here to the
consideration of those species which are the most fre-
quently occurring and the most common objects of our
practice; which are,  the Anasarca,  Hydrothorax, and j.
Ascites,  and each of  these  I shall treat of in  so many
separate sections.
                      SECTION I.
                  OF ANASARCA.*

1669.  THE Anasarca is a swelling upon the surface
of the  body,  at first commonly appearing in particular
  * To what our  author has, himself, given us, on the subject of dropsy
in general, we have but little to add, that eould prove either interesting, i' 
PRACTICE OF  PHYSIC.             337
  parts only, but at length frequently appearing over the
  whole.   So far as it extends, it  is  an  uniform swelling

  speculation, or useful, in practice:  We shall not, therefore, waste our time,
  in writing notes, merely to give our readers the trouble of perusing them.
    In relation to the cause of dropsy, we are told, that  it arises immediately
  from a destruction of the balance, between secretion and absorption.  Than
  this, there  can  be  no  position more true. But the inquiry ought  not
  to terminate here.  This " destruction of balance" is, itself, but an  effect.
  As  such, it, also,  must have  a cause; and that is the  primary  cause of
  dropsy.
    By many, dropsy is supposed to arise from an excessive loss of  blood.
  But this is to be regarded as a vulgar error.  Such a loss, weakens all parts
  of the system alike, without subverting the healthy balance, between any
  two of them.  It cannot, therefore, be productive of dropsy.
    The source of this error, however, it is not difficult to discover.  An exces-
  sive loss of blood, produces a diminution of the coagulating lymph,  and of
  the red globules of that fluid:  in common  language, it produces a  thin, and
  watery state of it.  So does the real cause of dropsy.  But these two causes,
  produce the same  effect in different ways.  An excessive  loss of blood, car-
  ries off the  coagulating lymph, and the red globules after they have  been
.  formed,- the  true cause of dropsy, which consists in a disease of some of the
  assimilating organs,  prevents  these parts from being formed.- The result  is,
  therefore, the same—a deficiency of them in the blood.
    We believe, that every case of anasarca and ascites, arises from a diseased
  state, of some one of the  abdominal viscera—the stomach, the liver,  the
i  spleen, or the intestines.  Hence the morbid appearances, which, on dis-
  section of those, who die of dropsies, are uniformly discovered, in these or-
  gans: and hence, all the powerful antihydropic medicines act, principally, on
  one  of these parts.
    Till of late, dropsy was, almost universally, supposed,  by European writers,
  to depend on an antiphlogistic diathesis—on what they denominated a laxity
1  tf the system.   We  believe the reverse of this to  be much  nearer the truth
  In a great majority of cases, dropsy is the result of congestion, inflammatory
i  irritation, and excessive action.  If  we might rely on our  own observation,
'  we would say, that it is always so :  for we have never known a case of this'
-  disease, to arise from any other source.   Indeed, it is not easy for us, at pre-
i  sent to perceive, how it is possible that it should arise  from any other.
    Oropsy is, always,  a symptomatic disease ; and, therefore, supposes, of ne-
(  eessity, the  pre-existence  of  some original  affection.   It  must, more fre-
•  quently, take its rise  from an increased secretion, than  a diminished absorp-
1  tion.  We have never witnessed an instance, in  which  we could consider it
i  as arising from the  latter source.  But an excess, in any  kind of secretory ao
t  tion, appears to us, necessarily, to imply a phlogistic diathesis, at least so far
.  as that secretion is concerned : the increase in the secretion is intended by
i  nature, to remove  such diathesis.                                    '
    An excessive secretion  of bile never takes place, but  as the result of a
i  state of congestion, and a phlogistic diathesis of  the liver:  an increased dte
     VOL. II.                   X  X 
338
PRACTICE  OF  PHYSIC.
  over the whole member,  at first always soft, and readily
  receiving the pressure of the finger, which forms a hoi-

 charge of saliva, affords positive evidence that the glands, which secrete it,
 are in a similar condition: an inflammation of the eye, extending its irritation
 to the lachrymal gland, produces an augmented flow of tears: while an in-
 flammatory state of the bladder, rectum, and schneiderian membrane,  pro-
 duces, from those parts, an altered and augmented secretion of mucus.
   We know, and acknowledge, moreover, that  a congestion and inflamma-
 tory condition of the  testicle, gives rise  to  hydrocele, and that hydro.
 thorax is, oftentimes, the result of catarrhal inflammation.
   Whence is it, then, that, in ascites^ and anasarca, which are known to be
 often accompanied by a schirrus, or chronic inflammation of the liver, the
 augmented secretion should arise, not only from a different, but an opposite
 cause ? As far as our own discernment avails us, we perceive no reason for
 believing, that it does arise from such a cause ?  Here, as in other instances,
 the preternatural  increase  of fluid is  produced,  by  increased secretory
 action; and this increase results from congestion, and a phlogistic diathesis.
   The phenomena attendant on anasarca and ascites, when duly considered,
 convince  us that this is the case.  In these diseases, perspiration is checked,
 and the urine is secreted, in  a diminished quantity.  Yet aliment and drink
 are received as usual—sometimes,  indeed, in an increased proportion.  The
 necessary consequence is, a fulness and  congestion, if not of the  whole, at
 least, of some parts of the system  ; which  must produce, of itself, preter-
 natural excitement.
   But we have still further evidence that anasarca and ascites arise from  a
 phlogistic diathesis.  In these complaints, the pulse, although not, perhaps,
 either full  or strong, very rarely  fails to be quick, tense, and, sometimes,
 considerably bounding and hard : qualities of arterial action, resulting from
 such a diathesis alone.  Besides the dropsical fluid, as well  as the  urine,
 very often contains a portion of matter, coagulable by heat: a phenomenon,
 which is well known never to take place, except as the result of inflamma-
 tory action.   Thus, if a blister be applied, on apart where the inflammation
 is unusually high, the fluid discharged is  frequently gelatinous.
   As an additional argument, in favour of the inflammatory nature of dropsy,
 \ye may observe, that, for fifteen or twenty years past, that disease has been
 much less prevalent, in the city of Philadelphia,  than it  had  formerly been.
 The reason of this, we believe to be, that, within the period mentioned, the
 lancet has been so freely used, in the treatment  of bilious fevers, of every
 description, as to prevent them from terminating  in inflammatory conges*:
 tions of the abdominal viscera:  for, as already mentioned, such congestions
 are among the most powerful causes of dropsy.
  The inflammatory character of dropsy, may be further, we think, inferred,
from the remedies which are found to be most successful, in  its treatment.
 These are, all evacuants, and calculated, therefore, to diminish action.  Tbey
are, the antiphlogistic regimen generally, venisection, emetics, purgatives,
diuretics, and sialagogues  But, to  be more particular:
  In the commencement of this disease, when the puis« is tense, frequeatj 
                   PRACTICE  OF  PHYSIC.               339

  low that remains for some  little time after the pressure
  is removed, but at  length rises again to its former  ful-

  and active, blood-letting is indispensable ; and must be repeated, according
  as circumstances may require.  The  blood, although superabounding in se-
  rum, is, oftentimes, found to be exceedingly sizy.
   In hydrothorax, emetics afford relief; and, in anasarca, prove, in some in-
  stances, highly useful.  A sudden and copious discharge of the distending
  fluid, has been known to follow their administration.  Their repitition must
  be left to the judgment of the practitioner.
   The importance of purgatives, in  the treatment of dropsy, must be fa-
 miliar to every one, who is at all conversant in  the practice of medicine.
 By them alone, the disease has been, oftentimes, completely removed.
   Of purgatives, sometimes the drastic, at other times, the more lenient, an-
 swer best; according to the sensibility of the stomach and bowels.
   The saline purgatives are highly useful.  We have known  several  drop-
 s'.cal affections to be removed, by the  exhibition of cream of tartar,  three
 or four times a day.  Glauber's salts  and soluble tartar may be, also, advan-
 tageously administered, in this disease.  The evacuations they produce are
 copious  and liquid: they are  correctly, therefore, denominated watery
 purges.
   The principal diuretics, used in this disease, are, nitre, squills, and digita-
 lis ,• to which may be added, the vegetable and fossil alkalis.   These are all
 active remedies ; and, when skilfully  directed,  seldom fail to  produce  some
 effect   Digitalis, however, has not, even in dropsy, sustained, in the United
 States, the weight of character, it brought with it from Great Britain.   Yet
 it is useful, as an antihydropic medicine.
   We have elsewhere observed, that the only genuine sialagogue is mercury.
 In cases of dropsy, where there exist  obstructions in the liver,  spleen, or
 other abdominal viscera, its employment is essential.  It is usually, however
 combined with nitre, squills, or digitalis.  To  prove effectual, it must be
 be given, until it produce its characteristic effect.
   Calomel, combined with squills, or digitalis, is also an important remedy,
 in hydrothorax.  It is in the treatment of this form of the disease, that the
 latter remedy is considered most powerful.  Here, in like manner, a ptyal-
 ism should be produced.
   As a remedy, in hydrothorax, perpetual blisters, aetons or issues, on some
 part of the chest, are found to be useful.   We  have seen the employment
 of them productive of good.
  In ascites, bandaging the abdomen, with a flannel roller, and the limbs, in
 anasarca, is a remedy on which some degree of reliance may be placed.
  We must not omit to  mention three other articles,  which are  recom-
 mended, as diuretics, in the treatment  of dropsy.  These are, spirits of tur-
 pentine, tincture of cantharides, and  a saturated tincture of tobacco.
  Of the first of these remedies, the dose is five or six drops, to be repeated
 three or four times a day ;  the quantity to be increased as the stomach and
 bowels will bear it, and as circumstances may require.  Of the second, the
Jose is, from ten to twenty drops, to  be repeated two or three times a 'day; 
340              PRACTICE OF PHYSIC.
 ness.   This swelling generally  appears, first, upon the
 lower extremities:  and  there  too  only in  the evening,

 and, of the third, from sixty to one hundred and twenty drops, to be re-
 peated in like manner, as the stomach will bear it.  Of these remedies, we
 have no experimental knowledge, in this complaint.
   We were, once, so fortunate, as to remove, an inveterate and most threat-
 ening case of dropsy (ascites and anasarca), in a patient, who had passed the
 sixty-second year of his age, by the use of water-melons.  By the diuretic
 quality of this fruit, the water was evacuated, with  unusual rapidity; and,
 by the subsequent  exhibition of bark and chalybeates, the tone of the sys-
 tem completely restored.  The individual lived three or four years, in good
 health ; and then died of an acute disease.  Perhaps the best, and most pow-
 erful form of chalybeates, in  this complaint, is the tinctura ferri muriati.
   In hydrothorax, anasarca and ascites, the practice is so much alike, that we
 do not think it requisite to particularize, in relation to either of them.
   That dropsy is the result of a phlogistic diathesis, is a doctrine which has
 long been familiar to the physicians of the United States; who have seldom
 lost  sight of it, in their treatment of that disease.  For several years past,
 the  same doctrine appears to have found advocates, both in  Great Britain
 and France.  Among these Dr. Blackall, of the Devon and Exeter hospitals,
 holds a distinguished rank.   To that gentleman's " Observations on the Na-
 ture and Cure of Dropsies," we  beg  leave to  refer the reader, for much
 curious and interesting, as well as useful matter, on the subject of these
 complaints.
   Hyijuocefhaltts Intehnus, although not included in Cullen's First Lines,
 is a disease, of too much importance to be passed unnoticed.   We shall en-
 deavour, therefore, to present our readers with a compressed  and practical
 view of it, adopting,  as our description of it, that which is contained in the
 writings of Dr Quin.
   "In  general, the patient is at first languid and inactive, often drowsy and
 peevish, but at intervals cheerful, and apparently free from complaint. The
 appetite is weak, a nausea, and, in many cases, a vomiting, occurs once or
 twice in a day, and the  skin is observed to be hot and dry, towards the even-
 ings ; soon after these symptoms have appeared, the patient is affected with a
 sharp head-ach, chiefly in the fore part, or, if not there, generallyin the crown
 of the head : it is sometimes, however, confined to one side of the head, and,
 in that case, when the posture of the body is erect, the head often inclines
 to the side affected. We frequently find, also, that the head-ach alternates
 with the affection of the stomach; the vomiting being less troublesome when
 the pain is most  violent, and vice versa; other  parts of the body are like-
 wise subject to temporary attacks of pain, viz. the  extremitses, or the bow-
 els, but more constantly the back of the neck, and  between the scapula:; in
 all such cases the head  is more free from uneasiness.
  "The patient dislikes the  light at this period ; cries much, sleeps little,
 and  when he does sleep, he grinds his teeth, picks his  nose, appears to be
uneasy, and starts often, screaming as if he were terrified : the bowels are,
in the majority of cases, very much confined, though it sometimes happens 
PRACTICE  OF PHYSIC.
341
disappearing again in the morning.   It is usually more
considerable as the  person  has been  more  in an erect

that they are in an opposite state: the pulse, in this early stage of the dis-
order, does not usually indicate any material derangement.
  " When the symptoms above mentioned have continued for a few days,
subject as they always are, in this  disease, to great fluctuation, the axis of
one eye is generally found to be turned in towards the nose; the pupil, on
this side is rather more dilated than on the other; and when both have the
axes directed inwards (which sometimes happens), both pupils are larger
than they are observed to be in the eyes of healthy persons: the vomiting
becomes more constant, and the head-ach more excruciating; every symp-
tom of fever  then makes its  appearance, the pulse  is frequent, and the
breathing quick; exacerbations of the fever take place towards the even-
ing, and the face is occasionally flushed ; usually one cheek is much more
affected than the other; temporary perspirations likewise break forth, which
are not followed by any alleviation of distress; a discharge of blood from the
nose, which  sometimes appears about  this period, is equally inefficacious.
  " Delirium,  and that of the most violent kind,  particularly if the patient
has arrived at the age of puberty, now takes place, and, with all the preced-
ing symptoms  of fever, continues for a while to increase, until about fourteen
days, often a much shorter space of time, shall have elapsed since the ap-
pearance of the symptoms, which  were first mentioned in the above detail.
  " The disease then undergoes that remarkable change, which  sometimes
suddenly points out  the commencement of what has been called its second
stage: the pulse becomes slow, but unequal, both as to its strength, and the
intervals between the pulsations;  the pain of the head, or of whatever part
had previously been affected, seems to abate, or at least the patient becomes
apparently less sensible of it;  the interrupted slumbers, or perpetual rest-
lessness which prevailed during the earlier periods of the disorder, are now
succeeded by an almost lethargic torpor, the strabismus, and dilatation of
the pupil increase, the patient lies with one, or both eyes half closed, which,
when  minutely examined, are oftenfound to be completely insensible to light;
the vomiting ceases;  whatever food or medicine is offered is usually swal-
lowed with apparent voracity;  the bowels, at this period, generally remain
obstinately costive.
  " If every effort made by art  fails to excite the sinking powers of life, the
symptoms of what has been called the second stage are soon succeeded by
others, which  mere certainly announce the approach of death.  The pulse
again  becomes equal, but so weak and quick, that it is almost impossible to
count it; a difficulty of breathing, nearly resembling the stertor apoplecti-
cus, is often observed; sometimes the eyes are suffused with blood, the
flushing of  the face is more frequent  than before, but of shorter duration,
and followed by a deadly paleness; red spots, or blotches, sometimes appear
on the body and limbs ; deglutition becomes difficult, and convulsions gene-
rally close the scene. In one case,  I may observe, the jaws of a child of four
years  of age were so firmly locked, for more than a day before death, that it
was impossible to introduce either food or medicine into his mouth ;'and, in 
342
PRACTICE  OF  PHYSIC.
 posture during the day; but there are  many  instances
 of  the exercise  of walking  preventing  altogether  its

another case, a hemiplegia,  attended with some remarkable circumstances,
occurred during the two days preceding dissolution.
  " Having thus  given as exact a history of apoplexia hydrocephalica as I
could compile from the writings of others, and from my own observations, I
sho'ild think myself guilty of imposition on my readers, if I did not caution
them that it must be considered merely as a general outline : the human
brain seems to be so extremely capricious (if the  expression may be allow-
ed) in the signais it gives to other parts of the system, of the injury it suffers
throughout the course of this disease, that, although every  symptom above
mentioned does occasionally occur, and indeed few cases of the disease are
to be met with, which do not exhibit many of them ;  yet it does not appear
to me, that any one of them is constantly and inseparably connected with it."
  To the description by Dr. Quin, may be subjoined  the following extracts,
from a treatise  on the same disease, by the late Dr. Rush.
  " I have not  found the dilated and insensible pupil, the puking, the deli.
rium, or the  strabismus, to attend universally in this disease.
  " 1 saw one  case  in which the appetite was unimpaired from the first to
the last stage of the disease.
  " 1 have met with one case  in which the disease was attended by blind-
ness, and another by double vision.
  " I have observed an uncommon acuteness in hearing to attend two cases
of this disease. In one of them the noise of the sparks which were discharg-
ed from a hickory fire, produced great pain and startings, which threatened
convulsions.
  " I have seen iliree cases in which the disease terminated in hemiplegia.
In two of them it proved fatal in a few days ; in a third it continued for nearly
eighteen months.
  " I have met with one case in which no preternatural slowness or intermit
sion was ever perceived in the  pulse.
  " I have seen the disease in children of nearly all ages.   I once saw it in
a child of six weeks old.  It was preceded by the cholera infantum."
  In its first  stages, hydrocephalus internus i9  always an inflammatory, and,
for the most  part, an acute disease, accompanied by a topical determination.
It belongs, therefore, of right, to the order phlegmasiae.
  The water, found in the ventricles of the brain, is an evidence of the fact,
that dropsical effusion, is one of the modes, in which inflammation termi-
nates.
  The first and leading indication of cure is, to prevent effusion, by subdn-
ing the inflammation which  threatens to produce it.
  This is best effected, by venesection, and copious  purging,  repeated at
often as circumstances may require; and by the application of leeches, cups,
and blisters  to the head.   When the febrile symptoms have been suffi-
ciently moderated, the application of blisters to the wrists and ancles, is an
useful remedy.  Throughout the treatment of the complaint, a strict adhe-
rence to the antiphlogistic plan shonld be inflexibly maintained. 
PRACTICE  OF  PHYSIC
34S
otherwise  usual  coming  on.    Although  this  swelling
appears at first only upon the feet and about the ankles;

  When hydrocephalus internus assumes a chronic form, mercury, exhibited
as an alterative, is the most promising remedy.   Calomel may be ,;iven in-
ternally, and the blue ointment applied  externally, in such quantities as cir-
cumstances may justify.
  In some instances, the ointment has been successfully employed, to a very-
large amount.
  We are authorized to state, that, in a  late case of a daughter of a gentle-
man of this city, about six years old, eight pounds and three quarters were
used, in  the space of  fifteen days.  The ointment was as strong as it could
be made ; large quantities of it were rubbed on the lower extremities, every
four hours; and the child was wrapt in flannels, completely besmeared with
it.  We have  the pleasure to add, that  the disease  terminated favourably,
and that the child is now in perfect health.
  The quantity of the ointment, lately used in the case of a child, the son
of a distinguished physician of Philadelphia, is  not  much inferior: it was
applied, in the same way;  and we are pleased in adding, that the termina-
tion of the complaint was equally fortunate.
  In the treatment of chronic hydrocephalus, a constant discharge should be
kept up  from the  head,  by means of the repeated application of blisters.
Open blisters, on the extremities, dressed with mercurial ointment, are also
useful.
  A doubt has been oftentimes expressed, whether recovery be practicable,
after effusion into the ventricles of  the brain has taken  place.  This doubt
is founded on another, still more extraordinary, viz. whether the brain con-
tain absorbents, by which the effused water may be removed.
  On this latter point, not a shadow of  doubt can rest. The absorbents are,
ef necessity, as universally diffused, throughout the body,  as the blood-vessels
themselves.   Neither  nutrition nor growth can be effected without them.
Every part, therefore, that is nourished and grows, is supplied with absor-
bents.  This position is supported by facts, that  are tantamount  to demon-
stration;  a truth, which  we could easily make appear, were the occasion  a
suitable one, to enter on the discussion.
  We have no doubt that hydrocephalus internus admits of a cure, subse-
quently to effusion.  We have, ourselves, we think, been witness to a case
of the kind.  The difficulty consists in the means of effecting it.  The ab-
sorbents  certainly exist, if they can only be excited  to  the proper  degree
of  action.
  All the symptoms  of  this disease, have been produced by worms, and
other irritating substances, in the alimentary  canal;  and  completely re-
moved, by active purging.
  When the heat of the head is great, and the action of the temporal arte-
ries bounding and strong; the application of ice to the part is recommended;
so,  under similar circumstances, is the  employment of digitalis, and saccha-
rum saturnum. But, from neither of these remedies, have we ever observed,
that any material advantage has been derived. 
344
PRACTICE OF PHYSIC.
 yet if the causes producing it continue to act, it gradu-
 ally  extends upwards, occupying the  legs,  thighs, and
 trunk of the body, and sometimes even the head.  Com-
 monly the swelling of the lower extremities diminishes
 during the night: and  in the  morning, the swelling
 of the face  is most  considerable, which again gene-
 rally disappears almost  entirely in the  course of the
 day.
    1670. The terms of Anasarca and Leucophlegmatkt,
 have  been commonly considered as synonymous; but
 some authors have proposed to consider them as denot-
 ing distinct diseases.  The authors who are of this last
 opinion employ the name of Anasarca for that disease
 which begins  in the lower  extremities, and is  from
 thence gradually extended upwards in the manner I have
 just now described;  while  the  term Leucophlegmatia,
 that in which the same kind of swelling appears  even
 at  first very generally over  the whole body.  They
 seem to think also, that the two diseases proceed from
 different causes; and that, while the anasarca may arise
 from the several causes in 1649—1660, the leucophleg*-'
 matia proceeds especially from a deficiency of red blood,
 as we have mentioned in 1661, et seq.  I cannot,  how-
 ever, find  any proper foundation  for  this  distinction.
 For although in dropsies  proceeding from the causes
 mentioned in 1661, et seq. the disease appears in  some
 cases  more immediately affecting the whole body; yet
 that does not establish a difference from the common
 case  of anasarca:  for the  disease, in all its circum-
 stances,  comes at  length to be  entirely the same: and
 in cases occasioned by a deficiency of red blood, I  have

  Blood-letting, general and local purging, blistering, and the use of mer-
cury, as already directed, constitute the only course, on which experience
permits us to rely. 
             PRACTICE  OF PHYSIC.           345

frequently observed it to come on exactly in the man-
ner of an anasarca, as above described.
  1671. An anasarca is evidently a preternatural col-
lection  of serous  fluid in  the  cellular texture  imme-
diately  under the skin.   Sometimes pervading the skin
itself, it oozes out through the  pores of the cuticle;
and sometimes,  too gross to pass  by these, it raises the
cuticle  in blisters.  Sometimes the skin, not allowing
the water to pervade it, is compressed and hardened,
and, at the same  time, so  much  distended,  as to give
anasarcous tumours an unusual firmness.  It is in these
last circumstances also, that an erythematic inflamma-
tion is ready to  come upon anasarcous swellings.
  1672. An anasarca may immediately arise from any
of the several causes of dropsy which act more gene-
rally upon the system: and even when other species of
dropsy, from particular circumstances, appear first; yet
whenever these  proceed from any causes more generally
affecting the system, an anasarca sooner or later comes
always to be joined with them.
  1673.  The manner in which this disease commonly
first appears, will  be readily explained by what I have
said in 1651, respecting the effects of the  posture of
the body.  Its gradual progress, and its affecting, after
some time, not only the cellular texture under the skin,
but probably also much of the same texture in the in-
ternal parts, will be understood partly from the commu-
nication that is  readily made between  the several parts
of the cellular  texture;  but especially from the same
general causes of  the disease producing their effects in
every part of the body. It appears to me, that the water
of anasarcous swellings is  more readily communicated
to the cavity of the thorax, and to the lungs, than to the
cavity of the abdomen, or to the viscera contained in it.
  1674. An anasarca is almost always attended with a
  VOL. JL.V */____________________ 
346
PRACTICE OF PHYSIC.
scarcity of urine; and the urine voided, is, from its scar-
city, always of a high colour; and from the same cause,
after  cooling, readily lets fall  a copious reddish sedi-
ment. This scarcity of urine may sometimes be owing
to an obstruction of the kidneys; but probably is gene-
rally occasioned by the watery parts of the blood run-
ning off into  the  cellular texture, and  being thereby
prevented from passing in the usual quantity to the kid-
neys.
   The disease is also generally attended with an unu-
sual degree of thirst; a circumstance I would attribute
to a like abstraction of fluid from the tongue and fauces,
which are extremely sensible to every diminution of the
fluid in these  parts.
   1675. The  cure of anasarca is to be attempted upon
three general  indications.
   1. The removing the remote causes of the disease.
   2. The evacuation of the serous fluid already collect-
ed in the cellular texture.
   3. The restoring the tone of the system, the  loss of
which may be considered in many cases as the  proxi-
mate cause of the disease.
   1676. The  remote causes are very often  such  as had
not only been applied, but had also been removed long
before the disease came on.   Although, therefore, their
effects remain, the causes themselves cannot be the ob-
jects of practice;  but if  the  causes still  continue to be
applied,  suth as  intemperance, indolence, and some
others, they must be removed.  For the  most part, the
remote  causes are  certain  diseases previous  to the
dropsy, which are to be cured by the remedies particu-
larly adapted to them, and cannot be treated of here.
The curing of these, indeed,  may be often diflicult; but
it was proper to lay down the present  indication, in
order to  show, that when these remote  causes  cannot 
PRACTICE OF PHYSIC.
347
 be removed, the cure of the dropsy must be diflicult, or
 perhaps impossible.  In many cases, therefore, the fol-
 lowing indications will be to little purpose; and  parti-
 cularly, that often the execution of the second will not
 only give the patient a great deal of fruitless trouble,
 but commonly also hurry on his fate.
   1677. The second indication for evacuating the col-
 lected serum, may be sometimes executed with advan-
 tage, and often, at least, with temporary relief. It may
 be performed in two ways.  First, by drawing off the
 water directly  from the  dropsical  part, by  openings
 made into it for that purpose:  or, secondly, by exciting
 certain serous excretions; in consequence of which, an
 absorption  may be excited in the dropsical parts, and
 thereby the serum absorbed and carried into the blood-
 vessels may afterwards be directed to run  out, or may
 spontaneously pass out, by one or other of the common
 excretions.
   1678. In an anasarca, the openings into the dropsical
 part are commonly to be made in some part of the  lower
 extremities;  and will be most properly made by  many
 small punctures reaching the cellular texture.  For-
 merly, considerable  incisions  were  employed for this
 purpose: but as  any wound made in dropsical parts,
 which, in order to their healing, must necessarily in-
 flame and suppurate, are liable to become gangrenous;
 so it  is  found to  be much safer to make the openings
 by small punctures only, which may heal up by the first
 intention. At the  same time, even with respect to these
 punctures, it is  proper to observe that they should be
made at some distance from one another, and that care
should be taken to avoid making them in the most de-
pending parts.
   1679. The water of anasarcous limbs may be some-
times drawn off by pea-issues, made by caustic a little 
348           PRACTICE OF PHYSIC.
below the knees: for as the great swelling of the lower
extremities is chiefly occasioned by the serous fluid ex-
haled into the upper parts constantly falling down to the
lower; so the issues now mentioned, by evacuating the
water from the upper parts, may  very much relieve the
whole of the disease.   Unless, however,  the issues be
put in before the disease is far advanced, and before the
parts have very much  lost their tone, the  places of the
issues are ready to become affected with gangrene.
   Some practical writers have advised the employment
of setons, for the same purpose that I have proposed
issues; but I apprehend, that setons will be more liable
than issues to the accident just now mentioned.
   1680. For the purpose of drawing out serum from
anasarcous limbs, blisters have been applied  to them,
and sometimes with great  success;  but  the  blistered
parts are ready to have a gangrene come upon them.
Blistering is therefore to be employed with great cau-
tion: and perhaps only in the circumstances that I have
mentioned above to  be fit for the employment of issues.
   1681. Colewort-leaves, applied to  the  skin,  readily
occasion  a  watery exudation from its surface; and ap-
plied to the  feet  and legs affected with anasarca, have
sometimes drawn off the water very copiously,  and  with
great advantage.
   Analogous, as  I  judge, to this, oiled  silk hose put
upon the feet and legs,  so as to shut out  all communi-
cation with the external  air, have been found sometimes
to draw a quantity of water from the pores of the skin,
and are said in  this way to  have relieved  anasarcous
swellings; but in several trials made, I have never found
either the application of these hose, or that of the cole-
wort-leaves, of much service.
   1682.  The second means proposed  in 1677,  for
drawing off the water from dropsical places, may be the 
PRACTICE OF PHYSIC.
349
employment of emetics, purgatives, diuretics,  or sudo-
rifics.
  1683. As spontaneous vomiting has sometimes ex-
ited an  absorption  in  hydropic  parts, and  thereby
drawn off the waters lodged in them, it is reasonable to
wppose that vomiting excited by art may have the same
effect; and accordingly it has been often practised with
advantage.  The practice, however, requires  that the
strong antimonial  emetics be  employed, and that they
be repeated frequently after short  intervals.
  1684.  Patients  submit more readily to the use of
purgatives, than  to those of emetics; and indeed they
commonly bear the former more easily than the latter.
At the same time, there are  no means we can employ
to procure a copious  evacuation of serous fluids with
greater certainty than the operation of purgatives, and
it is upon these accounts that purging is the evacuation
which has been most frequently, and perhaps with most
success, employed  in dropsy.  It has been generally
found necessary to employ purgatives of the more dras-
tic kind; which are commonly known, and need not to
be enumerated here.   I believe, indeed, that the more
ijrastic purgatives are the most effectual for exciting ab-
sorption, as their  stimulus is most readily communi-
cated to the other parts  of the system; but of late an
opinion has prevailed, that some milder purgatives may
be employed with advantage.  This  opinion  has pre-
vailed particularly with regard to  the crystals vulgarly
called the Cream of Tartar, which, in large doses, fre-
quently repeated, have sometimes answered the purpose
of exciting large evacuations both by stool and urine,
and has thereby cured dropsies.   This medicine, how-
ever, has frequently failed, both in its operation  and
effects,  when the drastic  purgatives have been more
successful. 
350
PRACTICE OF PHYSIC.
   Practitioners have long ago observed, that in the em-
 ployment of purgatives, it is requisite they be repeated
 after as short intervals as the patient can bear; probably  1
 for this reason, that when the purging is not carried to
 the degree of soon exciting an absorption, the evacua-
 tion weakens the  system,  and thereby increases the
 afflux of fluids to the hydropic parts.                   s
   1685. The kidneys afford a natural outlet for a great  ;i
 part of the watery fluids contained in the blood-vessels;  j
 and the increasing the excretion by the kidneys to a con;
 siderable degree, is a mean as likely as any other of ex-
 citing an absorption in dropsical parts.  It is upon this
 account that diuretic medicines have been always pro-
 perly employed in  the cure of dropsy.  The various
 diuretics that may be employed, are enumerated in eve-
 ry treatise of the Materia Medica and of the Practice of
 Physic, and therefore need not be repeated here.   It
 happens, however,  unluckily, that  none of them are  of
 very certain operation; neither is it well known why
 they sometimes  succeed, and  why they so often  fail;
 nor why one medicine should prove of service when
 another does not.   It has been generally the fault  of
 writers upon the Practice of Physic, that they give us
instances of cases  in which  certain medicines  have
proved very efficacious, but neglected to tell us in how
 many other instances the same have failed.
   1686. It deserves to be particularly  observed  here,
 that'there is hardly  any diuretic more certainly power-
ful than a large quantity of common water taken in by
drinking. I have indeed observed above, in  1659, that a
large quantity of water, or of watery liquors, taken in by
drinking, has sometimes proved a cause of dropsy; and
practitioners have been  formerly  so much afraid that
watery liquors, taken in by drinking, might run off into
the dropsical places and increase the disease, that they 
PRACTICE OF PHYSIC.
351
have generally enjoined the abstaining, as much as pos-
sible, from such liquors.  Nay, it has been further as-
serted, that by avoiding this supply of exhalation, and by
a total abstinence from drink, dropsies have been entire-
ly cured.  What conclusion is to be drawn from these
facts, is however very douhtful.  A dropsy arising from
a large quantity of liquids taken into the body, has been
a very rare occurrence; and there are, on the other hand,
innumerable instances of very large quantities of water
having been taken in and running off again very quick-
ly by stool and urine, without producing any degree of
dropsy.  With  respect to the total  abstinence from
drink, it is a practice of the most difficult execution; and
therefore has been so seldom  practised, that we cannot
possibly know how far it might prove effectual.   The
practice of giving drink very sparingly, has indeed been
often employed: but in a hundred instances I have seen
it carried to a great length without any manifest advan-
tage: while,  on the contrary, the  practice of giving
drink very largely has been found not only safe, but
very often effectual in curing  the disease.   The ingeni-
ous and learned Dr.  Millman has, in my opinion, been
commendably employed in restoring the practice of giv-
ing large  quantities of  watery liquors for the cure of
dropsy.  Not only from the instances he mentions from
his own practice, and from that of several eminent phy-
sicians in  other parts of Europe, but also from many
instances in the records of physic, of the good effects of
drinking large quantities of mineral waters in the cure
of dropsy, I can have no doubt of the practice recom-
mended by Dr. Millman being  very often extremelv
proper. I apprehend it to be especially adapted to those
cases in which  the  cure is  chiefly attempted by  diu-
retics.  It is very probable that these medicines can
hardly be carried in any quantity to the kidneys, without 
352           PRACTICE OF PHYSIC.
being accompanied with a large portion of water; and
the late frequent employment of the crystals of tartar
has often shown, that the diuretic effects of that medi-
cine are almost only remarkable  when accompanied
with a large quantity of water; and that without  this,
the diuretic effects of the medicine seldom appear.
  I shall conclude this subject with observing, that as
there are so many cases of dropsy absolutely incurable,
the practice now under  consideration  may  often fail,
yet in most cases it may be safely  tried; and if it ap-«
pear that the water taken in passes readily by the uri-
nary secretion, and especially that it increases the urine
beyond the quantity of drink taken in, the practice may
probably be continued with great advantage: but on the
contrary, if the urine be not increased, or be not even
in proportion to the  drink taken  in, it may be con-
cluded that  the water thrown in runs off by the  exha-
lents, and will augment the disease.
   1687. Another set of remedies  which may be em-
ployed for exciting a serous excretion, and thereby cur-
ing dropsy,  is that of sudorifics.   Such remedies, in-
deed, have been  sometimes  employed:  but however
useful they have been thought, there are few accounts
of their having effected a cure; and although I have had
some examples of  their success, in most instances  of
iheir trial they have been ineffectual.
  Upon this subject it is proper to take notice  of the
several  means that have been  proposed and employed
for dissipating the  humidity of the body;" and particu-
larly that of heat externally applied to the surface of it.
Of such applications I have had no experience; and
their propriety and utility must rest upon the credit of
the authors who relate  them.   1 shall offer  only this
conjecture upon the subject: that if such measures have
been truly useful, as  it has seldom been by the drawing 
PRACTICE OF PHYSIC.
353
out of any sensible humidity, it  has probably been by
their restoring the perspiration, which is so often  greatly
diminished in this disease; or, perhaps, by changing the
state of the skin from the imbibing condition which is
alleged to take place, into that of perspiring.
   1688. When, by the several means now mentioned,
we shall have succeeded in  evacuating the  water of
dropsies, there will then especially be occasion  for our
third  indication;  which is, to restore the tone of the
system, the loss of which is so often the cause of the
disease.   This  indication,  indeed,  may properly have
place from the very first appearance of the disease; and
certain measures adapted to this purpose  may, upon
such first appearance, be employed  with advantage. In
many cases of a moderate disease, I am persuaded that
they may obviate any future increase of it.
   1689. Thus,  upon what is commonly the first symp-
tom of anasarca, that is, upon the appearance of what
are called (Edematous  Swellings of the feet and  legs,
the three remedies of bandaging, friction and exercise,
have often been used with advantage.
   1690. That .some  degree of external compression is
suited to  support the tone of the vessels, and particu-
larly to prevent the effects of the  weight of the blood in
dilating those of the lower  extremities, must be suffi-
ciently evident; and  the  giving that compression by a
bandage properly applied, has been often useful.  In ap-
plying such a bandage,  care is to be taken that the
compression may never be greater on the upper than
on the lower part  of the limb; and this, I think, can
hardly ever be so certainly avoided, as by  employing a
properly constructed laced stocking.
   1691. Friction is another means  by which the action
of the blood-vessels may be promoted, and thereby the
stagnation of fluids in their extremities prevented.   Ac-
   VOL. II.               7. 7, 
354
PRACTICE OF PHYSIC.
 cordingly, the  use of the flesh-brush  has often contri-
 buted to discuss oedematous swellings.  It appears to
 me that friction, for the purposes now  mentioned,  is
 more properly employed in the morning, when the swell-
 ing is very much gone off, than in  the evening,  when
 any considerable degree of it has already come on.  I
 apprehend, also, that friction being made from below
 upwards only,  is more useful  than when  made alter-
 nately upwards and downwards.   It has been common,
 instead of employing the flesh-brush, to  make friction
 by warm and dry flannels; and this may  in some cases
 be the most convenient: but I cannot perceive that the
 impregnation of these flannels with certain dry fumes
 is of any benefit.
   1692. With  respect to exercise, I must observe, that
 although persons being much in  an  erect posture dur-
 ing the day, may seem to  increase the swelling which
 comes on  at night:  yet as the action  of the  muscles
 has a great share in promoting  the motion of the ve-
 nous blood, so  I am  certain, that as much  exercise in
 walking  as the  patient can easily bear, will often pre-
 vent that oedematous swelling, which  much standing,
 and  even sitting, would have brought on.
   1693.  These measures, however, although they may
 be useful at the coming on of a  dropsy, whose causes
 are  not very powerful, will be  often insufficient in a
 more violent disease; and  such therefore will  require
 more powerful  remedies.  These are,  exercise and
 tonic medicines; which may be employed both during
 the course of the disease, and especially after the water
 has been evacuated.
  1694.  Exercise is suited to  assist in every function
 of the  animal economy, particularly to promote perspi-
ration,  and thereby prevent the accumulation of watery
fluids in the body.  I apprehend also, that  it  may be the 
F
                   PRACTICE OF PHYSIC.           355

[    most effectual means for preventing the skin from being
    in an imbibing state; and, as it has been hinted above
    on  the subject of emaciation, (1603) I am  persuaded,
    that a full and large perspiration will always be a means
    of exciting absorption in  every part of the system. Ex-
    ercise, therefore, promises to be highly useful in dropsy;
    and any mode of it may  be employed that  the  patient
    can most conveniently admit of.   It  should, however,
    always be as much as he can easily bear:  and in ana-
    sarca, the share which the exercise of muscles has in
    promoting  the motion of the venous blood, induces me
    to think that bodily exercise, to whatever  degree the
    patient can bear it, will always be the most useful.  From
    some experience also,  I am persuaded, that by exer-
    cise alone,  employed early in the  disease, many drop-
    sies may  be cured.
       1695.  Besides exercise, various tonic remedies are
    properly  employed to restore the  tone of the  system.
    The chief of these are  chalybeates, the Peruvian bark,
    and various bitters.  These  are not only suited to re-
    store the tone of the system in general, but are particu-
    larly useful in strengthening the  organs of digestion,
    which in dropsies are frequently very much weakened;
    and  for the same  purpose also aromatics may  be fre-
    quently joined with the tonics.
      1696. Cold bathing is upon many occasions the most
    powerful  tonic we can  employ; but at the beginning of
    dropsy, when the debility of the system  is considerable,
    it can hardly be attempted with safety.  After, however,
    the  water of dropsies has been very fully evacuated, and
    the  indication is to strengthen the  system  for prevent-
    ing  a relapse,  cold bathing may perhaps have a place.
    It is, at the same time, to be admitted with caution; and
    can scarcely be employed till the system has otherwise
    recovered a good  deal of  vigour.   When that  indeed 
356 •          PRACTICE OF PHYSIC.
has happened, cold bathing may be very useful in con-
firming and completing it.
   1697.  In persons recovering from dropsy, while the
several means now mentioned for strengthening the
system are employed, it will be proper at the same time
to keep constantly in view the support of the watery ex-
cretions; and  consequently the keeping up the perspi-
ration by a great deal  of exercise, and continuing the
full flow of the urinary excretions by the frequent use
of diuretics.
                     SECTION II.

  OF THE HYDROTHORAX, OR DROPSY OF THE
                     BREAST.

 1698.  THE  preternatural collection of serous fluid
 in the thorax, to which  we give the appellation of Hy-
 drothorax, occurs more frequently than has been ima-
 gined.'Its presence, however, is not always  to be very
 certainly known; and  it often takes  place to a consider-
 able degree before it be discovered.
   1699.  These collections of watery fluids in the tho-
rax, are  found in different situations.  Very often the
water is  found at  the same time in both sacs of the
pleura, but frequently in one of them only.  Sometimes
it is found in the pericardium  alone; but for the most
part it only appears there when at the same time a col-
lection is present in one or both cavities of the thorax.
In some instances, the collection is found to be only in
that cellular texture of the lungs, which surrounds the
bronchias, without there being at the same  time any
effusion into the cavity of  the thorax. 
              PRACTICE OF PHYSIC.          357

  Pretty frequently the water collected consists chiefly
of a great number of hydatides in different situations:
sometimes seemingly  floating  in  the  cavity,  but fre-
quently  connected with, and attached to, particular
parts of the internal surface of the pleura.
  1700. From the collection of water being thus in va-
rious  situations  and  circumstances,  symptoms arise
which are different in different cases; and from thence
it becomes often difficult to ascertain the presence and
nature of the affection. I shall, however, endeavour here
to point out the most  common symptoms, and  especi-
ally those of that principal  and most frequent form of
the  disease, when the serous fluid is  present  in both
sacs of the pleura, or, as we usually speak, in both ca-
vities of the thorax.
  1701. The disease  frequently comes  on with a sense
of anxiety about the lower part of the sternum.   This,
before  it has subsisted  long, comes to be joined with
some difficulty of breathing; which at first appears only
upon the person's moving a little faster than usual, upon
his  walking up an acclivity, or upon  his ascending a
staircase; but after some time, this difficulty of breath-
ing  becomes more constant and considerable, especially
during the night, when the body is in a horizontal situa-
tion.  Commonly, at the same time,  lying upon one
side is more easy than upon  the other, or perhaps lying
upon the back more easy than upon either side. These
circumstances  are usually attended with a  frequent
cough, that is at first dry; but which,  after some time,
is accompanied with an  expectoration of thin mucus.
  With  all these  symptoms,  the  hydrothorax is  not
certainly discovered,  as the same symptoms often at-
tend other diseases of the breast. When, however, along
with these symptoms there is at the same time an oede-
matous swelling of the feet and legs, a leucophlegmatic 
358           PRACTICE OF PHYSIC
 paleness of the face, and a scarcity of urine, the exist-
 ence of a hydrothorax can be no longer doubtful.  Some
 writers have  told us, that  sometimes in this  disease,
 before the swelling of the feet comes on, a watery
 swelling of the scrotum appears; but  I have never met
 with afny instance of this.
   1102. Whilst  the presence of the disease is some-
 what uncertain, there is  a  symptom  which sometimes
 takes place, and has been thought to  be a certain cha-
 racteristic  of it; and that is, when soon after the patient
 has fallen asleep, he is suddenly awaked with a sense of
 anxiety and difficult  breathing, and with a violent pal-
 pitation of the heart.  These feelings immediately  re-
 quire an erect posture; and very often the difficulty of
 breathing continues to require and to  prevent sleep  for
 a great part of the night.   This symptom I have fre-
 quently found attending the disease;  but I have also met
 with several instances in which this symptom did not
 appear.  I must remark further, that  I have not found
 this symptom attending the empyema, or any other dis-
 ease of the thorax;  and therefore,  when it attends a
 difficulty of breathing, accompanied with any the small-
 est symptom of dropsy, I have had no doubt in conclud-
 ing the presence of water in the chest, and have always
 had my judgment confirmed by the symptoms which
 afterwards  appeared.
   1703.  The hydrothorax often occurs with very few,
 or almost none, of the symptoms above mentioned; and
 is  not, therefore,  very  certainly discovered till some
 others  appear.  The  most decisive  symptom is a  fluc-
 tuation of water in the chest, perceived by  the patient
himself, or by the physician, upon  certain  motions of
the body. How far the method proposed by  Auenbrug-
 ger will apply to ascertain the presence of water, and the 
PRACTICE OF PHYSIC.           359
 quantity of it in the chest, I have not had occasion or
 opportunity to observe.
   It has been said, that in this disease some tumour ap-
 pears upon the sides or  upon the back, but I have not
 met with any instance of this.  In one instance of the
 disease, I found one side of the thorax considerably en-
 larged, the ribs standing out farther on  that side than
 upon the other.
   A  numbness and a degree of palsy in  one or both
 arms, has been frequently observed to attend a hydro-
 thorax.
   Soon after this disease has made some progress, the
 pulse commonly becomes irregular, and frequently in-
 termitting: but this happens in  so many other diseases
 of the breast, that, unless when  it is attended with some
 other of the above-mentioned symptoms, it  cannot be
 considered as denoting the hydrothorax.
   1704.  This disease, as other dropsies, is commonly
 attended with thirst and  a scarcity of  urine,  to be ex-
 plained in the same manner as in  the case of anasarca,
 (1674.)  The hydrothorax, however, is sometimes with-
 out thirst, or any other febrile symptom; although I be-
 lieve this happens in the case of partial affections only,
 or when a more general affection is yet but in a slight
 degree.   In  both cases, however, and more especially
 when the disease is considerably advanced, some degree
 of fever is generally present: and  I apprehend it  to be
 in such case, that the  persons affected  are more than
 usually sensible to cold,  and complain of the coldness
 of the air when that is not perceived  by other persons.
   1705. The hydrothorax  sometimes appears alone,
 without  any other species of dropsy  being present at
the same time:  and in this case  the  disease,  for  the
 most part, is  a partial affection, as being either of one
side of the thorax only, or being a collection of hyda- 
360          PRACTICE OF PHYSIC.

tides in one part of the chest.   The hydrothorax, how-
ever, is very often a part of more universal dropsy, and
when at the same time there is  water in all the  three
principal cavities and in  the cellular texture of a great
part of the body.   I have met with several  instances in
which  such universal dropsy began  first by an effusion
into the thorax.   The hydrothorax, however, more fre-
quently comes on from  an anasarca gradually  increas-
ing; and, as I have said above,  the general diathesis
seems  often to affect the thorax sooner than  it does
either  the head or the abdomen.
   1706. This disease seldom admits of a cure, or even
of alleviation,  from remedies.   It commonly proceeds
to give more and more  difficulty of breathing,  till the
action  of the lungs  be entirely interrupted by the quan-
tity of water effused: and the fatal event frequently hap-
pens  more suddenly than was  expected.   In many of
the instances of a fatal hydrothorax, I have  remarked a
spitting of blood to come  on several days before the pa-
tient died.
   1707. The cause of hydrothorax is often manifestly
one or other of the general  causes  of dropsy pointed
out above:  but what it is that determines these general
causes to act  more especially in the thorax, and par-
ticularly what  it  is that produces  the partial  collec-
tions that occur there, I do not find  to  be easily  ascer-
tained.
   1708. From what has  been said above, it will be evi-
dent, that the cure of hydrothorax must be very much
the same with that of anasarca; and when the former is
joined  with the latter as  an  effect of the same general
diathesis, there can be no doubt of the method of cure
being the same in both.   Even when the hydrothorax
is alone, and the disease  partial,  from particular causes
acting in the thorax only, there can hardly be any other 
PRACTICE OF PHYSIC.
361
measures employed,  than  the general ones proposed
above.   There is only one particular measure adapted
to the hydrothorax; and that is, the drawing off the ac-
cumulated waters by  a paracentesis of  the thorax.
  1709. To what cases this operation may be most pro-
perly adapted, I find  it difficult to determine.  That it
may  be executed with safety, there is no doubt;  and
that  it has been  sometimes practised  with  success,
seems to be very well vouched.   When the disease de-
pends  upon a general hydropic diathesis, it cannot
alone prove a cure, but may  give a temporary  relief;
and when other remedies seem to be employed with ad-
vantage, the drawing off the water may very much fa-
vour a  complete cure.   I  have not, however, been so
fortunate as to see it  practised with any success;  and
even where it was most promising, that is, in cases of
partial  affection, my expectations  have  been  disap-
pointed from it.
                    SECTION ill.

OF ASCITES, OR DROPSY OF  THE LOWER BELLY.

1710. THE name of Ascites is given to every collec-
tion of waters causing a general swelling and distention
of the lower belly; and such collections are more fre-
quent than those which happen in the thorax.
  1711. The collections in the lower belly, like  those
of the thorax, are found in different  situations.   Most
commonly they are in the sac of the peritonaeum, or
general  cavity of the  abdomen: but  they  often begin
by sacs formed upon, and connected  with one or  other
of the viscera; and  perhaps the most frequent in-
stances of this kind  occur in the ovaria of females^
 VOL. IT                 3 A 
362
PRACTICE OF PHYSIC.
Sometimes the water of ascites is found entirely with-
out the peritonaeum, and between this and the abdomi-
nal muscles.
   1712.  These  collections  connected with particular
viscera, and those formed without the peritonaeum, form
that disease which authors have  termed the  encysted
dropsy, or hydrops saccatus.   Their  precise seat, and
even their existence, is very often difficult to be ascer-
tained.   They are  generally formed by collections of
hydatides.
   1713.  In the most  ordinary case,  that of abdominal
dropsy, the swelling at first is in some measure over
the whole belly, but generally appears most  considera-
ble in the epigastrium.  As the disease, however, ad-
vances, the swelling becomes more  uniform over the   ^
whole.   The  distention, and  sense of  weight, though
considerable,  vary  a little,  according as the posture
of the body is  changed; the weight being felt the most
upon the side  on which  the patient  lies, while at the
same time on  the opposite side the distention becomes
somewhat less.  In almost all the  instances  of ascites,
the fluctuation of the water within, may be perceived
by the practitioner's feeling, and sometimes by his hear-
uig.   This perception of fluctuation,  does not certainly
distinguish the different states of dropsy; but  serves
very well to distinguish dropsy from  tympanites, from
cases of physconia, and from the state of pregnancy in
women.
   1714.  An ascites frequently occurs when no other
species of dropsy does at the same time appear; but
sometimes the ascites is a part only of universal dropsy.
In this case, it usually comes on in consequence of an
anasarca, gradually increasing; but its being joined with
anasarca, does not always denote any general diathesis,
as for th& most part an ascites sooner or later occasions 
PRACTICE OF PHYSIC.
363
 edematous swellings of the lower extremities.  When
 the collection of water in the abdomen, from whatever
 cause, becomes considerable, it is always attended with
 a difficulty of breathing; but this symptom occurs often
 when, at the same time, there is no water in the thorax.
 The ascites is sometimes unaccompanied with any fe-
 ver; but frequently there is more or less of fever pre-
 sent with it.  The disease is never considerable, without
 being attended with thirst and a scarcity of urine.
   1715. In  the diagnosis of ascites, the greatest diffi-
 culty that occurs, is in discerning when the water is in
 the cavity of the abdomen, or when it is in the different
 states of encysted dropsy above mentioned.  There is,
 perhaps, no  certain means of ascertaining this in all
 cases; but in many  we  may attempt  to form some judg-
 ment with regard to it.
  When the antecedent circumstances give suspicion of
 a general  hydropic diathesis; when at the same time
 some degree of dropsy appears in  other parts of the
 body; and when, from its first appearance, the swelling
 has been equally over  the whole belly, we may gene-
 rally presume that the water is in the cavity of the ab-
 domen. But when an ascites has not been preceded by
 any remarkably cachectic state of the system, and when
 at its beginning the tumour and tension had appeared in
 one part of the belly more than another, there is reason
 to suspect an encysted dropsy. Even when the tension
 and tumour of the belly have become general and uni-
 form over the whole; yet if  the system  of the body in
 general appear to  be  little  affected; if  the patient's
 strength  be little  impaired; if the  appetite  continue
 pretty entire; and the natural sleep be little interrupted;
 if the menses in females continue to flow as usual;  if
 there  be yet no anasarca; or,  though  it may have al-
ready taken place,  if it be  still confined to the lower 
364
PRACTICE OF PHYSIC.
extremities,  and there be no leucophlegmatic paleness
or sallow colour in the countenance; if there be no fe-
ver, nor so much thirst,  or scarcity of urine, as occur
in a more general affection; then, according as more of
these different circumstances  take place, there will be
the stronger ground for supposing the  ascites to be of
the encysted kind.
   The chief exception to be made from this as a gene-
ral rule, will, in my opinion, be when  the ascites may,
with much probability,  be presumed to have come on
in consequence of a  scirrhous liver; which, I  appre-
hend, may occasion a collection of water in the cavity
of the abdomen, while the general  system of the body
may not be otherwisemuch affected.
   1716.  With respect to the cure  of  ascites when  of
the encysted kind, it does not, so far as I know, admit
of any.  When the collection of water is in the abdo-
minal cavity alone, without any other species of dropsy  H
present at the same time, I apprehend the ascites will
always be of difficult cure; for it may be presumed to
depend upon a scirrhosity of the liver, or other consi-
derable affection of the abdominal viscera, which I con-
ceive to be of very difficult cure, and  therefore  the as-
cites depending upon them.  At  the same  time,  such
cases  may often admit of a temporary relief by the pa-
racentesis*
  * Since the publication of the first edition  of this work, we were so for-
tunate as to remove, by means of a blister, in the case of a lady of Phila-
delphia, a very large ascetic effusion, in a manner not altogether unworthy
of a recital.
  Owing to an indurated condition of the liver, the lady was dropsical the
third time.  On the two former occasions she had been tapped, and the
quantity of fluid drawn off each time-was about sixteen quarts.  Judging
from appearances, there was every reason to believe the third effusion
equally copious
  Our patient was affected with such a degree of gastric irritability, that she
rejected by vomiting every thing she swallowed.
  To allay this,  a blister wa6 applied on the region of the stomach.  The 
                 PRACTICE OF  PHYSIC.             365

   1717. When the ascites is a part of universal dropsy,
it may,  as far as other cases of that kind can, admit of
cure: and it will be obvious,  that such a cure must be
obtained by the same  means as above proposed for the
cure of general anasarca.
   It frequently  happens, that the ascites  is  attended
with a  diarrhoea; and, in that  case, does  not  admit of
the  use of purgatives so freely as cases of anasarca com-
monly do.  It is therefore often to be treated by  diure-
tics almost alone.
   The diuretics that may be employed are  chiefly those
above  mentioned;  but in ascites, a peculiar one  has
been  found out.    It is a long continued gentle friction
of the skin over the whole of the abdomen, by the fin-


effect proving favourable, the blistered part was suffered to heal, which it
did in a few days, without any unusual discharge.
  On our next visit, the lady, who was not free from some  peculiarities both
of feeling and disposition, asked permission, as a favour,  to apply another
blistering plaster to the same part, that, to use her own language, she might
" have something to amuse her."
  The request was granted, and the plaster applied.
  The part being exceedingly susceptible, the action was almost immediate.
  The tender cuticle soon gave way, and the discharge became profuse, far
beyond what we had ever witnessed. It penetrated, in a short time, through
twenty-four folds of woollen, cotton, and linen cloths, several of which were
blankets and counterpanes, through a mattrass and the sacking-bottom of
the bedstead, and was received into a vessel placed underneath.
  Pressure, gentle and equable, was made on the abdomen, by a suitable
bandage, until, in  less than forty-eight hours, the hydropic effusion had en-
tirely disappeared.
  During this process, there was no increase in the evacuation from any of
the natural emunctories of the body. Through the blistered part alone was
the discharge effected.  Thus, in two days and nights, were sixteen quarts of
water evacuated by the secretory action of a blistered part, not exceeding
in dimension four and a half or five inches square.  As far as we know, the
case is unique.  The records  of medicine offer no parallel,,
  In this singular cure, the modus operandi is perfectly obvious.   The  re-
medy acted with equal efficiency by direct stimulation and by sympathy.  By
the former, it excited the part of the cutis to which it was applied, to a pre-
ternatural secretion, and by the latter, it roused the absorbents of the abdo-
men to such an augmented action, as enabled them to take tip, with an  un-
exampled rapidity, the liquid  effused, 
366
PRACTICE OF PHYSIC.
 gers dipped in oil.  This has sometimes been useful in
 exciting an increased flow of urine; but in most of the
 trials of it which I have known made, it has failed in
 producing that effect.
   1718. The ascites admits of a particular means for
 immediately drawing off the collected waters: and that
 is the well-known operation of the paracentesis of the
 abdomen.   In what circumstances of ascites this opera-
 tion can most properly be proposed, it is difficult to de-
 termine; but, so far as I can judge, it must be regu-
 lated by very much the same considerations as those
 above mentioned with regard to the paracentesis of the
 thorax.
   The manner of performing the paracentesis of the ab-
 domen,  and the precautions to be taken with respect to
 it, are now so commonly  known, and delivered in so
 many books, that it is altogether unnecessary for me to
 offer any directions upon that subject  here; especially
 after the full and  judicious information and directions
 given by Mr. Bell, in the second  volume of his Sys-
tem of Surgery.
                    chapter rv.

OF GENERAL SWELLINGS, ARISING, FROM AN IN-
  CREASED BULK OF THE WHOLE SUBSTANCE OF
  PARTICULAR PARTS.

1719. UPON the subjects of this chapter, several no-
sological difficulties occur, and  particularly with re-
spect to admitting the Physconia into the order of gene-
ral swellings.   At present, however, it is not necessary
for me to discuss this point,  as I am here to  omit en 
PRACTICE  OF PHYSIC.
367
tirely the consideration of Physconia; both  because  it
can  seldom admit of  any  successful practice, and be-
cause  I cannot deliver any thing useful either with re-
gard to the pathology or practice in such a disease.
   1720.  The  only  other genus of disease compre-
hended under the title of the present chapter, is the Ra-
chitis;  and this being both a  proper example  of the
class of Cachexy, and of the order of Intumescentice or
General Swellings, I  shall offer some observations with
regard to  it.
             OF  RACHITIS, OR  RICKETS.*


1721. THIS  disease has been supposed to have ap-
peared only in modern times, and not above two  hun-
dred years ago.  This  opinion, notwithstanding it has
been maintained by  persons of the  most  respectable
authority,  appears  to  me, from many considerations,
improbable; but it is  a point of too little consequence
to detain my readers  here.   The only application of it
which deserves any notice is, that it has led to a notion

  * Fortunately for the people of the United States, rickets is much of a
Stranger, in this country.  Our experience in it, is, therefore, very limited.
  We have seen enough of it, however, to be persuaded, that it consists in a
diseased, and inefficient state  of the organs of digestion, assimilation, and
nutrition.  It commences, no doubt, in the stomach, and is thence communi-
cated, by sympathy, to the bowels, the lacteals, the mesenteric glands, and,
ultimately, to the whole system.
  The practice in it, as far as practice may avail, is plain and simple.  It con-
sists, in a purely tonic and corroborative course—in the pursuit of such a
regimen, and the administration of such remedies, as  are calculated to in-
crease the powers, and invigorate the action of the various organs, that are
tributary to nutrition. But this scheme of practice has been so often un-
folded, in the present work, that a detailed view of it, here, would be alto-
gether superfluous.
  Those who wish to be further informed, respecting this disease, may con-
sult Nooth de Rachitide—Moore de Rachitide--Veirac and Portal. 
.368
PRACTICE OF PHYSIC.
of the disease having arisen from the lues venerea, which
had certainly made its  first appearance in Europe not
very long before the date commonly assigned for the
appearance of rachitis: but I shall hereafter show, that
the supposed connexion between the Syphilis and Ra-
chitis is without foundation.
   1722. In delivering the history of the Rickets, I must,
in the first place, observe that, with respect to the  ante-
cedents of the disease, every thing to  be found in au-
thors upon this subject, appears to me to rest upon  a
very uncertain foundation.   In particular, with respect
to the state of the parents whose offspring become af-
fected  with this disease, I have met with many instances
of it, in children from seemingly healthy parents, and
have met likewise  with many instances of children who
never  became affected with it, although born of pa-
rents who, according to the common accounts, should
have produced a rickety offspring: so  that, even making *\
allowance for  the uncertainty of fathers* I do not find
the general opinion of authors upon this subject to be
properly supported.
   1723. The  disease, however, may  be justly consi-
dered as proceeding from parents; for  it often appeal's
in a great number of the same family: and my observa-
tion leads me to judge, that it originates more frequently
from mothers than from fathers.  So far as I can  refer
the disease of the children to the state of the parents,  it
has appeared to me most commonly to arise from some
weakness, and pretty  frequently from  a scrophulous
habit in the  mother.   To conclude the subject, I  must
remark that in many cases I have not been able to dis-
cern the condition of the parents, to which I could re-
fer it.
  When nurses, other than  the mothers, have  been
employed to suckle children, it has been  supposed that 
PRACTICE OF PHYSIC.
369
 such nurses have frequently given occasion to the dis-
 ease, and when nurses  have both produced and  have
 suckled  children who became rickety, there may  be
 ground to suspect their having occasioned the disease
 in  the children of other persons: but I have had few
 opportunities of ascertaining this matter.  It has in some
 measure appeared to me, that those  nurses are  most
 likely to produce this disease,  who give infants a large
 quantity of very watery milk, and who continue to suckle
 them longer than the usual time.  Upon the whole, how-
 ever, I am of opinion, that hired nurses seldom occasion
 this disease, unless when a predisposition to  it has pro-
 ceeded from the parents.
   1724.  With regard to the other antecedents,  which
 have been usually enumerated by authors as the remote
 causes of this disease, I judge the accounts given to be
 extremely fallacious; and I  am very much persuaded,
 that the circumstances in the rearing of children, have
 less effect in producing rickets  than has been imagined.
 It is indeed  not  unlikely, that  some of these circum-
 stances mentioned as remote causes may favour, while
 other circumstances may resist, the coming  on  of the
 disease; but at the same time, 1 doubt if any of the for-
 mer would produce it were there was no predisposition
 in the child's original constitution.   This opinion of the
 remote causes, I have  formed from observing that the
 disease comes on when none of these had been applied,
 and more frequently that many of them had been ap-
 plied without occasioning the disease. Thus the learned
 Zeviani alleges, that the disease is produced by an  acid
from the milk with which a child is fed  for the  first
nine months of its life: but  almost all  children are fed
with the same food, and in which also an acid is always
produced; while, at the same time, not one in a thou-
sand of the  infants  so fed becomes affected with the
  VOL. II.              3 B 
370
PRACTICE OF  PHYSIC.
 rickets.   If, therefore,  in the infants who become af-
 fected with this disease, a peculiarly noxious acid is
 produced, we must seek for some peculiar cause of its
 production, either in  the quality of the milk, or in the
 constitution of the child,  neither of which,  however,
 Mr. Zeviani has explained.   I cannot indeed believe
 that the ordinary acid of milk has any share in produc-
 ing this  disease, because I have known many instances
 of the  acid being produced and occasioning various
 disorders, without, however, its ever producing rickets.
   Another of the remote causes commonly assigned is
 the child's being fed with unfermented farinaceous food.
 But over the whole world, children are fed with such
 farinacea while the disease of rickets is of rare occur-
 rence:  and I have known many instances where chil-
 dren have  been fed with a greater than usual propor-
 tion of fermented farinacea, and also a greater propor-
 tion of  animal food,  without these preventing the dis-'
, ease.   In my apprehension, the like observations might
 be made with respect to most of the circumstances that
 have been  mentioned as the remote causes of rickets.
    1725. Having  thus  offered my opinion  concerning
 the supposed antecedents of this disease, I proceed now
 to mention the phenomena occurring after it has actu-
 ally come on.
   The disease seldom appears before the ninth month,
 and seldom begins after the  second year of a child's
 age.  In the interval between these periods, the appear-
 ance of the disease is sometimes sooner, sometimes later;
 and commonly at first the disease comes on slowly.  The
 first appearances are, a flaccidity of the flesh, the body
 at the same time becoming leaner, though food be taken
 in pretty largely.  The  head appears  large with re-
 spect to the body; with the fontanelle, and perhaps the
 sutures, more open than usual in children of the same 
PRACTICE OF PHYSIC.
371
 age.   The head continues to grow larger; in particular
 the forehead becoming unusually prominent; and at the
 same time the neck continues  slender, or seems to be
 more so, in proportion to the head.  The dentition is
 slow, or much later than usual; and those teeth which
 come out, readily become black,  and frequently again
 fall out.  The ribs lose their  convexity, and become
 flattened on the side; while the sternum is pushed  out-
 ward, and forms a sort of ridge.  At the same time, or
 perhaps sooner, the epiphyses  at the several joints of
 the limbs become swelled; while the limbs between the
 joints appear,  or perhaps actually become, more slender.
 The bones seem to be every where flexible, becoming
 variously distorted; and  particularly the spine of the
 back becoming incurvated in different parts of its length.
 If the child, at the same time the disease comes on, had
 acquired the power of walking, it becomes daily more
"feeble in  its  motions, and more  averse to  the exer-
 tion of them,  losing  at length  the  power of walking
 altogether.  Whilst these symptoms go on increasing,
 the abdomen is always full,  and preternaturally tumid.
 The appetite is often good, but  the stools are generally
 frequent and  loose.   Sometimes the faculties  of the
 mind are impaired, and stupidity or fatuity prevails;  but
 commonly a premature sensibility appears, and they ac-
 quire the faculty of speech sooner than usual.   At the
 first coming on of the disease, there is generally no fever
 attending it: but it seldom continues long, till a frequent
 pulse,  and other febrile symptoms, come  to be  con-
 stantly present.  With these symptoms the disease pro-
 ceeds, and continues in some instances for some years-
 but very often in the  course of that time, the disease
 ceases to advance, and  the health is entirely established,
 except that  the distorted  limbs, produced during  the
 disease, continue for the rest of  life.   In other cases. 
372
PRACTICE OF PHYSIC.
however, the disease proceeds increasing, till it has af-
fected almost every function of the animal  economy,
and at length  terminates  in death.   The variety of
symptoms which in such cases appear,  it does not seem
necessary to enumerate, as they are not essential to the
constitution of the disease, but are merely consequences
of  the more violent conditions of it.   In the bodies of
those who  have died, various  morbid affections have
been  discovered in  the  internal parts.   Most  of the
viscera of the abdomen have been  found to be preter-
naturally enlarged.   The lungs have also been found in
a morbid state, and seemingly from some inflammation
that had come on towards the end of the disease.  The
brain has been commonly found in a flaccid state, with
effusions of a serous fluid into its cavities.  Very uni-
versally the bones have  been found very soft, and so
much softened  as to be  readily cut by a knife.   The
fluids have been always found in a dissolved state, and
the muscular parts very soft and tender; and the whole
of the dead body without  any degree  of that rigidity
which is so common in almost all others.
   1726. From  these  circumstances of the disease, it
seems to consist in a deficiency of that matter  which
should form the solid parts of the body.  This especially
appears in the faulty state of ossification, seemingly de-
pending upon the deficiency of that matter which should
be deposited in the membranes which are destined to be-
come bony, and should give them  their due firmness
and bony hardness.   It appears that this matter is not
supplied in due quantity;  but that, in place of it, a mat-
ter fitted to increase their bulk, particularly in the epi-
physes, is applied too largely.  WThat this deficiency of
matter depends upon, is difficult to be ascertained.  It
may be a fault in the organs of digestion and assimila-
tion, which prevents the  fluids in general from being 
PRACTICE OF PHYSIC.
373
    properly prepared: or it may be a fault in the organs of
    nutrition, which prevents the secretion of a proper mat-
    ter to be  applied.   With respect to the latter, in what it
    may consist, I am entirely ignorant, and cannot  even
    discern that  such a condition  exists: but  the former
    cause, both in its  nature and existence, is more readily
    l^rceived; and it is probable that it has a considerable
    influence in the matter; as in rachitic persons a thinner
    state of the blood, both during life and  after death, so
1    commonly appears.   It is this state of the  fluids, or a
    deficiency of bony matter in them,  that I  consider as
    the proximate cause of the disease; and which again
    may in some measure depend upon a general laxity and
    debility of the moving fibres of the organs that perform
    the functions of digestion and assimilation.
    .  1727. There is, however, something still wanting to
*    explain, why these  circumstances discover themselves
    at a particular time of life, and hardly ever either before
    or after a certain  period;  and  as  to this I would  offer
    the following conjectures.  Nature having intended
    that human life should proceed  in a certain manner, and
    that certain  functions should be exercised at a certain
    period of life only: so it has generally provided, that at
    that period, and not sooner, the  body should be fitted
    for the exercise of the functions suited to it.   To apply
    this to our present subject, Nature  seems  to  have in-
    tended that children should walk only at twelve months
    old; and  accordingly has provided that against that age,
    and no sooner, a  matter should be prepared fit to give
    that firmness to the bones which is necessary to prevent
    their bending  too easily under the weight of the body.
    Nature, however,  is not always steady and exact in ex-
    ecuting her own purposes; and if therefore the prepara-
    tion of bony  matter shall not have been made against
    the time there is a particular occasion for it, the disease 
374          PRACTICE OF PHYSIC.

of rickets, that is, of soft and flexible bones, must come
on; and will discover itself about the particular period
we have mentioned.  Further, it will be equally proba-
ble, that if, at the period mentioned, the bones  shall
have acquired their due firmness, and that nature goes
on in preparing and supplying the proper bony matter,
it may be  presumed, that against the time a child is two
years old,  such a quantity of bony matter will be ap-
plied, as to prevent the bones from becoming again soft
and flexible during the rest of life; unless it happen, as
indeed it sometimes does, that certain causes occur to
wash out again the bony matter from the membranes in
which it had been deposited.   The account I have now
given of the period at  which the rickets occur, seems
to confirm the opinion of its proximate cause being a
deficiency of bony matter in the fluids of the body.
   1728. It has been frequently supposed, that a syphi-
litic taint has  a share in producing rickets^ but such a
supposition is altogether improbable.   If our opinion
of the rickets having existed in Europe before the syphi-
lis was brought into it,  be  well founded, it will then
be certain that the disease  may be occasioned without
any syphilitic acrimony having a share  in  its produc-
tion.   But further, when a syphilitic acrimony is trans-
mitted from the parent to the offspring, the symptoms
do  not appear at a particular time of life only, and  com-
monly more early than the period of rickets; the symp-
toms are also  very different from those of rickets, and
unaccompanied with any appearance of the latter; and,
lastly, the symptoms  of syphilis are cured by means
which, in the case of rickets, have  either no effect, or
a bad one.  It may indeed possibly happen, that syphi-
lis  and rickets may appear in the same person; but it is
to be considered as an  accidental complication: and the
very few instances of it that have occurred, are by no 
PRACTICE OF PHYSIC.
S73>
means  sufficient to establish any  necessary connection
between the two diseases.
  1729. With respect to  the deficiency of bony mat-
ter, which I consider as the proximate cause of rickets,
some further conjectures might be offered concerning
its remote causes; but none of them appear to me very
satisfying;  and whatever they might be, it  appears to
me they must again be resolved into the supposition of
a general laxity and debility of the system.
   1730.  It is  upon this supposition almost alone that
the cure of rickets has entirely proceeded. The reme-
dies have  been such especially as were suited to im-
prove the tone of the system in general, or of the sto-
mach in particular: and we know that the latter are not
only suited to  improve the tone of the stomach itself.
but by that means to improve also the tone of the wholo
system.
   1731. Of tonic remedies, one of the most promising
seems  to have been cold bathing; and  I have found it
the most powerful in preventing the  disease.  For a
long time past, it has been the practice in this country.
with people of all ranks, to wash their children from
the time of their birth with cold water; and from  the
time that children  are a month  old, it has been  the
practice with people of better rank to have them dip-
ped entirely in cold water every morning: and wher-
ever this  practice has  been  pursued,  I have not met
with any instance of rickets.  Amongst our common
people, although they  wash their  children with cold
water  only, yet they do not so commonly practise im-
mersion: and when amongst these 1 meet with instances
of rickets, I prescribe cold bathing; which accordingly
has often  checked the progress of the disease,  and
sometimes seems to have cured it entirely.
   1732. The remedy of Ens Veneris, recommended by 
376
PRACTICE 0F PHYSIC.
 Mr. Boyle, and since his time very universally employ-
 ed, is to be considered as entirely a tonic remedy. That
 or some other preparation of iron I have  almost con-
 stantly employed,  though not indeed always with suc-
 cess.  I have been persuaded,  that  the ens veneris  of
 Mr. Boyle, notwithstanding his  giving  it this appella-
 tion, was truly a preparation of iron, and no other than
 what we  now name the Flores Martiales:  but  it ap-
 pears, that both Benevoli and Buchner have employed
 a preparation of copper;  and I  am ready to  believe  it
 to be a more powerful tonic than the preparations of
 iron.
   1733. Upon the supposition of tonic remedies being
 proper  in  this  disease, I have endeavoured to employ
 the Peruvian bark: but from the difficulty of adminis-
 tering it to infants in  any useful quantity,  I have not
 been able to discover its efficacy; but I  am very ready
 to believe the testimony of De Haen upon this subject.
   1734. Exercise, which is one of the most powerful
 tonics, has been properly recommended for the cure of
 rickets;  and as the exercise of gestation only can be
 employed,  it should always be, with the child laid in  a
 horizontal  situation; as the carrying them, or moving
 them in any degree of an erect posture,  is very  apt to
 occasion some  distortion.   It is extremely probable,
 that, in this disease, friction with dry flannels may be
 found an useful  remedy.
   1735.  It is also sufficiently probable, that the  avoid-
 ing of moisture  is not only advisable, but may likewise
 be of service in the cure of this disease.
  There is no doubt that a certain diet may contribute
to the same end; but what may be the most eligible,  I
dare not determine.   I have no  doubt  that  leavened
bread may be more proper than unfermented farinacea; 
PRACTICE OF PHYSIC.
377
but I cannot find any reason to believe that strong beer
can ever be a proper remedy.
  Practitioners have been divided in opinion concern-
ing the use of  milk  in this disease.   Zeviani, perhaps
from theory, condemns the use of it; but Benevoli em-
ployed it without its impeding the cure of the disease.
This last I have often remarked in  the course of my
own practice. As it  is difficult to feed children entirely
without  milk;  so I have commonly admitted it as a
part of  the diet of rickety children;  and in many in-.
stances I can affirm, that it did not prevent the cure of
the disease.  In cases,  however, of  any appearance of
rickets,  and particularly of a slow dentition, I have dis-
suaded the continuance of a child upon the breast; be-
cause the milk of women is a more watery nourishment
than that of cows: and  I  have especially dissuaded the
continuing a child upon the breast, when I thought the
nurse gave rather too much of such a watery nourish-
ment; for, as  has been above mentioned, I have had
frequent occasion to suspect, that  the milk  of  such
nurses has a tendency  to favour the coming on of the
rickets.
  1736.  Besides the remedies and regimen now  men-
tioned, practitioners have  commonly employed in this
disease,  both emetics and purgatives. When the appe-
tite and  digestion are considerably impaired, vomiting,
if neither violent nor frequently  repeated, seems  to be
of service; and by a moderate agitation of the abdomi-
nal viscera, may in some  measure obviate the stagna-
tion  and  consequent  swelling  that usually occur in
them.
  As the tumid state of the abdomen, so  constantly to
be met with in this disease, seems to depend very much
upon a tympanitic affection of the intestines; so, both by
obviating this,  and by deriving from  the abdominal vis-
  vol. n.               % c 
378             PRACTICE OF PHYSIC                    |

cera, frequent  gentle purgatives may be of service.  Ze-   |
viani, perhaps  properly, recommends in particular rhu-
barb; which, besides its purgative quality, has those also

of bitter and astringent*
   1737. I  have  now mentioned  most of the remedies
commonly  employed  by  the practitioners  of  former
times: but  I  must not  omit mentioning some others
that have been lately suggested.   The late Mr. De Haen
recommends thetestacea; and assures us of their having
been  employed with success: but in the few trials which
I have had occasion to  make, their good effects did not

appear.
   The late baron Van  Swieten  gives  us one instance
of rickets cured by the use of hemlock: but I do not
know that the  practice has been repeated.f

  * We are told that, of late, frequent and very active purging has been re-  ■
sorted to in the treatment of rachitis, with the happiest effects.  Although
we have seen no treatise recommendatory of such a practice, we are not un-
prepared to believe in its efficacy.                                   j
  We have long considered rickets as  having its primary seat in some por-  J
tion of the alimentary canal; and there are  but few, if any diseases of that
description, in which purging is not useful.
  Professing to have no experience in  this mode of practice in the disease
under consideration, we speak of it only as a matter of opinion. Should the
hint here given induce practitioners of judgment to make the experiment,
benefit may result from it to the sick and to  our profession.
  ■j- The testacea can, at best, serve only as a palliative in this disease, in
cases where the stomach is troubled with acidity.  The idea of such a re-
medy has been suggested by one of the many adulterations which chemis-
try has unfortunately introduced into medicine.
  A considerable amount of calcareous earth enters into the composition of
human bones.   In rachitis, that article not being prepared from the blood
in sufficient quantity,  the bones lose their firmness, and become as flexible
as cartilage.  In some instances they become membranous.
  Hence chemical physiologists—a name synonymous with that of no physit-
legists at all—pronounce the cause of rickets to be nothing else than a defi-
ciency of calcareous  matter in the blood.   To remedy this, they direct the
administration of calcareous earth in various forms, that from the stomach it
may pass formally into the blood, and thence into the bones.
  An error more gross and shameful than this, does not disgrace the annals
of medicine. A belief in the existence of an  elixir vitae scarcely surpasses it.
  A deficiency in the preparation of phosphate of lime is but an  effect of 
PRACTICE  OF  PHYSIC
379
                            BOOK III.


   OF  THE  IMPETIGINES;  OR  DEPRAVED  HABIT,
           WITH  AFFECTIONS  OF THE SKIN.


 1738.  I FIND it difficult to give  any sufficiently cor-
 rect and proper character of this order.   The  diseases

 rickets—as much and as evidently so, as a deficiency in  the formation of
 urine or perspiration is an effect of bilious or inflammatory fever. The real
 cause and seat of the disease are to be sought for in a deep derangement of
 the digestive and assknilatory organs.   And this state of things no prepara-
 tion of lime can remedy.
  As to the blood, it is really one of the last parts of the body to suffer from
 disease, notwithstanding the disposition of physicians to consider it as among
 the foremost.  In rickets it is not very perceptibly deteriorated.  In all the
 materials of secretion and nutrition it  is sufficiently rich. It does not refuse
 to supply phosphate of lime for the nourishment of the  bones, because it
 does not formally contain it, (for no blood thus contains it,) but because the ves-
 sels destined to secrete that article from it, are deficient in their duty.   Re-
 store them to healthy action,  and the bones  will receive their requisite nou-
 rishment, even though the blood continue the same.
  As pretended evidence, that preparations of lime must be  thrown  for-
 mally into the blood,  before  they can, by secretion, be formed out of it,
 chemists tell us, that unless the females of our domestic fowls eat calcareous
 earth, they produce eggs -without shells.
  This is a mistake which ought to astonish us, and into which no American
 of common observation should suffer himself to fall.
  In the states of Georgia, South Carolina, North Carolina,  Virginia,  and,
 Maryland,  there is scarcely to  be found within forty leagues of the  sea
 coast, a  single ton of calcareous earth—in many places, not a particle.  The
 sand, gravel, and pebbles, are altogether silecious.
  Yet have the eggs of fowls in that tract of country as firm shells, as they
 in regions where every thing is calcareous.                             *■
  Those persons who allege that the feathered race swallow gravel to aid in
 the formation  of egg-shells, are lamentably  ignorant  of the science of orni-
 thology.  We seriously advise them to inform themselves better.
  In manufacture of a further argument in  support of their hypothesis on
 this topic, chemists tell us, that  in the  milk of females soon after parturition,
 there exists a  greater abundance of phosphate or carbonate of lime, than at
a later period.  This,  say they,  is a most  wise and beneficent arrangement
 of nature,  in as much as the bones of  new-born  infants, being exceedingly
 soft, require, for their nourishment and hardening, a superabundant amount
 of calcareous matter. 
380
PRACTICE OF PHYSIC.
comprehended under it depend, for the most part, upon
a depraved state of the whole of  the fluids, producing
tumours, eruptions, or other preternatural affections of
the skin.   Although  it  be  extremely difficult to find a
general character of the order that will apply  to each
of the genera and species, I shall treat of the principal
genera which have been commonly comprehended  un-
der this order, and which I have enumerated in  my No-
sology.
CHAPTER I.
       OF SCROPHULA, OR THE  KING'S  EVIL.


 1739. THE character of this disease I have attempted
in  my Nosology: but it will be  more properly taken
from the whole of its history, now to be delivered.


  Here again we find ample evidence of an entire want of knowledge and
reflection.
  Many infants are surrendered, immediately after birth,  into the hands of
nurses whose milk is six, eight, or even ten months old.  Yet they remain
in health, grow with rapidity, and acquire, in the usual time, the usual firm-
ness of bone and muscle.  This, however, could not be the case, were milk
superabounding in calcareous earth requisite for their nourishment.
  Our antagonists should, moreover, recollect, that all young animals, whose
bones are soft, do not feed on milk. None feed thus, except the young of
the mammiferous family.
  The eaglet, the young vulture, the crow, and indeed the young of the
whole feathered tribe, live on the same kind of food with their parents.
Their daily fare contains no superabundance of calcareous matter. Yet ra-
chitis is a disease which does not trouble them. A rickety eaglet has never,
perhaps, been seen, by the most experienced  ornithologists.  Nor has a
rickety bird of any other description. Their bones grow hard on the com-
mon food of their kind.
  In fact the whole doctrine of the necessity of feeding old fowls with lime
to form egg-shells, and young animals with the same article, to form bones,
is futile and ridiculous. 
PRACTICE  OF PHYSIC.
381
    1740. It  is  commonly, and very generally, a here-
 ditary disease;  and although  it sometimes may, yet it
 rarely appears, but in children whose parents had at
 some period of their lives been affected with it.  Whether
 it may not fail to appear in the children of scrophulous
 parents, and discover itself afterwards in their offspring
 in  the succeeding generation,  I cannot  certainly deter-
 mine; but believe  that this has frequently happened.
 It  appears  to me  to  be derived more  commonly from
 fathers  than from mothers; but whether this  happens
 from there  being more scrophulous men than scrophu-
 lous women married,  I am not certain.
   With respect to  the influence of parents in produc-
 ing this  disease, it  deserves to be remarked, that  in a
 family of many children,  when one of  the pareuts has
 been affected with scrophula, and the other not; as it is
 usual for some of the children  to  be in constitution
 pretty exactly like the one parent, and  others of them
 like the other; it commonly happens, that those children
 who  most resemble the scrophulous parent become af-
 fected with scrophula, while those resembling the other
 parent entirely  escape.*
   1741. The scrophula generally appears  at a particu-
 lar period of life. It seldom appears in the  first, or even
 in the second year of a child's life, and most commonly
 it occurs from the second, or,  as  some allege, and per-
 haps more properly, from  the third to the seventh year.
 Frequently, however,  it discovers itself at a later period;
 and there are instances of its first appearance, at every
 period till the age  of puberty; after which,  however,
 the first  appearance of it is very rare.
  * What is here said of scrophula, is true of all hereditary complaints.
They are communicated, with most certainty, to those children that most
resemble the diseased parent.  Scrophula, although hereditary-, is not con-
tagious. Dr. Kortum made various efforts to communicate it, by inocula
tion, without success. 
382
PRACTICE OF  PHYSIC.
   1742. When it does not occur very early, we can ge-
nerally  distinguish the habit of body peculiarly disposed
to it.  It most commonly affects children of soft and
flaccid habits, of fair hair and blue eyes; or at least af-
fects those much more frequently than those  of an op-
posite complexion.  It affects especially children  of  t
smooth  skins and rosy cheeks; and such children have
frequently a tumid upper lip, with a chop in the middle
of it;  and this tumour is often considerable, and extend-
ed to the columna nasi and lower part of the nostrils.
The disease is sometimes joined with, or follows rickets;
and although it frequently appears in children who have
not had rickets in  any great degree, yet it often attacks
those who by  a protuberant forehead, by tumid joints,
and a tumid abdomen, show that they had some rachi- -
tic disposition.  In parents  who, without having had
the disease themselves, seem to produce  scrophulous'
children, we can commonly perceive much of the same
habit and constitution that has just now been described.
  Some authors have supposed that the small-pox has
a tendency to  produce  this disease; and Mr. De Haen
asserts its following the inoculated, more frequently than
the natural, small-pox.  This last position, however, we
can confidently affirm to be a  mistake; although it must
be allowed, that in fact the scrophula does often come
on immediately after the small-pox.  It is, however, dif-
ficult to find any connection between the two diseases.
According  to  my observation, the  accident only hap-
pens in  children who  have pretty manifestly  the scro-
phulous disposition; and I have had several instances of
the natural small-pox coming upon children affected at
the same time with scrophula, not only without this dis-.
ease being  any ways aggravated by the small-pox, but
even of its being for some time after much relieved.
  1743.  The  scrophula generally shows itself first  at 
PRACTICE OF PHYSIC.           383
  a particular season of the year; and at some time be-
  tween the winter and summer solstice; but commonly
  long before the latter period.  It is to be observed fur-
  ther, that the course of the disease is usually connected
  with the course of the seasons.  Whilst the tumours and
'  ulcerations peculiar to this disease, appear first  in the
  spring, the ulcers are frequently healed up in the course
  of the succeeding summer, and do not break out again
  till the ensuing spring, to follow again with the season
  the same course as before.
    1744.  Frequently the first appearance of the disease
  is the tumid and chopped lip above mentioned.   Upon
  other occasions the first appearance is that of small sphe-
  rical or oval tumours, moveable under the skin.   They
  are soft,  but with some elasticity.   They  are without
  pain; and without any change in the colour of the skin.
  In this state they often continue for a long time; even
  for a  year or two, and sometimes longer.   Most com-
  monly they first appear upon the sides of the neck be-
  low the  ears; but sometimes also under the chin.   In
 ■either case, they are supposed to affect in these places
  the conglobate or lymphatic glands only; and not at all
  the salivary glands, till  the disease is very greatly ad-
  vanced.  The disease frequently affects, and even at first
  appears in, other parts of the body.   In particular, it
  affects the joints of the elbows and ankles, or those of
  the fingers and toes.   The appearances about the joints
  are not commonly, as elsewhere, small moveable swell-
  ings;  but a tumour almost uniformly surrounding the
  joint, and interrupting its motion.
    1745. These tumours,  as I have said, remain for some
  time little changed; and, from the time they first ap-
  peared in the spring, they often  continue  in this way
  till the return of the same season in the next, or per-
  haps the second year after.   About that time, however. 
384
PRACTICE OF PHYSIC.
 or perhaps  in the course of the season in which they
 first appear, the tumour becomes larger and more fixed;
 the skin upon it acquires a purple, seldom a clear red-
 ness: but growing redder by degrees, the tumour becomes
 softer, and allows the fluctuation of a liquid within to be
 perceived.  All this process, however, takes place with
 very little pain attending it.   At  length some  part of
 the skin becomes paler; and by one or more small aper-
 tures a liquid is poured out.
   1746. The matter poured out has at first the appear-
 ance of pus, but it is usually of a thinner kind than that
 from  phlegmonic  abscesses, and the matter as  it con-
 tinues to be discharged, becomes  daily less purulent,
 and appears more and more a viscid serum, intermixed
 with small pieces of a white  substance resembling the
 curd of milk.   By degrees the tumour almost entirely
 subsides, while the ulcer opens more, and spreads broad-
 er: unequally, however, in different directions, and there-
 fore, is without any regular circumscription. The edges
 of the ulcer are  commonly flat and smooth, both on
 their  outside and their inner  edge, which seldom puts
 on a callous appearance.  The ulcers, however, do not
 generally  spread  much, or become deeper; but at the
 same  time their edges do not  advance, or put on any
 appearance of forming a cicatrix.
   1747. In this condition the ulcers often  continue for
 a long time;  while new tumours, with ulcers succeeding
 them  in the manner above  described, make their ap-
 pearance in  different parts  of the body.   Of  the first
 ulcers, however, some heal up, while other tumours and
 ulcers  appear in their vicinity, or in other parts  of the
body: and in this manner the disease proceeds, some of
the ulcers healing up, at least to a certain degree, in the
course of the summer, and breaking out  in the suc-
ceeding spring:  or it continues, by new tumours and 
PRACTICE OF PHYSIC.          $35
ulcers succeeding them, in  the  spring season,  making
their appearance successively for several years.
   1748.  In this way the disease goes on  for several
years;  but  very  commonly in four or five years it is
spontaneously  cured, the former ulcers being  healed
up, and no  new tumours appearing: and thus at length
the disease  ceases entirely,  leaving only some indelible
eschars, pale and smooth, but in some parts shrivelled;
or, where it had occupied the joints, leaving the motion
of these impaired, or entirely destroyed.
   1749.  Such is the  most favourable course  of this
disease; and with us, it is more  frequently such, than
otherwise: but it is often a more violent, and sometimes
a fatal  malady.   In these cases, more parts of the body
are at  the same time affected; the ulcers also seeming
to be imbued with a peculiarly sharp acrimony, and
therefore becoming more deep,  eroding, spreading, as
well as seldomer healing up.  In such cases, the eyes
are often particularly affected.   The edges of the eye-
lids are affected with tumour and superficial ulcerations;
and  these commonly excite obstinate inflammation in
the adnata,  which frequently produces an opacity of
the cornea.
   When  the scrophula especially affects the joints, it
sometimes produces there considerable tumours; in the
abscesses following which, the ligaments and cartilages
are eroded, and the adjoining bones are affected with a
caries of a peculiar kind.  In these cases, also, of more
violent scrophula, while every year produces a number
of new tumours and ulcers, their acrimony seems at
length  to taint the whole fluids  of the body, occasion-
ing various disorders; and particularly a hectic fever,
wjth all its symptoms, which at length  proves fatal, with
sometimes the symptoms of a phthisis pulmonalis.
   1750. The bodies of persons who have died of  this
   vol. u.               3 D
\ 
386           PRACTICE OF  PHYSIC.
disease show many of the viscera in a very morbid state;
and particularly most of the glands  of the mesentery
very  much  tumefied, and frequently  in an  ulcerated
state.  Commonly also a great number of tubercles or
cysts, containing matter of various kinds, appear in the
lungs.
   1751.  Such is the history of the disease;  and from
thence it may appear, that the nature of it is not easily
to be ascertained.   It seems to be a peculiar affection
of  the lymphatic system;  and  this in some measure ac-
counts for its connexion with a particular period of life.
Probably, however, there  is a peculiar acrimony of the
fluids that is the proximate cause of  the  disease;  al-
though of what nature this is, has not yet  been disco-
vered.  It may perhaps be generally diffused in the sys-
tem, and exhaled into the several cavities and cellular
texture of the body; and therefore, being taken up by
the  absorbents, may discover itself especially  in the
lymphatic system.   This, however, will hardly account
for its being more confined to that system, than happens
in the case of many  other acrimonies  which may  be
supposed to be as  generally diffused.   In short, its ap-
pearance in particular constitutions, end at a particular
period of life, and even  its being a hereditary disease,
which so frequently depends upon the  transmission of
a peculiar constitution, are all of them circumstances
which lead  me to conclude upon  the whole,  that this
disease depends upon a peculiar constitution of tfie lynx*
phatic system.
   1152.  It seems proper to ooserve here, that the scro-
phula  does not appear  to be a contagious  disease; at
least I have  known many instances of  sound children
having had  frequent  and  close intercourse with scro-
phulous  children,  without being infected with the dis-
ease.   This certainly shows, that in this disease the pe- 
PRACTICE OF PHYSIC.
387
culiar acrimony of it is not exhaled from the surface of
the body, but that it depends especially upon a peculiar
constitution of the system.
   1753.  Several authors have  supposed the scrophula
to have been derived  from the venereal disease; but
upon  no just grounds that I can  perceive.   In very
many instances,  there can hardly be any suspicion of
the parents producing this disease having been  imbued
with syphilis, or with  any syphilitic  taint; and I have
known several examples of parents conveying  syphilis
to their offspring, in whom, however, no scrophulous
symptoms at  any time afterwards appeared.  Further,
the symptoms of the  two diseases are very different;
and the difference of their natures  appears particularly
from hence, that while mercury commonly and readily
cures the syphilis, it does no service  in scrophula, and
very often rather aggravates the disease.
   1754. For the cure  of scrophula, we  have not yet
learned any practice that is certainly  or even generally
successful.
   The remedy which  seems to be the most successful,
and which our practitioners especially trust to and em-
ploy, is the use of mineral waters; and indeed the wash-
ing out, by means of these, the lymphatic system, would
seem to be a  measure promising success: but in very
many instances of the use of waters,  I have not been
well satisfied that they had shortened the duration of
the disease  more than had often happened when no
such remedy  had been employed.
   1755.  With  regard to the  chojee of the  mineral
waters most fit for the purpose, I cannot with any con-
fidence give an opinion.  Almost all kinds of  mineral
waters, whether chalybeate, sulphureous or saline, have
been employed for the  cure of scrophula, and seemingly
with equal  success  and  reputation: a  circumstance 
388           PRACTICE OF PHYSIC.
tvhich leads me to think, that, if they are ever success-   -
ful, it is the elementary water that is the chief part of
the remedy.
   Of late, sea water has been especially recommended
and employed; but  after numerous trials, I cannot yet
discover its superior efficacy.
   1756.  The other remedies  proposed by  practical
writers are very numerous; but, upon that very account,
I apprehend  they  are little to be  trusted: and, as  I
cannot perceive any just  reason for expecting success
from them, I have very seldom employed them.
   Of late, the Peruvian bark has been much  recom-
mended: and as in scrophulous  persons there are gene-
rally some marks of laxity and flaccidity, this tonic may
possibly be of service; but in a great variety of trials,   <!
I have never seen it produce any immediate  cure of the   j
disease.                                              '
   In several instances, the leaves of coltsfoot have ap-   1
peared to me to be successful.   I  have used  it fre-
quently in strong decoction, and  even  then  with ad-
vantage; but have found more benefit from the expressed
juice, when the plant could be had in somewhat of a
succulent state, soon after its first appearance in the   ,
spring.                                               ,
   1757. I have also frequently employed the hemlock;  j
and have sometimes found  it useful in discussing obsti-
nate swellings: but in this, it has also  often disappointed
me; and I have not  at any time observed that it disposed "%
scrophulous ulcers to heal.                             i
   I cannot conclude the subject of internal medicines
without remarking,  that I have never found,  either mer-   I
cury or antimony, in any shape, of use in this disease;
and when any degree of a feverish state had come on,
the use of mercury  proved manifestly hurtful.
   1758. In the progress of scrophula, several external   j 
PRACTICE OF PHYSIC.            389
medicines are requisite.  Several applications have been
used for discussing the tumours upon their first coming
on; but hitherto my own practice, in these respects, has
been attended with very little success.   The solution of
saccharum saturni has seemed to  be useful; but it has
more frequently failed: and I have had no better  suc-
cess with the spiritus Mindereri.  Fomentations of every
kind have been frequently found to do harm; and poul-
tices seem only to hurry on a suppuration.   I am doubt-
ful if this  last be ever practised  with  advantage; for
scrophulous  tumours  sometimes  spontaneously disap-
pear, but  never after any degree  of inflammation has
come  upon them; and therefore poultices,  which com-
monly  induce inflammation, prevent that discussion of
tumours, which might otherwise have happened.
   Even when scrophulous tumours  have advanced to-
wards suppuration, I am  unwilling to hasten the spon-
taneous opening, or to make it by the lancet:  because
I apprehend the scrophulous matter is liable to be ren-
dered more acrid by communication  with  the  air,  and
to become  more eroding and spreading  than when in its
inclosed state.*

  * We have lately had great pleasure, in witnessing a cure, by the nitric
aoid, of a most  painful and threatening scrophulous ulcer, on the face of a
lady, in this city, under the direction of Dr. Chapman.
  At a consultation of physicians, held on the subject, the ulcer was pro-
nounced to be, if not incurable, at least, of a nature, not to be touched, un-
less by the most simple and lenient dressings—such as could make no im-
pression on the sore. But the excruciating pain, which the patient expe-
rienced, rendered it necessary to do something for her relief.
  Under these circumstances, Dr. Chapman commenced the use of the acid,
administering from two to three drachms of it daily, and frequently moisten-
ing the surface of the ulcer, with the same article, in a diluted state.
  In a-short time the change produced was truly surprising. Not more than
three days elapsed, when the  ulcer ceased to be painful; and assumed a
healthy aspect.  Instead of retorted edges, and a fungous centre, the skin,
around the sore, became soft; and  fine granulations appeared, in every part
of it.  l:i a few weeks, the cure was complete; and there seems tr> be no dis- 
390            PRACTICE  OF PHYSIC.
    1759. The management of scrophulous  ulcers has,
 so far as I know, been as little successful as that of the
 tumours.   Escharotic preparations,  of either mercury
 or copper, have  been sometimes useful in bringing on
 a proper suppuration, and thereby disposing the ulcer
 to heal; but they have seldom succeeded, and more com-
 monly they have caused the ulcer to spread more.   The
 escharotic from which I have received most benefit  is
 burnt alum,  and a  portion  of that, mixed with  a  mild
 ointment,  has been as useful an application as any  I
 have tried.   The application, however, that I have found
 most serviceable and  very universally admissible, is that
 of linen cloths wetted with cold water,  and frequently


position in the ulcer to  recur.  The nitric acid was the only remedy em-
ployed in the treatment.
  Scrophula appears to be, in no small degree, assimilated to rickets. Like
that disease, it arises, no doubt, from a want of vigour, accompanied by a pe-
culiarly vitiated action, in the organs of digestion, assimilation and nutrition.
The conglobate glands, which are concerned in nutrition, are particularly
affected in it.
  In common with rickets, it is much under the influence of regimen.  The
liberal use of a wholesome and nourishing diet, sufficient exercise, in the open
air, and a continued course of tonic remedies, constitute all that  physicians
can recommend for it. To give high health and vigour to the system, is the
best means of  counteracting,  or removing, the scrophulous diathesis.  The
mode of effecting this, has been so often mentioned, and must be, therefore,
so perfectly familiar to the reader, that its repetition, here, would be alto-
gether superfluous.
  A method, reported sometimes to succeed, in the discussion of threaten-
ing scrophulous tumours, and which is not, we believe, very generally known,
is, to rub them, once or twice a day, with an ointment, consisting of sweet
oil, or fresh lard, holding in mixture, a quantity of tartarized antimony. The
use of this preparation, is followed, in a few days, by a crop of peculiar pus-
tules, which appears to be instrumental in preventing the suppuration of
the tumours.   Scrophulous tumours  are sometimes discussed, by long con-
tinued blistering.
  When completely formed, rickets and scrophula—to which,  confirmed
syphilis may, perhaps, be subjoined—appear to be the most universal of dis-
eases.   In addition to the soft parts, the bones themselves are not exempt
from their ravages. W'hen under their influence, it may be truly said, of
man, that" there is no soundness in him."  Hence the extreme difficulty of
eradicating them from the system. 
             PRACTICE  OF PHYSIC.          391

changed when they are becoming dry, it being inconve-
nient to let them be glued to the sore.  They are there-
fore to be changed frequently during the day; and a cloth
spread with a mild ointment or plaster may be applied
for the night.  In this practice  I have sometimes em-
ployed sea water; but generally it proved too irritating;
and neither that nor any mineral water has appeared to
be of more service than common water.
  1760. To  conclude what  I have to offer  upon  the
cure of scrophula, I  must observe, that cold bathing
seems to have been of more  benefit than any other re-
medy that I have had occasion to see  employed.
                    CHAPTER II.

   OF SYPHILIS, OR THE VENEREAL DISEASE.

 1761. AFTER practitioners  have had so much ex-
 perience in treating this disease,  and  after so many
 books have been published  upon the subject,  it does
 not seem necessary, or even proper, for me to  attempt
 any full  treatise concerning it; and I shall therefore
 confine myself to such general remarks, as may serve
 to illustrate some parts of the pathology or of the prac-
 tice.
   1762.  It  is sufficiently probable, that anciently, in
 certain parts of Asia, where the leprosy prevailed, and
 in Europe after that disease had' been introduced  into
 it, a disease  of the genitals, resembling that which now
 commonly arises from syphilis,  had frequently  appear-
 ed: but it is equally probable,  that a new disease,  and
 what we at present term Syphilis, was first brought into
Europe about the end of the fifteenth century; and that
the distemper now  so  frequently occurring, has been 
39^
PRACTICE OF PHYSIC.
 very  entirely  derived  from that  which was imported
 from  America  at the period mentioned.*
    1763.  This  disease,  at least  in its principal  circum-
 stances, never  arises in any person but from some com-
 munication with a person already affected  by it.   It is

  • For a very curious and interesting inquiry, into the origin of the vene-
real disease, the reader is referred to an inaugural dissertation, by Dr. Tongue,
published by Thomas and William Bradford, and contained in the volume of
" Select Theses," for the year 1806.
  The number of valuable treatises, on the Venereal disease, which are now
extant;  and, one or more of which, it is the duty of every physician in our
country to possess, renders it superfluous for us to dwell on the  subject, in
this place.
  We have another reason, for not descending to particulars, in the present
instance.
  The discrimination and treatment of plain and simple cases of the disease,
are sufficiently obvious, from what our author has, himself given us ; and it
would be impossible for us, within the compass of a reasonable note, to con-
dense what would be satisfactory, in relation  to difficult ones.
  For ample information, on this subject, the  reader is referred to Astruc—
Swediaur—Hunter—Foote, and Bell.
  As a matter of abstract belief, we feel persuaded that perpetuity does not
attach to any thing earthly.  Change is a fundamental law of creation. Like
human life, every thing begins, progresses, and terminates.
  These remarks appear to us applicable to the venereal disease. The com-
plaint, at present, is certainly marked with much less violence, obstinacy,
and malignity, than it has been, even within our own remembrance.
  The same  thing is true in the countries of  Europe.  In the southern sec-
tion of that continent, especially in Spain, where its ravages were once pro-
verbially formidable, the venereal  disease is now entirely divested of its ter-
rprs.  It is said to be treated without mercury, and cured without difficulty
or danger.
  Something like this, although not to the  same extent, is true in Englnnd
and France.  Compared to itself in  former times, the disease is  there both
mild and tractable.   By many practitioners of great respectability, mercury
is no longer considered essential to its cure.
  In the large cities of our own country, the complaint is no  longer the
scourge it is known  to have been in former years.  In the treatment of it,
mercury, although not yet abandoned, is administered only in certain cases,
and in very moderate quantities.
  Upon the whole, there seems reason to believe, that, like other  complaints
which have risen, prevailed for a time, and then disappeared, the venereal
disease is certainly on the decline; and that the time is not, perhaps, far dis-
tant, when it shall have ceased to  be the scourge of illicit pleasures.
  That such has been the career of sundry complaints, the  records of me-
dicine abundantly testify. 
PRACTICE OF PHYSIC.           393
 most commonly contracted  in consequence of coition
 .with an infected person; but in what manner the infec-
 tion is communicated,  is not clearly explained.   I am
 persuaded, that in coition, it is communicated without
 there being any open ulcer either in the person commu-
 nicating, or in the person receiving  the infection; but
 in all other cases, I believe it is never communicated in
 any other way than by a contact of ulcer, either in the
 person communicating, or in the  person receiving the
 infection.
   1764. As it thus arises from the contact of particu-
 lar parts, so it always appears first  in the neighbour-
 hood of the parts to which the infecting matter had been
 immediately applied; and therefore, as most commonly
 contracted by  coition,  it generally appears first in the
 genitals.
   1765.  After its first appearance in particular parts,
 more especially when  these are the genitals of either
 sex, its effects for  some time seem to be confined to
 these parts; and, indeed, in many cases, never extends
 further.  In other cases, however, the infecting matter
 passes from the parts first affected, and from the geni-
 tals, therefore, into the blood-vessels; and being there
 diffused, produces disorders in many other parts of the
 body.
   From  this  view  of  the   circumstances, physicians
 have very properly distinguished  the  different states  of
 the disease, according as they are local or are more uni-
 versal.  To the former they have adapted appellations
suited to the manner in which the disease appears: and
to the other, the general affection, they have almost to-
tally confined the appellations of Syphilis, Lues Vene-
rea, or Pox. In the remarks I am  now to offer I shall
begin with considering the local affection.
  VOL. ii.              3 E 
394           PRACTICE OF  PHYSIC.

   1766. This local affection appears chiefly in the form
of gonorrhoea or chancre.
   The phenomena of gonorrhoea, either upon  its first
coming on or in its after progress, or the symptoms of
ardor urinae, chordee, or others attending it, it is not
necessary for  me  to  describe.  I shall only here ob-
serve, that the chief circumstances to be taken notice of,
is the inflamed state of the urethra, which I  take to be
inseparable from the disease.
   1767.  In  these well known circumstances, the go-
norrhoea continues for a time longer or shorter, accord-
ing to the constitution of the patient; it usually remain-
ing longest in the most vigorous and robust,  or accord-
ing to the  patient's regimen, and the  care taken to
relieve or cure the disease.  In many cases, if by a pro-
per regimen the irritation of the inflamed state is care-
fully avoided, the gonorrhoea spontaneously ceases, the
symptoms of inflammation gradually abating, the mat-
ter discharged becoming  of a thicker and more viscid
consistence, as well as of a whiter colour;  till at length,
the flow  of it ceases altogether; and whether it be thus
cured spontaneously, or by art, the disease often ei.lsts
without communicating any infection to the other parts
of the body.
   1768.  In  other cases, however, the disease  having
been neglected, or by an improper regimen aggravated,
it continues with all its symptoms for a long time;  and
produces various other  disorders,  in the genital parts,  j
which, as commonly taken notice  of by authors, need
not be described here.   I shall only observe, that the
inflammation of the urethra,'which at first seems to be  |
seated chiefly,  or only,  in its anterior parts, is in such  j
neglected and  aggravated cases spread  upwards along
the urethra, even to the neck of the bladder.  In these
circumstances, a more considerable inflammation is oc- 
               PRACTICE OF PHYSIC.           395

  casioned in certain  parts of the urethra; and conse-
  quently, suppuration and ulcer are produced, by which
  the venereal poison is sometimes communicated to the
  system, and gives rise to a general syphilis.
    1769. It was some time ago a pretty general suppo-
  sition, that the gonorrhoea depended always upon ulcers
  of the urethra, producing a discharge of purulent mat-
  ter;  and such ulcers do indeed sometimes occur in the
  manner that has been just now  mentioned.   We are
  now assured, however,  from many  dissections of per-
  sons who had died when labouring under a gonorrhoea,
  that the disease  may exist,  and  from many considera-
  tions it is probable that it commonly does exist, without
  any ulceration of the  urethra; so  that the discharge
  which appears, is entirely that of a vitiated mucus from
  the mucous follicles of the urethra.
    1770. Although most of the symptoms of gonorrhoea
  should be removed, yet it often happens that a mucous
  fluid continues to  be discharged  from the urethra for
  a long time after, and sometimes  for a great part of a
  person's life.  This  discharge  is what is commonly
  called a Gleet.
   With respect to this, it is  proper  to observe,  that in
  some cases,  when it  is certain the  matter discharged
  contains no venereal poison,  the matter may, and often
  does put on that  puriform appearance, and that  yellow
  and greenish colour, which appears in the discharge at
 the beginning and during the course of a virulent go-
 norrhoea.  These appearances in  the matter of a gleet
 which before had been of a less  coloured kind, have
 frequently given occasion to suppose that a fresh'infec-
 tion had been received: but I am  certain that such ap-
pearances may be brought on by, perhaps, various other
 causes;  and particularly, by  intemperance in venery
 and drinking concurring together.   I believe, indeed. 
396
PRACTICE OF  PHYSIC.
that this seldom happens to any but those who had be*
fore  frequently laboured  under a virulent gonorrhoea.
and have more or less of  gleet remaining with them:
but I  must also observe, that in persons who at no pe-
riod of their life had ever laboured under a virulent go-
norrhoea, or any other symptom of syphilitic affection,
1 have met with instances of discharges from  the ure-
thra resembling those of a virulent gonorrhoea.
  The purpose of these observations is, to suggest to
practitioners what I have not found them always aware
of, that in persons labouring under a gleet, such a re-
turn of the appearances of a  virulent gonorrhoea may
happen without any new infection having been received,
and consequently not requiring the treatment  which a
new infection  might  perhaps demand.   When, in the
cure of gonorrhoea, it was the practice to employ pur-
gatives very frequently, and  sometimes those of the
drastic kind, I have known the gleet, or spurious gonor-
rhoea, by such a practice much increased and long con-
tinued, and  the  patient's constitution very much hurt.
Nay, in order more certainly  further to prevent  mis-
takes, it is to be observed, that the spurious gonorrhoea
is sometimes attended with heat of urine, and some de-
gree of inflammation;  but these symptoms are seldom
considerable, and merely by the assistance of a cool re-
gimen, commonly disappear in a few  days.
   1771. With respect  k> the cure of a virulent gonor-
rhoea, I have only to  remark, that if it be true, as I have
mentioned above, that the disease will  often,  under a
proper legimen, be spontaneously cured;  and that the
whole of the virulent matter may be thus entirely dis-
charged without the assistance of art;  it would seem
that there is nothing required of practitioners, but to
moderate and remove that inflammation which continues
the disease, and occasions all the troublesome symptoms 
PRACTICE OF PHYSIC.           397
   timt ever attend it. The sole business therefore of our
   art in the cure of gonorrhoea, is to take off the inflam-
   mation accompanying  it: and this  f think may  com-
   monly be done,  by avoiding  exercise, by using a low
   and cool diet, by abstaining entirely from fermented and
   spirituous liquors, and by taking plentifully of mild dilu-
   ent drinks.
     1772. The heat of urine, which is so troublesome in
   this disease,  as it arises from the increased sensibility of
   the urethra in its inflamed state; so, on the other hand,
   the irritation of  the urine has the effect of increasing
   the inflammation, and is therefore to be removed as soon
   as possible.   This can be done most effectually by tak-
   ing in a large  quantity of mild  watery liquors.  De-
   mulcents may be employed; but unless they be accom-
   panied with a large quantity of water, they will  have lit-
   tle effect.  Nitre  has been commonly employed as a
   supposed refrigerant: but, from much observation, I am
   convinced, that in a small quantity it is useless, and in
   a large quantity certainly hurtful; and,  for this reason,
   that every saline matter passing with the urine  general-
   ly gives some irritation to the urethra.   To prevent the
   irritation of the urethra arising from its increased sensi-
   bility, the injection of mucilage or of mild oil into it has
   been practised,  but I have seldom found this of much
   service.
    1773.  In gonorrhoea, as costiveness may be  hurtful,
   both by an irritation of the  system in general, and of
  the  urethra in particular, as this is occasioned always by
  the  voiding of hardened faeces;  so costiveness  is to be
  carefully avoided  or removed; and the frequent use  of
.  large glysters of water and oil, I have found of remarka-
  ble benefit in this disease. If glysters, however, do not
  entirely obviate costiveness, it will be necessary to give
  laxatives by the  mouth:  which,  however, should be of 
398
PRACTICE OF PHYSIC.
 the mildest kind, and should do no more than keep the
 belly regular, and a little loose, without much purging.
   The practice of frequent purging,  which was for-
 merly so much in use, and is not yet entirely  laid aside,
 has always appeared to me to be generally superfluous,
 and often very hurtful.   Even what are supposed  to be
 cooling purgatives,  such as Glauber's salt,  soluble tar-
 tar, and crystals of tartar, in so far as any part of  them
 pass by urine, they in the same manner as we have said
 of  nitre, may be hurtful; and so far  as they produce
 very liquid stools, the matter of which is generally acrid,
 they irritate the rectum, and consequently the urethra.
 This last effect, however, the acrid, and  in  any degree
 drastic, purgatives, more certainly  produce.
   1774. In cases of a gonorrhoea attended with violent
 inflammation, blood-letting  may be of service;  and in
 the  case of persons of a robust and vigorous habit, in
 whom the disease is commonly the most violent, blood-
 letting may be  very properly employed.  As general
 bleedings, however, when there is no phlogistic diathe-
 sis  in the system, have little effect in removing topical
 inflammation; so in gonorrhoea, when the inflammation
 is considerable,  topical bleeding applied to the urethra
 by leeches, is generally more effectual in relieving the
 inflammation.
   1775. When there  is  any phymosis attending a go-
 norrhoea,  emollient  fomentations applied to the whole
 penis are often of service.  In such cases,  it is neces-
 sary, and in all others useful, to keep the penis laid up
 to the belly, when  the patient either walks  about  or is
 sitting.
  1776. Upon occasion of frequent priapism and cbor-
dee, it has been found  useful to apply to the whole of
the penis a poultice of crumb of bread moistened  with
a strong solution of sugar of lead.   I  have, however, 
PRACTICE OF PHYSIC.
393
 been often disappointed in this practice, perhaps by the
 poultice keeping the penis too warm, and thereby excit-
 ing the very symptoms I wished to prevent.   Whether
 lotions of the external urethra with the solution of the
 sugar of lead, might be useful in this case, I have  not
 properly tried.
   1777.  With respect to the  use of injections, so fre-
 quently employed  in gonorrhoea, I  am persuaded, that
 the early use of astringent injections is pernicious; not
 by occasioning a syphilis, as has been commonly ima-
 gined; but by fncreasing and giving occasion to all the
 consequences  of the  inflammation, particularly to the
 very troublesome symptoms of swelled testicles.  When,
 however, the disease has continued  for some time, and
 the inflammatory symptoms  have very much abated, I
 am of opinion, that by injections of moderate astrin-
 gency, or at least of this  gradually  increased, an  end
 may be sooner put to the disease than would otherwise
 have happened;  and that a gleet, so readily occurring,
 may be generally prevented.
   1778.  Besides the use of  astringent  injections, it
 has  been  common enough to employ those  of a mer-
 curial  kind.  With respect to these,  although  I  am
 convinced that the infection producing gonorrhoea, and
 that  producing  chancres and syphilis, are one and the
 same;  yet I apprehend,  that  in gonorrhoea mercury
 cannot be of use by correcting the virulence of the in-
 fection; and therefore that it is not universally necessa-
 ry in this disease.   I am persuaded, however, that mer-
 cury applied to the internal surface of the urethra, may-
 be of use in promoting the more full and free discharge
 of virulent matter from the mucous  glands of it.   Up-
 on this supposition, I have frequently employed mercu-
rial injections, and, as I judge, with advantage,; those
injections often bringing on such a state of the consist- 
400
PRACTICE OF PHYSIC.
 ence and colour of the matter discharged, as we know
 usually  to  precede its spontaneous  ceasing.  I avoid
 these injections, however, in recent cases, or while much
 inflammation is still present;  but when  that inflamma-
 tion has somewhat abated, and the discharge notwith-
 standing still continues in a virulent  form, I employ
 mercurial injections freely.   I employ those only that
 contain  mercury entirely in  a  liquid form, and avoid
 those which may deposit an acrid powder in the urethra.
 That which I have found most useful  is a solution of the
 corrosive sublimate in wrater;  so much diluted as not to
 occasion any violent smarting, but not so much diluted
 as to give no smarting at all.  It is scarce necessary to
 add, that when there is reason to suspect there are ul-
 cerations already formed in the urethra, mercurial injec-  ,
 tions are not only proper, but the only effectual remedy
 that can be employed.                               , ,
    1779. With regard to the cure of gonorrhoea, I havty  \
 only one other remark to offer.   As  most of the symp-
 toms arise from  the irritation  of a stimulus applied, the
 effects of V "s irritation may be often  lessened by di-
 minishing,  e irritability  of the  system; aud it is well
 known,  tlia. the most certain means of accomplishing
 this is by employing opium. For  that  reason, I consider
 the practice  both of applying  opium  directly to the
 urethra,  and of  exhibiting it  by the  mouth, to be ex*
 tremely useful in most cases of gonorrhoea.
   1780.  After thus offering some remarks  with respect
 to gonorrhoea in  general,  I might proceed to consider
particularly  the various symptoms which so frequently-vl
attend  it; but it does not seem necessary for me to at- 1
tempt this after the late publications of Dr. Foart Sim-J
mons, and of Dr. Schwediaur, who  have treated the ^
subject so fully, and with so much discernment and skill. "J
   1781. The other form of the local affection of syphiHH 
PRACTICE OF PHYSIC.
401
lis, is that of chancre. The ordinary appearance of this
I need  not  describe, it having been  already so often
done.   Of the few remarks I have to offer, the first is,
that I believe chancres never appear in any degree with-
out immediately communicating to the blood  more  or
less of the venereal poison: for I have constantly, when-
ever chancres had appeared, found, that unless mercury
was immediately given internally, some symptoms of a
general syphilis did certainly come on afterwards; and
though the internal use of mercury should prevent any
such appearance, it is  still to be presumed that  the
poison had been communicated, because mercury could
act  upon it in  no other manner than as diffused in the
fluids.
  1782. It  has been a question  among practitioners,
upon the  subject of chancres, whether they may be
immediately  healed  up by applications  made to  the
chancres, or if they should be left open for some time
without  any such application? It has been supposed,
that the sudden healing up of chancres might imme-
diately force into the blood a poison which  :ght have
been excluded  by being discharged f{ ^  t£  chancre.
This, however, is a supposition that is  \ij uoubtful;
and, upon the other  hand, I  am certain, that the longer
a chancre is kept open,  the more  poison it perhaps ge>
nerates, and certainly supplies it more copiously to the
blood.  And although the above mentioned supposition
were true, it will  be of  little consequence, if the  inter-
nal use of the mercury, which I judge necessary in every
case of chancre, be immediately employed. I have often
seen very troublesome consequences follow from allow-
ing chancres to remain unhealed;  and the symptoms of
general syphilis have always seemed to  me to be more
considerable and violent in proportion as chancres had
been suffered to remain  longer unhealed.   They should
 vol.. n.                 3f 
402           PRACTICE OF PHYSIC.
always,  therefore, be healed as soon as possible; and
that, by the  only very effectual  means,  the  application
of mercurials to the chancre itself.   Those that are re-
cent, and have not yet formed any considerable ulcer,
may often be healed by the common mercurial ointment:
but the  most powerful means of healing them has  ap-
peared to me, to be the application of red precipitate in
a dry powder.
   1783. When, in consequence of chancres, or of  the
other circumstances above mentioned, by which it may
happen the  venereal poison has been communicated to
the blood, it produces many different symptoms in  dif-
ferent parts  of the body, not necessary to be enumerated
and described here, that  having been already done by
many authors with great  accuracy.
   1784. Whenever any of those symptoms do in  any
degree appear, or as soon  as it is known  that the circum-
stances which gave occasion to the communication of
the venereal poison have taken place, I hold the inter-
nal use of mercury to be  immediately necessary; and I
am well persuaded, the mercury employed without  de-
lay, and in sufficient quantity, will pretty certainly pre-
vent  the symptoms which  would otherwise have soon
appeared, or will remove those that may have already
discovered themselves.  In both cases, it will secure the
person from any  future consequences of syphilis from
that infection.
   1785. This advice for the early and  full  use of mer-
cury, I  take to be  the most important that can be given
with  respect to the venereal disease:  and although I
must admit that  the virulence of the poison may be
greater in one case than  in another, and even that  one
constitution  may be more  favourable than another to the
violence of the disease; yet I am thoroughly convinced
that mosfr of the instances which have  occurred of the 
               PRACTICE OF PHYSIC.         403

violence  and obstinacy of syphilis have been  owing
very entirely to the neglect of the early application of
mercury.
   1786. Whatever other remedies of syphilis may be
known, or may hereafter be found out, I cannot pretend
to determine; but I am well persuaded, that in most
cases mercury properly employed will prove a very cer-
tain  and effectual remedy.  With respect  to  others
that  have been  proposed, I  shall offer this remark only,
that  I have found the decoction of the mezereon contri-
bute to the healing of ulcers which seemed to have re-
sisted the power of mercury.
   1787.  With  regard to the many and various prepa-
rations of mercury, I do not think it necessary to give
any enumeration of them here, as they are commonly
very well known, and have been lately well enumerated
by Dr. Schwediaur.  The choice of them seems to be for
the most part a matter of indifference; as I believe cures'
have been, and  still may be  effected by many different
preparations, if properly administered.  The proper ad-
ministration  seems to  consist, first,  In  the choosing
those preparations which are the least ready to run off
by stool; and therefore the applications externally by
unction are in many cases the most convenient. 2dly, In
employing the unction, or in giving a preparation of
mercury internally, in such quantity  as  may show its
sensible effects in the mouth.  And, 3<%, without car-
rying these effects to a greater length, in the continu-
ing the employment of mercury for several weeks, or
till the symptoms of the disease shall have for some time
entirely disappeared.   I say nothing of the regimen
proper and necessary  for patients during the employ-
ment of mercury, because I presume it to be very well
known.
  1788. Among the other  preparations of mercury, 1 

404            PRACTICE OF PHYSIC.

believe the corrosive sublimate has often been employed
with advantage: but I  believe  also, that  it  requires
being continued for a longer time than  is necessary in
the  employment of other  preparations in the manner
above proposed;  and I  suspect  it has often failed in
making a cure, because employed while persons were
at the same time exposed  to the free air.
   1789.  Upon  these points, and others relative to the
administration of mercury, and the cure of this disease,
I might  offer some particular  remarks: but I believe
they are generally understood; and it is enough for me
to say here, that if practitioners will attend, and patients
will submit, to the  general rules given above, they will
seldom fail of obtaining a  certain and speedy cure of
the  disease.
                         chapter m.

                       OF SCURVY*


  1790.  THIS disease  appears so  frequently, and the
  effects of it are so often fatal in fleets and armies, that

   • Every phenomenon, connected with scurvy, pronounces it to be a gas-
 trie disease.  It commences in the stomach, and thence propagates its mor-
 bid action, throughout the entire system of assimilating organs; to which we
 might add, the organs of nutrition.  Hence the change that ensues in the
 state of the fluids.  The whole apparatus, which prepares them, being dn
 ordered in its action, it cannot be expected that they will remain sound.
 But the fluids neither are, nor can be, the part of the system, that is origi-
 nally assailed.  They are, in all cases, and, essentially, the children of the solids,
 and immediately dependent on them, for their state and condition. As long,
 therefore, as the constitution of the parents continues sound, and their action
 orderly, the constitution of their descendants cannot be impaired: for, it if,
( in living, as in dead matter, a law of nature, that, under similar circumstance!,
 similar causes are, necessarily, productive of similar effects.  From the heal-  \
 thy action of healthy solids, therefore, healthy fluids must always proceed. 
                PRACTICE OF PHYSIC.            405

it has very properly engaged the particular attention of
physicians.   It is indeed surprising that it has no sooner
attracted the especial notice of both statesmen and phy-
sicians, so as to have produced those measures and regu-
lations that might  prevent the havoc  which it so often
occasions.  Within these last fifty years, however, it has
been so much attended to  and  studied,  that we might
suppose every circumstance relating  to it so fully  and
exactly  ascertained,  as  to  render  all  other  labour
upon the subject  superfluous.   This perhaps may be
true; but it appears to me, that there are  still  several
circumstances regarding the disease  not  agreed upon
among physicians,  as well as different opinions formed,
some of which may have had a bad effect upon the prac-
tice;  and this seems to me to be so much the case,  that
I hope I shall be excused in endeavouring here  to state

  Scurvy appears, almost exclusively, on board of ships, at sea, during long
voyages, and in besieged towns and garrisons, on shore.
  Both its prevention and cure, are exceedingly simple, and well understood
—as well, perhaps, as those of any other disease, we are called to en-
counter.
 In addition to  cleanliness, moderate exercise, and  the breathing of, a
free, pure, and dry atmosphere, they consist, principally, in the use of a
diet, composed of a due mixture of fresh animal, and acid, or acescent vege-
table, food.
  In the prevention of scurvy, these measures, when they can be pursued
to a proper  extent, are considered infallible. Nor, unless when the dis-
ease has already advanced, to the last extremity, do  they often fail in effect-
ing a cure.
  A new remedy, for this  disease, said to be now successfully used, in the
British navy, is a solution of nitre in vinegar.  Dr.  Patterson, who ap-
pears to have first employed this preparation, speaks of its efficacy, in the
highest terms.
  We confess ourselves sufficiently sceptical, to apprehend, that his report
is much exaggerated.  The doctor appears to place his chief reliance,  on
the introduction of oxygenous gas into the system; a measure, which we are
persuaded will never cure the scurvy.
  The writers, that may be most advantageously consulted, in this disease
are, Rouppe—Lind—Macbride—Mil man,  and Trotter.  These authors'
should be found in the library of every naval and military surgeon and phy-
sician. 
406
PRACTICE OF PHYSIC.
the facts as they appear to me from the best authori-
ties, and to offer remarks upon opinions which may in-
fluence the practice  in the prevention and  cure of this
disease.
   1791. With respect to the phenomena of the disease,
they have  now been so fully observed, and so accurately
described, that there is no longer any  doubt in discern-
ing the disease when it is present,  or in distinguishing
it  from almost every other ailment.  In particular it
seems  now to be fully determined, that there is one dis-
ease only, entitled to the appellation of Scurvy; that it
is  the same upon the land as upon the sea; that it is the
same in all climates and seasons, as  depending  every
where  upon nearly the same causes; and that it is not
at all diversified, either in its phenomena or its causes,
as had been imagined some time ago.
   1792. the phenomena of scurvy, therefore, are not to
be described here, as it has been so fully and accurately
done elsewhere; and I shall only endeavour to ascer-
tain those  facts with respect to the prevention and cure
of the disease which seem not yet to be exactly agreed
upon.   And first, with respect to the antecedents that
may be considered as the remote causes of the disease.
   1793. The most  remarkable circumstances amongst
the antecedents of this disease, is, that it has most com-
monly  happened  to men living  very much on  salted
meats;  and whether it ever  arise in any other circum-
stances, is extremely doubtful.  These meats are often
in a putrescent  state:  and to the circumstance of the
long continued use of animal food  in a putrescent and
somewhat indigestible state, the disease has been  espe-
cially  attributed.   Whether the circumstances of the
meat's  being salted, has  any effect  in producing the
disease, otherwise than by being rendered  more  indi-
gestible, is a question that remains still in dispute. 
PRACTICE OF PHYSIC.           407
   1794. It seems to me that the salt concurs in produc-
ing the effect:  for there is hardly any instance of  the
disease appearing, unless where salt meats had been em-
ployed, and scarcely an example where the long conti-
nued use of these did not produce it; besides all which,
there are some instances where, by avoiding salt meats,
or by diminishing the proportion of them in diet, while
other circumstances remained much the same, the dis-
ease was prevented from appearing. Further, if it may
be admitted as an argument upon this subject, I shall
hereafter endeavour to show, that the large use of salt
has a tendency to aggravate and increase the proximate
cause of scurvy.
   1795. It must,  however, be allowed, that the prin-
cipal circumstance in causing scurvy, is the living very
much and very long upon animal food, especially when
in a putrescent state; and the clear proof of this is, that
a quantity of fresh vegetable food  will always certainly
prevent  the disease.
   1796. While it has been held, that, in those circum-
stances  in which scurvy is produced, the animal food
employed was  especially hurtful by its being of difficult
digestion, this opinion has been attempted to be confirm-
ed, by observing, that the rest of the food employed in
the same circumstances was also of difficult digestion.
This is  supposed to  be especially the  case of unfer-
mented farinacea, which so commonly makes a part of
the sea diet.  But I apprehend this opinion to be very ill-
founded; for the unfermented  farinacea, which are in
a great proportion the food of infants, of women, and of
the greater  part of mankind, can hardly be supposed to
be food of difficult digestion: and with respect to the
production of scurvy, there are facts which show, that
unfermented farinacea, employed  in large proportion,
have had a considerable effect in preventing the disease. 
408
PRACTICE OF  PHYSIC.
   1797.  It has been  imagined that a certain impreg-
nation of the air upon the sea had an effect in produc-
ing scurvy.   But it is altogether improbable: for the
only impregnations which could be suspected, are those
of inflammable or mephitic air;  and it is  now  well
known, that these impregnations are much less in the
air  upon the sea than in that upon the land; besides,
there are otherwise many proofs of the salubrity of the
sea air. If, therefore, sea air have any effect in produc-
ing scurvy, it must be by its  sensible qualities of cold
or moisture.
   1798.  That cold has an effect in favouring the pro-
duction of scurvy, is manifest from hence, that the dis-
ease is more frequent  and more considerable in cold
than in warm climates and seasons; and that even warm
clothing  has a considerable effect  in preventing it.
   1799.  Moisture may in general have an effect in fa-
vouring the production of scurvy, where that of the at-
mosphere in which men are placed is very considerable:
but the ordinary moisture of the sea air is far from being
such.  Probably it is  never considerable, except in the
case of unusual rains; and even  then  it is perhaps by
the application of moisture to the bodies of men in damp
clothing  only that it has any share in the production of
scurvy. At the same time, I believe, there is no instance
of either cold or moisture producing scurvy, without
the concurrence of the faulty sea  diet.
   1800.  Under those circumstances which produce
scurvy, it commonly seems to occur most readily in the
persons who  are the least exercised; and it is  therefore
probable, that confinement and want of exercise may
have a great share in producing the disease.
   1801.  It appears that weakness, in whatever manner
occasioned, is favourable to the production of scurvy.
It is therefore probable,, that unusual labour and fatigue 
             PRACTICE OF PHYSIC.          409

may often have some share in bringing it on: and upon
the same account it is probable that sadness and despon-
dency may induce a weakness  of the circulation; and
thereby, as has  been remarked, be favourable  to the
production of scurvy.
   1802. It has also been observed, that persons negli-
gent in keeping their skin clean by washing and change
of clothing,  are  more liable  than others to  be affected
with scurvy.
   1803. Several of these causes, now mentioned, con-
curring together, seem to produce scurvy; but there is
no proper evidence that any one of them alone will pro-
duce it, or that all  the other  uniting together will do it,
without the particular  concurrence  of  the sea diet.
Along with this,  however, several of the other circum-
stances  mentioned,  have a great effect in producing it
sooner,  and in a  more considerable degree, than should
otherwise have happened from the diet alone.
   1804. From this view of the remote  causes, it will
readily  appear, that the prevention of the disease may
in  some measure  depend upon the avoiding of those
circumstances, which we have enumerated as contri-
buting to bring  on the disease sooner  than it would
otherwise come  on.  At the same time,  the only effec-
tual means will be, by avoiding the diet of salted meats;
at least by lessening the proportion of these, and using
meat preserved otherwise than by salt: by using in diet
any kind of esculent vegetable matter that can be ob-
tained; and especially by using vegetable matters the
most disposed to acescency, such as malt; and by drink-
ing a large quantity of pure wrater.
   1805. The cure of scurvy seems now to be very well
ascertained, and when the necessary means can be ob-
tained,  the disease is commonly removed very quickly.
The chief means is a food of fresh and succulent vege*-
   m^.-     ----a^
mti'^rfm_____________________________________________________     ________ 
410          PRACTICE OF PHYSIC.

tables, and those almost of any kind that are at all escu-
lent.   Those  most immediately effectual are the acid
fruits,  and, as beins of the same nature, all sort offer-
mented liquor.
   1806. The  plants named alkalescent,  such as  those
of the garlic tribe and  of the tetradynamiae, are also
particularly useful in the cure of this disease; for, not-
withstanding their appellation, they, in the first part of
their fermentation, undergo an acescency, and seem to
contain a great deal of acescent matter.  At the same
time,  they have generally  in their composition an acrid
matter that readily passes by urine, probably by perspi-
ration; and by promoting both  excretions, are useful
in the disease.  It is probable, that some plants of the
coniferous tribe, such as the spruce, fir, and others pos-
sessed of a diuretic power, may likewise be of some
use.
   1807. It is sufficiently probable, that milk of  every
kind,  and particularly its productions, whey and butter-
milk,  may prove a cure of this disease.
   1808. It has been common in this disease to employ
the fossil acids; but there  is reason to  doubt if they be
of any service, and it is  certain  they  are not effectual
remedies. They can hardly be thrown in in such  quan-
tity as to be useful antiseptics; and as they do not seem to
enter into the composition of the animal fluids, and pro-
bably pass off unchanged by the excretions, so they can
do little in changing the state of the fluids.
   1809.  The great debility which constantly attend?
scurvy, has naturally led physicians  to employ tonic and
strengthening medicines, particularly the Peruvian bark;
but the efficacy of it seems  to me very doubtful.   It is
surprising how soon the use of a vegetable diet restores
the strength of scorbutic persons; which seems to show
that the preceding debility had depended upon the state 
PRACTICE OF PHYSIC*           411
ef the fluids; and consequently,  till the sound state of
these can be restored, no tonic remedy can have much
effect: but as the Peruvian bark has little power in chang-
ing the state of the fluids, so it can have  little effect in
scurvy.
  1810. I shall conclude my observations upon the me-
dicines employed in scurvy, with remarking, that the use
of mercury is always manifestly hurtful.
  1811. After having observed that both the preven-
tion  and cure of this disease  are now very well known,
it may seem unnecessary to enter into much discussion
concerning its proximate cause: but as such discussions
can hardly be avoided, and as false opinions may in some
measure corrupt the  practice,  I  shall venture  to sug-
gest  here what appears to me most probable upon the
subject.
  1812. Notwithstanding what has been asserted  by
some eminent persons, I trust  to the concurring testi-
mony of the most part of the authors upon the subject,
that  in scurvy the fluids suffer a considerable change.
  From these authors we learn, that in the blood drawn
from the veins of persons labouring under the  scurvy,
the crassamentum is different both  in colour and con-
sistence from what it is in healthy persons; and that at
the same time the serum is commonly changed both in
colour and  taste.   The excretions also, in  scorbutic
persons, show a change in the state  of the fluids.  The
breath is fetid: the urine is always  high-coloured, and
more acrid  than usual; and if that acrid exudation from
the feet, which Dr. Hulme  takes  notice of, happens
especially in scorbutic persons, it will be a remarkable
proof to the same purpose.   But however this may be,,
there is evidence enough that in scurvy the natural state
of the fluids is considerably changed.   Further, I ap-
prehend it may be confidently presumed from this, that 
4U
PRACTICE OF PHYSIC.
the disease is brought on by a particular nourishment
introduced into the body, and is as certainly cured by
the taking in of a different  diet.   In the latter case, the
diet used  has no other evident operation, than  that of
giving a particular state and condition of the fluids.
   1813.  Presuming, therefore, that the disease depends
upon  a particular  condition of the fluids of the body,
the next subject of inquiry is, What that condition may
be?
   With this  view I must observe, that the animal eco-
nomy has a singular power of changing  acescent ali-
ments, in  such a manner, as to render them much more
disposed to putrefaction; and although, in a living state,
they hardly ever proceed to an actually putrid state; yet
in man, whose aliment is of a mixed  kind, it is pretty vjj
certain, that  if he  were to live  entirely upon  animal  J
food, without a frequent supply of vegetable aliment,
his fluids  would advance further towards putrefaction
than is consistent with health.  This advance towards
putrefaction seems  to consist in the production and evo-
lution of  a saline matter which did not  appear in the
vegetable aliment, and could not be produced or evolved
in it,  but  by carrying on its fermentation to a putrefac-
tive state. That this saline state is constantly in some
measure produced  and evolved by the animal process,
appears from this, that certain excretions of saline mat-
ter are constantly made from the human body, and are
therefore presumed necessary to  its health.
   From all this, it  may be readily understood, how the
continual use of animal food, especially when already
in a putrescent state, without a  mixture of vegetable,
may have the effect of carrying the animal process too
far, and particularly of producing and evolving a larger
proportion of saline matter.  That such a preternatural
quantity of saline matter does exist in the blood of scor- 
PRACTICE OF PHYSIC.           413
butic persons, appears from the state of the fluids above
mentioned.   It will be a confirmation of all this to ob-
serve, that every interruption of perspiration, that is, the
retention of saline matter, contributes to the production
of scurvy;  and this interruption is especially owing to
the application of cold, or to whatever else  weakens the
force of the circulation; such as the neglect or want of
exercise, fatigue, or despondency of the mind.   It de-
serves indeed to be remarked here,  that one of the first
effects of the scurvy once induced, is very  soon to occa-
sion a great debility of the system,  which occasions of
course a more rapid progress of the disease.   How the
state of the fluids may induce such a debility is not well
understood; but that it does depend upon such a state of
the fluids, is rendered sufficiently presumable from what
has been said above with regard to both the causes and
the cure of scurvy.
   1814.  It is possible that this  debility may have a great
share in producing several of the phenomena  of scurvy;
but a preternaturally saline, and consequently dissolved,
state of the blood, will account for them with more pro-
bability; and I do not think it necessary to persons who
are at all accustomed to reason upon  the  animal eco-
nomy, to explain this matter more fully.   I  have only
to add, that  if my opinion in supposing the proximate
cause of scurvy to be a preternaturally saline state of the
blood, be at all founded, it  will be sufficiently obvious,
that the throwing into the body along with the aliment
an unusual quantity of salt, may have a great share in
producing the disease.   Even supposing  such salt to
suffer no change in the animal body,  the effect of it may
be considerable; and this  will be rendered  still more
probable, if it may be presumed, that all  neutral salts,
consisting of a fixed alkali, are changed in the animal
Hedy into an ammoniacal salt; which I apprehend to be 
414           PRACTICE OF  PHYSIC.
that especially prevailing in scurvy.  If I be at all right
in concluding, that meats, from being salted, contribute
to the production of scurvy, it will readily appear, how
dangerous it may be to admit the conclusion  from ano-
ther theory, that they are perfectly innocent.
   1815.  Having thus endeavoured to  explain what re-
lates to the cure of scurvy  in general, I judge it proper
to leave to other authors, what relates to the manage-
ment  of those symptoms  which  require a  particular
treatment.
                    CHAPTER IV.

                  OF JAUNDICE.

1816.  I HAVE here passed over several  of the titles
in my nosology,  because they are diseases not of this
island.  In these, therefore, I have no experience; and
without that, the compiling from other writers is always
extremely fallacious.   For these reasons I omit them;
and  shall  now only offer some remarks upon the sub-
ject of jaundice, the last in order that I can possibly in-
troduce into my  course of lectures.
   1817. The jaundice consists  in a yellow colour of
the skin over the whole body, and particularly of the
adnata  of  the eyes.  This  yellow colour may occur
from different causes; but in the jaundice, hereafter to
be more exactly characterized, I judge it to  depend
upon a quantity  of bile present  in the mass of blood;
and which, thrown out upon the surface, gives  its own
proper colour to the skin and eyes.
   1818. That the disease depends upon this we know
particularly and certainly from the causes by which it is' 
PRACTICE OF PHYSIC.
415
produced.   In order to  explain these, I must observe,
that bile does not exist in its proper form in the mass of
blood, and cannot appear in this form till it has passed
the secretory organ  of the liver.   The bile, therefore,
cannot appear in the mass of blood,  or upon  the  sur-
face of the body, that is, produce jaundice from any in-
terruption of its secretion; and accordingly, if jaundice
does appear, it must be in consequence of the bile, after
it had been secerned, being again taken into the blood-
vessels.
   This may happen in  two ways; either by an inter-
ruption of its excretion, that is, of its passage into the
duodenum,  which by accumulating it in the biliary ves-
sels, may give occasion to  its  passing again into the
blood-vessels; or it may pass  into these,  by its being
absorbed  from the alimentary canal, when it happens to
be accumulated there in an unusual quantity.  How far
the latter cause can take place, or in what circumstances
it does occur, I cannot  clearly ascertain, and I  appre-
hend that jaundice is seldom produced in that manner*
   1819.  The former cause of stopped excretion may
be understood more clearly; and we have very certain
proof of its being the ordinary, and indeed the  almost
universal  cause of this disease. Upon this subject it will
be obvious,  that  the interrupted excretion of the bile
must depend upon an obstruction of the ductus commu-
nis choledochus; the most common cause of which is  a
biliary concretion formed in the gall-bladder, and from
thence falling down into the ductus communis, it being
at the same time of such a size as not to pass readily

 * We doubt whether jaundice is ever produced, by an absorption of bile
from the alimentary canal.  That fluid, from whatever place it may be ab-
sorbed, does  not carry its bitterness into the blood.  By the taste alone, the
serum of the blood, in jaundice, cannot be distinguished from that of the
blood of a person in perfect health. 
416           PRACTICE OF PHYSIC.
through that duct into the duodenum.   This duct may
likewise be obstructed by a spasmodic  constriction af-
fecting it:  and such spasm may happen, either in the
duct itself, which we  suppose to be contractile;  or  in
the duodenum pressing the sides  of the duct close to-
gether;  or, lastly, the duct may be obstructed by a tu-
mour compressing it, and that arising either in the coats
of the duct itself, or in  any of the neighbouring parts
that are, or may come to be, contiguous to it.
   1820. When such obstruction happens, the secreted
bile  must  be accumulated in the biliary ducts; and from
thence it  may either be absorbed  and  carried by the
lymphatics into the blood-vessels, or it may regurgitate
into the ducts themselves, and pass from them directly
into the ascending cava.   In either way, it comes to be
diffused in the mass of blood; and from thence may past
by every exhalant vessel, and produce  the disease  in
question.*
   1821. I have thus shortly explained the ordinary pro-
duction of jaundice:  but it must be  observed further,
that it is  at all  times accompanied with certain  other
symptoms, such  as a whiteness of the forces  alvina,
which  we readily account for from the absence of bile
in the  intestines; and generally, also, with a certain con-
sistence of the faeces, the cause of which is not so easy
to explain. The disease is always accompanied also with
urine  of a yellow colour, or at  least with urine that
tinges  a linen cloth with a yellow colour.  These are
  * Bile cannot pass into the blood-vessels, through any other channel than
that of absorption. It  betrays, in our author, a most glaring deficiency of
physiological  knowledge, to assert, that the bile " may regurgitate in its
ducts, and pass, from them, directly into the ascending vena cava."  On
grounds, just as tenable, might he have asserted, that the blood may regur-
gitate from the right ventricle of the heart, and pass, by an inverted move-
ment, to the left, as to have declared hia belief,  in this retrograde march of
the bile.   In either case, an equal degree of violence mast be done to (he
order of nature. 
PRACTICE OF PHYSIC.
417
  constantly attending symptoms; and though not always,
  yet there  is commonly, a pain felt in the epigastrium,
  corresponding, as we suppose, to the seat of the ductus
  communis. The  pain is often accompanied with vomit-
  ing; and even when the pain is not considerable, a vo-
  miting sometimes occurs.  In some cases, when the pain
  is  considerable,  the pulse becomes frequent, full, and
  hard, and some other symptoms of pyrexia appear.
     1822.  When  the jaundice is occasioned by tumours
t». of the neighbouring parts  compressing the biliary duct,
  I believe the disease can very seldom be cured.   That
  such  is the cause of jaundice, may with some probabi-
  lity be supposed, when it  has come on  in consequence
  of other diseases which had subsisted long before, and
  more especially such as had been attended with symp-
  toms of obstructed viscera.   Even when the jaundice
  has subsisted long without any intermission, and with-
  out any pain in the  epigastrium, an external compres-
  sion is to  be suspected*
     1823.  In such circumstances, I consider the disease
  as incurable; and it is  almost only when the disease is
  occasioned by biliary concretions obstructing the biliary
  duct, that we may commonly expect relief, and that our
  art may contribute to the obtaining it.  Such cases may
  be generally known  by  the disease frequently disappear-
  ing and returning again; by our finding, after the former
  accident, biliary  concretions amongst the fasces; and by
  the disease being frequently accompanied with pain of
  the epigastrium, and with vomitings arising from such
  pain.
     1824. In these cases, we know of no  certain and im-
  mediate means of expediting  the passage of  the biliary
  concretions.  This is generally a work  of time depend-
   * Jaundice, produced by an obstruction of the liver—a cause, from which
  it often proceeds—may be cured, by the use of mercury.
     VOL. II.......  3 u 
418
PRACTICE  OF PHYSIC
 ing upon the gradual dilatation of the biliary duct; and
 it is surprising to observe, from the size of the stones
 which sometimes pass through, what dilatation  the duct
 will admit of.  It proceeds, however, faster or slower
 upon different occasions; and therefore the jaundice.
 after a  various  duration,  often ceases  suddenly  and
 spontaneously.   It is this which  has given rise to the
 belief, that the jaundice has been cured by such a num-
 ber and  such a variety of different remedies.   Many of
 these, however, are perfectly inert, and many others of
 them such as cannot be supposed to have any  effect in
 expediting the passage of a  biliary concretion.   I shall
 here, therefore, take no notice of the numerous reme-
 dies of jaundice mentioned by the writers on  the Ma-
 teria Medica, or  even of those to be found  in practical
 authors; but shall confine myself to the mention of those
 that  may with probability be  supposed  to  favour the
 passage  of the concretion,  or remove the obstacles to
 it which may occur.
    1825. In  the treatment of  this disease,  it is, in the
 first place, to be  attended to,  that as the distention of
 the biliary duct, by a hard mass that does not easily pass
 through  it, may excite  inflammation there; so, in per-
 sons of tolerable  vigour, blood-letting may be an useful
 precaution; and when much pain, together with any de-
 gree of pyrexia, occurs, it becomes an absolutely neces-
 sary remedy.  In some instances  of jaundice  accom-
 panied with these symptoms, I have found the blood   ,
 drawn covered with an inflammatory crust as  thick as
 in cases of pneumonia.*

  * With regard to the  necessity of using the lancet, in such cases of jaun-
dice, as are mentioned in this article, our author is perfectly correct in hn
sentiments.  We have seen cases,  in which several repetitions of blood-let-
ting were required; the blood being as sizy as in pleurisy or hepatitis. In
such instances, the practitioner must be governed, entirely, by the state of 
PRACTICE OF  PHYSIC.
419
    1826. There is no means of pushing forward a bili-
 ary concretion that is more probable than the action of
 vomiting; which, by  compressing the whole abdominal
 viscera, and particularly the full and distended gall-blad-
 der  and  biliary  vessels,  may contribute,  sometimes
 gently enough, to the dilatation of the biliary duct.  Ac-
 cordingly vomiting has often been found useful for this
 purpose; but  at the  same time it is  possible, that  the
 force exerted in the  act  of vomiting may be too violent,
 and  therefore gentle vomits ought only to be employed,,
 And either when, by the long continuance of the jaun-
 dice, it may be suspected that the size of the concre-
 tion  then passing is large; or more  especially when
 pain attending  the   disease gives apprehension  of in-
 flammation,  it may be prudent to avoid vomiting alto-
 gether.
    1827. It  has been usual in  the jaundice to employ
 purgatives;  and it  is  possible that the action of the in-
 testines may excite the action of  the  biliary ducts, and
 thus favour the expulsion of the biliary concretion: but
 this, I  think,  cannot be of much effect; and the attempt-
 ing it by the  frequent use of purgatives, may otherwise
the pulse, the pain that is felt, and the effects that are produced, by the use
of the remedy.
  Our practice, in jaundice, has, usually, consisted,  in  blood-letting,  when
necessary; puking, purging—which, notwithstanding what our author says,
is an important remedy—opiates, blisters, applied on the region of the liver,
 and a mercurial ptyalism. Adding to these, a diet, easy of digestion, fric-
tion on the region of the liver, or electricitj', passed through the same, and
moderate exercise, when not forbidden by fever, we have never failed, in
recent cases, to effect a cure.
  Balsam capivi, administered in doses  of half a drachm, three or four
times a day, we have found exceedingly  useful, in the treatment of jaun-
dice.
  Inasmuch as no remedy ever enters the lacteals, and the circulation, in a
formal state; but must first undergo a process of assimilation, which com-
pletely deprives it of its medicinal qualities; to administer articles, with a
view to the solution of biliary calculi, that may be obstructing the ducts, it
alike useless and unphilosophical. 
420
PRACTICE OF PHYSIC.
hurt the patient.  For this reason  I apprehend, that
purgatives can never be proper, excepting when there
is a slow and bound belly.
   1828. As  the relaxation of  the skin  contributes  to
relax the whole system, and particularly to relieve the
constriction of subjacent parts:  so, when the jaundice is
attended with pain, fomentations of the epigastrium may
be of service.
   1829. As the solids  of the living body are very flexi-
ble and yielding; so it  is  probable, that  biliary concre-
tions would in many cases find the biliary duct readily
admit  of such  dilatation  as  to render  their passage
through it  easy, were it not that  the  distention occa-
sions a preternatural spasmodic contraction of the parts
below.   Upon this account, opium is often of great be-
nefit in jaundice; and the benefit resulting from its use,
proves  sufficiently the  truth of the theory upon which
the using of it has been founded.
   1830. It were much to  be wished, that a solvent of
biliary concretions,  which might be  applied to them  in
the gall-bladder or  biliary ducts,  was discovered; but
none such, so far as I know, has yet been found; and
the employment of  soap in this disease, I consider as a
frivolous attempt.   Dr. White of York has found a sol-
vent of biliary concretions when these are out of the
body; but there is not  the least probability that it could
reach them while lodged within.
APPENDIX. 
APPENDIX

      TO VOL. II.
                 Dysenteria, or Dysentery.

 A NOVEL method of using emetic medicines in  dysentery
 has been  recommended by a late  writer;*  and we are assured
 by him that he has  found  the practice highly successful.   This
 is in the form of a clyster; and that which he has experienced to
 answer best, has been about three drachms of ipecacuanha  root,
 bruised and boiled in a quart of water down to  a pint, which he
 repeats twice or thrice in twenty-four hours.
   If dysentery is accompanied with violent retchings or a severe
 vomiting on its attack, so as to threaten the patient with cholera
 morbus, neither emetics, purgatives, nor diaphoretics, will be ad-
 visable at first.  In such cases the stomach must be evacuated of
 its contents by the gentle stimulus of large  draughts of chamo-
 mile-tea.   The same, or weak broth,  may be thrown up the in-
 testines in  the form  of  clysters  until these are  cleansed ; after
 which  an opiate should  immediately be given.   If  the opium is
 rejected, a double quantity of it is then to  be administered in a
 clyster.
   Should  the vomiting  continue very  obstinate  notwithstanding
 these means, the safety of the patient will then depend on bathing
 the region of the stomach well with tincture of opium  and cam-
 phorated spirits;  on  repeating  the clysters frequently, with a
 proper quantity of opium in each ; and on adopting  the other
 steps advised under the head of Cholera Morbus.   A blister ap-
plied over the stomach may sometimes be  useful.

 • See  Observations on the Nature and Cure of the Diseases of the East
»nd VVesi Indies, by Thomas Clarke, Surgeon.
  VOL. II. >* "r   .....**mn '"A   '  "" 
APPENDIX.
   In dysentery, when the abdomen is hard, tense, and painful to
the touch, and the gripings are frequent and severe, the applica-
tion of  flannels, wrung out in a warm decoction of chamomile-
flowers  and  poppy-heads, with a small addition of  camphorated
spirits,  to the part, may afford considerable relief: but should
fomentations not procure the desired effect, a blister ought to be
put  on.   Most  cases of  dysentery, and particularly during the
acute stages of  the disease, may be relieved by immersing the
patient  in a warm bath  of a model ate temperature, and keeping
him in it tor some time.   Perhaps rubbing the abdomen with
some warm  and stimulating embrocation,* on his being taken out
of the bath, might increase its effect.
   To defend the inner  coat of the intestines from  the acrimony
of its contents, and to counteract the vain attempts at evacuation,
it will be  necessary to give  something to be discharged.   Here
then we should  not  only administer mucilaginous substances,
such as solutions of gum acacia in milk, preparations of barley,
rice, arrowroot, &c.f by the mouth ;  but we should likewise in-
ject a clyster of a similar nature:}:  three or four  times  in the
course of the day.  All vain attempts to go to stool, as also all
violent  strainings in evacuating the contents of the bowels, ought
carefully to  be  avoided by the patient throughout  the  disease;
for if obedience  be paid to every seeming call of nature, the
straining which ensues will be highly  detrimental, as little or
nothing, except  mucus and blood,  comes  away in four  out of
five efforts.
   If the fundament becomes inflamed or excoriated,  the parts
should be anointed with a little soft  pomatum or prepared lard,
after each evacuation.
  In the cure of Indian dysentery, mercury is the  remedy now

   * Take Soap Liniment, one ounce and a half.
         Tincture of Opium, half an ounce.
         Oil of Rosemary, one drachm.
     Mix them for an embrocation.
   f Take Gum Acacia, two ounces.   Dissolve it in
         Barley Water, two pints, and add
         Syrup of Orange Peel, two ounces.
     The patient may take this for ordinary drink.
  Or, Take Mixture of Burnt Hartshorn, one pint daily.
   $ Take Decoction of Starch, five ounces.
         Olive Oil, half an ounce.
     Add occasionally
         Tincture of Opium, half a drachm to one drachm.
     Mix them for a clyster. 
APPENDIX.
iii
much relied on, but it is to be employed in an early stage of the
disease.   The plan recommended is, to give the hydrargyri sub-
rnurias in a considerable dose night and morning without inter-
ruption,  accompanied by a mercurial friction of the abdomen
until the mouth  becomes sore.   If diarrhoea ensues, this symp-
tom is not to be interfered with, but rather  encouraged by an
occasional purgative of the sulphate of  soda or rhubarb.   I am
much inclined to doubt, however, whether mercury  so employed
as to produce salivation will  be found useful, or even  innocent,
in the cure  of real  dysentery.  Indeed  I should think it could
not fail, in many  instances, to prove hurtful, and particularly in the
doses which are mentioned.  When given, it probably might be
found best to combine it with ipecacuanha, as, for instance, half
a grain of calomel with one of ipecacuanha every two hours, until
the gums are affected, or we may administer it combined with
antimonial powder and opium.
  In the  inflammatory variety  of dysentery, the  necessity of
previous bleeding and purging to the  employment  of mercury,
with the view  of producing ptyalism, must be obvious to  every
practitioner.
  Where there exists a disease of the liver, or any diseased ac-
tion of the biliary system in dysentery, mercury has  certainly
been found highly useful; and  it is from its singular utility in
this combination of disease, that the practice has become in warm
climates so general of treating it, in all its stages, by this remedy;
a treatment, however, which  must in  many cases be improper.
The connexion between dysentery  and the deranged functions of
the skin  and  liver has been illustrated by Dr. Johnson, who is a
great advocate for scruple doses  of hydrargyri submurias, com-
bined with small portions of opium.  We are also told by a mo-
dern writer* that a proper combination of these  two medicines
has a surprising  effect in restoring the natural balance of the vas-
cular system, and in promoting the free  secretion of  bile.   He
says, that when it fails in acting forcibly on the skin in dysentery,
small doses of the pulvis antimonialis and camphor may perhaps
be added with advantage, the warm bath being  occasionally used
at the same time, to equalize  the circulation.
  There are some grounds for presuming that the disease which

  * See Practical Illustrations of Typhus and other Febrile Diseases, by J.
Armstrong, M. D. 
IV
APPENDIX.
 the authors here quoted* have  called the dysentery of India, ii
 in  iis nature, symptoms, and  causes, and likewise in its method
 of  treatment, very different from that which is described  under
 this name in other countries ; that it  differs in nothing from
 the bilious fluxes so  commonly to be met with there, and arises
 from an affection of the  liver ; for they describe the stools as
 being copious and liquid, frequently bilious, and seldom or never
 as containing scybala—symptoms by no means characteristic of
 true dysentery.
  The  singularity in the appearance of the  faeces  (as seldom
 passing by the anus in  the form of  scybala, but, whether by the
 action of medicine or otherwise, being generally loose and liquid)
 has not been passed by unobserved  by Sir James McGregor,Mr.
 Banfield,f and others, and it has been conjectured that this peculi-
 arity in tropical dysentery arises probably from the  intestinal
 secretions  being considerably increased  in  consequence of cli-
 mate, the secretions in such  temperatures being more thin and
 acrid than in the climates of Europe, and hence scybala are easily
 broken  down  and amalgamated with  the  more  fluid  matter, in
 their passage along the intestinal canal to the rectum.
  In the  secondary attacks of Indian dysentery,  where the re-
 laxed and weakened state of the bowels seemed to keep up the
 disease, the nitric acid, in the quantity of about  two drachms in
 the day, in barley-water, has proved an useful adjunct in the cure,
 and has been found to  diffuse an agreeable sensation of warmth
 through the whole line of the alimentary canal.   On leaving off
 the use of this  medicine, an infusion of quassia, columbo, or
 cascarilla, may be administered till the stomach and bowels have
 recovered their  vigour and  proper tone.
  At the commencement of dysentery it would  be improper to
 employ either opiates or astringents;  but in the second  stage,
 where the patient's strength is exhausted by frequent returns of
 the complaint, proceeding  rather from a weak relaxed  state of
 the bowels than from any remains of malignancy, a use of these
 remedies will  prove both proper and beneficial, taking care to
 obviate costiveness, and evacuate the  contents of the intestines
 from time to time, by administering a few grains of rhubarb, or
 some such gentle laxative.
  *  See M'Gregor's Medical Sketches; Clarke on the Diseases of Warm
Climates; Milne's  Account of the  Diseases that prevailed during two Voy-
ages t<> the fcasi Intl.es ; and Essay on the  Influence of Tropical Climates on
European Constitutions, bj J Johnson, M  D
  f  bee his Practical Treatise on Tropical Dysentery. 
APPENDIX.
v
  In this stage of the disease, should the patient's rest  be much
disturbed throughout the course of the night, from the frequency
of the motions, we may direct an  opiate* to be taken at bed-
time
  The hyoscyamus (henbane,) by its anodyne and  gentle laxa-
tive qualities, seems a medicine well adapted to this disease, and
may be tried when we cannot venture on opium.
  In chronic and habitual fluxes, which  are complaints frequent
with those who have suffered much sickness in tropical  climates,
it is seldom, indeed, that relief can be obtained without  the aid of
opium, and it is often found necessary to add it to all the other
medicines  we administer.   Opiates,  especially  those  of the
warmer  kind, such as the confectio opii,  &c. are as valuable in
these cases as the bark of cinchona is in  intermiltents.
  When the bowels have been, effectually relieved, it often hap-
pens, after the disease has continued for some time, from the
tender state of the rectum, that a severe and troublesome tenes-
mus remains.  Under such circumstances, or in the  advanced
stage of the disease, soothing and  anodyne  clysters are much
used by professional men;  but in some instances  the  irritation
produced by introducing the pipe  more  than counterbalances
the soothing effects of the injections.  As a commodious substi-
tute for anodyne clysters, we may therefore direct the patient to
insinuate into the anus a pill of  about two  grains of opium, pre-
viously somewhat softened betwixt the fingers.  We  may  also
cause warm fomentations to be applied  to the parts, and a blad-
der filled with hot water to the hypogastric region.   These  will
be likely to afford great relief to the patient.
  We are told that opium, combined with the nitric acid, agree-
able to the  prescriptionf  here advised, has,  on various trials, been
found to have been attended with the best effects in the advanced
stage of dysentery, when all other remedies  have proved inef-

   * Take Cinnamon Water, six drachms.
         Spirit of Pimenta, half an ounce.
         Syrup of Ginger, one drachm.
         Tincture of Opium, forty drops.
    Mix them as a draught.
  Or, Take Opium, one grain to two grains.
         Antimonial Powder, one grain.
         Aromatic Confection, a sufficiency to form a pill.
  | Take Nitric Acid, two drachms.
         Tincture of opium, forty-five drops.
         Pure Water, three ounces.
    Mix them, and take about a tea-spoonful three or four times a day. 
vi
APPENDIX.
 fectual, and  even in cases where death seemed almost inevi-
 table*
   The astringents best adapted  for the cure of a dysentery,  are
 the  different  preparations of catechu,  gum kino, logwood, Sec.
which may be  given as below,t  the patient  at the same time
taking Port wine  properly  diluted  with water  for  his ordinary
drink.  Lime-water  mixed  within  an equal proportion of milk
ha*been  much recommended  as a  useful  remedy in the latter
stage of the disease.  During my residence in the West Indies
I was  in the habit of recommending a  strong  decoction of log-
wood, with the barks of pomegranate-fruit,  and the cushew cher-
ry-tree, or  anacardium, as an astringent drink, from which my
patients seldom failed to experience a good effect.
   In the advanced and chronic stage of the disease, as acidity at
the stomach  is apt to prevail, absorbents, such as the mistura
cretae, pulvis cretae compositus, liquor calcis, &c. combined with
opiates, will be useful.—See Dyspepsia  for formulae of these me-
dicines.
   Where  there exists an extreme  degree of  atony, and a fre-
quent  discharge of faeces without pain,  small doses of zinci sul-
phas combined with  opium have proved of singular utility  in
many instances.
   The impaired tone of the intestines is likewise to  be restored

   *  See Observations on the Effects of Nitric Acid and Opium in the Cure
 of Dysentery, in vol. iii. p. 413, of the Medical and Physical Journal.
   |  Take Extract of Logwood, one drachm.
         Chalk Mixture, four ounces.
         Tincture of Catechu, two drachms.
         Spirit of Nutmeg, one ounce.
     Of this mixture, take two table-spoonfuls every four hours.
  Or, Take Aromatic Confection, one drachm.
         Cinnamon Water, five ounces.
         Spirit of Pimenta, one ounce.
         Tincture of Kino, two drachms.
     This mixture may be taken as the former, adding occasionally to each
       dose,
         Tincture of Opium, fifteen drops.
  Or, Take Opium Confection, ten grains.
         Cinnamon Water, one ounce and a half.
         Tincture of Catechu, one drachm and a half.
     Mix them, and take this draught every four hours.
  Or, Take Electuary of Catechu, fifteen grains.
         Pimenta Water, one ounce and a half.
         Tincture of Kino, one drachm.
         ----------Opium, fifteen drops,
     Mix them for a draught. 
APPENDIX.
vii
by a use of tonics and bitters,* together  with a light nutritive
diet and moderate exercise.  The application  of  cold water to
the abdomen, and particularly to the lower parts of it, by means
of cloths or sponges ;  or the immersion of the lower part of the
trunk in a tub of water, may probably prove a good auxiliary mean.
  The fever accompanying this disease  sometimes appears un-
der an intermittent or remittent form, and  is protracted much
longer than it otherwise would have been, in consequence of its
being so complicated.  In such  cases its treatment is to be re-
gulated as directed under these heads, by  a use of the bark of
cinchona, Sec.
  In those instances  where  a dusky sallow hue of the counte-
nance,  tenderness upon pressure over the  region of the liver,
and a clayey appearance in  the faeces which happen occasionally
to be voided, manifest the presence of a  diseased or  obstructed
state of the liver;  we  should resort  to  mercury,  pushing it to
such an extent as to keep up a  gentle affection of the mouth un-
til the symptoms are mitigated.   We may give the nitric acid at
the same time.
  In the first stage of dysentery, a use of ripe fruits will be pro-
per; but in a more advanced period, where any morbid  acidity
seems to  prevail in the stomach,  they should not  be' recom-
mended.

  *  Take Simarouba Bark, bruised,
         Cascarilla Bark, of each half an ounce.
     Boil them in a pint of water until reduced to eight ounces, strain off
      the liquor, and add—
         Spirit of Cinnamon, two ounces.
         Tincture of Opium, forty-five drops.
     Mix them, and let the dose be three table-spoonfuls every four hours.
  Or, Take Infusion of Augnstura Bark, six ounces.
         Tincture of Columbo, one ounce,
         ----------Catechu, two drachms.
         Nitric Acid, one drachm.
     Of this mixture the  dose may be three table-spoonfuls thrice a day.
  Or, Take Decoction of Peruvian Bark, one ounce and a half.
         Tincture of Columbo,
         ----------Orange Peel, of each one drachm and a half.
         ----------Kino, forty c^rops.
     Mix them for a draught, to be taken three or four  times a day.
  Or, Take extract of Gentian,
         ----------Logwood, of each one drachm,
         Sulphate of Iron,
         Gum Myrrh, of each half a drachm.
         Syrup of Ginger, a sufficiency to form the mass, which is to be
           divided into forty pills, and of these three are to be taken
           morning, noon, and night, washing them down with about
           two ounces of a decoction of Simarouba Bark, or an infusion
           of Cascarilla. 
Vlll
APPENDIX.
  Every sort of food which readily tends to putrefaction ought
carefully to be avoided  throughout the whole course of the dis-
order, as also all kinds of  fermented and spirituous liquors, sup-
porting the patient's strength with preparations of barley, rice,
sago, flour, panado, Indian arrow-root boiled  in  milk, occasion-
ally  varied for gelatinous broths.   During the  state of conva-
lescence, Port wine or Madeira, or even a moderate quantity of
brandy, properly diluted with water, may be allowed.
  Persons  recovering from a dysentery, should observe the great-
est caution and regularity  in their mode of living, and they should
go warmly clothed, by  wearing flannel next the skin, as the dis-
ease is very liable to relapse  from any fresh  exposure  to cold,
wet, damp night air, or sudden atmospherical vicissitudes.
  The importance of warm clothing, both in the prevention and
cure of bowel complaints, is too obvious  to require my saying
much on the subject; I will therefore only observe, that warmth
ought not  to be  a secondary object; on the contrary, it ought to
be the first; for if a patient only wears  his ordinary clothing, he
will  receive comparatively little  benefit from  any medicine.  A
waistcoat of flannel  or  fleecy  hoisery next to the skin, ought al-
ways to  be worn, as likewise sliders of  the same ; and  these
should be  laid  aside  with caution,  and by slow  degrees.   The
writer* of a small tract on dysentery, lays much stress on swath-
ing the abdomen  with flannel bandages, as being the best  mode
of confining a certain degree of  heat over that part of the body
which is the seat of the disease;  and this practice is reported by
Sir James  M'Gregort to have  been found very serviceable in
many cases, both as affording an equal support, and  keeping up
a due degree of warmth on the surface of the abdomen.
                     Vermes, or Worms.

  The human body is infested by three kinds of worms, viz. the
ascarides, or small white worm ;  the teres, or round worm ; and
the taenia, or tape worm, which  is flat, consists of many  joints,
and is usually of a considerable  length.  The last is,  however)
more rarely met with in  this country than  the others;  but in

  * See H. Dewar's Observations on Diarrhoea and Dysentery, as those
 Diseases appeared in the British Army during the Campaign in Egypt in
 1801
  f See Medico-Chirurgical Observations, vol. vi. p. 433. 
APPENDIX.
IX
 Germany and Switzerland,  the  inhabitants  are much troubled
 with it.  Different  situations of the intestines have been men-
 tioned as being occupied by each kind, particularly  the rectum
 as the seat of the ascarides, where they are observed always in-
 volved in mucus; the teres occupy the small intestines,and some-
 times the stomach ; the taenia the whole intestinal tube, more es-
 pecially  the ilium.
   Unwholesome food, with a bad digestion, seems to be the prin-
 cipal cause of worms.   They appear most frequently in those of
 a relaxed habit, and whose bowels contain a preternatural quan-
 tity of mucus or slimy matter.   Hence it is a disease most com-
 mon to children ; but they sometimes prevail in adults to a very
 high degree, particularly in those who live chiefly on a vegetable
 diet.   The tape worm is not often met with in infancy or child-
 hood ;  instances of it do, however, now and then occur.
   Worms may readily be distinguished by the following symp*
 toms, viz.  variable appetite, fetid breath, acid eructations,  and
 pains in  the stomach, grinding of the teeth during sleep, picking
 of the nose, paleness of countenance, hardness and fulness of the
 belly, slimy stools, with occasional griping pains, more particu-
 larly about the navel, heat and itching about the anus, short dry
 cough, emaciation of the body, slow fever, with evening exacer-
 bations, and irregular pulse, and sometimes convulsive fits.
   It is often a very difficult matter to expel worms from  the body,
 but more especially the taenia.   When they  prove fatal, it is by
 their erosion of particular parts, and their inducing a tabid state.
  In the cure of this disease we  must have in view, first, the ef-
 fecting the destruction  and  discharge of the  worms;  and,  se-
 condly, the preventing their future generation.
  The first of these is to be.accomplished by  certain remedies
 known  by the name of vermifuges, which all  act in one of the
 three following ways:—
   1st. By simple evacuation or purging, as  mercury,  rhubarb,
jalap, and aloes; as also the different strong bitters, as rue,tansy,
 and wormwood.
  2dly. Mechanically, as the pulvis stanni, cowhage, Sec, or,
  3dly. Chemically, as  lime-water, which loosens their adhesion
to the intestines by  dissolving the mucus in  which they are in-
rolved.
  We may begin with those which act mechanically,* and which

  * Take Filings of Tin,
         Cassia Confection, of each half an ounce.
   VOL. II.            **+ B 
X
APPENDIX.
have been found the most powerful;  and after continuing  them
for two or three days we may have recourse to those which have

a purgative  effect,* changing both after a continuance of some
time for those which act  chemically.t  Along with those which
act mechanically it will be proper  to employ some kind of bitter

infusion 4
  If these means prove ineffectual, we may then make use of the
Indian pink root, or spigelia, which has on  many  occasions been
found  a very powerful medicine.   About" ten grains of the pow-
der may be given morning and night to a  child  of  eight or ten
years old, to which  age the doses  of  the preceding remedies are
adapted.   The spigelia  is without doubt  a poisonous and nar-
cotic vegetable, and it is in all probability by virtue  of this poi-
sonous quality that  it proves  so beneficial in cases of worms.
  By a proper use of stizolobium or cowhage, (the dolichos pru-
riens  of  Linnaeus,) with  the  submuriate of  mercury combined
with jalap,- or the oleum  ricini every  third  or fourth morning as
£ purgative, we seldom, however, shall have occasion to seek re-
lief from any other  medicine, as in several  hundred cases where


         Syrup, a sufficiency.
    Mix them.  Of this electuary the  bulk of a  nutmeg may betaken
      twice a day.
 Or, Take the Down of Cowhage, six grains to ten.
          Pilings of Tin, ten grains.
    Mix them.  This is to be taken night and morning, mixed with a lit-
       tle  syrup or honey.
 Or, Take the Down of Cowhage, six to ten grains.
          Honey or Treacle, a sufficiency to form a bolus, which is to be
           given twice a day.
 Or, Take Down of Cowhage, one drachm.
          Common Syrup, a sufficiency.
    Form an electuary, of which take a tea-spoonful every morning for
       three days on an empty stomach.*
   * Take Submuriate of Mercury, three to five grains.
          Powdered Rhubarb, ten grains.
    Mix them. This purgative powder is to be taken on the fourth morn-
       ing after any of the preceding vermifuge medicines.
 Or, Take Powder of Jalap, ten grains.                        <
          Submuriate of Mercury, three grains.
    Mix them for a cathartic.
 Or, Take Castor Oil, half an ounce to one ounce for a dose.
   f Take of Lime Water, half a  pint in the day.
   + Take Gentian Koot, bruised,
          Wormwood Leaves,
          Rue Leaves,
          Lemon Peel, of each two drachms.
          Warn water, one pint.
    Infuse them for an hour, and then  strain off the liquor.  Of this infu-
       sion three table-spoonfuls may be taken twice or thrice a day. 
APPENDIX.
xi
I had used  it, during my practice  in  the West Indies, I never
knew it once to fail.   It appears to  have been but very lately in-
troduced into  this country, which, considering its wonderful ver-
mifuge power, is somewhat surprising.
  The stizolobium  or  dolichos  is a  plant like the vine, long,
slender, and creeping.  The leaves are thin, pointed, and covered
with a down.  The flowers grow in clusters, and are followed by
a pod, somewhat similar  to  the common  pea in shape and size,
and containing several'purple beans.  The pods are thickly co-
vered by very fine stiff pointed hairs,  which, upon being applied
to the skin, produce an  intolerable itching, and it is only this
downy portion of the plant that is employed to destroy worms.
  A  decoction  of the  Geoffraea inermis, or cabbage bark, is
another remedy much used in the West  Indies, but  more par-
ticularly in  Jamaica, for destroying worms, and often with a very
happy effect.
  For the destruction of  ascarides it  is very  usual to throw up
injections into the rectum that will  prove obnoxious, and thereby
dislodge them.   Any of those  recommended below* may be
tried.
  Turpentine has been  used also  with success in the form of
clyster.  About two drachms of it, blended with a decoction of
oatmeal, may be thrown up at a time.
  An injection  of the down or hairy part of  the  stizolobium,
mixed in a  little thin gruel,  might  possibly have a very good ef-
fect.  Dr. Darwin has proposed the introduction of a piece of
candle up the rectum well smeared with mercurial ointment, as
a likely method  to destroy ascarides.
  A peculiar  mode of employing tobacco in cases of worms has

   * Take Lime Water of a tepid warmth; ten ounces for an injection.
  Or, Take Rue Leaves,
         Wormwood Leaves, of each half an ounce.
     Boil them in a pint of water until reduced to ten ounces, strain off the
      liquor, and add
         Castor Oil, half an ounce.
     Mix them for a clyster.
  Or, Take Down of Cowhage, ten grains.
         Thin Gruel, six ounces.
     Mix them for a clyster.
  Or, Take Common Aloes, one drachm.
         Thin Gruel, ten ounces.
     Mix them for a clyster.
  Or, Take Tobacco Leaves, from one scruple to half a drachm.
         Warm Water, ten ounces.
     Infuse them for half an hour, and then strain off the liquor for a clyster. 
Xll
APPENDIX.
been recommended by Dr. Barton,* and which wc arc informed
by him has in many instances produced very happy effects.  The
leaves are pounded with vinegar, and applied in the  shape  of a
poultice to the region of the stomach or abdomen.  " In  con-
sequence  of this application, worms are often discharged," he
mentions, " after powerful anthelmintics have in vain been admi-
nistered internally."   A similar practice I  know is adopted in
the West  Indies, where it is usual to apply a  cataplasm of the
expressed juice of the aloe-tree to the abdominal region, for the
purpose of dislodging worms, and I have observed that in many
cases the  remedy seemed  to prove a powerful auxiliary to other
means.   Its efficacy has extended however  only to cases of the
round worm.
  The male fern, or filix mas, which forms the basis of Madame
Noufler's celebrated  remedy, is a medicine which has been much
extolled for its destructive powers  to the tape-worm, which, of all
others,  proves the most difficult to expel from the body.   The
dose for an adult is from one to two drachms.   After two doses,
it will be  right to give a purge of the submuriate of mercury and
jalap, in about the proportion of five grains of the former to five-
and-twenty of the latter.
   The common  spirit of turpentine, it appears,! has recently been
administered with a very good effect in some cases of tape-worm,
having caused  many feet in length of the animal to be brought
away, or expelled.
   For a delicate female, the proper dose will be an ounce ;  for a
robust female or small man, an ounce and a half;  and for  a ro-
bust man, two  ounces.   The best vehicle  for it appears to be
milk.  It should be  taken  early in the morning on  an empty
stomach.  Purging  will be produced by  it,  and this speedily.
 When the dose is considerable, it may be advisable to direct the
 patient to drink  plentifully of emollient liquors with the view of
 sheathing the stomach and  kidneys.
   The pomegranate root has been found a very effectual reme-
 dy:}: for destroying the tape-worm.
   Sulphureous waters, such as  those of  Harrowgate, in this
 country, and of the islands of Jamaica and Nevis, in the West

   * Reported in vol. viii. page 428, of the Medical and Physical Journal.
   f Reported in No. 131 and 132 of the Medical and Physical Journal.
   —See Transactions of the London Medical Society, vol. i.
   * See Edinburgh Medical Journal for January 1807. 
APPENDIX.
xiii
Indies, have been found, when drunk upon the spot, to be very
good anthelmintics.
  Harrowgate water is a safe and  powerful remedy against the
round worm and ascarides, when taken in such a dose as to prove
a brisk purgative; and in the latter case, when used likewise as
a clyster, the ascarides being chiefly confined to the rectum, and
therefore within  reach of this form of medicine.
  Common salt was administered by Dr. Rush as an anthelmintic
remedy, with some success; and by some other physicians it has
been thought to  possess a  power destructive to worms.   Those
who do not make use of it with their food, have been observed
to be much predisposed to these vermin.
  Such as  are afflicted with worms should abstain from all crude
vegetables and unripe fruits, making their diet consist chiefly of
animal food that is light, nutritive, and easy of digestion.
  After a proper course of the vermifuge medicines which have
been advised, we should employ such others as have.a tendency
to strengthen the stomach and intestines,  in order to  prevent
any worm from being generated in future ; a relaxation of these
parts being a constant attendant on the disease.  The most pro-
per  tonics are the cinchona bark, astringent bitters, and chaly-
 beates ; various forms of which will be found under the head of
Dyspepsia.



       Of Suspended Animation and Resuscitation.

   In consequence of drowning, or a long exposure to the action
 of severe cold, and also of suffocation and strangulation, a consi-
 derable check  is  often given to the principle of  life,  without
 wholly extinguishing it.  When it happens from the first of these
 causes, the circulation becomes gradually more feeble and slow,
 and much  anxiety is felt about the praecordia; to relieve which
 the person attempts to rise to the  surface of the water;  he then
 discharges a quantity of air from the  lungs, and  receives into
 them a very small portion of water,  when he again sinks.  After
 struggling in this mannerfor some short time, convulsive spasms
 arise, the organs of  respiration cease to act, and he at last ex-
 pires ; soon after which the skin becomes of a purple or blue
 cast, particularly about the face and neck, and the body sinks.
   It has been supposed, and the  opinion is indeed still very ge-
 neral among the common people, that in the act of drowning the 
xiv
APPENDIX.
water enters  the lungs and completely fills them.  Experience,
however,  has shown, that unless the body lies  so  long in  the
water as to have its living principle entirely destroyed, the quan-
tity of fluid present in  the lungs is inconsiderable; for upon
drowning  kittens, puppies,  See. in ink, or other coloured liquors,
and  afterwards examining  these viscera, it has been observed
that very little of the coloured liquor has gained admittance to
them.   The circumstance may readily be accounted for by re-
collecting, that the muscles which  form the  opening into the
tra*chea are exquisitely sensible, and  contract violently upon the
least irritation, as we frequently experience when any part of the
food or drink happens to come in contact with  them.
  In those cases where a person  has  been long exposed to the
action of  cold in a severe  degree, and  is suffering from great
numbness, and a sort  of intoxication, he  is apt to  fall  quickly
asleep, and becomes quite insensible.  Occasionally he comes
to himself without assistance,  but  more frequently he falls a
sacrifice.
  When a person dies from suffocation, the symptoms are nearly
the same as in apoplexy.—See Aerial Poisons.
  The phenomena which attend  on strangulation are, convulsive
paroxysms, superadded to the apoplectic symptoms.
  Livid and dark-brown spots on the  face, with great rigidity and
coldness of the body, a glassy appearance of the  eyes, and a flaccid
state of the skin, denote a perfect extinction of  life : but  the only
certain  sign is actual putrefaction ;  and therefore in every case
where this symptom is not present, and where we are unacquaint-
ed with the length of time the body may have been under water,
every possible means should be  employed immediately  upon its
being found for restoring it to life, as the noble machine may be
stopped, and  the spring nevertheless still retain, in some degree,
its elastic  vigour.
  Dissections of those who have died by drowning, show that an
accumulation of blood in the venous system forms the great mor-
bid change which takes place  in accidents of  this nature.  The
lungs are  in a slate of collapse, and the  accumulation of blood is
confined to the vena cava, the heart,  and the parts of the venous
system.   In some  cases the stomach is  found  to contain a small
quantity of water; in others, none is to be perceived.  From the
muscles of the trachea having  lost  the principle of life, upon
which the power  of muscular contraction depends, they become
relaxed, the water  enters  the wind-pipe.  In all instances, the 
APPENDIX.
xv
external surface of the brain appears of a  highly florid colour,
without any great distention of vessels, or marks of effusion.  It
has been supposed, however, by many,  that persons  who die by
drowning, suffer from the intervention of apoplexy.   After  a re-
covery from apoplexy, the person is generally paralytic, whereas
no such event follows the recovery from a  suspension of life by
drowning.   In both hanging and drowning, the proximate cause
appears to be the stoppage of air to the lungs, which the follow-
ing experiment, made  some years  ago  by an  eminent medical
professor at Edinburgh, clearly confirms.  A dog was suspended
by  the neck with a cord, an  opening  having been previously
made in the wind-pipe  below the place where the cord was ap-
plied, so as to admit air into the  lungs.   In this state he was al-
lowed  to hang three quarters of an hour, during which time the
circulation  and  breathing went  on.  He  was then cut down,
without appearing to have suffered much from the  experiment.
The cord was now shifted below the opening into the wind-pipe,
so as to prevent  the ingress of  air to  the lungs; and the ani-
mal being  again  suspended, he  was completely dead  in a few
minutes.
  The appearances exhibited on dissection, in cases of strangula-
tion and suffocation,  are pretty similar to those in drowning, ex-
cept the absence of water in the lungs and stomach :  and that in
these instances there is always a  greater turgescence in the ves-
sels of the pia mater.
  The following are the  means to be employed for the recovery
of persons recently drowned.
  As soon as the body is taken out of the  water, it is to be  spee-
dily conveyed  in men's arms, or placed upon a door,  or in a cart
upon straw, if the distance is considerable, to the nearest house,
where it is quickly to be stripped of the wet clothes;  to be wiped
perfectly dry ; and then to be laid between warm blankets, spread
upon a mattress or a low table, and on the right side in prefer-
ence to the  left, in order that the passage of the blood from the
heart may be favoured by the position.   The head is at the same
time to be covered with a woollen  cap, being properly elevated
with pillows, and bags filled with warm sand, or  bricks heated
and wrapped in flannel, are to be applied to the feet.   The  doors
and windows of  the  apartment are  to be thrown  open, in  order
that the cool air may be freely admitted, and no persons but such
as  are necessary to give due assistance,  should  be allowed to
enter it. 
xvi
APPENDIX.
  Having taken these steps, we should next endeavour to ex-
pand the lungs, and make them, if possible, reassume their office.
When not furnished with a flexible tube made of elastic gum,
and of a sufficient length, or with  the bellows  invented  by Mr.
Hunter for this express purpose (which is of such a construction,
that, by one action, fresh air is thrown into the lungs, and by an-
other it is thrown out again, so as to imitate or produce artificial
breathing,) we must be content with blowing in air, by means of
a common pair: or by inserting a pipe into one nostril, com-
pressing the other, shutting the person's mouth at the same time,
and then blowing through the pipe with a considerable  degree of
force. By  any of these means we may  be able to inflate the lungs.
  At the same time that  the lungs are inflated, we should rub
every part of the body with warm flannel  cloths.  On all occa-
sions it will be the best way to divide the assistants into  two sets;
the one being employed in endeavouring to restore the  heat of
the body;  the other, in instituting an artificial breathing in the
manner just  pointed out.   Should the frictions not be attended
with any effect, we ought to apply flannel cloths,  wrung out in
very hot water,  over the heart and thorax, or we may  put the
person into a warm bath.  A high degree of heat will not be ne-
cessary ; a moderate degree will be sufficient.  If the weather be
under the freezing point, and the body, when stripped, feel cold,
and nearly in the same condition with one that is frozen, it will
be necessary at first to rub it well with snow, or wash it with cold
water; the sudden application of heat in such cases having been
found very pernicious.  In  a short time, however, warmth must
be gradually applied.
   To assist in rousing the vital principle,  it has been customary
to apply various stimulating matters, such as common salt, and
rectified,  and also volatile spirits, to  different parts of the body;
but as the skin loses its sensibility in  proportion as it is deprived
of heat, and  does not recover it again until the natural degree of
warmth be  restored, it is obvious that previous to the  restora-
tion of heat, all such applications are useless.   Rectified spirits
evaporate fast, and thereby, instead of increasing warmth, as they
are  expected to do, carry off a part  of the heat from the body.
Volatile spirits  are liable to the  same objections, and are, be-
sides, distressing to the  eyes of the assistants.  Common salt
 quickly frets the skin, and has, in some  cases, produced sores
 which were difficult to heal after recovery.  When there is rea-
 son to think the skin has, in  some degree, recovered its sensi- 
APPENDIX.
xvu
 bility, the wrists, ankles, temples, and parts over the stomach and
 heart, may be rubbed with a little of the linimentum ammonia
 subcarbonatis, which  will evaporate  but slowly, and produce no
 cold in being  rubbed in.  In cases of suspended animation, it has
 likewise been  usual to stimulate the stomach and intestines; the
 former by means of some moderately warm liquor,  such as ne-
 gus highly spiced, introduced into the organ through a  flexible
 tube, and the latter by means of injections.
   Some  time  ago it was the practice to employ the smoke of to-
 bacco ; but this, instead of  answering our wishes, would prove
 injurious, by further depressing the vital principle. Instead of it,
 we may recommend a clyster,  consisting of a pint or more of
 water, moderately warmed, to which may be added a little vola-
 tile spirit,  essence of  peppermint, or rectified spirit.
   Electricity is  sometimes had recourse to, in order to promote
 a restoration of life; unless employed by insulation alone, it will,
 however, be more likely to do harm  than good.  The body may
 be completely insulated, by placing it on a door, supported by a
 number of quart bottles, whose sides are previously wiped with
 a dry towel to remove any moisture  they may have  contracted.
 Moderate  shocks  are found to  answev best, and  these may, at
 intervals., be passed through the chest in  different  directions.
 They may  likewise be sent through the limbs, and along the
 spine; but it is doubtful how far it is safe to pass them through
 the brain, as many have recommended.
   From some  late experiments made by Professor Aldini, of the
 University of Bologna, on the body of a malefactor, who was ex-
 ecuted for murder in London, it would appear that galvanism, as
 an  auxiliary, promises great advantage to the interests  of hu-
 manity, in  cases of apparent death by drowning, and others of
 asphyxia.   Before dissection, the corpse was  made  to exhibit
 very powerful muscular contractions, and these continued for
 upwards of seven hours.   On the first application of  galvanism
 to the face, the jaw of the deceased criminal began to quiver, and
 the adjoining muscles were horribly contorted, and one eye was
 actually opened.   In  the  subsequent part of  the process, the
 right hand  was raised and clenched, and the legs and thighs were
 set in motion.  We are further told, that it appeared to the un
informed part  of the by-standers, as if the wretched man was
about to be restored to life.
  The mode recommended by M. Aldini for the employment of
 galvanism,  as a mean of restoring suspended animation, is as fol-
  VOL.  II.          -      *  C 
xviii                   APPENDIX.
lows.  He immerses the hand in a solution of muriate of soda,
and establishes an arc, one of the extremities of which is made to
pass round the fore-arm, while the other is brought in contact
with the bottom of the pile.  He adapts to the extremity of an-
other arc  an  elastic probe, which is applied  to one of the ears,
moistened by means of a syringe with the same solution, and
connects the other extremity of the arc with the summit of the pile.
  Bleeding is a remedy which is sometimes employed in  cases
of a suspension of the vital powers from drowning.  Where stu-
por, headach, 8cc, remain after the person  has come to himself,
it certainly will be advisable to draw off some blood, and possi-
bly the best way of doing it  will be by the application of leeches
to the temples; but where these symptoms do not prevail, or be-
fore the natural heat is restored to the body,  bleeding in any
manner will be more likely to do harm than good, by hazarding
the entire destruction of those feeble powers which yet remain,
to increase and support which our best endeavours should be di-
rected.
  Hanging the patient by the  heels, as is sometimes adopted by
the ignorant, in cases of suspended  animation  from drowning,
under  the mistaken principle  that this is induced by the water
taken into the stomach and lungs, or both,  is a most dangerous
practice, calculated only to extinguish the spark of life1, if any re-
mained, and consequently to exclude every hope of recovery.
  The means which have been advised are diligently to be per-
severed in for a considerable time, and the case by no means to be
given up as irretrievably lost until at least after the expiration of
four or five hours' trial, as recoveries have been  effected to this
extent.
  When the  patient is so far recovered as to be able to swallow,
he should be  put into a  warm  bed, with his head and shoulders
properly elevated with pillows.  Warm wine whey, or any other
light  and  nourishing  drink, should now be given in moderate
quantities at  a time, and a gentle diaphoresis promoted by wrap-
ping the feet and legs in flannels well wrung out of hot water.
If the  stomach and bowels  feel distended and uneasy, a clyster
composed of  a pint of warm water,  with about an ounce of pur-
gative salt dissolved in it, and a little oil, may be administered.
The general practice in this case is, to give an emetic; but from
the powers of the machine being still very weak,  the agitation of
vomiting would appear somewhat hazardous.  The patient should
on no account be left alone^until the senses are perfectly restor 
APPENDIX.
xix
ed, and he is able to assist himself, some persons having relaps-
ed and been lost, from the want of proper attention to them, after
the vital functions were, to all appearance,  tolerably established.
  In cases where life is suspended by hanging, the same means
recommended for  drowned persons are to  be  pursued,  with the
addition of  opening the jugular veins, or  applying cupping-
glasses to the neck, which will tend considerably to facilitate the
restoration of life, by lessening the quantity of blood contained in
the vessels of the head, and thereby taking off the pressure from
the brain.  Except in persons of a full plethoric habit, the quan-
tity drawn off need seldom exceed an ordinary tea-cupful, which
will in general be sufficient to unload the vessels  of the head,
without weakening the powers of life.
  The  method of treatment to be adopted in cases  of general
torpor from  an exposure to a severe degree of cold, should be as
follows:
  The person should be removed with all speed to a  convenient
place where the necessary aid can be given. If the body is naked,
it should be  covered, having the head and face bare.  If snow
can be got, the body may  be rubbed at first with it gently from
the stomach  to the extremities.  In a few minutes afterwards the
frictions may be made with cloths steeped in cold water, the tem-
perature of which is to be increased, so as to heat the body gradu-
ally and by slow degrees.  The  face may  at  the same time be
sprinkled  with water, the lips and nostrils be irritated  with a fea-
ther and volatile alkali, or some such stimulant.   As soon as the
body is restored to  some degree of warmth,  and the limbs become
somewhat flexible, the person should be placed in a dry but not
warmed bed, and be well rubbed with flannels or a brush: his
lungs  may also be inflated, and an irritating clyster (composed of
a pint of water with an addition of a spoonful of spirit of harts-
horn with  a little mustard, or a little rum, brandy, or  gin, added
instead of these) be administered from time to time.
  When the power of swallowing is restored, we should give the
person some warm and gently stimulating drink, such as thin
broth with a  little brandy in it, or water with some wine, which
may be administered by a spoonful at a time.
  While the body is cold, and the circulation and the respiration
are  languid, I think blood-letting would be improper.   If, how-
ever,  after these functions and the  natural temperature are re-
stored, the patient  should remain any time in a  comatose state, 
XX
APPENDIX.
with a strong full pulse, the propriety and necessity of venesec-
tion can hardly be doubted.
  Before I close this subject, I think it proper to observe, that in
all cases of drowning as well  as in every other instance  where
death appears to be the consequence of apoplexy, syncope, le-
thargy, hysteria, or  asphyxia,  8cc. we should be cautious  in not
allowing the body to be interred until evident signs of decom-
position or putrefaction are apparent: as the suspension of res-
piration, rigidity of the limbs, abolition of sensation and motion,
the want of pulsation in the heart and arteries, coldness of the
body, and the collapse, opacity, and want of lustre in the eyes, are
but equivocal symptoms of death, and ought not therefore to be
relied on alone.
                       Frost-bitten.

  If a person has exposed his hands and feet to a very severe cold,
the excitability of these parts will be so much accumulated, that
if they are brought suddenly near  a fire, a violent inflammation
and even a mortification may take  place, which has indeed often
happened; or, at any rate, that inflammation called chilbain, will
be produced from the violent action of the heat upon those  parts;
but if a person, so circumstanced, were to put his hands and feet
into cold water, very little warmer  than the atmosphere to  which
he had been exposed, or rub them with snow, which is not often
colder than 33 degrees, the morbid excitability will gradually be
exhausted, and no bad consequences w'ill  ensue.  When the
hands, feet, nose, or any other part  of the body, have therefore
been exposed to violent cold, so as to be frost-bitten, they  ought
at first either to be well rubbed with sno   or be put in  cold wa-
ter, and afterwards be subjected to warmth in  the most  genu"*
and gradual manner.
              The Diseases of Pregnancy.

  Three different stages evidently exist during a state of preg-
nancy, each of which has  a distinct set of symptoms; and when
we reflect on the alteration which the constitution suffers in con-
sequence of impregnation, and the  vast  distention and dislodg-
ment of the uterus which, prevail at a more advanced period, we 
APPENDIX.                    xx»
 cannot be surprised at the many  complaints and irregularities
 which then arise.
  The first stage  of pregnancy is usually accompanied with a
 suppression of the menses, together with  frequent nausea and
 vomiting, heart-burn, indigestion, peculiar longings, headach,
 giddiness, toothach, and sometimes a slight cough ;  the  breasts
 become enlarged,  shooting pains  extend through them, and the
 circle round the nipple alters  to  a dark brown colour.  There
 often occurs likewise a feverish disposition, with debility, emacia-
 tion, irritability, and peevishness of temper, and a total altera-
 tion of the countenance, every feature of which  becomes much
 sharpened.   Some women breed so  easily as  to  experience
hardly any kind of  inconvenience whatever : whilst others again
 are perfectly incapable of retaining the least thing on  their sto-
 mach, and are thereby reduced to  a state of extreme  weakness.
  With some women the vomiting will continue during the whole
 or greater part of the second  stage of pregnancy, as well as the
 first; but this does not usually happen. Partial suppressions of
 urine with a frequent inclinatiop  to  void  it;  itching  about the
 external parts of generation, costiveness, tenesmus, and the piles,
 are what they are chiefly  incommoded by during this  period.
 Most women quicken about the sixteenth week after  conception,
 at which time the mother becomes sensible of the slightest efforts
 of the child;  and  besides  the  complaints just enumerated, she
 will then be  liable to sudden  faintings, and slight  hysteric af-
 fections.
  According  to the common  received opinion, quickening, so
 termed, has been generally understood  to commence at the time
 when particular sensations are perceived by the mother, supposed
 to be oc«asioned by the first motion of the child. The most usual
 time of feeling any such symptoms is about  the latter end of the
 fourth or beginning of the fifth month of pregnancy : at this pe-
 riod the uterus filling up the pelvis, slips out and rises above the
 rim ;  and from that sudden transition, women of  a delicate con-
 stitution and  irritable fibre, are apt to faint, more particularly so
 if in an erect position.*
  During the  last  three months,  or  third  stage of pregnancy,
 general uneasiness, restlessness, (particularly by night,) costive-
 ness, oedematous swellings of the feet, ankles, and private parts,
 cramps in the  legs and thighs, difficulty of retaining the urine for

           * See Obstetrie Studies, by Mr. James Hogben 
xxii
APPENDIX.
any length of time, varicose swellings of the veins of the belly
and  lower extremities, and  the piles, are the affections which
usually prove most troublesome.  In weak delicate women, of
an irritable habit, convulsive fits sometimes arise, which are ever
to be regarded in a dangerous light.
  Nausea and vomiting.—It has been  observed,  that frequent
nausea and  vomiting are apt to prove somewhat troublesome to
pregnant women, and in many c.ases to reduce them to a state of
very great debility. As these most frequently arise immediately
upon first getting out of bed in the morning, the  patient should
be recommended,  under  such circumstances, never to rise until
she has taken either a dish of tea, coffee, or whatever else she has
 usually accustomed herself to for breakfast.
   If the vomiting should become at any time so severe as to
 threaten the bringing on a miscarriage from the violence of strain-
 ing, it may then be advisable to direct two or three table-spoonfuls
 of the saline medicine to be taken every now and then in such a
 manner as that the effervescence shall ensue after it is swallowed;
 besides which, the patient's body should be kept open with some
 gentle laxative.   If these means do  not succeed, we may order
 about six ounces of blood to be drawn from the arm, and which,
 if necessary, may be repeated in a week's time.  The sickness in
 such cases depends on irritation, and is only to  be removed with
 certainty by bleeding.
    Local applications have been recommended to abate excessive
 vomiting.   As such, a piece of folded linen cloth, moistened with
 tinctura opii, may be kept constantly applied to the region of the
 stomach.  Probably a small addition of  aether might increase its
 good effect.  It sometimes happens that vomiting is incessant for
 many  days together, accompanied  with  great  prostration of
  strength and constant thirst, and at the same time  an utter im-
  possibility of retaining any thing on  the stomach.  In this state
  the application of leeches to the pit of it,  and a constant atten-
  tion to suffer nothing to be swallowed that can irritate, allowing
  the patient only  asses'  milk, and that  by single  spoonful, have
  been found to afford relief.  If a  considerable degree of nausea
  prevails, without the ability of throwing up, fourteen or fifteen
.  grains of pulv.  ipecac, may then be given, experience having
  proved that gentle emetics may be administered with perfect
  safety to pregnant women.
     Headach, with plethora.—When either headach, drowsiness,or
  a sense of fulness in the vessels, proves troublesome, drawing oft 
APPENDIX.                   xxiii
a few ounces of blood from the arm in robust women will  most
likely be attended with advantage.  In those  of a weak, irritable
habit, the application of  a leech or two to each  temple will be
more advisable than bleeding from the system, where the headach
proves obstinate, and resists the other means we have employed.
The bowels are at the same time to be kept in a proper state by
some gentle aperient.
   Toothach.—For the alleviation of the toothach,  the external as
well as internal application of a few drops of the oil of cloves,
cajeput,  juniper, or any  other  essential  oil, will often prove
effectual.
   Heartburn.—If the patient is incommoded by heartburn,(which
usually proceeds from an acidity in the stomach,) half a drachm
of magnesia may be taken morning  and evening, to obviate it:
and if this fail, we may then have recourse to  the absorbent  mix-
ture advised below,* which  Dr. Sims  informs usf he has found
the most efficacious of all remedies for the removal of  this dis-
tressing symptom in pregnant women.
  Longings.—When peculiar longings arise in a state of preg-
nancy, they should always be  gratified, if possible, as women are
apt to  miscarry from the anxiety these  occasion when not in-
dulged in them: but that the child in utero  can  be marked by
any depraved appetite of the mother, or be mutilated by  any dis-
agreeable object being presented  to her, cannot  be admitted.
All aberrations from the usual form ought to be ascribed to the
irregular operation of the powers concerned in generation, and
are not produced by the imagination of the mother.
  Hysteria.—Should any hysterical affection or sudden  fainting
arise, little more will be necessary, than to expose the patient to
a free open air, to place her in a horizontal position ;  and to  give
her a glass of cold water with a few drops of the liquor ammoniac
subcarbonatis, or a little wine  sufficiently diluted.
  Costiveness, Piles, isfc.—Costiveness, partial  suppressions of
urine, and the piles, which attend on the second stage of preg-
nancy, are occasioned by the great pressure of the uterus on the
rectum and bladder.  The first and last of these symptoms are to

  • Take Magnesia, one drachm.
         Pure Water, five ounces and a half.
         Spirit ot Cinnamon, three drachms.
         Solution of Ammonia, one drachm.
    Mix them, and take two or three table-spoonfuls for a dose, as the occa-
      sion may require.
 f See the Medical and Physical Journal, No. viii.p. 206. 
XXiv
APPENDIX.
be obviated by a daily use of some gentle laxative, such as a solu-
tion of manna, or the electuary advised below.*  Pills composed
principally of aloes (such as Anderson's) are too generally used
by pregnant women for this purpose: but they are highly im-
proper, as being of  too stimulating a nature, and very apt to oc-
casion haemorrhages and  the piles.  In troublesome piles, which
are externally seated, the best application  is leeches, and the irri-
tation may afterwards be  lessened by preparations of the plumbi
superacetas.  Ten grains of this, dissolved in four ounces of rose
water, form a good lotion, with  which the parts may be washed
frequently.   If necessary, a little of the vinous tincture of opium
may be added.
   Diarrhxa.—If diarrhoea  arises in pregnant women, it should
be treated just as at any other time; (see this disease;) and after
the stomach and intestines are cleared, astringents may be used,
if there is no great degree of fever.   If fever is present, that must
be attended to  chiefly, and be first removed.
   Suppression of Urine.- When a  suppression of urine takes
place, which is apt to happen in the advanced stage of pregnancy,
besides making use of emollient fomentations, clysters, and gen-
tle purgative medicines, such  as the oleum  ricini, the  patient
drinking plentifully at the same  time of diluent liquors, it will be
necessary to have recourse to chirurgical assistance, by drawing
it off by means of a catheter, morning and evening.
   Retroverted Uterus.—It sometimes happens that a retrover-
sion of the uterus ensues, in which  case it becomes misplaced
downwards and backwards,  because  the os uteri is tied forwards
to the meatus urinarius, and there is  no communication behind
by which it is held to the  rectum ; but anteriorly it is connected
with the neck of the bladder by close cellular substance; there-
fore whatever raises the bladder will raise the cervex uteri, and
what raises  this, must at  the same time depress the fundus: so
that in a retroversion of the  uterus, the urethra is drawn up close
behind the symphysis pubis; and in the  case now under consi-
deration, the bladder rises and draws up the os uteri with it.
   The only period of pregnancy at which a retroversion of the
uterus is apt to arise is between the end of the third and fourth

   * Take Electuary of Senna, two ounces.
         Supertartrate of Potass, two drachms.
         Powder of Jalap, half a drachm.
         Syrup of Roses, a sufficiency.
    Mix them, and of this electuary the patient may take the bulk of»
      nutmeg, at bedtime, or occasionally. 
                       APPENDIX.                   xxv

months;  for in the early months of pregnancy, the  uterus in
length, from the fundus to the cervex, is not so great as to fill the
space between the sacrum and the neck  of the  bladder, and
cannot, for that reason, produce suppression!  This applies to all
situations of the uterus in unimpregnated women, and women
who are  with  child, till the  close of the fourth month of preg-
nancy ; after which, the uterus cannot be made to go down into
the pelvis.  When the uterus has once fairly ascended into the
abdomen, it is impossible for  it to return into the pelvis until its
volume has been diminished  by delivery or abortion.
  In most of these cases the suppression  of urine is the only
material  object to be attended to;  for the uterus  being retro-
verted, the  woman cannot make  water; therefore it muM be
drawn off by the  catheter.  If  necessary, this operation is to be
repeated twice a  day, till the uterus, by a gradual  enlargement,
recovers  its natural situation, which will be preferable to any in-
terference of the attendant to reduce it.  Where it is impossi-
ble for him to attend twice a day for the purpose of drawing off
the water, the reduction may  possibly be effected by the patient
placing herself on her hands and  knees, and then passing two
fingers of one  hand into the vagina, and a finger of the other into
the rectum, by which means it is possible sometimes to succeed.
Where the event is left to time, the uterus is sure to recover its
proper situation; for which reason it is preferable to leave it.
   In passing the catheter in cases of retroverted uterus, it will
be necessary to attend to its curve, which curve is given by hold-
ing the instrument in one  hand, and pressing the thumb on the
other hand on one side, while it is gently drawn through the hand.
The point of the catheter must be dexterously introduced close
behind the pubes; for if some dexterity is not used it frequently
will not pass into the bladder.
   Troublesome Itchings.—Where a severe  itching  about the
parts of  generation attends on pregnancy, it will be proper to
keep the woman's body perfectly open with some  cooling laxa-
tive, and  to wash the parts three or four times a day with a solu-
tion of lead, such as the liquor plumbi  acetatis dilutus;  if much
inflammation  accompanies the itching, topical bleeding may be
requisite.
   Oedematous Swellings—The swellings of the feet, ankles, and
private parts, which  arise in tht* last  stage of pregnancy* are
occasioned by the pressure made by the womb, which now pre-
?ents the free return of the  blood  from the lower extremities.
    VOL. II.                *  D 
XXVI
APPENDIX.
Gravid  women are usually free  from these complaints  in the
morning,  but  towards night they frequently suffer much from
them. Slight scarifications with the edge of a lancet, to discharge
the stagnated fluid, with the after application of flannels wrung
out in a warm infusion of emollient herbs, have been employed
in cases of great distention.  In general, however, it will only be
necessary that the patient does  not keep her feet in a pendant
position for any length of time.
   Cramp.—Cramps of the legs  and thighs are  to be relieved by
rubbing the parts with cold vinegar, with camphor dissolved in
oil, or the liniments here* advised, the person wearing stockings
in bed.   At an advanced period of pregnancy they are only to be
relieved by labour removing the cause.  Where the stomach is
affected with spasms, proper doses of aether and tincture of opium,
with  the  other means  advised under  the head of Hysteria, in
cramps of that organ, will afford the greatest benefit.  In such
cases the patient  must carefully avoid every kind of food that is
apt to prove flatulent or hard of digestion, and she must keep her
body  perfectly open.
   Inability of Sleeping, and Restlessness.—Inquietude and inabi-
lity to  sleep,  prove troublesome  complaints towards the latter
period of pregnancy, the patient being obliged  to rise frequently
throughout the course of the night, in order to expose  herself to
the influence of cool air.  Nothing affords so great relief in cases
of this nature, as bleeding in small quantities, with the occasional
use of  some cooling laxative medicine.   Opiates are never at-
tended  with advantage in such conditions.
   Varicose Veins,—The veins of the legs, thighs, and belly, often
become varicose in  the last stage of pregnancy, and sometimes
put on  an alarming appearance from their great enlargement and
distention.  No bad consequences have, however,  been observed
to attend such a condition; and the only thing necessary to be
done, is  to empty the vascular system  by moderate  bleeding,
gentle  purging,  and a spare diet.  Should the vein of  any parti-
cular part become so distended as to prove troublesome, it may
be advisable to apply a bandage of a moderate tightness, so as to
give  the necessary support to it.
   Jaundice.—In some instances the woman is affected with a pain

   *  Take Camphorated Spirit, one ounce.
          Spirit of Sulphuric JEther.
          Tincture of Opium, of each half an ounce.
      Mix them for a liniment. 
APPENDIX.
xxvii
in her side, and excessive sickness at the stomach and retchings,
the  skin assuming a deep yellow colour.  It is only under these
circumstances that the complaint proves distressing, and  it is
usually occasioned by the formation of one or more gall-stones,
and the obstruction which they oppose to the usual and  regular
passage of the bile.  The means most conducive to relieve the
woman from this degree of the complaint, are blood-letting, warm
fomentations to the painful part, and large doses of opium,  with
such laxatives as shall counteract the effects of the opiates.
  Jaundice, or any other bilious affection,  prevailing during a
state of pregnancy from the  pressure of the  uterus on the  gall-
bladder  or ducts,  is to be obviated  by keeping the body open
with some gentle laxative, such  as pills composed of rhubarb and
soap.
  Incontinency of Urine.—This is a very disagreeable complaint,
as it keeps the woman constantly in an uncomfortable.state.  It
is to be removed only by delivery, but may be  moderated by a
frequent horizontal posture.  Its bad effects may be prevented
by a scrupulous attention to cleanliness, and the use of a thick
compress  of linen,  or  a sponge of considerable size, properly
fastened.
  Over-distention of the Abdominal Skin.—In the latter months of
pregnancy the integuments of the abdomen will sometimes be-
come cracked and sore, the skin seeming to suffer from over-
distention.  In this case nothing is so effectual as a frequent use
of warm oil by friction ; and  to give it somewhat of a medicated
appearance, a little camphor may be added.
  False Pains.—Pains somewhat resembling those of labour, and
known by the name of false pains, are apt  to come on at an ad-
vanced stage of pregnancy, and often to occasion  an unnecessary
alarm.   In such cases, confinement in a horizontal position, bleed-
ing* if plethoric, laxative medicines if costive, and administering
small and  frequent  doses of some opiate  until the patient finds
ease, will be necessary.
                       Convulsions.

  Convulsions may occur either during pregnancy or  labour,
and are of different  kinds, requiring opposite treatment.  One
species is the consequence of great exhaustion from a  tedious
labour, excessive fatigue, or profuse haemorrhage.  This makes 
xxviii
APPENDIX.
its attack without much warning, and generally alternates with
deliquium, or great feeling of depression of strength and debility;
the muscles about the face and chest are chiefly affected, and the
pulse is small, frequent, and compressible, the face pale, the eyes
sunk,  the extremities cold.  The fits succeed each other pretty
quickly, and very soon terminate in a fatal syncope.  Apparently
it was this species of  convulsion that destroyed her toyaj high-
ness the Princess Charlotte of Wales.
   In all cases of this nature, it should be our object to check the
further operation of the exciting cause, by restraining haemor-
rhage, if present, or preventing every kind of exertion, and thus
husband the  strength  which  remains, or recruit  it by cordials.
Opiates will be of infinite service in conjunction with aether and
camphor.   Delivery is usually necessary.
   Hysterical convulsions  are more  common during  gestation
than during labour.   Here it may, therefore, only be necessary
to add to what has already been said under the head of Hysteria,
that, if they do not speedily yield to antispasmodics, venesection
had better be resorted to ; and, if that fails, we should, if possible,
deliver the woman.
   The species of puerperal convulsions most generally met with
bears  some likeness to epileptic fits; and it is only by being aware
of the different degree of violence attending each, that  at first
 sight  we can distinguish them.   A fit of puerperal convulsion is
much more severe than one of epilepsy, and  a paroxysm of the
 former is usually so violent, that a woman, who, when in health,
 was by no means strong,  has been so convulsed as to shake the
 whole room, and to resist the coercive powers of many attendants.
 No force, indeed, can  restrain  a woman when in these convul-
sions.  The distortion of her countenance is beyond conception:
in regard to deformity of countenance, nothing bears any resem-
blance to the. progress of this disease ; the rapidity with which
the eyes open and shut, and the  sudden twirlings of the mouth,
are inconceivable and frightful.
   Puerperal convulsions seldom happen before the sixth month,
but may occur at any time between this period and the comple-
tion of labour.   They may arise as the first symptom of labour,
or after  the labour is finished.  This species of convulsion de-
pends on the state of the uterus,  and has been observed to arise
oftener during the first pregnancy than in any after one* particu-
larly where the woman is unmarried.
  The characteristics of puerperal convulsion are as follow:— 
APPENDIX.
xxix
The paroxysms occur periodically like labour pains, so that there
is a considerable space between them at first, but afterwards they
become more  frequent.  They not only occur with the labour
pains,  but  in  the intervals between ;  and whether there have
been labour pains or not before they come on,  we shall usually
find the os uteri somewhat dilated, and it is sure to become still
more so from  the continuance of these convulsions.   At length,
if the woman is not relieved, and the convulsions continue without
destroying life, the child is actually expelled by the contraction
of the uterus,  which power is capable of expelling it even alter
death.
   The immediate symptoms are somewhat similar to those of the
epileptic paroxysm.  The  woman suddenly loses all sensation,
and stretches  herself out;  the muscles then  become extremely
rigid,  and  are speedily afterwards thrown into violent convul-
sions, the face is distorted,  the eyes are protruded, she gnashes
her teeth and foams at  the mouth.  After the paroxysm is over,
she remains in a comatose state,  and has stertorous breathing,
similar to what takes  place in apoplexy.  At length, except in
very aggravated cases,  she slowly  comes to herself, but without
being conscious that she has been in a fit.   After a longer  or
shorter interval a fresh attack takes place in the manner just de-
scribed, for it rarely happens that there is not a repetition of  the
paroxysm in all cases of true puerperal convulsion.  During the
fit the  skin becomes dark and purple, proving that the circulation
through the lungs is not free, which purple colour leaves  the
woman after the fit is over.   By the introduction of the hand into
the uterus, when these convulsions  have come on,  it has been
ascertained that this organ is contracted, but  with a tremulous
undetermined  sort  of force, perfectly  different from  what takes
place at any other time.
   There are two cases of puerperal convulsion which  are very
distinct: one is a convulsion dependant on an irritable or excita-
ble state of the nervous system;  the other on  a  fulness of the
vessels of the  brain, or perhaps a  slight extravasation from  the
vessels thereof.  When puerperal convulsion  arises from  the
latter cause, it is always preceded by some symptoms, which, if
watched, will  enable us to relieve, if the patient applies in time,
but which is rarely done: and if these symptoms  are neglected,
at some period or  another convulsions will follow.  In a woman
strongly disposed to this complaint from such a cause there will 
XXX
APPENDIX.
be a sense of great fulness in the head, giddiness in the advanced
periods of pregnancy, drowsiness, and a sensation of weight when
she stoops forward, imperfect vision, and atoms floating before
the eyes.  These symptoms strongly denote fulness of the ves-
sels of the head, and, if allowed to continue, may lead to extrava-
sation or puerperal convulsion ; but, if early attended to, may be
removed, and premature labour prevented.  Under such circum-
stances, the first step to be adopted is,  to draw  ten or twelve
ounces of blood from  the arm, repeating the operation the next
day or so, if no alleviation takes place.   After the first bleeding
the bowels should be opened  by some mild purgative, such as a
solution of any of the neutral salts and manna, which may be re-
peated every third or fourth morning until the plethora is remov-
ed.  With these means the patient ought to abstain from all solid
food, wine, 8cc.
   When these precautionary means have not been adopted, and
puerperal convulsions have ensued, we are, on being called in, to
open a vein immediately, particularly the jugular, or  even  the
temporal artery, and to draw off blood in a considerable quantity,
being regulated therein by the appearance of the person and her
habit of body.   From twelve to twenty ounces may be the extent
of the first bleeding.   If the disease goes on, and the os uteri
does not admit of delivery from its not being dilated, the convul-
sions not abated or gone off, and the pulse in such a state as to
admit of it, we should  bleed again and again.   Sixty  ounces of
blood have been drawn off in the course of the twenty-four hours
under  these circumstances, and with a  happy effect.   Women
in such a state admit of divided bleedings very largely.  On ex-
amining the bodies of women who have died  of puerperal con-
vulsions, the vessels of the brain are always found enormously
turgid; in  some cases  blood  is extravasated, and  the heart is
often perceived completely empty*
   After the first bleeding a blister of considerable size  should be
applied to the neck, or between  the shoulders;  the head be
shaved and  cooled with evaporating lotions ; and, if judged ne-
cessary, blood  be  drawn from the temples by several leeches.
The next point to be attended to is, to  get the bowels to act as
quickly as possible, and this will  be effected  by throwing up a
smart or active clyster, and then giving a strong solution of some

   * See cases reported by Mr. Chevalier, in the Medico-Chirurgical Trans-
 actions. 
APPENDIX.
xxxi
neutral salt, as magnesiae, sulphas, potassae tartras, or soda tar-
tarizata, in an infusion of senna, as soon as the patient becomes
capable of swallowing.  The bladder is also to be emptied by a
catheter, if necessary.
  If it is a case of convulsion depending upon irritation, we may
likewise bleed, but we must proportion the quantity accordingly.
Eight or ten ounces of blood will be  sufficient, and where more
may appear necessary, it will be best to draw the remainder by
applying leeches to the temples. In cases dependant on irritation,
opium  will be very proper, and it  ought to be given  to the
highest possible extent, the form of a clyster being that to which
we ought to give a preference.   We are  at the same time not
to neglect the  bowels, which  should be kept perfectly open.  Dr.
Denman proposes that a clyster containing six grains of  opium
should be administered, under the supposition, that  by putting
a stop to the contractions of the uterus, the convulsive contrac-
tions in other parts of the body may also cease.  From the ten-
dency  of opium to  affect the brain,  some practitioners have
strongly objected to its use in puerperal convulsions.  By  throw-
ing it into the  intestines it will not, however, be so likely to affect
the sensorium as when received into the stomach.
  Some physicians  recommend the use of a warm bath,  while
others again disapprove of it.   The pediluvium, or the applica-
tion to the soles of the feet of bottles filled with warm  water, may
at any rate be proper.
  The  warm  bath is  strongly recommended  by Dr. Denman
among the means of preventing  convulsions in women previous
to, or during, their confinement.  He states, that from its occa-
sional use women will often  find much  benefit, and that it is one
of the principal  means  which professional assistance  is capable
of affording for preventing puerperal  convulsions, and for insur-
ing an undisturbed labour.   He also  recommends a warm bath
in labours rendered complex by convulsions, and this upon  a long
and extensive experience.  He says, that when convulsions have
continued or  increased, notwithstanding copious bleeding and
the use of all  other rational means, the patient may be put into
the  warm  bath, in which she may remain a considerable  time if
the  convulsions are  suspended while she is in  it.  In instances
where a warm bath could not be procured, or while it was pre-
paring, he has directed flannels wrung out of hot water to  be ap-
plied over the  whole of the abdomen. 
xxxii
APPENDIX.
   Dr. Denman* mentions, that he has seen the patient relieved
from that state  of  irritation immediately preceding the convul-
sion by dipping feathers in cold water, and dashing it with force
over the woman's face, as this  roused her,  and interrupted the
progress of the fit.   Where the further application of cold may
be deemed necessary, and appear advisable, we may throw water
over the patient's head, bringing tlais over the side of the bed,
and holding an empty pail underneath to receive  it.   It should
be done on the approach of the fit, which may be  ascertained by
attending to the vibrations of the intercostal muscles.
  In all cases of puerperal convulsion, after having paid due at-
tention  to the lessening of the cause which has given  rise  to it,
we should uniformly exert our  best  endeavours to deliver the
woman  as expeditiously as possible, where  it is practicable
without violence.   When we find that the os uteri begins to re-
lax and open, and which may take  place  although there be no
labour pains, we must introduce the hand slowly, dilate it, and
deliver the child.
  If convulsions take place after the delivery of the child for the
first time, then the placenta, if it have not come away, ought im-
mediately to  be  extracted; and  if the pulse does  not  expressly
forbid it, a vein is to be opened,  and afterwards the bowels
purged.
  Where convulsions continue after the uterus is emptied of its
contents, all  that we can do  is to keep the brain unloaded, the
bowels open, and the irritability  of the system counteracted by
opium,  joined with  other antispasmodics, such as musk, cam-
phor, and aether.  Where the  disorder continues many hours,
we may apply a large blister to the head, and if benefit is not ob-
tained by the next day, one may also be applied to the inside of
each leg.   These, by exciting an irritation upon a part distant
from the seat  of the disease, may tend to diminish the diseased
action, and thereby  afford some relief.
  To prevent puerperal  convulsions from supervening, as they
are in every instance to be considered as highly dangerous, par-
ticularly at an advanced stage of pregnancy, it will  be prudent, in
robust and  plethoric habits, to pay an early attention to a use of
the lancet  during the progress of pregnancy,  by  drawing off  a
sufficient quantity of blood at different periods; taking care, at
the same time, and  particularly  near the termination  of preg-
* See his Introduction to the Practice of Midwifery. 
                       APPENDIX.                  xxxiii

nancy, to keep the body oppn by cooling purgatives.  In women
of an irritable constitution, all  exciting causes should be care-
fully avoided, and the habit be strengthened as much as possible,
and thereby be rendered less susceptible of disagreeable or ready
impressions.
                          Abortions.

   By abortion is to be understood the expulsion of the contents of
 the gravid uterus at a period of gestation so early as to render it
 impossible for the  foetus to live.  It is an accident or  disease of
 frequent occurrence, which is always attended with disagreeable
 circumstances; and which,  although it seldom proves immedi-
 ately fatal, may still be productive of much mischief at a future
 period.
   Abortions  may happen at any period of pregnancy, but they
 take place most frequently about the third or fourth month.
   From the end of the  third month to the period of quickening
 there is a greater susceptibility in the uterus to have  its  action
 interrupted than either before or afterwards, which is the reason
 of more miscarriages  happening at  that time than at any other,
 and points out the necessity of redoubling our  vigilance in
 watching and guarding against the operation of any of the causes
 from the  tenth to the sixteenth week that may be likely to  excite
 abortion.
   When  a woman happens to part with her burden before  the
 seventh month, she  is  said to have miscarried  or aborted;  but
 when delivered  of it after this time, the term labour is usually
 applied.
   Children born at  the end  of the  seventh month are seldom
 reared ; and when they are, they usually prove small and weakly :
 but those  of eight months are frequently preserved by bestowing
 proper care on them.
   In consequence of an imperfect conception it sometimes hap-
 pens that moles or substances of a fleshy nature (which  upon be-
 ing cut open contain not the smallest  vestige of a child) are  form-
 ed in the  uterus; and these at length becoming detached, give
 rise to a considerable degree of haemorrhage.
  As some women menstruate during the first months  of  preg-
nancy, it will be necessary to distinguish between an approaching
  VOL.  II.                 * E 
xxxiv                   APPENDIX.
miscarriage and a visitation of the menses, which may readily be
done by inquiring whether or not the haemorrhage has proceeded
from any evident cause,  and whether it flows  gently or is ac-
companied with  unusual  pains.  The  former  generally arises
from some fright, surprise, or accident, and does not flow gently
and regularly, but bursts out of a sudden, and again stops all at
once, and  is also  attended with severe pains in the back, and
bottom of the belly; whereas the latter is marked with no such
occurrences.
  Voluptuous women, who  are of a plethoric  habit, as well as
those who are of a weak and irritable frame, are most apt to mis-
carry;  but accidents of this nature sometimes occur from a ge-
neral defective  constitution, or from a malconformation  of the
sexual  organs.
  The causes which give rise to floodings during a state of preg-
nancy are, violent exertions of strength, lifting some heavy weight,
severe  exercise, as dancing or much walking, the fatiguing dis-
sipations of fashionable life, sudden surprises  and frights, violent
fits of passion,  great  uneasiness of mind, uncommon longings,
over-fulness  of blood, partial  spasmodic action about the os
uteri, aloetic purges, profuse evacuations, excessive venery, for-
mer miscarriages, weakness in the parts  immediately concerned,
a diseased stale of the uterus, general debility of the system, ex-
ternal  injuries,  as blows  and bruises,  strong acrid medicines,
such as savin and hellebore, which  are often taken for the ex-
press purpose of exciting abortion, and the death of the child.
  A pregnant woman may be attacked with a  flow of blood from
the womb in consequence of any cause which is capable of sepa-
rating  a part of the ovum from the corresponding part of the
uterus.   The vessels which before passed straight from its inter-
nal surface into the membranes or placenta, and connected them
together, now open, so as to allow the blood  to escape between
them, and to flow externally.  This  separation  and consequent
rupture may arise from any of the various causes just recited,
but in a few instances it  is occasioned by an implantation  of a
part of  the placenta immediately over the os  uteri, which cause
is by far the  most important, because it  is the most dangerous,
and the least likely to find a spontaneous remedy.
  Abortions are sometimes induced  by what  is termed a retro-
version of the  uterus,  in which the fundus uteri is retroverted
and pressed down between  the rectum  and  the vagina.  This
rarely occurs, however, beyond  the first or second month of ges- 
APPENDIX.
xxxv
tation, and is generally preceded by a difficulty in making water,
and a consequent tumour of the bladder; a violent pain about the
perinaeum is thus caused, and a miscarriage is liable to follow.
  Abortions are often preceded by a general sense of coldness,
flaccidity of the breasts, slight pains in the loins and lower region
of the belly, and sometimes with a slight febrile  state of the sys-
tem.   In  plethoric  habits, and where  abortion proceeds from
over-action pr  haemorrhagic  action of  the uterine vessels, the
fever is idiopathic and precedes the haemorrhage.  After a short
continuance of these symptoms a slight discharge of blood ensues,
coming away sometimes in clots,  and at others gushing out in a
florid stream, then stopping perhaps for a short  time, and again
returning violently.
  Sometimes nothing but coagulum can be perceived, that is so
firm, and the globules and lymph so disposed, as to make it as-
sume,  more especially if it has been retained for any time about
the  uterus or vagina, a  streaked or fibrous appearance, which
often gives rise to a supposition that it is an organized substance.
When the contents of the uterus are expelled, a bloody discharge
continues tfor  a few  hours,  and  is then succeeded by a serous
fluid.
  When the pregnancy is advanced beyond the third month, and
abortion is likely to ensue, we have much bearing down, together
with a derangement of the stomach, causing sickness and faint-
ness, and we have likewise a most rapid discharge, owing to the
increased size of the vessels.   In  this stage the membranes often
give way, and the foetus escapes with the liquor amnii, whilst the
rest of the ovum is retained for some hours, or even days, when
it is at length expelled with coagulated blood.  In some instances
the  whole ovum comes away entire.   After the expulsion the
haemorrhage ceases,  and is succeeded by a discharge somewhat
resembling the  lochia.
  With regard to the symptoms and duration of abortion, there
is a  great diversity in different instances.   In some  cases, the
pains are very severe and long continued ;  in others, short  and
trifling.  Sometimes the haemorrhage is profuse and  alarming ;
at other times, although circumstances may not be apparently
very different, it is moderate or inconsiderable.  Often the sym-
pathetic effects'of the stomach and bowels are scarcely  produc-
tive of inconvenience ; whilst, in the greater number of instances,
they are very prominent symptoms.  As there is a diversity in
the symptoms,  so there is also in the duration of abortion;  for, 
XXXV1
APPENDIX.
whilst a few hours in-many, and not above three days in the ma-
jority of cases, is sufficient to complete the process, we meet with
other instances in which it is threatened for a long time, and pos-
sibly some weeks elapse before the expulsion takes place.
  Floodings are more or less dangerous according to  the stage of
pregnancy in which they happen.  The farther  a  woman  is ad-
vanced therein, the greater will be the risk, especially if unaccom-
panied by labour pains, as the mouths of the vessels  which pour
out the blood are much enlarged during the last stage of preg-
nancy, and of course a vast quantity will be discharged in a short
space of time.  Although miscarriages before the fifth month are
seldom attended with immediate danger, the loss of  blood being
usually small, they nevertheless frequently lay the  foundation of
many grievous ailments by happening repeatedly.  Some women
are visited by habitual miscarriages,  and observe a stated period
for several successive pregnancies, which is more  usually  about
the third month  than at any other time.
  The danger of abortion is  to be estimated by considering the
previous state of health and habit of the patient, and by attending
to the  violence of the  discharge, the duration of the complaint,
the difficulty of  checking it,  the disposition to  expulsion which
accompanies  it, the period of gestation at which it  is  threatened,
the frequency of its occurrence, and  its combination with spas-
modic affections or convulsions.
  Previous to my pointing out the  best means for checking an
abortion,  and  the method of conducting the woman through it
when it cannot be avoided, it appears proper to notice those steps
which should be taken for  preventing miscarriages  in  those to
whom they are rather habitual. In all such cases it  will be highly
necessary to attend to the history of such former accidents, to the
usual habitudes and constitution of the woman, and to her condi-
tion when she becomes pregnant.
  A woman that is subject to habitual abortions, and who is of a
full plethoric habit, ought to be bled just before the usual time of
her miscarrying.  She should likewise keep her body perfectly
open with gentle aperient medicines ; use a spare diet, consisting
principally of vegetables, and avoid all agitations of the  mind,
severe exercise, violent efforts, and such objects as  may be likely
to make a disagreeable impression on her.  The "sleep should be
abridged in quantity, and not be taken on a bexl of down, but on a
firm mattress, preventing, at the same time,  the accumulation of
too much heat about the body.  Every day she ought to take re- 
APPENDIX.                 XXXvii
gular and moderate exercise, being cautious at the same time not
to carry it to the length of exciting fatigue.
  To bridle the circulation in women of a full plethoric habit that
are subject to habitual abortions, in addition to drawing off a little
blood from the arm when the pulse is full or inclined to throb it
wopld appear advisable to give half a grain of digitalis twice or
thrice a day, continuing this medicine until  after the usual period
of the woman's miscarrying.
  In women of a weak, lax habit, bleeding would be highly im-
proper, as a mean of preventing habitual abortion.  For such, a
nutritive and generous diet, moderate exercise in a carriage, cold
bathing, and a course of chalybeates, with other tonics, will be ne-
cessary, the patient at the same time avoiding all exciting causes.
Until gestation  be  far advanced,  it would  even be advisable to
live absque marito.   Indeed, in every instance  of habitual abor-
tion, whatever the  condition may be that gives rise to it, it will
be essential that the greatest attention be paid to the  avoiding the
exciting causes.  In some cases it may even be  necessary  to con-
fine the patient  to her room until the period at which she usually
aborts is past.
  In those cases of habitual abortions accompanied with spasmo-
dic pains in the uterus,  or a disposition to convulsions,  opium
given in small doses, twice a  day, might  prove eminently ser-
viceable.
  Where nausea or vomiting prevails in a  high degree, in addi-
tion to  the means  before pointed out, we may apply either an
opium plaster or a blister to the region of the stomach.
  An abortion being threatened  in  consequence of  some slight
separation of the placenta from the uterus,  may frequently be
stopped  by immediately adopting proper steps,  and  the woman
be enabled to go out her full time.
  On the first appearance of a flooding, the woman should  be
confined to her bed, and  be placed with her hips somewhat more
elevated than her head, keeping her, at the  same time, perfectly
cool and extremely  quiet,  debarring her of  all food of a heating,
stimulant nature, giving her cold liquors to  drink sharpened with
some agreeable acid, and applying linen cloths wetted in vinegar
and water, to the loins and private parts.  Ice (if to be procured)
contained in bladders and laid on the thighs and pubes, may oc-
casionally be substituted.
  With the view of moderating the symptoms attending the pro-
gress of a threatened abortion, and preventing it, if possible,  from 
xxxv'm                APPENDIX.

actually taking place, it may be proper, in robust and plethoric
habits, and where the pulse is in any degree full and frequent, to
take away a little blood from the arm; after which, if the bowels
are confined, we may administer a laxative clyster.
  If the discharge is  copious, and is accompanied with irregular
spasmodic contraction of the uterus, or with severe pain, it will be
advisable to prescribe opiates in  small  and frequently repeated
doses, so as to keep  up a constant effect, and they may be com-
bined either with refrigerants,* or with astringents,! or with both.
Equal parts of tincture of opium and sulphuric acid make a good
medicine in uterine haemorrhage;  but it is only in such cases as
are attended with irregular spasmodic contractions, or with se-
vere pains, that opium is given by  the most judicious practition-
ers.   To assist the effect of the medicines, anodyne clysters may
be injected from  time to time.
  Astringent injections composed of a saturated solution of alum,
sulphate of zinc,  or the plumbi superacetas, or of a decoction  of
oak-bark, are often employed in floodings ; and where  the hae-
morrhage is  slight, or remits for any  length of time,  they un-
doubtedly will prove  beneficial, and ought, therefore,  to be used
as mentioned under the head of Menorrhagia; but in floodings
unaccompanied by any remission, they are by no means likely  to
afford much relief.
  In such cases it will be best to trust to the formation of a co-
agulum.  Rest will be absolutely necessary if we wish the woman
to go out her full time, and, therefore, it is sometimes necessary
to confine her for a few weeks perhaps  to  her bed, at the same
time that we put her upon an effective course of digitalis,*, giving

   * Take Infusion of Roses, one ounce and a half.
          Nitrate of Potass, one scruple.
          Tincture of Opium, fifteen drops.
     Mix them.  This draught is to be taken every three or four hours.
   f  Take Confection of Opium, one scruple.  Mint Water, one ounce and
         a half.  Tincture of Catechu, ■      Kino, of each half a drachm.
     Mix them, and give this draught every four  or six hours.
  Or, Take Alum, fifteen grains.
          Gum Kino, five grains.
          Opium, half a grain.
          Confection of Roses, a sufficiency.
     Mix them, and let this bolus be taken every six hours, with three tabic-
      spoonfuls of the Acidulated Infusion of Roses.
   $ Take Powder of Purple Foxglove,
          Opium, of each half a grain.
         Confection of Roses, a sufficiency to form a pill,  which is  to be
           taken every four hours. 
APPENDIX.
xxxix
her an anodyne at bed-time, but taking care to keep the bowels
in a proper state by some gentle aperient medicine.
  Where we cannot prevent the abortion, our study must  be to
conduct  the patient  safely through the  process ;  and the point
which first claims our attention is the haemorrhage.  Bleeding is
an operation employed by some practitioners to check this;  but
unless the vessels are above their natural force  and strength of
action, it is not likely to do any good.  Indeed, the fulness and
strength  of the pulse are lost much sooner in an abortion than
can be explained by the mere loss of blood.  Instead of bleeding,
we had better, therefore, give the digitalis, if therejisno irritation
at the stomach.   In protracted cases,  where  the  discharge has
continued long, this medicine will be highly proper.
  When the means above mentioned have been pursued without
the desired effect, and the woman becomes exposed to imminent
danger from great loss of strength, it will  then be necessary to
have  recourse  to powerful astringents,* such as zinci sulphas
and plumbi superacetas.  Of this last we may give one, two, or
even three grains, repeating the dose'every three or four hours,
according to  the urgency of the case.  As soon, however, as the
haemorrhage has ceased, a gentle purge of the oleum ricini should
be administered, in order to prevent any bad effect from the ac-
tion of these remedies on the coats of the stomach and intestines.
Astringents  used  internally, have, however, been  thought  by
some to possess little effect unless they excite sickness, which is
a different operation from what is expected from them.
  The application of linen cloths dipped in cold water to the back
and external parts, will  have a much better effect  than internal
astringents, and ought therefore never to be neglected.   The in-
troduction of a small piece of smooth ice into the vagina has often

  Or, Take Tincture of Foxglove, twenty drops every four hours, in a little
      water, or any like vehicle.
  Or, Take Infusion of Foxglove, half an ounce.
         Tincture of Cardamom, two drachms.
         Pure Water, six drachms
    Mix them, and let this draught be given every four hours.
   * Take Sulphate of Zinc, two grains to five grains.
         Confect. of Roses, half a scruple.
         Opium, half a grain.
    Mix them. This bolus is to be taken every four hours.
  Or, Take Superacetate of Lead, two grains.
         Extract of Catechu, three grains.
         Opium, half a grain.
         Syrup, a sufficiency to form a pill, which may be taken every
           four hours, with a draught of the Infusion of Roses. 
xl
APPENDIX.
a very speedy effect in retarding the haemorrhage.  A snow-ball
wrapped in a bit of soft linen will have the same effect; but nei-
ther of these should be continued so long as to produce pain, or
much and. prolonged shivering.  The heat of the  surface may
also be moderated by covering the  bed lightly with clothes, and
admitting a free circulation of air.
  The most effectual local method,  however, of stopping the
haemorrhage, is by plugging up the vagina ;* and this is best done
by taking a pretty large piece of soft cloth,  dipping it in oil, and
then wringing it gently.  This is to be introduced with the finger,
portion after portion, until  the  lower  parts of the vagina be well
filled.  The remainder is then to be firmly pressed on the orifice,
and fixed by a T bandage, so as to  prevent the plug from being
displaced.  -This acts by giving time to the  effused blood to
coagulate at the mouths of the bleeding vessels, thereby prevent-
ing any further discharge.   In  obstinate cases, previous  to the
introduction of the plug, we may insert a little pounded ice tied
up in a rag or small bladder, if to be procured.
  To recapitulate the means which we are to employ for restrain-
ing the haemorrhage: if the pulse be full, hard, and  frequent,
bleeding is to be resorted to: but if not, we are to trust to digi-
talis : the application of cold to the thighs and pubes, admitting
cool air freely  into the bedchamber, keeping the heat of the*body
at a low temperature, absolute rest  in a  horizontal position, and
which must be continued during the whole process, however long
it may be, cold acidulated  liquors  for ordinary drink, light food
taken in small portions at a time, carefully abstaining from every
thing stimulant, and plugging up the vagina.
  Where any sickness or great feebleness attends on an abortion,
the body is to be kept at rest with the head low;  and we may at
the same time give small quantities of some stomachic cordial,
such as a few drops  of aether in a little cinnamon-water, or a
little peppermint-water with fifteen  or twenty drops of the tinc-
ture of opium.  In very urgent cases, Madeira or diluted brandy
may be  given,  but  these  are  not to be  frequently  repeated.
Where spasmodic contractions attack the  stomach, producing
sudden and violent pain, a full dose of the tincture of opium con-
joined with aether must be  ordered immediately.  Spasms about
the intestines are also to be relieved  by opium in some form or
other.

              • See Mr. Burn's Treatise  on Abortions. 
APPENDIX.
xli
  Where abortion is accompanied by strong hysteric paroxysms,
besides attending to the state of the discharge, the best practice
is to keep the  woman very cool, and to give  her thirty or forty
drops of tinctura opii, with about two drachms of tinctura Vale-
rianae ammoniata in a little peppermint-water every four or six
hours.  A clyster composed of cold water, with the addition of
two drachms of  the tincture  of asafoetida, is also sometimes of
service.
  In all cases  where a considerable haemorrhage has begun, but
particularly at an advanced stage of pregnancy, the first thing of
importance to  be inquired into and ascertained is its cause, and
this can hardly be done too early;  for as long as the accoucheur
allows himself to act without this piece of essential information,
his practice must necessarily be uncertain, and the life of his pa-
tient be exposed to danger.   In such cases it will therefore be of
the utmost importance to subject the woman to an examination,
and  in effecting this it will be necessary to introduce the hand
into the vagina, passing one finger without the os uteri.  This
will be preferable to the common mode; for in presentations of
the placenta, this part does not always adhere close to the orifice
of the womb, but is  sometimes attached inward to the collirm
uteri; and if we trust to the  common mode of examination we
shall be liable to fail in feeling the placenta, even when its pre-
sentation is the cause of the flooding.
   If the placenta is in the right place, it is probable, at any rate
it is possible, that the haemorrhage may subside permanently by
the aid of a horizontal posture, a low diet, the application of cold,
and a use of the other means before noticed ;  but if, on the con-
trary, the placenta be placed over the mouth of the womb, how-
ever these remedies may afford a  temporary relief, we  may be
assured that the discharge  will return ; for the next time that a
dilatation  of the os uteri takes place, and which must recur
sooner or later, a fresh portion of  the placenta will become de-
tached, and other bleeding vessels unavoidably be opened.   Our
practice ought, therefore, to be determined by the result of the
examination.  If it appears that the placenta is in the right place,
the means and remedies before pointed out may be  trusted in,
unless the symptoms be so alarming as to compel us to deliver
the woman; but, on the contrary,  if the placenta is discovered
over the mouth of the womb, or very near thereto, even should
there have  been only one  considerable discharge,  we should
    VOL. II.                * F 
xlii                    APPENDIX.

watch the patient with the greatest vigilance, and proceed to de-
liver her as soon as the  parts are  sufficiently dilatable  to allow
the introduction of the hand without improper force.
  In all cases during the last stage of pregnancy where our en-
deavour to stop or  repress the haemorrhage prove abortive, and
the life of the woman becomes endangered by its severity, it will
be advisable to deliver her as soon as possible, although we may
encounter some difficulty, unless somewhat assisted by  the com-
ing on of the natural labour pains.  If the ovum be still entire,
and the pregnancy considerably advanced, the  expulsive action
is to be excited by rupturing the membranes.
  It sometimes happens in abortions, that the whole ovum does
not come away at once, but only the foetus, and that either a part
or the whole of the secundines remain behind.   These by long
retention give rise  to an  offensive discharge from the vagina, and
a febrile state  accompanied with hysterical affections.  In such
instances, instead of endeavouring to  extract the remains of the
ovum, either with the forceps or fingers, which would be pro-
ductive of irritation, it will be advisable to keep the parts clean,
by injecting an infusion of chamomile-flowers with a small quan-
tity of oxygenated muriatic acid ; to keep the bowels open with
gentle laxatives or clysters; to support the strength  by light
nourishment, with small portions of wine frequently  repeated,
and plenty of sub-acid fruit; whilst at the same  time we procure
rest or allay irritation by opiates, if necessary.
  After every abortion the woman should be confined to bed for
a few days, as  getting up too soon is apt to produce a debilitating
discharge.   Should any morbid symptoms present themselves,
they are to be obviated by a suitable treatment.  If the patient
continues weakly for any time, the use of  a cold bath, with bark
and other tonics, a generous diet, and pure air, will be necessary.
  It has been  before observed, that miscarriages are sometimes
induced  during the first or  second month  of  gestation by the
fundus uteri  being retroverted and pressed down between the
rectum  and the vagina; in which case they are preceded  by a
difficulty of making water, and a consequent tumour of the blad-
der, together with  a violent pain about the perinaeum or rectum.
On such occasions draw off the  urine with a catheter, and in-
ject an enema with sixty drops of  the tincture of opium, if it can
be done.  Should  these symptoms recur after the miscarriage,
a wax candle, or a pessary, made by rolling some  emplastrum 
APPENDIX.
xliii
plumbi spread on linen, may be introduced into the rectum, and
worn as a compress to prevent the return for a few days, till the
parts recover  their strength.—See Dr. Hunter's  Tables of the
gravid Uterus, and London Medical Observations, vol. iv. p. 388.
            Diseases of the Puerperal State.

  Parturition, it is well known, is a natural process, and cannot
therefore be considered as a disease; but still it often lays the
foundation of many distressing complaints, and is now and then
attended suddenly even with fatal consequences.
  On the separation of the placenta, and on the sudden removal
of pressure on the expulsion of the uterine contents, every par-
turient woman encounters some degree of risk:  the latter is in-
deed not unfrequently a source of danger, which  has not been
sufficiently insisted upon and practically attended to.
  A woman sometimes appears safely put  to  bed  after an easy
and natural labour; she has suffered no unusual loss of blood on
the separation and' removal  of the placenta;  the uterus, on the
application of the hand, is found well  contracted, and the patient
thus far at least appears in a fair  way to  do  well; but notwith-
standing these favourable appearances, and perhaps even during
the congratulations of her friends upon the termination  of her
sufferings, she complains of a degree of faintness, attended with
an inexpressible sensation of sinking: this is followed by  rest-
lessness, with an anxious, depressed countenance, and occasion-
ally by pain and a sense of constriction at the pit of the stomach;
and expressions of alarm for approaching dissolution are not un-
frequently repeated.   Shortly  afterwards  the restlessness in-
creases, the  countenance  becomes more dejected and  ghastly,
the pulse gradually sinks and fails in its stroke,  the oppressive
constriction on  the epigastrium becomes intolerable, so as con-
siderably to affect respiration; and if relief to these symptoms
be not speedy, she becomes shortly a corpse.
  That a woman  may die suddenly from the rupture of a vessel
in the brain, or in the thoracic or abdominal cavities, during the
violent efforts of labour, is a conclusion sufficiently natural; but
in accidents of this nature there would be symptoms of pressure
on the sensorium in the one instance, and of internal haemorrhage 
xliv
APPENDIX.
 in the other;  and the cause of death, on inspection, would be
 apparent.
   To theorize, or reason, on a parturient woman suddenly falling
 into deliquium animi, and almost immediately expiring, is incon-
 sistent with the nature of this work ;  but it has been attributed to
 the removal of pressure from the parietes of the abdomen, and
 the contents of its cavity.
   At  the commencement of faintness without  loss of blood, we
 should have recourse to the exhibition of brandy, or other spirits,
 undiluted or diluted, according to the urgency of the symptoms
 and the rapidity  of  their progress, and in such quantity  as may
 seem  adequate  to answer  the intended  purpose.  That being
 attained, and the patient relieved, the medicated stimuli, as cam-
 phor, aether, volatile spirit, cordial  tinctures,  8cc. may be sub-
 stituted.  Moderate  pressure  upon the abdomen with the hand,
 or a bandage  applied round the body, will assist the general in-
 tention ; and the patient ought, on no consideration, to be allow-
 ed to raise herself from the recumbent posture till she be so far
 recovered  as  to warrant security from the recurrence  of the
 symptoms of alarm and danger.
  The most usual complaints,  however, which occur after deli-
 very,  and  which  demand the attention and' assistance  of the
 medical practitioner, are as follow : viz.
                        AFTER-PAINS.
   Shortly after delivery these usually come on, and with some
 women prove remarkably severe.  The quicker  the labour has
 been, the slighter will they  prove in general.  Women with their
 first child are  seldom much troubled  with after-pains; but as the
 uterus is thought to contract less readily after each future labour,
 so they are more liable to  suffer from them in any succeeding
 delivery than in the first.
  When after pains prove so troublesome as to deprive  the pa-
 tient of her rest, it will be necessary  to have recourse to  opiates
joined with  other antispasmodics.*   Heated cloths,  or bladders

   * Take Cinnamon Water, one ounce.
         Tincture of Opium, thirty to forty-five drops.
         ---------Castor, half a drachm.
         Syrup of Violets, two drachms.
    Mix them.  This draught is to be taken about bed-time.
  Or, Take Castor, five grains.
         Camphor, three grains.
         Opium, one grain and a half.
         Confection of Roses, a sufficiency to form a bolus, which may be
           taken at bed-time. 
APPENDIX.
xlv
filled with warm water, may be applied as  an external fomenta-
tion.  These means are to be assisted by keeping up a suffi-
cient pressure on the belly at the same time, by means of abroad
bandage.
                       COSTIVENESS.
  This is apt to prevail after delivery, and should always be re-
moved by a laxative clyster, or some gentle purgative, such as a
solution of some neutral salt and manna, or about an ounce of
the oleum ricini.
                  FLOW OF THE LOCHIA.
  In all women a  certain degree of  haemorrhage  usually takes
place after  delivery,  produced by the removal of  the placenta,
which thereby lays bare the mouths of the blood-vessels in the
inside of the uterus; and this commonly continues until the womb
contracts to such a size as to  close them up again.  The dis-
charge  for the four or five first days  consists usually of florid
blood, after which time it assumes a mucous appearance, and so
ceases gradually.
  In weak and relaxed habits it sometimes happens, that instead
of saturating a cloth now and then,  as  is natural to all women,
the blood gushes  out  with  such rapidity and violence as to run
quickly through all the bed-clothes, and even  to soak through the
bed itself; in which case the patient will be reduced to a state of
great debility if the haemorrhage is not soon  restrained.  To ef-
fect this, the means recommended under the heads of Menorrha-
gia and Abortions, must be adopted.
  Where a suppression  of the lochia ensues before the accus-
tomed period, the discharge ought again to be promoted, if pos-
sible, by plentiful dilution, and the application of warm fomenta-
tions to the parts.   Should these means prove ineffectual, gentle
evacuation from the bowels must be made.

                     THE MILK FEVER.
   About the third or fourth day after delivery, the breasts gene-
rally become turgid and painful, from the secretion of milk which
then takes place in them.  When this  is moderate and free no
inconvenience will be experienced;  but when copious,  and ac-
companied by any obstruction in the lactiferous tubes, in conse-
quence of the use of some repellent application, or of an exposure
to cold, the breasts will then become hard, swelled, and painful, 
xlvi
APPENDIX.
and a small fever will arise, accompanied by nausea, restlessness,
pains in the head and back, and a considerable degree of thirst.
  To prevent  any consequences of this  kind, it will always be
advisable to apply the child to the breasts at a very early period
after delivery.   By delaying to do so immediately, on the secre-
tion of milk commencing, the breasts are not only apt to become
much enlarged and distended, but the nipples are often so much
retracted that the child cannot lay hold of them without the great-
est difficulty.
  Whether the mother's health will not admit of her suckling the
child, or any other thing happens to prevent it, she should be care-
ful to have her breasts drawn three or four times a day by some
other person ;  and, with the view of preventing a copious secre-
tion of milk, she should use a very spare diet,  keep her body per-
fectly open with laxative medicines, and  abstain as much as
possible from  all liquids.  This mode of proceeding will be far
preferable to the use of repellent applications to dry up, or put a
stop  to, the secretion.
  If any degree of fever arises, besides confining the  patient tot
spare diet, keeping her very quiet, and obviating  costiveness by
means of cooling laxatives, we may give her small and frequently
repeated doses of antimonials, together with refrigerants, such as
the nitrate of potass, as advised under the head of simple Fever.

      INFLAMMATION AND TUMOURS IN THE BREASTS.
  From exposure to cold, and neglecting to put the  child at an
early period to the breasts, or to get them drawn by  some other
person, accidents of this nature happen very frequently to lying-
in women.
  With respect to the mode of treating these kind of tumours,
practitioners differ very much ; some asserting  that  discussion
should always  be attempted, and others, that they ought  to be
allowed to suppurate; as when the discussion does not succeed,
there may be some danger of inducing a scirrhous affection  of an
obstinate nature. I think the same practice should be adopted in
this case of inflammation as in every other, and that  the  discus-
sion of the tumour ought by all means to be attempted on its first
appearance;  the distress and  pain which always attend  on  a
suppuration of the mamma being very great.   When the inflam-
mation and swelling have been of such long standing as to  show
an evident tendency to suppurate, any attempt to discuss the tu-
mour will not be advisable. 
                       APPENDIX.                   xlvii

  Where discussion is proper, recourse should be had, at a very
early  period, to a strict pursuance of the  antiphlogistic plan.
The strength is to be supported by a cool, spare diet; the body
is to be kept perfectly open with mild laxatives; febrile heat is to
be abated by refrigerants, such as the nitrate of potass, with the
aid of frequent small doses of some antimonial, such as the pulvis
Jacobi, pulvis antimonialis, or solution of tartarized antimony;
pain and irritation are to be allayed by sufficient doses of opium;
and the  inflammation, when  considerable, is  to be abated by
means of leeches applied to the part, as likewise by the constant
application of linen  cloths dipped in  some sedative lotion.*  To
assist the effect of these means, the  breasts are to be evacuated
frequently throughout the course of the day, but more particu-
larly  the one diseased, either by the infant or some other person
accustomed to the business.  When they are so much  swelled as
not to allow of laying hold of the nipple, the proper glasses made
for that purpose, should be employed.
 " If the tumour proceeds to suppuration, notwithstanding we may
have  used every endeavour to prevent it, we should then  assist
the operations of nature by the application of emollient poultices
and fomentations. As soon as the suppuration is completed, the
tumour should be opened, after which it may be dressed with dry
lint, and a pledget, spread with some kind of digestive ointment,
be laid over all.  Should any fresh suppuration ensue, which not
unfrequently  happens, the same  mode  of treatment must be
adopted; and that proper pus may be formed, the bark of cin-
chona, with a moderate quantity of wine, will be necessary.
              EXCORIATIONS OF  THE NIPPLES.
   From  the constant state of moisture in which these parts are
kept with those who, give suck, such occurrences are very apt to
happen.  When excoriations do arise, the parts should  be washed
two or three times a day with a diluted solution of alum, the su-
peracetate of lead, or a few drops of the liquor plumbi acetatis,
in  rose-water, and then be sprinkled with a little powder of cala-

    * Take Solution of Acetate of Ammonia,
          Rectified Spirit,
          Distilled Water, of each, two ounces.
     Mix them, and use them as a wash.
  Or, Take Muriate  of Ammonia, two drachms.
          Distilled Vinegar, diluted, two ounces.
          Camphorated Spirit, half an ounce.
          Solution of Acetate of Lead, twenty-five drops.
     Mix them. 
 xlviii                  APPENDIX.

 mine or tutty, or they may be dressed with a little of what is re-
 commended  below,* thinly spread on lint, and so applied to the
 parts.  To prevent the sore  from being aggravated by sticking
 to the woman's clothes, a little cup made of wax may be laid over
 the nipple, which is the part most apt to suffer.  If only one nip-
 ple is affected, the child may be confined to the other; but if both
 are affected,  and the pain occasioned by its sucking is too great
 to be borne, the woman must then desist from  the  duties of a
 mother until the excoriations are somewhat healed,  taking care
 however to have her breasts drawn regularly twice or thrice  a
 day.  As long as we are under the necessity of applying any of
 the preparations of lead to the nipples of the mother, it will be
 prudent not to suffer the child to suck her,  as there is reason to
 fear that  it  might be  materially injured by  so doing.  Where
 this cannot however be dispensed with, the part  should be well
 washed with a little warm water each time previous to giving the
 child the breast.
  When great soreness of the nipples has taken place, it has
 been proposed, with the view of protecting them, to use an arti-
 ficial teat, by which the child will be able to suck tolerably well,
 and the nipple itself, being undisturbed, to heal soon.   The way
 in which one of these substitutes is prepared, is to procure a fresh
 teat from  a heifer, and  scooping out the inside, to well steep it in
 cold water, then  put it  into spirits till an hour or two before using
 it, when it must be again laid in water to take away the spirituous
 taste.  The teat is then to be  wiped dry, and sewn closely and
firmly at the edges to the row of holes made in the shield.  Such
 shields are usually made of silver, and may be procured from Mr.
 Savigny,  the instrument maker; but ivory ones turned on the
 same model will answer equally well.   The teat ought to project
 somewhat longer than the shield, that  it may the more readily
yield to the infant's mouth.  Great attention should be paid to
 washing the whole thoroughly after suckling, and to keep it con-
 stantly in  cold water.  A woman is often capable of giving milk
with a flat or even  concave surface, by drawing out the nipple
with a glass tube that has a small ball to it, by which a vacuum
 is produced; immediately after the glass is removed, the child be-
 ing put to the breast, will keep it  out by sucking until satisfied.

  •  Take Sub-borate of Soda, half a drachm.
         Honey,  half an  ounce.
         Wheaten Flour, a sufficiency to gite the whole a proper conj
          sistence. 
APPENDIX.
xlbt
                   MILIARY ERUPTIONS
  In consequence of keeping women very warm, and of using a
heating diet,  it not unfrequently happens that miliary eruptions,
attended  with some degree of fever,  arise during a puerperal
state.   Sometimes they are dispersed over the whole body, but
they are more usually observed about  the neck and chest.
  To conduct the patient with  safety through  the disease, the
practitioner must have recourse to the means advised under the
head of Miliary Fever.  Should the eruptions strike in suddenly,
and the pulse sink, blisters,  with cordial sudorific medicines and
wine, will be proper.
  Affections of this nature may, however, be avoided in general
by an attention to diet,  by keeping the patient's body perfectly
open, and her bed lightly covered with clothes, and by admitting
a proper  and free ventilation through her chamber.
PHLEGMASIA DOLENS PUERPERARUM, OR THE PAINFUL INTU-
  MESCENCE OF THE LOWER EXTREMITY, INCIDENT TO LYING-
  IN WOMEN.
  Although this disease must  have  existed as long as most of
the others to which lying-in women are subject, still it seems to
have been  only  slightly noticed  by any of the  ancient writers.
Mr. White's Inquiry into its nature and causes, which made its
appearance in the year 1784, was  the first regular treatise on it
in this country, and it excited the attention of other practitioners
to the complaint.  In the year  1792, Mr. Tyre, of Gloucester,
published a small essay on the subject; and at different periods
since that time, Dr. Ferriar, and Dr. Hull, of Manchester, have
written on it.
  Phlegmasia dolens  appears, however,  to be  a disease of no
frequent  occurrence ;  for Mr. White mentions, that, out of 1897
women delivered at the Westminster General Dispensary, five
only were attacked with it; and of 8000 women delivered at the
Manchester Lying-in  Hospital, and their own houses,  no more
than four were seized with  it.   During a practice of forty-five
years,  only three cases have fallen under my care.  When we
find practitioners giving in a report  of  numerous cases which
came under their observation, we may, therefore, naturally pre-
sume that they have mistaken other diseases for it, such as ana-
sarca,  phlegmon,  erysipelas, abscess, rheumatism, peritonitis,
and puerperal fever.  The  disease, however, to which, in my
opinion, it bears the strongest resemblance, is the glandular affec
  VOL.  II.                  *  G 
1
APPENDIX.
tion of the thigh and leg, so frequently met with in the island of
Barbadoes, and noticed under the head of Elephantiasis.
  The characteristic of phlegmasia dolens is a firm, glossy, warm,
tense,  elastic, painful, sudden  swelling, of a pale white colour,
which  attacks  the  hypogastric region,  the  loins,  nates, groin,
labium pudendi, thigh, leg, and foot, of  a lying-in  woman some
days after delivery, or miscarriage at an advanced period of preg-
nancy.  Mr. White looks on the swelling of the labium pudendi
as an invariable symptom of the  disorder; and he asserts, that
when one limb only is affected, the intumescence  is confined so
exactly to the labium pudendi of that side,  that if a line were
drawn from the navel to  the anus it would  be found never to go
beyond that line in  the smallest degree.  We are told, however,
by Dr. Hull, that the swelling of the labium pudendi is to be con-
sidered rather as marking the extent, than serving to characterize
the complaint; and  he positively denies that this particular symp-
tom is always to be met with ; for some cases had fallen under his
care in which it did not exist.   On this point/as well as on most
others relating to the nature and causes of  phlegmasia dolens,
these gentlemen do not agree in opinion.
  Mr. White attributes  the proximate cause of the  disease in
question to an obstruction, detention, and accumulation of lymph
in the limb, and imagines the lymphatics  to be obstructed as high
up at least as where they enter the pelvis under Poupart's  liga-
ment, in consequence of  some accident happening during labour,
or some state peculiar to childbed.   He  conceives it  might pro-
bably arise from the continued pressure of the lymphatic vessels
by the head of  the  foetus on the pelvis,  which, he says, is often
rough and sharp on its ridge, and might be  followed by a rupture
of these vessels in some part of their course.
  The disease has been attributed by Mr. Tyre to an obstruction
of the lymphatics:  but he apprehends that this originates in the
inflammation of the trunk or trunks of these vessels, which in-
flammation may be  excited by pressure or the absorption of some
acrimonious matter.
  Dr. Denman entertains sentiments pretty similar  to those of
Mr. Tyre; for he believes the disease to arise first in the inguinal
glands by the absorption  of some irritating principle in the  dis-
charge, the  consequence of an  unhealthy secretion from the
uterus.
  Dr. Ferriar is of  opinion,* that phlegmasia dolens may exist
          * See his Medical Histories and Reflections, vol. iii. 
APPENDIX.                      li
independently of every circumstance regarding parturition,* and
he does not think it impossible for it to take place before deli-
very.   The violent pressure on the internal iliacs and the accom-
panying veins and nerves, which takes place during labour, must
undoubtedly  be considered as a powerful occasional cause of
lymphatic inflammation, quite sufficient to account for the pheno-
mena without the supposition of a rupture of the vessels.
  He adds, that the constitution is much  more irritable, more
liable to febrile and inflammatory  complaints after than before
delivery.   The balance of the circulating fluids is suddenly and
violently changed ;  there  are  new determinations, new sympa-
thies, produced in a state of debility, agitation, and anxiety.  It
cannot, therefore, surprise us, that, under circumstances so pecu-
liar, a set of vessels, commonly exempted from inflammatory
affections, should take on  an unusual disposition.
  These theories are rejected by Dr. Hull, as being inadequate
to explain  the various phenomena of the  disease;  and  he offers
the following,  which he  conceives to be more  consonant to its
real nature.!   As predisposing and exciting causes to it, he
enumerates—1st, The  increased irritability and disposition to
inflammation which prevail  during pregnancy,  and in a  still
higher degree for some time after parturition.  2dly, The over-
distended or relaxed state of the blood-vessels of the inferior part
of the trunk,  and of the lower extremities.   3dly, Contusions, or
violent exertions of the muscles about the pelvis and thighs. 4thly,
Plethora, occasioned by  a  suppression or  diminution of the
lochia, or of the secretion of milk.   5thly, Food taken too freely;
and, 6thly, Standing or walking too much or too early.
  The proximate cause he supposes to consist in an inflamma-
tory affection,  producing  suddenly a considerable effusion of
serum and coagulable lymph from the exhalents into the cellular
membrane of  the limb ; and he thinks that there exists a close
connexion  between  phlegmasia dolens, puerperal fever, peritoni-
tis, and some other disorders.
   Such a conclusion, in my humble opinion, is not well founded;
for phlegmasia dolens is a disease as distinct from either puer-
peral fever or peritonitis  as it is  possible to be.   Little or no
inflammatory  tendency prevails in the system in  this complaint,
neither are any of the  abdominal  viscera, nor  their peritoneal

  * It certainly may ; for I had a case lately under my care in an aged woman,
and of course unconnected with pirnintion.
  »  See his K.ssay on Phlegmasia Dolens. 
ill
APPENDIX.
covering, occupied by inflammation.  The disease appears to be
of a local nature, and confined to the lymphatics of the limb on
the side affected.  The slight  temporary derangement  which
takes place in the system appears to be  induced wholly  by the
local affection, pain, and distention.
  Phlegmasia dolens  generally takes place on  one  side only at
first, and commonly begins in the hypogastric or inguinal region,
or in the  hip, or  top of the thigh, and corresponding labium
pudendi, preceded by rigours, and followed by pyrexia.  In this
case the patient perceives a sense of pain, weight, and stiffness,
in some of these parts,  which are increased by every attempt to
move the pelvis, or lower limb.   If the part be carefully examin-
ed it generally is found rather fuller or hotter than natural, and
tender to the touch, but not discoloured.   After a little time the
pain increases, always  becomes severe, and, in some cases, is
highly excruciating : it extends along the thigh, and at length the
top of the labium pudendi becomes greatly swelled and distended;
but,  on this happening, the pain is usually somewhat alleviated
in these parts.   It however extends down to the knee,  and is
generally most severe on the inside and back of the thigh.   When
it has  continued for some time, the whole thigh becomes in its
turn swelled, and the  pain extending down to the leg and foot,
these parts also swell; but, on the swelling taking place, there is
a considerable abatement of pain, and the woman does not expe-
rience  much except she moves  the limb.
  The extremity being now swelled  throughout its whole extent,
appears perfectly or  nearly uniform, and is  not perceptibly les-
sened by a  horizontal  position like  an oedematous  limb.  It is
whiter than the natural colour,  is hotter than usual, excessively
tense,  and exquisitely tender when touched.  When pressed by
the finger in different parts, it is perceived to be elastic, little, if
any> impression  remaining, and that only for a short time.  If a
puncture is made into the limb, in some instances no fluid is dis-
charged; in others, a small quantity of fluid escapes, which does
not coagulate, but the  whole of the effused matter  cannot be
drawn off in this way.   The swelling of  the limb varies both in
degree and in the space of time requisite for its full formation.
In most instances, it arrives at  double the natural size, and,  in
some cases, at a much greater.  In lax habits, and in patients
whose legs have been very much affected with anasarca during
pregnancy, the swelling takes place  more rapidly than in those
who are differently circumstanced :  it sometimes, in the  former 
APPENDIX.
liii
class of patients, arrives at its greatest extent  in twenty-four
hours, or less, from the first attack.
  After some days, generally from two to eight, the febrile symp-
toms diminish, and the swelling, heat,  tension, weight, and ten-
derness of the lower extremity begin  to  abate, first about the
upper part of the thigh or knee, and afterwards in the leg and
foot.  Some inequalities are found in the limb, which at first feel
like indurated glands; but, upon being more strictly examined,
their edges are not so well  defined as those of conglobate glands,
and they appear to be occasioned  by the effused  matter being in
different degrees of consistence in different points.   The con-
globate glands of the thigh and leg are sometimes felt distinctly,
and are tender to the touch, but are seldom much enlarged ; and,
as the swelling subsides, it has happened that an enlargement of
the lymphatic vessels in some part of the limb has been supposed
to be felt.
   The febrile symptoms having gradually disappeared, the pain
and tenderness of the limb being much  relieved, and the swelling
and tension considerably diminished, the patient is much debili-
tated, and the extremity feels stiff, heavy, benumbed, and weak.
It seldom, if ever, returns to its former size, but usually is con-
siderably enlarged for the  remainder of life, being always more
easily affected by cold than the other, and after exercise it will be
more stiff and weak  than the sound  extremity.  It sometimes
happens, that after the disease abates in one limb, the other is
attacked in a similar way, goes through the same  stages, and con-
tinues much about the same time as the first.
   Phlegmasia dolens is often slow in its progress, and tedious in
its cure;  but it  is rarely followed either by  suppuration or gan-
grene ; and still more rarely does it  terminate  fatally;  the ex-
travasated fluid being at length taken up, and returned into the
circulation, although, from  the great distention of the limb, there
is usually much tenderness, pain, and a febrile disposition.  We
are told by Mr. White, that when not complicated with  any
other disease, he has never known it to have a fatal termination ;
neither has he ever observed the  skin  to be so discoloured as to
point out the presence of  local  inflammation: on the  contrary,
it is of a paler white than  ordinary, which circumstance has in
duced him to name the disease phlegmasia alba dolens puerpe-
rarum.  By Dr. Hull we  are, however, informed, that  he has
seen  cases which  have terminated  in suppuration, as  also in
death. 
nv
APPENDIX.
   With respect to the treatment oi  phlegmasia  dolens, much
must be left to the discretion of the practitioner,  who ought to
prescribe according to circumstances.  Should the disease be
complicated with any other, such  as  phlegmon, erysipelas, ana-
sarca, thoracic inflammation, puerperal fever,  peritonitis, then
the means which  are  advised under  these  heads must be re-
sorted to, in addition to paying a proper  attention to the  com-
plaint itself.
   When a woman who is  of  a robust plethoric habit is attacked
shortly after delivery with a painful, tense swelling of one of the
lower extremities, accompanied by much  heat, thirst, restless-
ness,  and other symptoms of pyrexia, the antiphlogistic  plan
ought certainly to be pursued.   Bleeding  from the  system in a
moderate quantity, keeping the body open with saline purgatives,
so as  to procure one or two motions daily; administering small
and frequently repeated doses of  some antimonial preparation,
to promote a regular and  gentle  determination to the surface;
giving plentifully of diluent liquors; confining the patient to bed;
covering her lightly with bed-clothes, and  keeping her chamber
of a proper coolness, will undoubtedly be  highly  proper  in  all
such cases.  Where nausea exists at the commencement of the
attack, an emetic may likewise be advisable, but otherwise it ap-
pears unnecessary.
  If the irritability or  excitability (adopt which term you may)
of the system is much  increased, and from the severity of the
pain in the limb the  patient is deprived of  rest for a succession
of nights, we may with  safety and much advantage, having pre-
mised proper  evacuations, employ opium.  The  best mode of
administering  it will be, to combine it with some diaphoretic,*
and probably the pulvis ipecac, compos, may be as good a medi-
cine as we can use.  Along with the remedies before enumerated,
warm bathing, or the semicupium, may possibly be of service.
   Such is the  general treatment to be  adopted in phlegmasia
dolens, when arising in a robust or plethoric  habit, and where

   * Take Solution of Acetate of Ammonia, three  drachms.
         Camphor Mixture, one ounce.
         Tincture of Opium, thirty drops.
         Syrup of Poppies, two drachms.
    Mix them, and let this draught be taken at bed-time.
  Or, Take Tincture of Opium, forty drops.           '
         Solution of Tartarized Antimony, fifteen drops.
        Pure Water, one ounce.
         Common Syrup, two drachms
    Mix them for a draught. 
APPENDIX.                      lv
the febrile symptoms run very high; but the antiphlogistic plan
would certainly be improper for a woman of lax  fibres, and who
has already been much debilitated by floodings, or other evacua-
tions.   In all those cases which are marked with general debility,
an impoverished state of the blood,  and a diminution of the tone
and action of the heart and arteries, we should pursue the fol-
lowing course:—
  To remove the affection of the system, and at the same time
expedite the cure of the local complaint, we should endeavour to
restore  proper energy to the constitution, as well as improve the
state 01 the blood;  and  this is to be effected by bitters, chaly-
beates,  and other tonic medicines,  a nutritious diet, with a mo-
derate allowance of wine, daily exercise on horseback or in a car-
riage, but more particularly the latter, and by cold bathing.  To
assist in carrying off the effused fluid, it may likewise be advisa-
ble to  employ diuretics, such as  the  supertartrate of potass,
squill,  digitalis, &c. combined with  cinchona, cascarilla,  and
other tonics.—See  Anasarca.
  Mercury has been recommended both  by Mr. Tyre and Dr.
Hull in phlegmasia dolens, but I think it is a remedy from which
no benefit is likely to be derived, and particularly in debilitated
habits.
  Our  attention is  next to be directed to the local treatment.
When the limb ai.d labium pudendi are occupied by much  pain,
and any degree of  inflammation, the application of two or three
leeches will be proper; after which the parts may be well foment-
ed with flannel cloths wrung out in hot vinegar, renewing these
as often as they become cold.  This simple mean, unassisted by
any other than merely keeping the bowels regular with gentle
aperients, such as the neutral salts, has, I understand, been adopt-
ed in all cases of phlegmasia dolens with  invariable success, in
one oi the best regulated lying-in hospitals in London.  Should
it fail, however, in other hands, some  more powerful sedative or
discutient may be  substituted, such as a  solution of  muriated
ammonia in  vinegar, or a diluted  solution of the  liquor plumbi
acetatis.  A liniment composed of a  drachm of camphor, dis-
solved in an ounce of olive oil, with about ten grains of powdered
opium,  and used night and morning, will be a good application.
Much relief has been received by surrounding the limb with a
soft poultice, composed of bran, olive oil, with  the  addition of
half an ounce of tinctura opii, and  a sufficient quantity of warm 
Ivi                    APPENDIX.
water to give it a proper consistence, renewing it morning and
night.
  To drain off some of the fluid effused in the limb, it  will  be
advisable in an early stage of the disease, to apply a blister to the
calf of the leg, renewing the application from time to time in the
neighbourhood of the former, when it ceases to produce the de-
sired  effect.  In some  instances coagulation quickly succeeds
the effusion, and therefore neither  scarifications  nor punctures
would be likely to prove beneficial.
  Notwithstanding  every attention, the complaint often  leaves
considerable weakness in the leg, requiring a  laced stocking  or
roller applied round it from the bottom to  the top, avoiding  at
the same time much standing or walking.   To increase the ac-
tion of the absorbents in the limb, frequent frictions with rubefa-
cient  liniments, or  simply  with the  hand, flannel, or a  flesh-
brush, may be employed, the effects  of which may be assisted
by topical cold bathing, or  by cold water, fresh or salt, dashed
upon  the  parts, and by electricity.   Immersing  the  limb in  a
bath of tepid sea-water has sometimes been found beneficial. Pro-
bably the application of heat  in the manner advised for anasar-
cous limbs, might prove serviceable.—See Anasarca.
   HYSTERITIS, Oil AN INFLAMMATION OF THE UTERUS.*
  In natural labours, as well as in those of a difficult sort, many
causes of injury to the  uterus and the peritonaeum which covers #
it will be applied.   The long-continued action of  the  uterus  on
the body of the child, and  the great  pressure made by its head
on the soft parts, will farther add to  the chance of injury.  Be-
sides these, an improper application  of instruments, or an offi-
ciousness of the midwife in hurrying the  labour, or extracting
the placenta, may  have contributed to the violence.  To these
causes may be added exposure to cold, by taking the woman
too early out of bed after delivery, and thereby throwing the cir-
culating fluids upon the internal parts, putting a stop to the se-
cretion of milk, or occasioning a suppression of the lochia.
  An inflammation  of the womb is sometimes perfectly distinct,
but it is more frequently communicated to the peritonaeum* Fal-
lopian tubes, and ovaria :  and having once begun, the natural

  * This disease, as well as the two which succeed, belong properly to  the
class of Pyrexia ■. but as the two first do not often occur in the unimpreg-
nated state, and the last is a disease  confined to  that of the  puerperal, J
have judged it most proper to insert them all here. 
APPENDIX.      0            lvii
junctions of the organ become much disturbed,  which event
greatly adds to the disease.
  It is oftener met with in women of a robust and plethoric habit
than in those of lax fibres and a delicate constitution, particularly
where they have indulged freely in food of a heating nature, and
in a use of spirituous liquors.   It never prevails as an epidemic,
like puerperal  fever, for which it has probably often been mis-
taken; and  to  this-we may, with some reason, ascribe  the dif-
ference in the mode of treating the disease which has taken place
among physicians.
  An inflammation of the uterus sho.ws itself usually about the
second or third day after delivery, with a painful sensation at the
bottom of the belly, which gradually increases in violence, without
any kind of intermission.  On examining externally, the uterus
appears much increased in size, is hard to the feel, and on making
a pressure upon it,  the patient experiences great soreness and
pain.
   Soon  afterwards  there ensues an  increase  of heat over the
whole of the body, with pains in the  head and back, extending
into the groins, rigours, considerable thirst, nausea, and vomiting.
The tongue is white and dry, the secretion of milk is usually
much interrupted, the lochial discharge is greatly  diminished,
the urine is high-coloured and scanty, and if the inflammation
has extended to the bladder, it becomes totally obstructed ; the
body is costive, and the pulse is full, hard, and frequent.
   These are  the  symptoms  which  usually present themselves
when the inflammation does not run very high, and is perfectly
distinct;  but  when  it  is so  extensive as to  affect the perito-
naeum, those of irritation generally succeed, and soon destroy the
patient.
   Where the uterus has been ruptured, a vomiting comes on,
and the matter thrown up is of a black colour, resembling coffee
grounds, the pulse  sinks and becomes irregular, cold clammy
 sweats break out,  and frequent syncope ensues.
   Uterine inflammation is  always attended with much danger,
particularly where the symptoms  are violent, and the proper
means  for removing them have not  been timely adopted.  In
 such cases it may  terminate  either in suppuration, scirrhus, or
 gangrene and mortification.
    Frequent rigours, succeeded by flushings of the face, quickness
 and weakness of the pulse, great depression of strength, delirium,
and the sudden cessation of pain and soreness  in the region of the
   VOL. II.                  * H 
lviii
%    APPENDIX.
 abdomen, denote a fatal termination :  on the  contrary, the ensu-
 ing of a gentle diarrhoea, the lochial  discharge returning in due
 quantity and quality, the secretion of milk recommencing, and
 the uterus becoming gradually softer and less tender to the touch,
 with an abatement of heat and thirst, prognosticate a favourable
 issue.
   When shiverings attack the patient after several  days' con-
 tinuance of the symptoms, but little relief can be afforded by me-
 dicine,  the event being generally fatal.   In this case the woman
 emaciates and'loses her strength, becomes hectic, and  sinks un-
 der colliquative sweating or purging.
   Upon opening the bodies of women who have died of this dis-
 ease, and where it existed in a simple state, little or no extrava-
 sated fluid is usually to be met with in the cavity of the abdomen.
 In some instances the peritonaeal surfaces have been discovered
 free from the disease ; while, in others, that portion which covers
 the uterus and  posterior part of the bladder,- has been found par-
 tially inflamed.  The inflammation has been observed in some
 cases to extend to the ovaria and Fallopian tubes, which, when
 cut open, are often loaded with  blood.  The uterus itself usually
 appears of a  firm substance, but is larger than in its natural state,
 and when cut into, a quantity of pus is often found.  Gangrene
 and mortification are seldom, if ever,  to be met with.
   By an early attention to the disease on its first approach, we
 may often subdue it, and prevent the inflammation from  pro-
 ceeding to any  great height.  Our immediate and  speedy care
 ought, therefore, to be directed towards diminishing the quantity
 of the circulating fluids, and weakening  the action  of the heart
 and arteries; and  this is to be done  by  drawing blood from the
 system, regulating the quantity which we take away by the vio-
 lence of the symptoms, the state of the pulse, and the age and
 habit of the patient.  In repeating the operation, we are to  be
 governed by the same  circumstances, and by  the  effect pro-
 duced by the former evacuation.   In plethoric habits, a second or
 a third  repetition  may be  necessary;  but in  those who are less
 robust,  if the inflammatory symptoms  are not  entirely  carried off
 by the first bleeding, it may be more  advisable to draw off blood
 by  the application of six  or eight leeches to the belly, than to
 make use of the lancet again.
   To remove the  tension  and alleviate  the pain and  soreness,
 flannel cloths wrung out in a warm decoction of  bruised poppy-
heads and chamomile-flowers, with an  addition of about an eighth 
APPENDIX.
lix
of spiritus camphorae, may be kept pretty constantly applied,
throughout the course of the day, to the abdominal region, and
at night it may be anointed with a little of the linimentum cam-
phorae.   In using fomentations, due care must, however, be taken
that they are not applied so wet as  to run  about the bed, and
thereby occasion  inconvenience to the "patient.
  Some practitioners of late have recommended the application of
linen cloths, wetted in camphor mixture and cold water, to the ab-
domen, instead of warm fomentations.—See Peritonitis.
  Injecting tepid water into the uterus morning and evening, by
means of a proper syringe, may be likely, I think, to add to the
good.effects of fomentations externally applied.
  Evacuation by  purging would be improper in this inflamma-
tion ; but it would be right to  preserve the regular motion of the
bowels, by giving, from time to time, as may be found necessary,
some gentle laxative, or by administering emollient aperient clys-
ters, which perhaps may be the preferable way of procuring stools,
as they not only unload the intestines, but likewise act as fomen-
tations.
  In most internal inflammations, blisters prove a useful remedy ;
but in that of the uterus,  their application  is attended with the
risk of  increasing the irritation in the system, and of adding to
the inflammation, by affecting the bladder and kidneys.   When-
ever they are made use of in this disease, with the hope of afford-
ing  relief, they  ought  to  be  sprinkled  with camphor,  and  be
applied to the upper part of the thighs, with the view of remote
counter-excitement,  and the  patient should drink plentifully of
diluted mucilaginous liquors.  Diluents will  indeed be  proper,
whether we have recourse  to blistering or not.
  To determine  to the  surface of the body, and excite a gentle
perspiration,  which often proves highly serviceable in this inflam-
mation,  it will be advisable to give diaphoretic medicines.  As
such, we may employ the pulvis ipecac, compositus, in the quan-
tity  of eight  or ten  grains, repeated every four hours ; or the
pulvis  antimonialis, in the quantity of about two grains, and half
a grain of opium, made into a  bolus, with a little of the confectio
rosae rubra.   These may  be washed down with two or three
spoonfuls of a saline mixture.
  In order to alleviate the  pain, (which alone would greatly ag-
gravate  the disease,) procure rest, and prevent symptoms of
irritation from arising, the use of opium is  indispensably neces-
sary ; and its dose ought to be  increased until the desired effect is 
IX
APPENDIX.
procured.  Opium is, however, not to be prescribed in hysteritis,
until the  inflammation  has  been .subdued by  venesection and
aperient medicines.
  Should a diarrhoea arise spontaneously in the course of this dis-
ease, it ought by no means to be checked, unless it proceeds with
such violence as to exhaust the woman's strength.  Under such
circumstances,  the  mistura  cretae, with an  addition of a small
quantity of tinctura  opii, may be given with  advantage.  Should
the remedy not be  found sufficiently powerful in lessening the
number of evacuations, three drachms of the tinctura kino,  or
catechu, may be added to about six ounces of the mixture.
  Where the inflammation has extended to the bladder, and occa-
sioned a suppression of urine, we must employ the catheter.
  Throughout  the  whole course  of the disease, the patient is to
be supported by food of a light nutritive nature, and such as is
easy of digestion, carefully avoiding all kinds of fermented liquors.
  In chronic inflammation of the  uterus,  or  state  of scirrhosity,
the repeated application of several leeches above the pubes, or to
the perinaeum, the use of gentle laxatives, emollient clysters, and
fomentations and blisters to the lower part of the abdomen, fre-
quent immersion of the  lower parts of the body in  a warm slipper
bath, with an antiphlogistic regimen, and detaining the patient as
much as possible in a horizontal posture,  appear to be the most
probable means of  affording relief at an  early period.   Hyoscy-
amus and conium, joined  with cinchona and opium, both by the
mouth and in the form of clyster, more particularly the latter, to
assuage pain, together with injections of tepid water and milk, or
of some  gently astringent liquor, together with  warm  bathing,
may be the most advisable remedies in the advanced or carcino-
matous stage of the disease.  In order to  prevent  excoriation
from the acrimony of the discharge, some simple ointment should
be applied to the parts over  which it passes.  -
  Too much caution cannot be observed by women in guarding
against any exposure to cold after delivery,  as  they are thereby
apt to bring on diseases, which, if they do not prove quickly fatal,
not unfrequently leave effects behind them of which they will be
sensible the whole future period of their life.
  PERITONITIS, OR INFLAMMATION OF THE PE1UT0N,EU.M
  The peritonitis of the puerperal state appears to be only the
common inflammation of the peritonaeum  attacking a woman
already labouring under debility,  and being somewhat conjoined
thereby with puerperal fever. 
APPENDIX.
lxi
     Peritonaeal  inflammation  frequently occurs in  women after
   delivery, and is produced by the same causes which give rise to
   an inflammation of the uterus,  viz. tedious and difficult labours,
   officiousness in the midwife, the use of instruments, the applica-
   tion of cold,  and  administering heating liquors to excess.  The
   disease has, by some authors, been called puerperal fever; but this
   seems improper, as it  neither  is attended with contagion  nor
   ever prevails epidemically ; and, therefore, the term is more pro-
   perly applicable to the disorder  treated of under that particular
   head.
     In some cases of peritonitis,  the inflammation attacks only a
   small portion of the membrane at first, and is afterwards commu-
t   nicated to the whole of it; and in others, it occupies the whole at
   once.  The patient usually is seized with rigours and shiverings,
   thirst, fever, and  an accelerated pulse, and soon feels considera-
   ble pain, with soreness, either in a particular part of the abdomen,
   or over  the whole of it.  The uneasiness  and  pain  increasing
   rapidly,  the  abdomen becomes puffed  up and swelled to'a size
   nearly equal to what it was before delivery.  From the inflamed
   state of the parts, and the exquisite pain which prevails, the very
   weight of the bed-clothes becomes irksome and insufferable; and,
   in order to support it, the patient is obliged to  lie on her back,
   with  her knees bent in towards  her belly.  She is,  moreover,
   incapable of bearing the least motion.
     The stomach, in most cases, is much affected, and  a constant
   sickness, with a vomiting of bilious matter, ensues. The state of
   the intestines is  variable;  sometimes costiveness prevails, at
   others a purging,  and sometimes the body is perfectly regular.
   The bladder likewise  becomes much affected, and there arises a
   constant inclination to make water, but which comes away, how-
   ever, in a very small quantity at a time.
     As the disease advances, and the tumefaction  augments, great
   difficulty of breathing ensues ; and, in consequence of the general
   determination to the bowels, the secretion of milk becomes much
   diminished,  and is at  last  entirely stopped ;  the breasts  are
   flaccid and  empty, and  the lochial discharge is,  perhaps, wholly
   suppressed.
     The system is usually affected-with a mixture of general in-
   flammation  and symptoms of irritation;  the pulse is frequent,
   small, and contracted, beating about 120 or 130  in a minute;  the
   skin is dry and hot, with flushing of the face and redness of  the
   eves;  the tongue is white and  dry, with the prevalence of grea-: 
lxii
APPENDIX.
 thirst; the appetite is diminished,  but not wholly lost;  and the
 patient is restless, uneasy, and gets little or no sleep.
   The disease continuing to proceed in its course, all the symp-
 toms  become highly aggravated, and  at last a total cessation of
 pain ensues ; the pulse becomes still smaller, but is at the same
 time more frequent; cold clammy sweats break out, the urine and
 faeces come away involuntarily, the extremities are cold,  and the
 patient is carried off in the course of the sixth, seventh, or eighth
 day.
   Chronic inflammation of the peritonaeum is not a very unusual
 sequela of the acute species, when the patient survives that.
   We may  regard the following appearances in a favourable light:
 —The pulse becoming fuller and less frequent, the skin moister
 and cooler,  the respiration less laborious, the urine being voided
 in a proper  quantity and less frequently, the return of the milk in
 the breasts, the re-appearance of the lochial discharge, a gradual
 diminution  of the pain and tension in the abdomen, with the abi-
 lity oT remaining in a sitting  posture, and the coming on  of a
 gentle diarrhoea towards the close of the disease.  On the  con-
 trary, we are to consider the sudden cessation of pain, with a
 sinking pulse, effusion, and tumefaction, as fatal symptoms.
   Peritonaeal inflammation is to be distinguished  from enteritis
 by the pain  being permanent; by its being increased by pressure,
 even before any tension has taken place on the abdomen;  by its
 producing no inclination to go to stool; and by its not being dimi-
 nished if this evacuation should take place spontaneously.
   The appearances on  dissection have been those of inflamma-
 mation in the peritonaeum covering the different viscera, as the
 stomach, liver, spleen, omentum, intestines, 8cc.; but that which
 covers the uterus and bladder is usually found in a higher  state
 of inflammation  than any other part.  Moreover,  there is  a re-
 markable change in the omentum, which is frequently as thick as
 a person's hand,*  and there is generally perceived in the cavity of
 the abdomen a large quantity of a  fluid resembling serum,  min-
 gled with  pus, and intermixed with  shreds  of coagulable lymph,
or portions  of solid matter, similar to what is mentioned under
the head of Puerperal Fever.   It seldom happens  that gangrene
or mortification of any of the viscera is to be observed  ; but the
intestines are usually greatly distended with air.
  In the cure of this disease, nearly the same mode of treatment
• See Morbid Anatomy, by Dr. Baillie. 
                        APPENDIX.      -            lxiii

 which has been advised for an  inflammation of the uterus  must
 be adopted'.   Bleeding from  the  system to about  sixteen or
 twenty ounces should therefore be had recourse to at a very early
 period, particularly where  the  patient  is of a robust, plethoric
 habit, and with such it may be  necessary to repeat the operation
 within twelve hours.   In  those cases where there is no mixture
 Of phlegmonous inflammation with the symptoms of irritation,
 drawing  blood  a  second  time, by  the application of  a  dozen
 leeches applied to the abdomen, may be  preferable to  taking it
 away from the arm.
   In the pure  peritonitis, local blood-letting should never  be
 solely trusted to, and indeed  ought not to be advised until there
 appears some diminution of  pain from  general bleeding,-or  till
 the  constitutional effects occasioned by the local inflammation
 are partly removed, and the disorder thereby  reduced to a  state
 more nearly approaching to a simple topical affection.  Then the
 repeated application of several leeches  to the  abdomen, so as to
 keep up a copious flow of blood, will be useful.
   An occasional irregularity in  the complaint often occurs, which
 is liable to mislead the practitioner  : and that is, at the very first
 attack there is  sometimes so  great a degree  of prostration  of
 strength or seeming debility,  accompanied likewise by a pulse
 scarcely perceptible at the wrist, as might induce us to  consider
 the patient nearly at the point of death, and unequal to  undergo
 the  treatment  here recommended.  These appearances, how-
 ever, may be supposed to arise from the inflammation extending
 to the peritonaeal coat of the stomach and intestines.  Here the
 violence of pain and tenderness on pressure must be the chief
 criterion to determine our practii e,'but not the state of the pulse;
 and  if they should be found exquisite, no accidental symptom
 should lead us  from trusting chiefly to the lancet.  Such a de-
 cision will soon be justified by a greater freedom in the action of
 the arterial system, by an abatement of  the languor, and by a  di-
 minution of the pain and tenderness.
   Emollient and antispasmodic fomentations to the abdomen,  by
 means of flannel cloths wrung out in a  warm decoction  of equal
 parts of  chamomile-flowers,  and bruised poppy-heads, with a
 small addition of rectified spirit or spiritus  camphorae, will  be
 proper remedies in all cases of peritonitis, and ought therefore
not to be neglected.
  Some cases are recorded in  a  late publication,* attesting the
        * See Observations on Peritonitis, by T. Sutton, M. D. 
Ixiv                     APPENDIX.
good effects of cold  applications by. linen cloths dipped in can;
phor mixture and water, in this disease.
  Under an apprehension that the application of a blister to the
abdomen" might prove injurious by its  irritating  effect, some
physicians  have objected to advise it in peritonitis, while others
again have recommended it to be employed, under the idea that
its determining the inflammation to the external parts, and there-
by lessening it on  the internal ones, will greatly counterbalance
any excitement it may occasion. When the constitutional effects
occasioned  by the local inflammation are partly removed by ge-
neral bleedings, and the disorder is reduced to a state more nearly
approaching to a simple  topical affection, there can be no doubt,
I think, of the propriety of blistering the abdomen.
  Probably, more benefit  might  result, generally speaking, not
only in  this and other visceral affections, by  remote counter-ex-
citement, than from  the .prevailing  practice of employing it in
the immediate vicinity of  the  diseased organ.   Thus it might
prove more remedial to blister the upper parts of each thigh in
peritonaeal  inflammation, and to apply fomentations or linen cloths
dipped in camphor mixture and water, as  may be  judged most
proper, over the region of the abdomen.  A similar  practice is
certainly most salutary in phrenitis, and perhaps  it might be
safely extended to acute affections o.f the belly and chest.
  To empty the bowels freely, it  will be  necessary  to  employ
active purgatives from time to time.  A pill composed of three
or four  grains of the submuriate of mercury, followed by a full
dose of an infusion of senna  with sulphate  of magnesia, or of
castor oil, will not fail to afford relief by  promoting several evacua-
tions of fetid and dark stools.'
  Emollient clysters may be administered during the intervals of
our employing purgatives, as they will not only assist  in keeping
the bowels  open, but will act likewise as internal fomentations.
  Should there prevail great irritation at the stomach, with fre-
quent vomiting, the patient should be directed to drink  freely of
diluted  mucilaginous liquors, taking every two or three  hours a
saline draught in the  act  of effervescence, with  an addition  of
about twelve or fifteen drops of the tinctura opii.
  In order to determine the  circulating fluids to the surface of
the body, and excite a slight degree of perspiration,  we  should
administer small and repeated  doses of some diaphoretic ;* and to
* Take Antimonial Po#der, two grains. 
APPENDIX.
lxv
 procure sleep and alleviate pain,  having previously bled suffi-
 ciently, we may make an addition of opium, increasing the quan-
 tity according to its effects.  These may be washed down with
 two or three table-spoonfuls of the mistura camphorae, which will
 be  likely to prove a serviceable medicine.
  Where  the urine becomes suppressed by  the  inflammation
 having extended in a high degree  to  the bladder,  a warm bath,
 with an occasional use of the catheter, maybe necessary.
  In the early stage of  the disease, where phlegmonous inflam-
 mation simply prevails, it might be of service to make use ofthe
 nitrate of potass  and other refrigerants ; but at a more advanced
 period, and where symptoms of irritation  arise, they would be
 improper.   When these ensue, the cinchona bark, with a mode-
 rate quantity of wine, ought to be given.  Should the stomach
 not be capable of retaining the powder, a decoction or infusion
 may be tried, with a small addition  of the tinctura calumbae.
  If a gentle diarrhoea should come on in the course of the dis-
 ease, it is by no means to be checked,  unless when violent, as it
 may prove critical.
  The spirit of turpentine is a remedy which  has been strongly
 recommended  in puerperal  peritonitis by Dr. Brenan, of Dublin,
 and is said to  have been employed by him with  very favourable
 effects in several instances of the disease.  In extreme or very
 urgent cases, after the failure of the other means which have been
 pointed out, it may be worthy of a trial.
  Throughout the whole period of the disorder the patient is to
 be supported by food of  a light nutritive nature, administered in
 small  quantities at a time, and repeated frequently, so as never to
 overload the stomach.
  Where effusion in the  cavity of the abdomen with tumefaction
 takes place, no relief can be obtained by  medicine: death is  the
 infallible consequence.
  Chronic  peritonitis, the occasional sequela of acute, especially
when the depleting plan has  not been sufficiently acted upon,
must be treated  with  leeches, blisters, and  small  doses  of  the
 submuriate of mercury, together  with  some  active cathartic
twice a week.
         Confection of Roses,  ten grains.
    M x them, and take this bolus every four hours.
  Or, Take James's Powder, five grains.
         Opium, half a grain.
         Confection of Orange Peel, a sufficiency to form a bolus.
  Or, Take Compound Powder of Ipecacuanha, ten grains for a dose.
   VOL. II.                 * I 
Ixvi                   APPENDIX
       FEBKIS PUERPERAKl M, OR PUERPERAL FEVER.
   Great soreness,  pain, and tension of the  abdomen,  short.
 anxious breathing, uncommon quickness of  the pulse, increased
 temperature of the body, tensive pain over the forehead, peculiar
 wildness of the eyes, prostration of the vital powers, suppression
 or  diminution  of the  milk and lochia, a  flaccid  state of the
 mammae, and an unnatural condition of the excrements, accom-
 panied by diarrhoea, may be regarded as the pathognomic symp-
 toms of puerperal fever.  Its epidemical prevalence at times, is
 a sufficient characteristic of its nature, because this circumstance
 never  takes place with respect to simple inflammation of the
 uterus and peritonaeum.
  It is a disease peculiar to women after delivery, particularly in
 hospitals, and  is  supposed to occasion the  death  of  nearly one
 half of those who die in child-bed.  Until of late it had not been
 much noticed by medical writers, and even now various opinions
 are entertained with regard both to its nature and the causes pro-
 ducing it.  Some have doubted if it deserves the title of specific,
 or ought to be regarded as of a particular genus ;  and these have
 been accustomed to  look on it as onjy  a simple modification of
 the known species of fever, taking its  origin from the leaven of
 the prevailing epidemic constitution, whether inflammatory or
 putrid, modified by the habit of body, the mode of living, the
age  and temperament  of the patient, the preceding causes, the
 season of the year, and  temperature of the air, &c.  Others again
 have considered the  disease as uterine  and peritonaeal inflamma-
 tion, accompanied in its progress  by fever  of a low malignant
 nature, or typhoid type.*  Indeed the diagnosis between puer-
peral fever and the more common forms of peritonaeal and ute-
 rine inflammation which occur in the puerperal state, is still ob-
scure and undetermined :  the  limits   bounding some of these
cases are so indistinctly marked, that the one case  seems to pass
imperceptibly into the other.
  A stoppage of the lochia has been assigned as one of the causes
of puerperal fever;  but the circumstance of their being some-
times absent and sometimes present at  the attack, and  during the
progress of the disease, shows their perfect independence of each
other.  Others again have  thought  that puerperal fever is pro-
 duced by the absorption  of  a putrid sanies arising  from  dead

   • See Facts and Observations relative to  the Fever commonly called
 Puerperal, by J. Armstrong, M. O. 
                        APPENDIX.                  lxvii

parts of the omentum or mesentery, or some other putrid mate-
rial in the abdomen or uterus.  By a few physicians it has been
represented as owing its existence to an undue secretion of milk;
while others have supposed that it derived its origin either from
a redundancy, or too great acrimony of the bile, the secretion of
which appears to be much interrupted during the time of ges-
tation.
  The late Dr. Young, professor of midwifery at Edinburgh, was
of opinion, that the puerperal fever, strictly so called, is, in every
instance, the consequence of  contagion :  but he contends, that
the contagious matter of this disease is capable only of producing
its effects in consequence of a peculiar predisposition  given  by
delivery and its  consequences.   In support  of  this  doctrine he
remarks, in a paper read in the Philosophical Society  of that
city, that for many years the  disease  was altogether unknown in
the lying-in ward of the Royal Infirmary at Edinburgh ; but that
after it was once  introduced into  the hospital, almost every
woman was, in a short time after delivery, attacked  with it;  al-
though, prior to delivery, she  may have lain  even for weeks  to-
 gether, not only  in the same ward with the  infected, but even in
 the very next bed.  He further remarks, that it  was only eradi-
 cated from the hospital in  consequence of  the wards being  en-
 tirely emptied, thoroughly  ventilated, and new painted.  After
 these processes, puerperal females in  the hospital remained as
 free from the disease as formerly.
  With respect to the infectious nature of this fever, a great con-
 trariety of sentiment has  indeed existed;  the probability is in
 favour of its being  so, but  it  is nearly impossible to form a  de-
 cided opinion on the subject.  Doubtless it will be the safest
 practice to consider it as infectious, and to cut off all intercourse
 of  pregnant  and parturient women with those who  labour  un-
 der it.
  The real cause of puerperal fever is obscure, and not yet satis-
 factorily ascertained.   It is, however, certain, that it has a strong
 tendency to the typhoid type  in an advanced stage, although, at
 its  commencement, or during the first twenty-four or thirty-six
 hours it is usually attended  with inflammatory symptoms,  and
 even 'with topical inflammation  in  the abdominal  viscera,  but
 more particularly  the peritonaeum, or membrane which enve-
 lopes them.
   Under different  circumstances, the disease  assumes different
 appearances, and accordingly  different distinctions have been laid 
IxViii
APPENDIX.
 down by writers between its various forms; but such distinctions
 are of  no use in practice, and may, perhaps, be productive of
 embarrassment to the practitioner.  We may conclude, I think,
 that the only essential difference in the cases  that ought to be
 considered puerperal fever, consists in their-degree of violence,
 and their being epidemic, or simply sporadic;  for it seems to be
 admitted  that whenever the disease exists epidemically, it is more
 urgent  in all its symptoms.
   The  period'at  which women  are attacked with this disease is
 uncertain, as in a few instances it has arisen at the distance of a
 week after delivery;  but the most usual time of its attack  is on
 the third  or fourth day after that event.  The patient is seized at
 first with  a slight coldness and  shivering, succeeded  by pains in
 the head, ringing in the ears, flushing in the face, great anxiety
 and restlessness.   As the  disease advances, the  whole abdomen
 becomes affected, is highly painful to the touch, and much tume-
 fied.  She likewise feels great  pain in the back, hips, and some-
 times in the legs, and she performs respiration  with difficulty,
 the breathing being short and laborious, from the pressure against
 the diaphragm, as well as from an organic affection of the chest
 itself.  If  the milk has been previously determined to the breasts,
 it suddenly disappears on the approach of the disease ; but if the
 attack bf fever commences sooner, the milk does not  appear.
 The  lochia are altered both  in quantity and  appearance;  the
 urine is turbid, small in quantity, and voided with pain, and a
 tenesmus  often arises.  The skin is hot and dry, the pulse weak
 and frequent, the number of pulsations being often from 110 to
 130 in a minute;  thirst prevails, and there is vast prostration of
 strength, with anxiety, depression of spirits, a disinclination to
 suckle,  carelessness  about her child, and  watchfulness.   To
 these symptoms are added a tensive pain over the forehead, and
 a peculiar wildness of the eyes.
  A vomiting not unfrequently attacks at the same time, and in
 so high  a degree as to prevent the smallest quantity of food or me-
 dicine from being retained on the stomach.   The matter thrown
up  is of a xlark porraceous* colour, and often of a disagreeable
 smell.  The functions of the primae viae are likewise much dis-
turbed.   At the commencement they usually go on well; but in
the progress of the disease, a severe purging often ensues, par-
 ticularly in those cases where the abdomen  has been much dis-
tended,  and the dejections are abundant, serous, and putrid   It
 seldom happens that any violent delirium arises, but the  patient 
APPENDIX.
lxix
is apt to fall into a low comatose state, wishing by no means to
be disturbed.
  Alter one or two days' continuance of these appearances, the
fever often acquires a malignant and typhoid tendency, particu-
larly in hospitals and confined situations, or when the state of the
atmosphere predisposes to diseases of that nature; the lips,teeth,
and tongue are covered with a dark brown fur; aphthae beset the
whole  internal surface of  the  mouth, tongue,  uvula, tonsils, and
pharynx;  the breath is highly offensive;  the stools are fetid, of
a dark brown colour, and pass off involuntarily; and, in  a few
cases,  purple spots appear on different parts of the body.
  Such, in general, is the course of the  puerperal fever; the
symptoms of which, however, may be often varied, according to
the constitution of  the patient, the degree of the disease, and its
earlier or later invasion after delivery.
  Puerperal fever is readily to be  distinguished from that affec-
tion known by the name of after-pains, by the intervals of ease
which attend these last, and  by the  absence of fever and abdo-
minal  tension ; whereas in the former there is fever with its con-
comitant symptoms, great soreness and swelling of the abdomen,
and an almost uninterrupted continuance of pain throughout the
course of the disease.
   Many circumstances evince a dissimilarity between the puer-
peral and miliary fevers, notwithstanding  the  symptoms of anx-
iety and  oppression are common to both.  In the puerperal
fever, the rigour is more violent, of  longer duration, and not in-
terrupted, as in the other.  The pulse  at  first  is. fuller and
stronger;  the  skin is more hot; and the tongue, whether moist
or dry, though generally the latter, is not of a white, but brownish
appearance.
   Peritonaeal  inflammation is the  disease  which  bears  the
strongest resemblance to puerperal fever, but it never arises from
contagion, or prevails epidemically.
   By  paying proper attention, we may in general be able to dis-
tinguish simple peritonitis from puerperal fever.  In  the last,
the abdominal pain is not the most prominent symptom.  There
is more despondency, debility, and headach, less heat of the skin.
less thirst, and less  flushing of the face.  In the former, the pain
in the abdomen usually increases rapidly after its commencement,
and the swelling increases along with it:  pressure excites con-
siderable pain, and the fever is inflammatory throughout. 
Ixx
APPENDIX.
   Hysteritis has its proper symptoms, by which it may readily
be distinguished from puerperal fever.
   The progress of puerperal  fever is sometimes so very rapid,
particularly in warm climates and  hot  seasons, as to destroy the
patient in forty-eight hours.  Even in cases seemingly the most
favourable, we should look on  the event as doubtful, as the com-
plaint is apt to be accompanied with delusive remissions, and in-
dications arise in its progress which are by no means equal to the
danger.
   The risk seems however to  be greater  in proportion as the
accession is sooner after labour.   When  the disease comes on
at a late period after delivery, the depression of strength is usu-
ally less considerable, the tumefaction of the abdomen is less ex-
tensive, and  the other symptoms are not  so violent, and conse-
quently there will be a  greater  chance for the woman's re-
covery.
   The reappearance of the lochia, and a  gradual subsidence of
the abdominal tension and soreness after copious stools, the pulse
at the same time becoming slower, with a  moist skin, may be re-
garded in a very favourable light.  On the contrary, an agitated
countenance, with  a hurried, unconnected manner of speaking,
constant sighing, attended with a tossing about of the arms, pain
and oppression at the chest, visual deceptions, imaginary  strange
sounds and voices, muttering and stupor, are to be considered as
unfavourable symptoms.   An  extensive swelling of the belly, so
as to sound on striking it  with the  fingers, sudden  cessation of
pain,  irregularity  in  the  pulse, coldness  in  the  extremities,
clammy moisture  diffused over  the whole body, frequent dark-
coloured and fetid evacuations by stool, and an indifference to all
external objects, denote certain and speedy death.
   On a fair computation,  three-fourths of the women  who have
been attacked with this disease have fallen sacrifices to it.
   The morbid appearances observed on  dissection are  usually
confined to the abdomen.   The  first thing  that often presents
itself is a collection of  whey-like fluid in the cavity of the abdo-
men ; which  is  sometimes so considerable in quantity as to
amount to several quarts; and it has a peculiarity  of  smell, dif-
ferent from any  other fluid to be met with in the human body,
either in health or disease.  Where it is  large in  quantity, the
surfaces of the  different  viscera and  of  the peritonaeum will
usually be found covered with  a crust formed of a  solid  part of
this matter, resembling  coagulated lymph.  If  there be  any in- 
                       APPENDIX.                    Ixxi

terstices between the intestines or the other viscera, they are fre-
quently filled with large masses of  the same, adapted exactly to
the shape and size of such interstices.   In a few cases, a deposit
of a caseous and serous nature has been discovered likewise in
the head, breast, and external cellular membrane, as has before
been observed.  In most instances there is found a slight degree
of inflammation in some part of the cavity ;  but it is not confined
invariably to any particular place;  as the uterus, ovaria, perito-
naeum,  omentum, intestines, and  bladder, have all in their turn
been observed in a state of inflammation.  In many cases of dis-
section, a considerable  quantity of purulent matter has been found
in the cavity of the abdomen.
   Upon analyzing the  fluid effused into the peritonaeal cavity of
a woman dying from this fever, it has  been found to possess a
perfect  chemical identity with that furnished by the inflamed
pleura.   The peritonaeal fluid, after depositing  a copious whitish
precipitate, which afforded albumen to the different re-agents,
was of  a clear yellowish white colour,  and had the property of
turning green the syrup of violets.   But the nature  and propor-
tion of the alkali endowing it with this property, have not been
ascertained.   The flocculi which  float in the abdominal serum of
puerperal subjects  have been regarded as a  cheesy substance,
formed of the coagulum of the milk : but this seems erroneous.
Ammonia  mixed with the substance in  question  scarcely acts
upon it as a solvent, and evaporation  developes in it all the cha-
racters  of albumen.
   In a disease where the symptoms come on with such violence,
where the progress is  so  very rapid, and the event so generally
fatal, every  assistance should be afforfled as  soon  as possible.
Unfortunately, however,  there has  prevailed  a great diversity of
opinion among  physicians relative to the remedies to be em-
ployed during its first stage, some advising copious bleeding, and
others  highly disapproving of its being ever  adopted.   Under
such a contrariety of opinion, it will be best to pursue that plan
which seems most congenial to the nature of the disease.
   I shall consider puerperal fever admitting of the same variety
of treatment with other affections in which an  inflammatory dis-
position prevails on its first attack; but in which  a  typhoid and
malignant tendency is to  be observed after a continuance of one
or two days.
   During the first stage of puerperal fever,(which should not be
considered  as  extending beyond  twenty-four or six-and-thirty 
lxxii
APPENDIX.
 hours from its attack,) if the patient complains of abdominal pain
 and soreness, I am of opinion that we may advantageously resort
 to venesection, proportioning the quantity of blood that is drawn
 off to the habit of the patient and the violence of the symptoms.
 In strong plethoric women, it should not  be  less than twenty
 ounces, nor ought it to exceed thirty; and care should be taken
 that the orifice is made  large, so as  to produce a decisive effect
 at once.—(See Pleurisy.)   A repetition of the bleeding  ought in
 general to be avoided ; but if judged indispensable, from the ab-
 dominal soreness and pain not being removed or materially alle-
 viated within six hours, a smaller quantity, not exceeding twelve
 ounces, should be taken away  after this interval.  It is only dur-
 ing the first stage of puerperal fever, however, that blood-letting
 is advisable;  this being usually marked by inflammatory symp-
 toms ; whereas characters highly typhoid become manifest during
 its second stage.
   In a few instances of this fever, extreme debility (marked by-
 great depression  of strength  and a  small, feeble pulse) and  a
 typhoid tendency, may be apparent from its commencement.  In
 these it would be improper to draw blood from the arm; but
 where there  is much abdominal pain, with great  soreness, the
 application of several leeches to the  belly  may be advisable.  In
 some countries, the  application of leeches to the vagina or hae-
 morrhoidal veins has been considered as the best mode of bleed-
 ing in this disease, but its inefficacy must be obvious.
   The propriety of administering purgativesin puerperal fever
 has admitted  of as much  doubt as  that of  venesection.  Some
 physicians observing that women who die of  this fever are gene-
 rally molested with a diarrhoea, have been induced to  consider
 this symptom as  of the most dangerous and fatal tendency, and
 which ought to be restrained  by every possible means;  whilst
 others again have regarded it rather as  critical than  sympto-
■matical, and think it  ought  therefore to be moderately supported
 instead of beint^ restrained.  To  procure stools where costive-
 ness prevails, and remove putrid feculent matter, it  appears rea-
 sonable that we  might employ purgative medicines at the com-
 mencement of the disease  with  advantage; and possibly a few
 grains of the submuriate of mercury, with a small quantity of
 rhubarb or jalap, followed up by two  or three large spoonfuls of
 a solution of some neutral  salt every hour or two, until copious
 evacuations are procured,  will be most advisable.   Where the
 disease  is in  an advanced  stage, and the  patient reduced  in 
APPENDIX.
lxxiii
  strength, dislodging  the contents of the intestines by means of
  gentle laxatives, assisted by aperient clysters, appears to be the
  best mode of procuring evacuations, which at this period of the
  disease  are  usually of a dark brown colour, resembling coffee
  grounds, very copious, of the  consistence of thick gruel, and
  with  a fetid smell.
    In my opinion, the most rational method of treating puerperal
  fever, but more particularly when  attended  by abdominal pain
  and soreness, is to  abstract blood, from a large orifice, to a suffi-
  cient extent, at the first onset of  the disease, and then direct the
  attention to a free  evacuation of the alimentary tube throughout
  the continuance of the disease, at first by purgatives, and towards
  the close by aperient medicines and laxative clysters.
    A  very interesting account of a  puerperal  fever which was
  epidemic at Aberdeen, and published by Dr. Alexander Gordon,
  fives us to understand, that not only purgatives are useful in this
i  disease, but likewise  bleeding.   He tells us that the disease was
  infectious; that it  seemed to arise from the  contagion that was
  carried by the accoucheur, or nurse, from one lying-in woman to
  another; and that it  began with violent unremitting pain of the
  abdomen on the day of delivery, or the next, with shuddering, and
  a very quick pulse, often 140 in a minute.  If he saw the patient
  within  twelve or twenty-four hours of her seizure, he took away
  from sixteen to twenty-four ounces of  blood, which was always
  sizy.  He then immediately gave a cathartic, consisting of  the
  submuriate of mercury and jalap.   After this had operated, he
  prescribed an opiate at night, and so  continued the  purge and
  the opiate for several days.
    He asserts, that almost all those whom he was  permitted to
  treat in  this manner  early in the disease, recovered, to the num-
  ber of fifty, and that  almost all the rest died;  but that when two
  or three days were elapsed, the patients became  too weak  for
  this method, and the  matter was  already  formed which destroyed
  them.
    Dr. Armstrong  is of  opinion,* that  puerperal  fever bears a
  close analogy  to typhus complicated with  inflammation of  the
  abdomen, and  thinks it ought to  be arranged under three varie-
  ties,  namely, the sporadic, the epidemic, and the chronic.  He
  also is perfectly convinced that bleeding at the first onset of the

       » See his Illustrations of Typhus and other Febrile Diseases.
         ______Treatise on Puerperal Fever.
    VOL. II.                  * K 
Ixxiv
APPENDIX.
disease, assisted by purgatives, are the main remedies to be de
pended upon under every form ;  and he adds, moreover, that  it
is not simply bleeding and purging in which he places his confi-
dence, but in copious bleeding, immediately succeeded by copi-
ous purging, or rather in the  powers of these two means simul-
taneously exerted  on the disease at its  onset.   Mr. Hey, of
Leeds,* is also  an  advocate for the same  plan of treating this
fever.
  It often happens that nausea and a vomiting of bilious matter
attend an attack of this fever.  In such cases we may recom-
mend a gentle emetic of ipecacuanha to be taken, with a view of
cleansing the stomach: but I cannot agree with those who  ad-
vise a repetition of it, as the operation of vomiting  never fails to
aggravate the pain, and likewise to exhaust the woman, besides
endangering a great degree of irritation in the stomach, to which
there is naturally too great a tendency.                      •
  Although I object to a repetition of ipecacuanha or antimo-
nials, given  so as to produce  an emetic effect, still  I  think they
may be  administered with some  advantage at  the commence-
ment of  puerperal fever, in such small doses as to  determine to
the surface of the body.  As a diaphoretic, I know  of none pre-
ferable in the  present instance to ipecacuanha, which may be
prescribed in  doses of about two  grains,  to be  repeated every
three or  four hours; or perhaps it may be still more  efficacious
to give it combined with opium, as in the pulvis  ipecacuanhas
compositus.   Of this, about  six  grains made into  a bolus, with
a small  quantity of confection of roses, may be taken as before
mentioned, washing it down with a saline draught; and to make
the diaphoretic effect more  certain, the  patient should drink
frequently of diluting liquors, such as whey, barley-water, &c.
  To alleviate the soreness and  distention of the abdomen, we
may recommend the  application of fomentations both inwardly
and externally ; inwardly, by injecting tepid water into the uterus
every four or six  hours, and administering  emollient clysters
from  time to time; and externally, by applying flannel  cloths
wrung out in a warm  decoction of equal parts of chamomile
flowers and  bruised poppy-heads, with an addition of about one-
third of rectified spirit,  over the whole region of the abdomen;
and these ought to be renewed as often as they become cold.
* See Treatise on the same, by Mr. Hey. 
APPENDIX.
lxxv
taking due care that they are not so wet as to run about the bed
and incommode the patient.
  The warm bath has been recommended by some practitioners,
and  it often produces a calm  and disposes to  sleep; but this
being  the effect of  exhaustion,  it appears to be a doubtful
remedy.
  Where the abdominal cavity is  highly painful to the touch,
and  is  occupied by extensive inflammation, the application of
cold to the parts, by cloths dipped in camphor mixture and cold
water, has been attended with a good effect.*
  If the soreness and pain are  not relieved by the means which
have been  suggested, then the  application of  a  blister to the
upper part  of  each  thigh may be proper.   Blistering the abdo-
men might  not be advisable, at least not until the topical abstrac-
tion of blood  had been adopted by the application of several
leeches.—See  Peritonitis.
   Having employed gentle cathartics  at an early period, for the
purpose of obviating costiveness and dislodging the putrescent
matter from the bowels, we may then with safety have recourse
to  anodynes administered so as  to keep up a  constant effect.t
The dose of opium must depend on the severity of the pain, and
the age and constitution of the  patient, and it may be repeated
every four  or six hours.  Opium, when administered in  puer-
peral fever, diminishes the irritability of  the system, as well as
that of the stomach and intestines.   It eases pain, produces sleep,
and seems to excite a moderate diajfroresis. In a few instances,
I think, I have observed it to obviate  or relieve delirium in  the
same manner as in typhus.
   Should there be any great irritation of the stomach, the saline
 draught with a proper quantity of tinctura opii may be given, so
 as that the  effervescence shall take place after it is swallowed, as
 advised under the head of Simple Fever.  Should this medicine
 also  be rejected, the vomiting  may  perhaps  be restrained by
 opium in the form of pills, and by rubbing the region of the sto-
 mach frequently with some strong anodyne liniment.  The ap-
 plication of a blister  might  excite  injurious  irritation.   The

    * See Cases of Puerperal Fever, by T. Sutton, If. D.
    + Take Cinnamon Water, one ounce.
          Tincture of Opium, fifteen drops.
          Syrup of Marshmallow, two drachms.
          Compound Tincture of Lavender, half a drachm
      Mix them for a draught. 
Ixxvi                   APPENDIX.

strength must be supported by administering clysters, composed
of animal broths and other such nutritive liquids, until the sto-
mach becomes tranquil, and will bear the introduction of proper
nourishment.
  If a gentle purging arises in the first stage or commencement
of the  complaint, it ought not to be too hastily stopped, as the
fever has in some instances been carried off by such a spontane-
ous evacuation; but if the  disease is of some days' standing, the
stools very frequent, the patient much reduced, and no evident
relief has been afforded by the diarrhoea,  we must then give
astringents,* joined with opium, to restrain it; and for ordinary
drink she may  take the mistura  cornu  usti.  To support the
strength, wine may be necessary ; and this  should be given in a
moderate quantity, properly  diluted  with water, as  likewise
mixed with the food consisting of preparations of barley, sago,
panado, Indian arrow-root, tapioca, and the like, varied now and
then by broths, beef-tea, and milk.
  The oleum terebinthinae is a medicine, which is  highly spoken
of by one or two practitioners in this disease, but further  expe-
rience is requisite  to satisfy us  that it is deserving of  the cha-
racter ascribed to it.
  It has been observed, that this fever, after continuing a day or
two, very often acquires a malignant and putrid tendency. Under
such circumstances it will be  right to have immediate recourse
to the bark of cinchona joined with the mineral acids, but more
particularly the muriatic,  as^noticed under the head of Typhus
Gravior, and  to  exhibit it Treely in as large doses as the sto-
mach will bear.   If the powder is readily retained, it ought to be
preferred to any other preparation ; but if not, a decoction or in-
fusion may be substituted.t  Should it be rejected in all  these

   * Take Confection of Opium, ten grains to one scruple.
         Cinnamon Water, one ounce and a half.
         Tincture of Kino, two drachms.
         Compound Tincture of Lavender, half a drachm.
     Mix them.  This draught is to be taken three times a day.
  Or, Take Chalk Mixture, three ounces.
         Pimento Water,
         Cinnamon Water, of each two ounces.
         Tincture of Catechu, two drachms.
         -------of Opium, forty-five drops.
     Mix them, and take two table-spoonfuls every four hours.
   | Take Decoction or Infusion of Peruvian Bark, ten drachms.
         Tincture of Cascarilla, two drachms.
         Muriatic Acid, eighteen drops.
     Mix them.   This draught is to be given  every four hours. 
APPENDIX.
lxxvii
ways, it may then be given in clysters, with an  addition of about
five-and-twenty drops of tinctura opii to  each.  If it  occasions
any purging when taken by the mouth, a  few drops of  the tinc-
ture of opium may be added to each dose.
  When there  is no disposition to a putrid tendency, it will be
best to wait till a remission of the symptoms, or a partial subsi-
dence of febrile action has taken place, before we prescribe a use
of the cinchona.
  A late physician of  eminence* in treating  on this disease, ob-
serves, that the cinchona, although given  by  him in the different
stages of the complaint with remissions tolerably distinct, by no
means answered the intention as a febrifuge ;  but that in a few
cases  where the intermissions were complete it had  succeeded.
He likewise observes, that as a supporter of the general strength,
it has been found of less service than might have been expected,
on account of the disturbed and very irritable state of the bowels,
which  it has a tendency to increase.  Instead of cinchona, he
advises the columba-rootf in powder or infusion,} in doses to be
repeated every four hours.
  If hiccups and subsultus tendmum arise in the progress of the
disease, recourse must be had to antispasmodics, such as musk,
aether, and  the  like;  although it is probable they will avail but
little.  When any unusual coldness of the extremities is felt, the
application  of stimulating cataplasms will  be  proper.
  The carbonate of potass is a medicine which is strongly re-
commended by Monsieur Guinot§ in puerperal fever,  as well as
in all diseases connected with the secretion of milk in the female
breast.   He advises it to be given in doses of from ten to twelve
grains, three times a day, in any proper vehicle, and to employ at
the same time alkalies externally, such as a solution of soap in a
decoction of poppy-heads, taking care at the  same time not to
neglect other remedies indicated by the circumstances and symp-
toms of the case.

   * Dr. Denman.
   § See Extracts from his Memoir inserted in  the third volume of the
 Medical and Physical Journal, pages 80, 165, 264, and 363.
   •f Take Powder of Coluraba, half a drachm.
         Opium, half a grain.
         Confection of Roses, a sufficiency to form a  bolus.
   > Take Infusion of Columba, ten drachms.
   '     Tincture of Orange Peel, one drachm and a half.
         Muriatic Acid, fifteen drops.
     Mix them for a draught. 
lxxviii
APPENDIX.
  This alkaline treatment he recommends under the idea that
the disease is occasioned by the predominance of an acid.  Whe-
ther it acts by counteracting the acid, dissolving the clotted milk,
by neutralizing the acid which may actually exist  there, by its
action on the organs of perspiration, or by inducing other useful
crises, cannot be ascertained; but it appears to have proved very
successful  and advantageous  with  other practitioners besides
Monsieur Guinot, and may therefore be tried at an  early period
of the disease.   A combination of the carbonate of potass with
the cinchona bark might probably be useful in cases of puerperal
fever complicated with malignancy.
  It would appear that the effluvia of a patient under puerperal
fever is an animal poison sui generis, capable of acting on preg-
nant females, their situation giving the  predisposition necessary
for the operation of its influence.   The usual mode of commu-
nicating the infection in private practice is by being delivered by
some accoucheur who has lately been attending a woman labour-
ing under puerperal fever, or her  being  visited by female friends
who have been where it prevailed.   It therefore behoves every
practitioner, when  he  meets with the disease, to observe  every
possible precaution in changing his clothes, and by careful ablu-
tion of his hands to guard against conveying infection to other
parturient  women: moreover,  all pregnant women should be
excluded from the house; nor should the nurse or other persons
about the sick be permitted to go abroad  and visit women in a
stage of pregnancy.
  To prevent the  disease from occurring, it will  be proper to
keep the patient's mind, both before, during the time  of labour,
and afterwards, as  free from every kind of uneasiness as possible,
as anxiety might greatly predispose to an attack of it.  She should
likewise carefully  avoid any exposure to the infection of fever
before delivery, as well  as to  the  occasional causes of it after-
wards.   Every woman  lately delivered  ought  cautiously  to
guard against cold; but in doing this, her room should at  the
same time be kept of a proper temperature by allowing a suffi-
cient ventilation.
  It  being a  well-known fact that puerperal fever has been
chiefly confined to close apartments and small hospitals, and that
since the lying-in chambers have been made more airy and com-
modious,  and the hospitals larger, the  disease seldom  prevails
epidemically or becomes general, due attention should be paid
to a free ventilation: for it is by no means improbable that a cool 
                       APPENDIX.                 lxxix

air in a lying-in chamber will frequently prevent, and its opposite '
be likely to induce thte phenomena of puerperal fever.
  The patient should  observe the strictest cleanliness both as to
herself and the bedding.  On the coming of , iie milk, her breasts
ought to be drawn repeatedly throughout the course of the day,
by some  person accustomed to  the business, or  by applying the
child ; her body should be kept perfectly open alter she is deli-
vered, as well as before her confinement, by some mild purgative
medicine, and she should abstain from all food of a heating or
irritating nature.
  An upright posture  will be most proper,  in order to  dis-
charge  more readily  any putrescent matter  that  may be  in the
uterus.
  When the disease prevails as an epidemic among puerperal
women, or occurs in a lying-in hospital, all communication ought
immediately be cut off  between those who are affected and such
as have lately lain in, or expect shortly to do so; and in order to
root out the disease and stifle contagion, we should have recourse
to fumigations, as advised under the heads of Malignant  Fever
and Dysentery, and afterwards to painting, white-washing, and a
free ventilation.
  In situations where puerperal fever has been prevalent, some
advantage may be obtained by giving a decoction of  the bark of
cinchona with tincture of opium and cordials immediately after
delivery.  These will  in some measure enable lying-in women to
resist the powers of contagion.

                   MANIA PUERPERARUM.

  The  characteristics, symptoms, and  treatment of madness
arising in women after delivery are  fully detailed under the head
of Mania, which see.
                      INVERSIO UTERI.
  This complaint consists in the inversion of the cavity  of the
uterus, so that the fundus comes through the os uteri,  conse-
quently that part which was formerly the inside of the cavity be-
comes now the outside of a tumour, either in or projecting from
the vagina.   It  most commonly is  the consequence of misman-
agement of the placenta, by the midwife or accoucheur being in
too great a hurry to extract it.
  Its immediate effects are haemorrhage, faintness, and a sense
of fulness in the vagina. 
lxxx
APPENDIX.
   When early discovered, the uterus may easily be  reduced to
its natural  situation.  If the placenta be adhering  to the womb,
the latter should be reduced before  any  separation  of the former
be attempted, to prevent haemorrhage.

                    PROCIDENTIA UTERI.

   This complaint consists (as  the name implies) in a  change of
the situation of the  womb, by which this organ falls much lower
than it ought to do.  In some cases it absolutely protrudes en-
tirely without the  vagina.  The  slighter cases are  therefore
named a bearing down, and  the more violent ones  a  descent or
falling down  of the  uterus.  The  complaint is  met with  in
women  of  every  rank and age ; but  more frequently in those
who have had  several children than in such as have not had any.
   Every disease which induces general debility, or local weak-
ness in  the passage leading to the womb in particular, may lay
the foundation of  this  complaint; hence  immoderate venery,
frequent miscarriages, improper treatment during labour, and
too early or a long-continued erect posture of the body soon after
delivery, and in some cases after abortion, are in married women
the most common causes of procedentia  uteri.  At  this time the
womb weighs eight  or ten times more than when unimpregnated,
and descends by its  gravity.  In the  unmarried it is apt to take
place in consequence of violent exercise, such as jumping, danc-
ing, riding, lifting heavyweights, &c. while out of order.
   The proximate or immediate  cause of  prolapsus uteri is re-
laxation of the broad and round  ligaments above, and want  of
tone in the  vagina below.
   The disease comes  on  generally with an uneasy sensation  in
the loins whilst standing or walking, accompanied now and then
with a kind of pressure and bearing down, as also pains in the
groins extending to  the labia.  There is a sense of fulness in the
parts, and probably  an increased discharge of  transparent mucus
from the vagina.  All the symptoms are relieved by a recumbent
position.  In procidentia uteri the  symptoms arising  from the
uterogastric sympathy are in many cases very distressing; the
appetite fails, the stomach and bowels lose their tone, flatulence
and borborygmi are troublesome,  considerable debility ensues,
the spirits are  depressed, employment and exercise  become irk-
some, and life at last is scarcely desirable.  The dischai ge varies
much at times, the menstrual flow usually is increased, and me-
norrhagia not  unfrequently  attends.   Before  the external pro- 
APPENDIX.
lxxxi
trusion of the tumour, the discharge is greater than afterwards,
because the surface of the vagina ceases to secrete when per-
manently exposed  to the air.  After a time, patches of healthy
looking ulceration attack the exposed vaginal surface, but sel-
dom go deep : and the os uteri is not unfrequently assailed by
one of these.
  By neglecting to pay proper attention to  the early symptoms
and threatenings of the  disease, the woman becomes at length
incapable of making water without first lying down or pushing up
the swelling which seems to impede the discharge of urine ; and
if the complaint continues to increase, the womb is actually forced
out of the parts, and takes on the form of a bulky substance hang-
ing  down between the thighs.  This  severe degree of the dis-
order  seldom occurs, however, among women in  northern cli-
mates, except in  those who have had many children, and are at
the same time of  a relaxed and feeble frame ; but in warm cli-
mates it is very frequently to be met with, and particularly in ne-
groes and mulattoes, among whom I often observed the protrud-
ed parts considerably ulcerated, and occasioned, no doubt, by ex-
ternal irritation and a neglect of cleanliness.
  Although procidentia  uteri is a local  disease, it is frequently
productive of several  distressing symptoms which  undermine
the  constitution.   These principally arise  from  the disturbed
functions of the stomach and bowels, and an impaired condition
of the nervous system.
  In its early stages, if conception should take place, a confine-
ment for some weeks in a recumbent  position on  a sofa  or bed
will often enable  the parts to regain their tone, so as to  render
subsequent artificial assistance unnecessary.   Where pregnancy
does not exist we must have recourse to art.  If the disease is of
long standing it may be difficult to effect a cure.
  In  the treatment of procidentia  uteri,  the curative intentions
are to increase the tone of the  relaxed parts, both topically and
through the constitution, and to support the tumour: topically
by  cold and by astringents.  Cold water ought to  be applied to
the parts of generation, as also to the belly  and back, by means
of a large sponge, three or four times a day, the water being as
cool as possible.   Cold water may also be thrown into the vagina
as frequently by means of a syringe.  In very slight cases, these
means  assisted by a horizontal position, may be sufficient; but
in cases of some standing, astringent washes should be substituted
for simple water.   Alum  combined with zinci sulphas dissolved
  VOL. II.                * 1- 
lxxxii
APPENDIX.
in a decoction or infusion of some vegetable astringent, such as
thea viridis, petala rosae rubrae, cortex quercus, cortex granati,
gallae, Sec, will make an appropriate  injection, various formula:
of which are given under the head  of Leucorrhoea and Gonor-
rhoea Simplex, as also below.*
   In aid of topical applications, tonics must be administered in-
ternally, especially the bitter tonics, as gentian, columba, &c,
with cinchona and sulphuric acid:  for various formulae of these,
see Dyspepsia.
   A due attention must be paid at the same time to the state of
the bowels, and this be nicely regulated: the extreme of consti-
pation and diarrhoea being  equally injurious.  Aperients of the
mildest nature, when requisite, are therefore only to be employed.
The bladder should never be suffered to contain a large quantity
of urine.   When the stomach is not previously much weakened,
the use  of a  cold bath may prove a valuable  auxiliary to the
other me'ans;  and a  salt water bath will  be preferable to one of
fresh water.
   In every case of procidentia uteri, the recumbent posture on a
sofa or  hard mattress  as much as#possible ought to be enjoined,
keeping the room at the same time as cool as may  be consistent
with the patient's feelings.  The diet should be generous and
nutritive, and  a moderate quantity of wine be allowed.  As ex-
ercises, swinging in a cot or hammock, and riding in an easy car-
riage, will be most appropriate.
   If the disease resist these remedies, or it shall appear from the
first unnecessary to employ them from any idea of their ineffi-
cacy, the only relief that can then be  afforded, unless  the woman
becomes pregnant, is to be obtained by wearing a pessary.   This
is usually made either of wood or ivory, and if properly adapted
to the passage and  of  a fit construction, may be  worn without
much inconvenience, or any pain.  Whenever  such an instru-
ment is used, certain  attentions will, however, be  necessary.
Thus, the pessary should never be allowed to  remain in the pas-

   • Take Oak Bark, two ounces.
         Pure  Water, two pints.
     Boil it down to one pint, and to the strained liquor add
         Alum, one drachm and a half.
         Sulphate of Zinc, half a drachm.
     Mix them for an injection.
  0r, Take Alum, four scruples.
         Superacetate of Lead, half a scruple.
         Rose  Water, ten ounces.
     Mix fhem for an injection. 
APPENDIX.
lxxxiii
sage above  a few days at a  time, otherwise it may become the
source of some irritation.  It ought, therefore, to be withdrawn
occasionally on going to bed, be well cleaned, lest the secreted
matter attached  to it become acrimonious, and be re-introduced
in the morning before the patient quits her bed.
   Pessaries are always either circular or oval; the former can
only be used where the disease has not made much progress, and
when the tone of the vagina is not much impaired.  It will sel-
dom be safe to introduce a circular pessary, the diameter of which
exceeds two inches and a half; it should be large enough how-
ever to keep the situation in which it is placed, else it will slip
away;  but it should not be  of such a size as to incommode the
woman, or to injure the parts by its pressure.   Occasionally the
pessary should be changed for one of a smaller size, as the vagina
recovers its proper tone.  The oval pessary rests with its longest
diameter across the vagina,  neither interfering with the  rectum
nor urinary passages.  It seems best adapted  for those cases in
which the tone of the vagina is so much diminished as to  require
a  large  support.   Its longest diameter  ought not to  exceed
three inches and three quarters.*  All  pessaries ought to be in-
troduced with great care, and be placed as high up in the vagina
as possible.
   Before any attempt is made in the reduction of prolapsus uteri,
it will first be necessary to  empty the bladder and rectum : this
being  done, let the  patient  be so placed as that the pelvis shall
be much higher than the shoulders.   The practitioner  is then
to apply his fingers and thumb to the lower part of the  tumour
where the os uteri is situated, and by a gentle and gradual pres-
sure this is to be carried up into the centre of the tumour itself.
The pressure is.afterwards  to be continued until  the  parts are
returned into their proper place.  A pessary is then to be intro-
duced, and  the patient to be enjoined to remain in  a recumbent
posture for several hours.
   Where a woman who is liable to prolapsus uteri becomes preg-
nant, there will be no occasion for the pessary after the third
month, and by proper treatment after  delivery, a return of the
complaint may probably be prevented.
   In married women, whilst there remains a possibility of preg-
nancy, the hope of a radical cure continues, because the pro-
 cesses to which the vagina and parts connected with it are sub-

   * see Observations on the Piseases of Females, by Charles M. Clarke, 
ixxxiv
APPENDIX
jected after parturition, often produce a permanent reduction of
the tumour.   In these cases the principal remedies therefore are
pessaries.  But the complaint frequently remains after the period
of menstruation is over, and when all likelihood of a radical cure
is done away.  In cases of  this nature, Dr. Hamilton, of  Edin-
burgh, has attempted by exciting artificial inflammation of the
vagina, to procure an adhesion of its sides, and  thus to form
what he terms a fleshy pessary.  Unhappily Dr. Hamilton failed
in the experiment which he made for this purpose.
  A powerful  stimulant is certainly required to produce in the
vagina and other canals lined with a  mucous membrane, that
kind of inflammation which forms coagulable lymph ; for in these
parts a slight degree of inflammation occasions pus to be poured
forth, but a  greater is demanded for the formation of lymph, ex-
actly the contrary tp what occurs in most other parts of the ani-
mal body.  Mr. John Hunter says,*  that he produced  adhesive
inflammation in the vagina of an ass, by injecting a strong solu-
tion  of the oxymuriate of mercury.   The remedy would by no
means, however, be advisable in a woman.

              * See his Treatise on the Blood, p. 240.
THE END. 
 
NATIONAL LIBRARY OF MEDICINE
NLM QmMZ47fl M
NLM041424784